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Introduction: Breast cancer progression involves physiological mechanisms such as metastasis. Delays in diagnosis and treatment increase the risk of mortality and are associated with barriers to healthcare access. In Chile, breast cancer is highly prevalent, and early diagnosis has improved, although disparities in the disease evolution persist. This study characterized diagnostic and staging tests, waiting times, and sociodemographic profiles to identify delays and inequities in care. Methods: Survey study. Using a non-probabilistic sample, a questionnaire was applied in an encrypted platform with prior informed consent. The instrument collected data on requested tests, associated times, staging, and sociodemographic characteristics. These variables were analyzed using descriptive statistics, tests of association, confidence intervals, and comparison tests using bootstrapping. Results: A sample of 263 persons was obtained. The most requested tests were biopsy (99.62%) and blood tests (80.23%). The median number of tests requested was six (Q1:4, Q3:8), with a mean of 5.87 (standard deviation: 2.24). No significant differences were observed in the percentage of persons from whom the total number of examinations were requested according to the studied variables. The day-hour-result intervals ranged from 1 to 365 days. The median day-hour-result of the biopsy was 15 days (Q1:10, Q3:30). People between 40 and 49 years old, non-residents of the capital city, belonging to income quintile I, with high school education, from the public health system, with late-stage diagnosis had higher median day-hour-result in biopsy. There was no significant difference in the number of requested tests according to staging (I and II, or III and IV). Conclusions: Biopsy in Chile is the test of choice for diagnostic confirmation in breast cancer. Other tests are requested regardless of the diagnosis stage, contrary to the recommendations of clinical guidelines. Cancer prognosis is crucial, especially in countries with greater inequalities.

Introducción: La progresión del cáncer de mama involucra mecanismos fisiológicos como metástasis. Los retrasos en diagnóstico y tratamiento aumentan el riesgo de mortalidad y se asocian a barreras de acceso a la salud. En Chile, el cáncer de mama es altamente prevalente y su diagnóstico temprano ha mejorado, aunque persisten disparidades en el proceso de enfermedad. Este estudio caracterizó exámenes de diagnóstico y etapificación, tiempos de espera y perfiles sociodemográficos para identificar demoras e inequidades en la atención. Métodos: Estudio de encuesta. Utilizando una muestra no probabilística, se aplicó un cuestionario en plataforma encriptada previo consentimiento informado. En el instrumento se recogieron datos de exámenes solicitados, tiempos asociados, etapificación y características sociodemográficas. Estas variables fueron analizadas utilizando estadística descriptiva, test de asociación, intervalos de confianza y test de comparación utilizando . Resultados: Se logró una muestra de 263 personas. Los exámenes más solicitados fueron biopsia (99,62%) y exámenes de sangre (80,23%). La mediana de exámenes solicitados fue de 6 (Q1:4, Q3:8), con media 5,87 (desviación estándar: 2,24). No se observaron diferencias significativas en el porcentaje de personas a quienes se solicitó la totalidad de exámenes según variables estudiadas. Los intervalos día-hora-resultado oscilaron entre 1 y 365 días. La mediana día-hora-resultado de la biopsia fue de 15 días (Q1:10, Q3:30). Las personas entre 40 y 49 años, no residentes de la capital, pertenecientes al quintil I de ingreso, con educación media, del sistema público de salud, con diagnóstico en etapa tardía presentaron mayores medianas de día-hora-resultado en biopsia. No hubo diferencia significativa en la cantidad de exámenes solicitados según etapificación (I a II y III a IV). Conclusiones: La biopsia en Chile es el examen de elección para la confirmación diagnóstica en cáncer de mama. Otros exámenes son solicitados independientemente de la etapa del diagnóstico, existiendo una discordancia con las recomendaciones de la guía clínica. El pronóstico del cáncer es crucial, especialmente en países con mayores inequidades.

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OBJECTIVE: To identify factors associated with delays in beginning adjuvant therapy and prognosis impacts on non-metastatic breast cancer patients. METHODS: This assessment comprised a prospective cohort study concerning breast cancer patients treated at a public oncology centre. A time interval of ≥60 days between surgery and the beginning of the first adjuvant treatment was categorised as a delay. Factors associated with delays were evaluated through logistic regression analysis and the prognosis effects were assessed by a Cox regression analysis. RESULTS: The median time interval between surgery and the first adjuvant treatment for the 401 women included in this study was of 57.0 days (37.0-93.0). Independent factors associated with delays comprised not presenting an overexpression of the HER-2 protein, not having undergone neoadjuvant chemotherapy, and having undergone chemotherapy or other therapeutic modalities other than hormone therapy and chemotherapy as the first adjuvant treatment. Delays did not affect recurrence, distant metastasis, or death risks. Factors associated with recurrence and distant metastasis risks comprised a clinical staging ≥2B, having undergone neoadjuvant chemotherapy, presenting the luminal molecular subtype B and triple-negative tumours, and having children. Factors associated with death comprised triple-negative molecular tumours and neoadjuvant chemotherapy. CONCLUSION: Delays in beginning adjuvant treatment did not affect the prognosis of non-metastatic breast cancer patients. Clinical and treatment-related factors, on the other hand, were associated with delays, and recurrence, distant metastasis, and death risks.

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OBJECTIVE: The aim of this study was to conduct a detailed geospatial analysis of mobile phone signal coverage in the northwest macro-region of Paraná State, Brazil, seeking to identify areas where limitations in coverage may be related to lengthy travel times of the helicopter emergency medical service (HEMS) for the assistance of victims of road traffic injuries (RTIs). METHODS: An observational study was conducted to examine mobile phone signal coverage and HEMS travel times from 2017 to 2021. HEMS travel times were categorized into four groups: T1 (0-15 min), T2 (16-30 min), T3 (31-45 min), and T4 (over 45 min). Empirical Bayesian Kriging was used to map areas with low mobile signal coverage. The Kruskal-Wallis test and Dwass-Steel-Critchlow-Fligner comparative analyses were performed to explore how mobile signal coverage relates to HEMS travel times to RTI locations. RESULTS: There were 470 occurrences of RTIs attended by HEMS, of which 108 (23%) resulted in on-site fatalities. Among these deaths, 47 (26.85%) occurred in areas with low mobile phone signal coverage ("shadow areas"). Low mobile phone signal coverage identified at 175 (37.24%) RTIs locations, was unevenly distributed across the macro-region. The lowest medians of mobile signal quality were predominantly found in areas with HEMS travel times exceeding 30 min, corresponding to signal strength values of -98.44 (T3) and -100.75 (T4) dBm. This scenario represents a challenge for effective communication to activate HEMS. In the multiple comparison analysis among travel time groups, significant differences were observed between T1 and T2 (p < 0.001), T1 and T3 (p < 0.001), T1 and T4 (p < 0.001), and T2 and T3 (p < 0.001), indicating a potential association between lower mobile phone signal coverage and longer HEMS travel times. CONCLUSION: It can be concluded that poor mobile phone signals in remote areas can hinder HEMS activation, potentially delaying the start of treatment for RTIs. Identification of the shadow areas can help communication and health managers in designing and implementing the necessary changes to improve mobile phone signal coverage and consequently reduce delays in the initial response to RTIs.

