RESUMO

This study assessed the Family Health Strategy (ESF) health care accessibility in the municipal system, which is the health macro-region headquarters in Bahia. It consisted of two levels of analysis: the municipal management and the local organization of ESF teams. Data production combined documentary analysis, non-participant observation, and interviews with managers, professionals, and users. Goal-image was used with evaluative criteria and dimensions of the accessibility in Primary Care. Family Health Teams (EqSF) still do not entirely fulfill the role of preferential contact in municipal health services, and the health care accessibility reflects the interdependence of municipal and local factors. Rural and peripheral teams performed better in organizational accessibility, and central urban teams performed better in geographic accessibility. The assessment focused on geographic and organizational criteria, combining different sources of evidence and health system players using analysis levels considering the municipal and local PHC management are relevant contributions of this study, which can be extended to other municipal systems with similar characteristics.

Esse estudo avaliou a acessibilidade ao cuidado na Estratégia de Saúde da Família (ESF) em sistema municipal, sede de macrorregião de saúde no estado da Bahia. Tratou-se de estudo avaliativo em dois níveis de análise: a gestão municipal e a organização local das equipes da ESF. A produção dos dados combinou análise documental, observação não participante e entrevistas com gestores, profissionais e usuários. Utilizou-se imagem-objetivo com critérios e dimensões avaliativas da acessibilidade na Atenção Primária. As Equipes de Saúde da Família (EqSF) ainda não cumprem plenamente a função de contato preferencial nos sistemas municipais de saúde e a acessibilidade ao cuidado reflete interdependência de fatores municipais e locais. Equipes rurais e periféricas tiveram melhor desempenho na acessibilidade organizacional e equipes urbanas centrais melhor desempenho na acessibilidade geográfica. A avaliação centrada em critérios geográficos e organizacionais, na combinação de diferentes fontes de evidência e atores do sistema de saúde, além do uso de níveis de análise considerando a gestão municipal e local da APS, são contribuições relevantes desse estudo, que podem ser ampliadas para outros sistemas municipais com características semelhantes.

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RESUMO

Resumo Esse estudo avaliou a acessibilidade ao cuidado na Estratégia de Saúde da Família (ESF) em sistema municipal, sede de macrorregião de saúde no estado da Bahia. Tratou-se de estudo avaliativo em dois níveis de análise: a gestão municipal e a organização local das equipes da ESF. A produção dos dados combinou análise documental, observação não participante e entrevistas com gestores, profissionais e usuários. Utilizou-se imagem-objetivo com critérios e dimensões avaliativas da acessibilidade na Atenção Primária. As Equipes de Saúde da Família (EqSF) ainda não cumprem plenamente a função de contato preferencial nos sistemas municipais de saúde e a acessibilidade ao cuidado reflete interdependência de fatores municipais e locais. Equipes rurais e periféricas tiveram melhor desempenho na acessibilidade organizacional e equipes urbanas centrais melhor desempenho na acessibilidade geográfica. A avaliação centrada em critérios geográficos e organizacionais, na combinação de diferentes fontes de evidência e atores do sistema de saúde, além do uso de níveis de análise considerando a gestão municipal e local da APS, são contribuições relevantes desse estudo, que podem ser ampliadas para outros sistemas municipais com características semelhantes.

Abstract This study assessed the Family Health Strategy (ESF) health care accessibility in the municipal system, which is the health macro-region headquarters in Bahia. It consisted of two levels of analysis: the municipal management and the local organization of ESF teams. Data production combined documentary analysis, non-participant observation, and interviews with managers, professionals, and users. Goal-image was used with evaluative criteria and dimensions of the accessibility in Primary Care. Family Health Teams (EqSF) still do not entirely fulfill the role of preferential contact in municipal health services, and the health care accessibility reflects the interdependence of municipal and local factors. Rural and peripheral teams performed better in organizational accessibility, and central urban teams performed better in geographic accessibility. The assessment focused on geographic and organizational criteria, combining different sources of evidence and health system players using analysis levels considering the municipal and local PHC management are relevant contributions of this study, which can be extended to other municipal systems with similar characteristics.