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Aim: to evaluate the occurrence of maxillofacial infection cases, which were treated at local hospital, identifying the main risk factors that determine the need for hospitalization of patients and the factors associated with staying length. Methods: A retrospective review of 191 records of patients with maxillofacial infection of odontogenic origin was performed, statistically evaluated by frequency and percentage of involvement, p values (based on the chi-square test) and odds ratio with a 95% confidence interval. A p-value <0.05 was considered statistically significant. Results: Among all the 191 patients, 31 had some harmful habits, such as smokers (13%) and alcoholics (1%). In addition, 39 patients reported some general health problem, such as systemic arterial hypertension (8.3%), depression (6.8%), diabetes (3.6%) and some immunosuppression (1.57%). Involvement of infection in deep facial spaces was present, with 119 patients presenting a deeper infection (62.3%) and 72 patients a superficial infection (37.7%). The most prevalent clinical signs and symptoms in the initial evaluation were pain (91.1%) and edema (90.1%), followed by erythema/hyperemia (44.5%), trismus (37.7%), abscess (30.9%), cellulitis (27.7%), f istula (16.8%), fever (16.8%), dysphagia (11%), dehydration (9.9%), odynophagia (7.9% ) and dyspnea (3.7%). Pulp necrosis was considered a risk factor for treatment in a hospital environment (0.032) and root canal treatment decreases the risk of hospitalization (p=0.002). Considering the evaluated patients, 146 (76.4%) were admitted and 45 (37.7%) were not admitted for hospitalization after initial clinical evaluation. Conclusion: there is a high occurrence of maxillofacial infection cases of dental origin, considering that involvement of infection in deeper facial spaces, as well as presence of pain, edema, erythema/hyperemia, trismus, abscess, cellulitis and pulp necrosis, represent the main risk factors for hospitalization and staying length

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ABSTRACT Objectives To analyze factors associated with delayed initiation of breast cancer treatment at an oncology referral center in Juiz de Fora, Minas Gerais state, between 2010 and 2019. Methods This was a cohort study using data from the Hospital-based Cancer Registry. The probability of not starting treatment within 60 days, in accordance with Brazilian law, was estimated using Kaplan-Meier, method and its association with the factors studied was assessed using the Cox model, presenting hazard ratios (HR) and respective 95% confidence intervals (95%CI). Results Among the 911 participants, the probability of delayed treatment initiation was 18.8% (95%CI 16.4;21.5). Those who underwent treatment at a health service other than the one where the cancer was diagnosed had a significantly higher risk (HR: 3.49; 95%CI 3.00;4.07). Conclusion Receiving a diagnosis and treatment at the same institution may help reduce waiting time to initiate cancer treatment.

RESUMEN Objetivos Determinar los retrasos en el inicio del tratamiento de cáncer de mama en un centro de referencia en oncología de Juiz de Fora, MG, entre 2010 y 2019. Métodos Se trata de una cohorte con datos del Registro Hospitalario de Cáncer. La probabilidad de no iniciar tratamiento dentro de los 60 días, según la legislación brasileña, fue estimada mediante el método de Kaplan-Meier, y su asociación con los factores estudiados mediante el modelo de Cox, con la presentación del Hazard Ratios (HR) y los respectivos intervalos de confianza de 95% (IC95%). Resultados Se evaluaron 911 participantes, la probabilidad de iniciar el tratamiento con retraso fue del 18,8% (IC95% 16,4;21,5). Quienes se sometieron a tratamiento en un servicio de salud distinto al que estableció el diagnóstico de cáncer tuvieron un riesgo significativamente mayor (HR: 3,49; IC95% 3,00;4,07). Conclusión La realización del diagnóstico y tratamiento en una misma institución puede contribuir a reducir el tiempo de espera para el inicio del tratamiento.

RESUMO Objetivos Analisar fatores associados ao atraso para o início do tratamento do câncer de mama em um centro de referência em oncologia em Juiz de Fora, MG, entre 2010 e 2019. Métodos Trata-se de coorte com dados do Registro Hospitalar de Câncer. A probabilidade de não iniciar o tratamento em até 60 dias, conforme legislação brasileira, foi estimada pelo método de Kaplan-Meier, e sua associação com os fatores estudados pelo modelo de Cox, com apresentação das hazard ratios (HR) e respectivos intervalos de confiança de 95% (IC95%). Resultados Entre as 911 participantes, a probabilidade de iniciar o tratamento com atraso foi de 18,8% (IC95% 16,4;21,5). Aquelas que realizaram o tratamento em um serviço de saúde diferente do que estabeleceu o diagnóstico de câncer apresentaram risco significativamente maior (HR: 3,49; IC95% 3,00;4,07). Conclusão Realizar diagnóstico e tratamento na mesma instituição pode contribuir para a redução do tempo de espera para o início do tratamento.

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INTRODUCCIÓN: La duración del tratamiento de hemodiálisis en pacientes con enfermedad renal crónica puede impactar significativamente en su calidad de vida. Esto se debe a las exigencias que conlleva someterse a este procedimiento, ya que implica ajustes en las actividades cotidianas. OBJETIVO: Determinar la relación entre el tiempo de tratamiento y la calidad de vida en pacientes con enfermedad renal crónica en atención primaria. METODOLOGÍA: Estudio descriptivo correlacional, con una muestra de 103 pacientes con enfermedad renal crónica con tratamiento de hemodiálisis. La calidad de vida se midió a través del instrumento SF-36, se analizó en el paquete estadístico SPSS utilizando estadística descriptiva e inferencial. RESULTADOS: Se reportó una media de calidad de vida global de 56,78 (DE=18,24) de valores de 0 a 100, el 50,5% de los participantes tiene de 4 a 6 años con el tratamiento de hemodiálisis. Se demostró una correlación negativa y significativa entre el tiempo de tratamiento con el rol físico (rs = -0,218, p = 0,05). Así mismo, entre la edad del paciente con la calidad de vida global (rs = -0,393, p = 0,01), analizada a través de las dimensiones función física, rol físico, dolor corporal, vitalidad y salud mental. CONCLUSIÓN: La edad y el tiempo de tratamiento afectan la calidad de vida de pacientes con enfermedad renal en tratamiento de hemodiálisis. Se recomienda implementar en la atención primaria intervenciones de enfermería que involucren ambas variables para promover una mejora sustancial en la calidad de vida de los pacientes.

INTRODUCTION: The duration of hemodialysis treatment in patients with chronic kidney disease can significantly impact their quality of life. This is due to the demands of this procedure since it involves adjustments in daily activities. OBJECTIVE: To determine the relationship between treatment time and quality of life in primary health care patients with chronic kidney disease. METHODOLOGY: Descriptive correlational study with a sample of 103 patients with chronic kidney disease with hemodialysis treatment. The quality of life was measured through the SF-36 instrument and analyzed in the statistical package SPSS using descriptive and inferential statistics. RESULTS: A mean global quality of life of 56,78 (SD=18,24) with values from 0 to 100 was reported, and 50,5% of the participants had 4 to 6 years of hemodialysis treatment. A negative and significant correlation was demonstrated between treatment time and physical role (rs = -0,218, p = 0,05). Likewise, the patient's age and overall quality of life (rs = -0,393, p = 0,01) are analyzed through the dimensions of physical function, physical role, bodily pain, vitality, and mental health. CONCLUSION: Age and treatment time affect the quality of life of patients with kidney disease undergoing hemodialysis treatment. It is recommended to implement nursing interventions in primary health care that involve both variables to promote a substantial improvement in patients' quality of life.

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Background: Short period from diagnosis to breast cancer (BC) treatment initiation remains challenging for the public health system in Brazil, which may have been further affected by the coronavirus disease-2019 (COVID-19) pandemic. This study assessed BC diagnosis-to-treatment intervals (DTi) in Brazil and the possible effects of the COVID-19 outbreak on delays. Methods: The Painel de Monitoramento de Tratamento Oncológico database was queried to obtain the number of Brazilian patients with a BC confirmed diagnosis and initiating cancer treatment in the pre-COVID-19 (2013-2019) and during the COVID-19 (2020-2021) periods, adopting a 60-day limit as timely treatment. A p-value of <0.05 was considered significant. Results: A total of 315,951 cases were included (females: 99.3% and males: 0.7%), of which 251,667 and 64,284 records were computed before and during the COVID-19 years, respectively. Most patients failed to perform the first cancer treatment within 60 days (>60: 51.8%). We observed an upward trend in the number of BC treatments provided in the pre-COVID-19 years (r2 = 0.9575; p < 0.05), but the volume of treatments exhibited an average reduction of 24.6% yearly during the COVID-19 pandemic. The average DTi in days was 122.4, 122.5 and 122.3 in the total period studied, before and during the COVID-19 outbreak, respectively. The arrival of COVID-19 in Brazil increased the chances of treatment delay (OR = 1.043; p < 0.05) and inverted the proportion of early/advanced stages at BC diagnosis (55.8%/44.2%-48.4%/51.6%). Conclusion: COVID-19 has imposed changes in BC care in Brazil, reducing the number of treatments provided by the Brazilian public health system, increasing the chances of delayed treatment initiation despite no differences in DTi averages being identified, and raising the proportion of advanced-stage diagnoses.

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Evaluar los factores relacionados al éxito anatómico y funcional de la cirugía por desprendimiento de retina regmatógeno (DRR) en pacientes del Instituto Regional de Oftalmología "Javier Servat Univazo". Estudio observacional en una cohorte retrospectiva de 204 pacientes con DRR sometidos a diferentes técnicas quirúrgicas entre enero 2010-diciembre 2019, con al menos 6 meses de seguimiento. Éxito anatómico (re-aplicación primaria de retina) y éxito funcional (mejoría de agudeza visual (AV)); buscándose asociación entre estas variables y las demográficas, clínicas y tiempos de espera. Resultados: La edad promedio fue 50 + 16,5 (9-85) años. Éxito anatómico se alcanzó en 165 (80,9 %) pacientes y funcional en 110 (52,9 %). Hubo menor tiempo de espera quirúrgico en pacientes que lograron éxito anatómico (20,0 +/- 22,6 días (1-120)) vs. (29,8 +/- 40,1 días (1-210)) (p=0,04) y en los que tuvieron éxito funcional ( 13,3+/- 15,1 (1-100)) vs. (31,9 +/- 33,7 (1-210)) (p <0,001); y menor tiempo de enfermedad y menor tiempo total en los que tuvieron éxito funcional (29,7 +/-56,5 días (1-365) vs. (61,9 +/- 110,6 días (1-730)) (p=0,008) y (43,1 +/- 68,1 (5-465)) vs. 93,8 +/- 118,3 (3-766)) respectivamente (p<0,001). El menor tiempo de espera quirúrgico mostró asociación con el éxito anatómico y funcional de la cirugía por DRR. El menor tiempo de enfermedad y el menor tiempo total también mostraron asociación con el éxito funcional. Recomendamos implementar medidas para abreviar tiempos de espera e instaurar una terapia quirúrgica precoz y oportuna en estos pacientes.

To evaluate factors related to the anatomical and functional success of surgery for rhegmatogenous retinal detachment (RRA) in patients of the Regional Institute of Ophthalmology "Javier Servat Univazo". retrospective cohort study of 204 patients with RRD submitted to different surgical techniques between January 2010-December 2019, with at least 6 months of follow-up anatomical success (primary retinal reapplication) and functional success (improvement in visual acuity (VA)); looking for an association between these variables and demographics, clinics and waiting times. Results: The mean age was 50 + 16.5 (9-85) years. Anatomical success was achieved in 165 (80.9%) patients and functional in 110 (52.9%). There was a shorter surgical waiting time in patients who achieved anatomical success (20.0 +/- 22.6 days (1-120)) vs (29.8 +/- 40.1 days (1-210)) (p=0.04) and in those who had functional success (13.3+/- 15.1 (1- 100)) vs (31.9 +/- 33.7 (1-210)) (p <0.001); and shorter sick time and shorter total time in those who had functional success (29.7 +/-56.5 days (1-365) vs (61.9 +/- 110.6 days (1-730)) (p=0.008) and (43.1 +/-68.1 (5-465)) vs 93.8 +/- 118.3 (3-766)) respectively (p<0.001). The shorter surgical waiting time was associated with RRD surgery's anatomical and functional success. The shortest time of illness and the shortest total time were associated with functional success. We recommend implementing measures to shorten waiting times and establish early and timely surgical therapy in these patients.