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This cross-sectional study conducted in prisons in the city of Salvador, Bahia, Brazil, investigated the association between the presence of psychiatric disorders in 462 prisoners and the types of crimes committed by them. Psychiatric diagnosis was obtained by means of the Brazilian Portuguese version of the Mini-International Neuropsychiatric Interview. A statistically significant association was found between some psychiatric disorders and specific groups of crime: lifelong substance addiction with sex crimes and homicide; antisocial personality disorder with robbery and with kidnapping and extortion; borderline personality disorder with sex crimes; and lifelong alcohol addiction with fraud and conspiracy and with armed robbery and murder. It was concluded that the mental disorders considered more severe (psychosis and bipolar disorder) were not associated with violent crimes, suggesting that the severity of the psychotic disorder may be the factor that has caused psychosis to be associated with violent crimes in previous studies.

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The number of individuals affected by serious psychiatric disorders in Brazilian prisons is unknown. This cross-sectional study was conducted in prison complexes within the city of Salvador, Bahia, Brazil. The sample consisted of 497 prisoners, and the outcome measure was the Brazilian Portuguese version of the Mini International Neuropsychiatric Interview. The prevalence rates found in the closed and semi-open prison systems, respectively, were as follows: depression 17.6% and 18.8%; bipolar mood disorder 5.2% and 10.1%; anxiety disorders 6.9% and 14.4%; borderline personality disorder 19.7% and 34.8%; antisocial personality disorder 26.9% and 24.2%; alcohol addiction 26.6% and 35.3%; drug addiction 27.9% and 32.4%; psychosis 1.4% and 12.6%; attention deficit/hyperactivity disorder (ADHD) in childhood 10.3% and 22.2%; and ADHD in adulthood 4.1% and 5.3%. This study revealed higher rates of substance-related disorders and lower rates of psychotic and mood disorders compared to other prevalence studies carried out in prison populations.

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We report an unusual case of acute suppurative thyroiditis associated with juvenile systemic lupus erythematosus (JSLE) onset. A 10 year-old girl presented with a painful voluminous swelling in the anterior cervical region with fever and dysphagia. She also had dysphonia, myalgia, swelling of the small joints of the hands, weight loss, and erythematous malar rash. Thyroid ultrasonography disclosed an ill-defined solid cystic area containing abundant echoes in suspension suggestive of an abscess in both lobes compatible with suppurative bacterial thyroiditis. Fine-needle aspiration biopsy showed a secretion with positive culture for Staphylococcus aureus. Endoscopic evaluation did not demonstrate pyriform sinus fistula. The child had no previous thyroid disease. Hormonal evaluation showed thyrotrophin (TSH) 13 microIU/ml and free thyroxine (FT4) 0.4 ng/dl. After laboratory confirmation of JSLE, high dose 'pulse' therapy was performed with methylprednisolone (30 mg/kg/day for 3 days), followed by prednisone (2 mg/kg/day). The acute thyroiditis was treated with oxacillin, metronidazole and amikacin which ameliorated the symptoms of infection followed by normalization of thyroid function with levothyroxine. In spite of the known association between autoimmune diseases and thyroid disorders, the coexistence of suppurative thyroiditis and JSLE is rare, generally occurring during the course of lupus and not at diagnosis.

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A metodologia aqui proposta visa revelar relações entre o ambiente sociocultural e o processo saúde/doença. São pressupostos para essa análise: buscar a estrutura do texto para interpretá-lo a partir da explicação e não da compreensão; contextualizar historicamente o texto e relacioná-lo com outros do mesmo gênero. No primeiro nível de análise, ou análise baseada nas questões, abordam-se os domínios culturais e o conteúdo das narrativas referentes às informações obtidas por meio de respostas diretas às questões formuladas pelo pesquisador. O segundo nível de análise, ou análise baseada nas narrativas, refere-se às digressões em relação ao tema inicialmente proposto pelo pesquisador em entrevista semi-estruturada. Os procedimentos analíticos do segundo nível consistem na construção de mapas de rede semântica das narrativas, para posterior comparação.

The aim of this proposed methodology is to reveal the relationships between the sociocultural environment and the health-illness process. The premises of this analysis include: focusing on the structure of the text to interpret it based on explanation and not on understanding; placing the text in historical context and consdering it in relation with others of the same genre. The first level of analysis, or analysis based on questions, concerns the cultural domains and the content of the narratives referring to the information obtained from direct responses to questions formulated by the researcher. The second level of analysis, or analysis based on narratives, refers to digressions from the theme initially proposed by the researchers in a semi-structured interview. The analytical procedures of the second level consist in the construction of maps of the semantic network of the narratives, which will be used in a later hierarchical comparison.