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Resumo Este estudo retrospectivo investigou fatores associados ao tempo para submissão ao primeiro tratamento do câncer de mama entre 12.100 casos assistidos em estabelecimentos de saúde habilitados para a alta complexidade em oncologia no âmbito do SUS localizados no Rio de Janeiro entre 2013 e 2019. Regressão logística multivariada estimou razões de chances e intervalos de 95% de confiança. Foram submetidos ao primeiro tratamento em tempo >60 dias 82,1% dos casos. Entre aqueles sem histórico de diagnóstico anterior, alta escolaridade e estadiamento III e IV exibiram menor probabilidade de submissão ao primeiro tratamento em tempo >60 dias, enquanto tratamento em estabelecimento de saúde não localizado na capital exibiu probabilidade maior. Entre aqueles com histórico de diagnóstico anterior, idade ≥50 anos, raça/cor da pele não branca e estadiamento I exibiram maior probabilidade de submissão ao primeiro tratamento em tempo >60 dias, enquanto alta escolaridade, tratamento em estabelecimento de saúde não localizado na capital e estadiamento IV exibiram probabilidade menor. Em suma, fatores sociodemográficos, clínicos e relacionados ao estabelecimento de saúde estão associados ao tempo para submissão ao primeiro tratamento do câncer de mama.

Abstract The present retrospective study investigated factors associated with time-to-treatment initiation of breast cancer of a cohort of 12,100 cases of health facilities qualified for high complexity in oncology within the scope of the Brazilian Public Health System (SUS) of Rio de Janeiro between 2013 and 2019. Multivariate logistic regression was used to estimate odds ratios and 95% confidence intervals. Of all cases, 82.1% were submitted to the first treatment >60 days. Patients without previous diagnosis history, higher education and in stages III and IV were less likely to have their first treatment >60 days, while treatment at a health facility outside the capital showed a higher probability. Patients with a previous diagnosis history, aged ≥50, non-white race/skin color and in stage I were more likely to be submitted to their first treatment >60 days, while subjects with higher education, treated in a health facility outside the capital and in stage IV showed a lower probability. To summarize, sociodemographic, clinical and health facility-related factors are associated with time-to-treatment initiation of breast cancer.

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BACKGROUND: Cutaneous Leishmaniasis (CL) affects up to 5.000 people in Ecuador each year. L. guyanensis and L. braziliensis are the most common of the eight CL-causing Leishmania species. Earlier CL research concentrated on the easily accessible Pacific region. This study aims to describe the Leishmania species in Pacific and Amazon ecoregions, to analyze regional differences in CL patient clinical presentation, and to identify determinants of health-seeking delay. METHODS: All cases in this cross-sectional study were diagnosed using smear slide microscopy, PCR, or both. Cytochrome B gene sequencing was used to identify the causative Leishmania species in qPCR-positive samples. RESULTS: This study included 245 patients, with 154 (63%) infected in the Pacific region and 91 (37%) infected in the Amazon. Causative Leishmania species were identified in 135 patients (73% of qPCR positives). L. guyanensis was identified in 76% (102/135) of the samples and L. braziliensis in 19% (26/135). The Pacific region had a low prevalence of 6% (5/89) of L. braziliensis. For the first time, we report L. guyanensis from the central Amazon, L. braziliensis from the northern Pacific, and L. lainsoni from both the central Amazon and northern Pacific. Amazon cases had a longer median health-seeking delay in months (2.0, IQR 3.0) than Pacific cases (1.0, IQR 1.5). Prolonged health-seeking delay was associated with older age, Amerindian ethnicity, infection at lower altitudes, non-ulcerative lesions, and lesions on the lower limbs. CONCLUSIONS: In the Pacific region, health-seeking delay is relatively short and L. braziliensis prevalence remains low. Limited access to health care and stigma might explain the prolonged health-seeking delay in the Amazon. We recommend larger studies on the distribution of Leishmania species in Amazon CL cases and additional regional research into diagnostic test accuracy. Furthermore, the determinants of health-seeking delay in Ecuador should be investigated further.

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RESUMEN Introducción : de estar disponible, la angioplastia primaria (ATCp), en tiempos adecuados y en centros con experiencia, es la mejor estrategia de reperfusión para el infarto agudo de miocardio con supradesnivel del segmento ST (IAMCEST). El tiempo puerta-balón (TPB) es una expresión de eficiencia operativa de la institución que realiza la ATCp, con impacto en la evolución del paciente. El objetivo de este trabajo fue analizar los resultados a largo plazo de un programa de mejora continua del proceso TPB. Material y métodos : se incluyeron en forma prospectiva y consecutiva pacientes con diagnóstico de IAMCEST sometidos a ATCp desde enero de 2015 a mayo de 2022. La población se dividió en dos períodos: período de implementación inmediata y período de seguimiento a largo plazo. Resultados : se ingresaron 671 pacientes en forma prospectiva y consecutiva. En el primer período, de implementación, (P1), se incluyeron 91 pacientes, y en el segundo período, de seguimiento del programa, (P2), 580 pacientes. La mediana (rango intercuartilo, RIC) de TPB fue de 46 min (29-59) en P1 vs 42 min(25-52) en el P2, p = 0,055. En el segundo período se evi denció una reducción de las preactivaciones (P1 54,1% vs P2 30%,p = 0,02) y los procedimientos on hours (42% en p1 vs 30% en P2, p = 0,029). Conclusión : el registro mostró el mantenimiento de los buenos resultados a largo plazo a pesar de una reducción de las preactivaciones y los procedimientos on hours.

ABSTRACT Background : If available, primary transluminal coronary angioplasty (PTCA), performed timely and in experienced sites, is the best reperfusion strategy for ST elevation myocardial infarction (STEMI). The door-to-balloon (DTB) time expresses operational efficiency of the site in charge of the PTCA, with an impact on patient's progress. The aim of this study was to analyze the long-term results of a continuous improvement program for the DTB time process. Methods : Patients diagnosed with STEMI who had undergone PTCA from January 2015 to May 2022 were prospectively and consecutively enrolled. The population was divided in two periods: an immediate implementation period and a long-term follow-up period. Results : 671 patients were prospectively and consecutively enrolled. During the implementation period (P1) 91 patients were enrolled, and 580 during the program follow-up (P2). The median (interquartile range, IQR) DTB time was 46 min (29-59) for P1 vs 42 min(25-52) for P2, p=0.055). The second period showed a reduction in pre-activations (P1 54,1% vs P2 30% p=0.02) and on-hour procedures (42% for P1 versus 30% for P2, p=0.029). Conclusion : The registry showed long-term maintenance of good results, despite reduced reactivations and on-hour procedures.

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ABSTRACT Objective: To verify the association between sociodemographic, clinical, environmental, cognitive, and emotional factors and the decision time of people with ischemic stroke to seek a health service after the onset of symptoms or wake up stroke. Method: Cross-sectional study carried out from March to October 2019, with 304 patients, in a public hospital, a reference in neurology. Data obtained through interview and from medical records. Decision time was analyzed as a geometric mean. In the bivariate and multivariate analyses, linear regression was used and the Akaike Information Criterion was used to select the best model. Statistical significance of 5% was adopted. Results: The geometric mean of decision time was 0.30h (95% CI 0.23-0.39). The final model explained this time in 41%, showing an increase of 0.5 min for people with arterial hypertension; 10.8 min for those who waited for symptoms to improve; 1.4 min for those who were alone at the onset of symptoms; 3.9 min for those at home; 3.2 min for the ones at work; and 2.1 for those on the street/public space. Conclusion: The mean decision time for seeking a health service was high and influenced by clinical, environmental, cognitive, and emotional variables. The results guide nurses regarding health education.

RESUMEN Objetivo: Verificar la asociación entre factores sociodemográficos, clínicos, ambientales, cognitivos, y emocionales y el tiempo de decisión de las personas con accidente cerebrovascular isquémico para buscar un servicio de salud luego del inicio de los síntomas o Wake up stroke Método: Estudio transversal realizado de marzo a octubre de 2019, con 304 pacientes, en un hospital público, referencia en neurología. Datos obtenidos por entrevista y de la historia clínica. El tiempo de decisión se analizó como una media geométrica. En los análisis bivariados y multivariados se utilizó la regresión lineal y el Criterio de Información de Akaike para seleccionar el mejor modelo. Se adoptó una significancia estadística del 5% Resultados: La media geométrica del tiempo de decisión fue de 0,30h (IC 95% 0,23-0,39). El modelo final explicó este tiempo en un 41%, mostrando un aumento de 0,5 min para las personas con hipertensión arterial, 10,8 min para las que esperaron a que los síntomas mejoraran, 1,4 min para las que estaban solas al inicio de los síntomas, 3, 9 min para las que estaban en casa, 3,2 min para los que estaban en el trabajo y 2,1 en la calle/vía pública Conclusión: El tiempo promedio de decisión para buscar un servicio de salud fue alto e influenciado por variables clínicas, ambientales, cognitivas y emocionales. Los resultados orientan a los enfermeros hacia la educación en salud.

RESUMO Objetivo: Verificar a associação entre fatores sociodemográficos, clínicos, ambientais, cognitivos e emocionais e o tempo de decisão de pessoas com acidente vascular cerebral isquêmico para procurar um serviço de saúde após o início dos sintomas ou Wake up stroke Método: Estudo transversal realizado de março a outubro de 2019, com 304 pacientes, em hospital público, referência em neurologia. Dados obtidos por entrevista e no prontuário. O tempo de decisão foi analisado em média geométrica. Nas análises bivariadas e multivariada foi usada a regressão linear e o Critério de Informação de Akaike foi usado na seleção do melhor modelo. Adotou- se significância estatística de 5% Resultados: A média geométrica do tempo de decisão foi de 0,30h (IC 95% 0,23-0,39). O modelo final explicou em 41% esse tempo, mostrando aumento de 0,5 min para pessoas com hipertensão arterial; 10,8 min para quem esperou os sintomas melhorarem; 1,4 min para quem estava sozinho no início dos sintomas; 3,9 min para quem estava em casa; 3,2 min no trabalho e 2,1 na rua/via pública Conclusão: A média do tempo de decisão para procura de serviço de saúde foi alta e influenciada por variáveis clínicas, ambientais, cognitivas e emocionais. Os resultados orientam enfermeiros para a educação em saúde.

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Abstract The aim of this study was to evaluate the time elapsed from first symptoms to the treatment of oral and oropharyngeal cancer (OOC) and to identify variables associated with treatment delay. This is an observational study with retrospective and prospective data collection. Patients with a diagnosis of OOC seen at the Head and Neck Surgery outpatient clinic of a Brazilian public hospital were included and followed up to treatment initiation. Participants answered a questionnaire for the collection of socioeconomic, demographic, cultural, and clinical information, as well as information about the time elapsed from first symptoms to the first appointment with a head and neck surgeon. Time to treatment was classified into four intervals: 1- first symptoms to first medical appointment; 2- first medical appointment to specialized medical care; 3- specialized medical care to preparation for treatment; and 4- preparation for treatment to treatment initiation. Bivariate statistics were computed. Out of 100 participants, nine died before treatment. Mean time to treatment was 217 days. Highest mean time was observed for interval 2 (94 days), followed by interval 1 (63 days), interval 4 (39 days), and interval 3 (21 days). At interval 1, a longer time was associated with severe alcohol consumption, severe smoking, and family history of cancer. At interval 2, the delay was associated with appointment with a general practitioner, clinical diagnosis of disease other than cancer, and antibiotic prescription. At interval 4, delay in treatment was associated with surgical treatment. Patients with OOC experience delays from symptom onset to treatment initiation. The longest interval was associated with professional delay, followed by patient delay in help-seeking.

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Objective: to analyze treatment delay and the flow of care for women with breast cancer in Brazil in 2019 and 2020. Method: this was a follow-up study of breast cancer cases available from the Oncology Panel; a chi-square test and multilevel logistic regression were performed in order to analyze the explanatory variables associated with delay (greater than 60 days) in starting treatment. Results: 22,956 cases (54.5%) with delay in treatment were identified in 2019 and 17,722 (48.7%) in 2020; the Southeast region (54.6%) had the greatest proportion of delay; delay was greater when treatment was provided outside the municipality of residence and lower in 2020 compared to 2019; most outward flows were to the capital cities in the same Federative Units of residence. Conclusion: strategies to reduce cancer treatment delay and optimize health care networks in the Federative Units should be prioritized.