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OBJECTIVE: To present an up-to-date and practical review of how to safely withdraw glucocorticosteroid therapy. SOURCES: A review of the published literature identified by searching the MEDLINE and LILACS databases (1997-2007), selecting the most representative articles on the subject. SUMMARY OF THE FINDINGS: Three clinical situations may occur during glucocorticoid withdrawal: adrenal insufficiency secondary to negative feedback on the hypothalamic-pituitary adrenal (HPA) axis, steroid withdrawal syndrome and relapse of the disease for which the glucocorticoids were prescribed. Although there is no consensus on how to best discontinue prolonged glucocorticosteroid therapy, there is agreement that this withdrawal should be gradual. This article updates pediatricians on how to recognize these problems and provides recommendations on how to safely suspend glucocorticosteroid therapy. A brief review of the pharmacology of glucocorticoids is also presented. CONCLUSIONS: There is no good predictive test for predicting the risk of adrenal insufficiency in patients who have been on corticosteroid therapy chronically. There is a need for prospective studies to assess the true incidence of this problem and to propose rational strategies for preventing it. The current recommendation is that patients who have been on chronic and/or high dose glucocorticoids should be administered glucocorticoids during stress situations unless the integrity of the HPA axis has been established by dynamic tests.

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OBJETIVO: Apresentar uma revisão atualizada e prática sobre como efetuar de forma segura a retirada da corticoterapia. FONTES DOS DADOS: Revisão da literatura utilizando os bancos de dados MEDLINE e LILACS (1997-2007), selecionando os artigos mais atuais e representativos do tema. SÍNTESE DOS DADOS: Três situações clínicas podem ocorrer durante a retirada da corticoterapia prolongada: insuficiência adrenal secundária à supressão do eixo hipotálamo-hipófise-adrenal, síndrome de retirada ou deprivação dos corticóides e reativação da doença de base. Embora não exista consenso sobre o melhor esquema para descontinuar a terapia prolongada com corticóides, existe concordância quanto ao fato desta retirada ser gradual. Este artigo atualiza o pediatra quanto ao reconhecimento desses problemas e fornece orientações para a suspensão do tratamento prolongado com corticóide. Uma breve revisão da farmacologia dos corticóides também é descrita. CONCLUSÃO: Não existe teste com bom valor preditivo para antecipar o risco de insuficiência adrenal nos pacientes que receberam terapia crônica com corticóide. São necessários estudos prospectivos para avaliar a real incidência desse problema e assim propor estratégias racionais para sua prevenção. No momento, a menos que a integridade do eixo hipotálamo-hipófise-adrenal esteja estabelecida por testes dinâmicos, recomenda-se a administração de corticóide em situações de estresse nos pacientes que fizeram uso de corticoterapia crônica e/ou em doses elevadas.

OBJECTIVE: To present an up-to-date and practical review of how to safely withdraw glucocorticosteroid therapy. SOURCES: A review of the published literature identified by searching the MEDLINE and LILACS databases (1997-2007), selecting the most representative articles on the subject. SUMMARY OF THE FINDINGS: Three clinical situations may occur during glucocorticoid withdrawal: adrenal insufficiency secondary to negative feedback on the hypothalamic-pituitary adrenal (HPA) axis, steroid withdrawal syndrome and relapse of the disease for which the glucocorticoids were prescribed. Although there is no consensus on how to best discontinue prolonged glucocorticosteroid therapy, there is agreement that this withdrawal should be gradual. This article updates pediatricians on how to recognize these problems and provides recommendations on how to safely suspend glucocorticosteroid therapy. A brief review of the pharmacology of glucocorticoids is also presented. CONCLUSION: There is no good predictive test for predicting the risk of adrenal insufficiency in patients who have been on corticosteroid therapy chronically. There is a need for prospective studies to assess the true incidence of this problem and to propose rational strategies for preventing it. The current recommendation is that patients who have been on chronic and/or high dose glucocorticoids should be administered glucocorticoids during stress situations unless the integrity of the HPA axis has been established by dynamic tests.

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