Resumen Objetivo: analizar la demora en el tratamiento y el flujo asistencial de mujeres con cáncer de mama en Brasil en 2019 y 2020. Método: estudio de seguimiento de los casos de cáncer de mama disponibles en el Panel de Oncología. Para analizar las variables explicativas asociadas al retraso (mayor de 60 días) en el inicio del tratamiento se realizó la prueba de chi-cuadrado y la regresión logística multinivel. Resultados: se identificaron 22.956 casos (54,5%) en 2019 y 17.722 (48,7%) en 2020 con retraso en el tratamiento. La región Sudeste (54,6%) tuvo mayor proporción de atraso, siendo mayor cuando se realizó fuera del municipio de residencia y menor en 2020 en relación a 2019. Los flujos externos, en su mayoría, ocurrieron en las capitales de las mismas Unidades de la Federación (UFs) de residencia. Conclusión: se deben priorizar estrategias que reduzcan el intervalo de tiempo hasta el inicio del tratamiento del cáncer y optimicen las redes de atención de salud en los estados.

Objetivo: analisar o atraso para o tratamento e o fluxo assistencial de mulheres com câncer de mama no Brasil em 2019 e 2020. Métodos: estudo de seguimento de casos de câncer de mama disponibilizados no PAINEL-Oncologia; para analisar as variáveis explicativas associadas ao atraso (maior que 60 dias) no início do tratamento, realizou-se teste qui-quadrado e regressão logística multinível. Resultados: identificaram-se 22.956 casos (54,5%) em 2019 e 17.722 (48,7%) em 2020, com atraso para o tratamento; a região Sudeste (54,6%) teve maior proporção de atraso, que foi maior quando o tratamento foi realizado fora do município de residência, e menor em 2020, comparando-se a 2019; os fluxos externos, em sua maioria, ocorreram para as capitais das mesmas Unidades da Federação (UFs) de residência. Conclusão: estratégias que diminuam o intervalo de tempo até o início do tratamento oncológico e otimizem as redes de atenção em saúde nas UFs devem ser priorizadas.

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ABSTRACT Background: The number of tuberculosis (TB) cases in prisons is higher than that in the general population and has been reported as the most common cause of death in prisons. This study evaluated the delay in the diagnosis and treatment of TB in Brazilian prisons. Methods: A retrospective cohort study was conducted between 2007 and 2015 using data from the five largest male prisons in Mato Grosso do Sul, Brazil. TB case data was collected from the National Database of Notifiable Diseases (SINAN), GAL-LACEN, and prison medical records. The following variables were recorded: prison, year of diagnosis, age, race, education, HIV status, smoking status, comorbidities, number of symptoms, percentage of cures, delay in diagnosis, patient delay, provider delay, laboratory delay, and delay in treatment. Descriptive statistics were used for the variables of interest. Results: A total of 362 pulmonary TB cases were identified. The average time between the first symptom and reporting of data was 94 days. The mean time between symptom onset and laboratory diagnosis was 91 days. The average time from symptom onset to first consultation was 80 days. The time between diagnosis and treatment initiation was 5 days. Conclusions: Delays were significant between reporting of the first symptoms and diagnosis and significantly smaller from the time between notification and start of treatment. Control strategies should be implemented to diagnose cases through active screening, to avoid delays in diagnosis and treatment, and to reduce TB transmission.

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ABSTRACT Objective. To determine if there was an association between intrapartum stillbirths and both traveled distance for delivery and delivery care accessibility, assessing periods before and during the COVID-19 pandemic. Methods. This is a population-based cohort study. Patients had birth occurring after the onset of labor; the primary outcome was intrapartum stillbirth. City of residence was classified according to the ratio between deliveries performed and total births among its residents; values lower than 0.1 indicated low delivery care accessibility. Travel distance was calculated using the Haversine formula. Education level, maternal age, and birth sex were included. In each period, relative risk was assessed by generalized linear model with Poisson variance. Results. There were 2 267 534 deliveries with birth occurring after the onset of labor. Most patients were between age 20 and 35 years, had between 8 and 11 years of education, and resided in cities with high delivery care accessibility. Low delivery care accessibility increased risk of intrapartum stillbirth in the pre-pandemic (relative risk [RR] 2.02; 95% CI [1.64, 2.47]; p < 0.01) and the pandemic period (RR 1.69; 95% CI [1.09, 2.55]; p = 0.015). This was independent of other risk-increasing factors, such as travel distance and fewer years of education. Conclusions. Low delivery care accessibility is associated with the risk of intrapartum stillbirths, and accessibility reduced during the pandemic. Delivery of patients by family physicians and midwives, as well as official communication channels between primary care physicians and specialists, could improve patient healthcare-seeking behavior.

RESUMEN Objetivo. Determinar si hubo una asociación entre la mortinatalidad durante el parto y la distancia recorrida o la accesibilidad de la atención para el parto, mediante la evaluación de un período anterior y de otro coincidente con la pandemia de COVID-19. Métodos. Se realizó un estudio de cohorte de base poblacional. Se incluyó a las pacientes que dieron a luz tras el inicio de un trabajo de parto; el criterio de valoración principal fue la mortinatalidad durante el parto. Se clasificaron las ciudades de residencia conforme al cociente entre el número de partos atendidos y el total de partos habidos entre sus residentes; los valores inferiores a 0,1 indican que la accesibilidad de la atención del parto es baja. La distancia recorrida para el parto se calculó utilizando la fórmula de Haversine. Se utilizaron datos del nivel de estudios y la edad de la madre y del sexo biológico neonatal. Para cada período, se evaluó el riesgo relativo mediante un modelo lineal generalizado con varianza de Poisson. Resultados. Hubo 2 267 534 partos que se produjeron tras el inicio de un trabajo de parto. La mayoría de las pacientes tenían edades comprendidas entre 20 y 35 años, tenían entre 8 y 11 años de estudios y residían en ciudades donde la accesibilidad de la atención del parto era alta. Una accesibilidad baja de la atención del parto se asoció a un aumento del riesgo de mortinatalidad durante el parto en el período prepandémico (riesgo relativo [RR] = 2,02; IC del 95% = [1,64, 2,47]; p < 0,01) y también durante la pandemia (RR = 1,69; IC del 95% = [1.09, 2.55]; p = 0,015). Este resultado fuer independiente de otros factores que incrementan el riesgo, como la distancia recorrida para dar a luz y un menor nivel de estudios. Conclusiones. Una accesibilidad baja de la atención del parto se asocia a un mayor riesgo de mortinatalidad durante el parto; y se observó una reducción de la accesibilidad durante la pandemia. Los partos asistidos por personal de medicina de familia o de partería y los canales de comunicación oficiales entre el personal médico de atención primaria y el especializado podrían mejorar el comportamiento de las pacientes a la hora de buscar atención de salud.

RESUMO Objetivo. Determinar se existe alguma relação entre a morte fetal intraparto e dois fatores: a distância percorrida para o parto e o acesso à assistência ao parto, avaliando o período antes e durante a pandemia de COVID-19. Métodos. Este é um estudo de coorte de base populacional. As pacientes tiveram parto após o início do trabalho de parto; o desfecho primário foi morte fetal intraparto. A cidade de residência foi classificada de acordo com a razão entre os partos realizados e o total de nascimentos entre os residentes; valores inferiores a 0,1 indicavam baixo acesso à assistência ao parto. A distância percorrida foi calculada usando a fórmula de Haversine. Foram incluídos o nível de escolaridade, a idade materna e o sexo de nascimento. Em cada período, o risco relativo foi avaliado usando um modelo linear generalizado com variância de Poisson. Resultados. Foram registrados 2 267 534 partos com nascimento após o início do trabalho de parto. A maioria das pacientes tinha entre 20 e 35 anos de idade, entre 8 e 11 anos de escolaridade e residia em cidades com alto nível de acesso à assistência ao parto. O baixo acesso à assistência ao parto aumentou o risco de morte fetal intraparto no período anterior à pandemia (risco relativo [RR]: 2,02; intervalo de confiança [IC] de 95%: 1,64-2,47; p < 0,01) e durante a pandemia (RR: 1,69; IC 95%: 1,09-2,55; p = 0,015). Isso ocorreu independentemente de outros fatores de aumento de risco, como a distância percorrida e menor escolaridade. Conclusões. O baixo acesso ao atendimento de parto está associado ao risco de morte fetal intraparto, e a acessibilidade diminuiu durante a pandemia. A realização do parto por médicos de família e obstetrizes, bem como a existência de canais oficiais de comunicação entre médicos de atenção primária e especialistas, poderiam melhorar o comportamento de busca de saúde por parte das pacientes.

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INTRODUCTION: Rapid-cycle deliberate practice (RCDP) is a simulation-based educational strategy that consists of repeating a simulation scenario a number of times to acquire a planned competency. When the objective of a cycle is achieved, a new cycle initiates with increased skill complexity. There have been no previous randomized studies comparing after-event debriefing clinical manikin-based simulation to RCDP in adult cardiopulmonary resuscitation (CPR). METHODS: We invited physicians from the post-graduate program on Emergency Medicine of the Hospital Israelita Albert Einstein. Groups were randomized 1:1 to RCDP or after-event debriefing simulation prior to the first station of CPR training. During the first 5 min of the pre-intervention scenario, both groups participated in a simulated case of an out-of-hospital cardiac arrest without facilitator interference; after the first 5 min, each scenario was then facilitated according to group allocation (RCDP or after-event debriefing). In a second scenario of CPR later in the day with the same participants, there was no facilitator intervention, and the planned outcomes were evaluated. The primary outcome was the chest compression fraction during CPR in the post-intervention scenario. Secondary outcomes comprised time for recognition of the cardiac arrest, time for first verbalization of the cardiac arrest initial rhythm, time for first defibrillation, and mean pre-defibrillation pause. RESULTS: We analyzed data of three courses conducted between June 2018 and July 2019, with 76 participants divided into 9 teams. Each team had a median of 8 participants. In the post-intervention scenario, the RCDP teams had a significantly higher chest compression fraction than the after-event debriefing group (80.0% vs 63.6%; p = 0.036). The RCDP group also demonstrated a significantly lower time between recognition of the rhythm and defibrillation (6 vs 25 s; p value = 0.036). CONCLUSION: RCDP simulation strategy is associated with significantly higher manikin chest compression fraction during CPR when compared to an after-event debriefing simulation.

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BACKGROUND: Yearly, up to 1 million patients worldwide suffer from cutaneous leishmaniasis (CL). In Ecuador, CL affects an estimated 5000 patients annually. CL leads to reduced Health Related Quality of Life (HRQL) as a result of stigma in the Asian and Mediterranean contexts, but research is lacking for Ecuador. The objective of this study was to explore the influence of CL suspected lesions on the quality of life of patients in the Pacific and Amazon regions. METHODS: Patients for this study were included in the Amazonian Napo, Pastaza, and Morona Santiago provinces and the Pacific region of the Pichincha province. Participating centers offered free of charge CL treatment. All patients suspected of CL and referred for a cutaneous smear slide microscopy examination were eligible. This study applied the Skindex-29 questionnaire, a generic tool to measure HRQL in patients with skin diseases. All statistical analysis was done with SPSS Statistics version 28. RESULTS: The skindex-29 questionnaire was completed adequately by 279 patients who were included in this study. All patient groups from the Amazon scored significantly (P < 0.01) higher (indicating worse HRQL) on all the dimensions of the Skindex-29 questionnaire than Mestizo patients from the Pacific region. The percentage of patients with health seeking delay of less than a month was significantly (P < 0.01) lower in the Amazon region (38%) than in the Pacific (66%). CONCLUSIONS: The present study revealed that the influence of suspected CL lesions on the HRQL of patients in the Ecuadorian Amazon and Pacific depends on the geographic region more than on patient characteristics such as gender, age, number of lesions, lesion type, location of lesions, health seeking delay, or posterior confirmation of the Leishmania parasite. The health seeking delay in the Amazon might result from a lack of health infrastructure or related stigma. Together, the impaired HRQL and prolonged health seeking delay in the Amazon lead to prolonged suffering and a worse health outcome. Determinants of health seeking delay should be clarified in future studies and CL case finding must be improved. Moreover, HRQL analysis in other CL endemic regions could improve local health management.

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Introducción: la pandemia por COVID-19 ha afectado la salud de la mujer y en particular a los derechos sexuales y reproductivos. En el contexto de cambios asistenciales por la pandemia COVID 19, podría verse afectado el tamizaje y seguimiento de las lesiones premalignas de los cánceres de cuello de útero (CCU), poniendo en riesgo su diagnóstico oportuno y tratamiento precoz. El objetivo de este estudio es reportar los tiempos transcurridos entre el resultado de screening patológico y el tratamiento de lesiones premalignas de CCU, cotejando con los plazos establecidos por la ordenanza ministerial vigente y comparando los tiempos observados antes y durante la pandemia. Métodos: se realizó un estudio observacional, analítico, de corte transversal, mediante un análisis comparativo antes y después de la pandemia por COVID-19. Se incluyeron usuarias a quienes se les realizó conización quirúrgica en el Centro Hospitalario Pereira Rossell en dos períodos de tiempo: 1 de marzo de 2019 a 29 de febrero de 2020, y 1 de marzo de 2020 a 28 de febrero de 2021. Resultados: la media en días observada desde el PAP hasta la conización fue de 245 para el primer periodo y de 242 para el segundo. El porcentaje de pacientes que cumplen con la ordenanza ministerial en ambos períodos no supera el 5%. Conclusiones: no se evidenció una mayor demora en el seguimiento y tratamiento de estas usuarias durante la pandemia por COVID-19, sin embargo los tiempos observados superan ampliamente los establecidos por Ordenanza Ministerial en los periodos pre pandemia y durante la misma.

Introduction: the COVID-19 pandemic has affected women's health in general, and in particular their sexual and reproductive rights. Within the context of changes in health care services due to the COVID-19 pandemic, the screening and follow up of cervical precancerous lesions could be affected, and in turn, this could prevent timely diagnosis and early treatment. This study aims to report the period of time be-tween pathological findings in screening tests and the treatment of precancerous lesions of cervical cancer, analyze it within the context of deadlines set in the Ministry of Health regulations in force, and compare it to pre-pandemic deadlines and time frames during the COVID-19 pandemic. Method: observational, analytical and transversal study conducted by means of analyzing the situation before and after the COVID-19 pandemic. The study included users who underwent surgical conization at the Pereira Rossell Hospital during two periods of time: Between March 1, 2019 and February 29, 2020 and between March 1, 2020 and February 28, 2021. Results: average number of days from the PAP test until conization was 245 days for the first period and 242 for the second one. The percentage of patients that comply with the Ministerial decree in both periods is lower than 5%. Conclusions: the study found time to treatment in the follow up and management of users did not increase during the COVID-19 pandemic. However, the times ob-served widely exceed the deadlines set in the ministerial decree in both periods, that is before and during the pandemic.

Introdução: a pandemia de COVID-19 afetou a saúde das mulheres e em particular os direitos sexuais e reprodutivos. No contexto das mudanças na saúde devido à pandemia de COVID 19, o rastreamento e o acompanhamento das lesões pré-malignas do câncer de colo de útero (CCU) podem ser afetados, colocando em risco o diagnóstico oportuno e o tratamento precoce. Objetivo: descrever os tempos decorridos entre o resultado do rastreamento patológico e o tratamento das lesões pré-malignas do CCU, comparando-os com os períodos estabelecidos pela atual Portaria Ministerial, e comparar os tempos observados antes e durante a pandemia. Métodos: foi realizado um estudo observacional, analítico e transversal por meio de uma análise comparativa antes e após a pandemia de COVID19. Foram incluídos as usuárias que realizaram a conização cirúrgica no Hospital Pereira Rossell em dois períodos de tempo: 1º de março de 2019 a 29 de fevereiro de 2020 e 1º de março de 2020 a 28 de fevereiro de 2021. Resultados: a média de dias observados do PAP à conização foi de 245 para o primeiro período e 242 para o segundo. O percentual de pacientes que cumprem a Portaria Ministerial em ambos os períodos não ultrapassa 5%. Conclusões: não houve evidência de maior demora no acompanhamento e tratamento desses usuários durante a pandemia por COVID-19, porém os tempos observados superam em muito os estabelecidos por Portaria Ministerial nos períodos pré-pandemia e durante a mesma.

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Resumo O objetivo foi verificar a associação entre fatores individuais e organizativos do sistema de saúde com o tempo para o início do tratamento do câncer de pulmão pelo Sistema Único de Saúde (SUS) em Minas Gerais. Estudo de coorte retrospectiva com pacientes que iniciaram o tratamento para o câncer de pulmão pelo SUS de 2008 a 2015. Foram selecionadas variáveis sociodemográficas, clínicas e organizativas do sistema de saúde. O modelo de regressão logística avaliou a associação do desfecho do início do tratamento em até 60 dias após o diagnóstico com as variáveis explicativas selecionadas. Utilizou-se a odds ratio (OR) e o respectivo intervalo de confiança (95%) para mensurar a força de associação. A maioria dos tratamentos para o câncer de pulmão em Minas Gerais foram iniciados em até 60 dias após o diagnóstico, entretanto, ser do sexo masculino e diagnosticado em estadiamento IV aumentaram a chance de iniciar o tratamento em até 60 dias; todavia o aumento da idade, iniciar o tratamento por radioterapia, e o local de residência, diminuíram. O tempo para início do tratamento está associado a características individuais e à provisão de serviços nas macrorregiões, e as desigualdades observadas possivelmente se originam a partir do melhor ou pior acesso da população aos serviços prestados.

Abstract The aim was to verify the association of individual factors and healthcare system characteristics with time to initiate treatment of lung cancer by the Brazilian National Health System, in Minas Gerais state. A retrospective cohort study, with patients who initiated treatment for lung cancer by the SUS, from 2008 to 2015. Sociodemographic and clinical characteristics of patients, besides organizational variables of the healthcare system were selected. The logistic regression model evaluated the association of selected explanatory variables with the outcome of initiating treatment within 60 days after diagnosis. Odds ratio (OR) and respective 95% confidence interval were used to measure the power of association. Most treatments for lung cancer in the state of Minas Gerais initiated within 60 days after diagnosis. However, being male and diagnosed as stage IV increased the likelihood of starting treatment within 60 days. On the other hand, the patient's age, radiation therapy as first treatment, and the place of residence decreased such chance. Time to initiate treatment is associated with individual characteristics and provision of services in macroregions, and the observed inequalities possibly raised from the better or worse access of the population to the services provided by SUS.

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