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Abstract Background The analytical rubric serves as a permanent reference for guidelines on clinical performance for undergraduate dental students. This study aims to assess the rubric system used to evaluate clinical class II composite restorations performed by undergraduate dental students and to explore the impact of gender on overall student performance across two academic years. Additionally, we investigated the relationship between cumulative grade point averages (CGPAs) and students’ clinical performance. Methods An analytical rubric for the assessment of clinical class II composite restoration in the academic years of 2022/2023 and 2023/2024 was used by two evaluators. These two evaluators were trained to use the rubric before doing the evaluations. The scores were based on a 4-point scale for the evaluation of five major parameters for pre-operative procedures (10 points), cavity preparation (20 points), restoration procedures (20 points), and time management (4 points). At the same time, chairside oral exam parameter was 15 points based on a 5-point scale. Descriptive statistics were calculated for the different analytical rubric parameters, and the independent t-test was used to compare the scores between the student groups and the evaluators. Other tests, such as the Kappa test and Pearson’s correlation coefficient, were used to measure the association among CGPA, evaluators, and gender participants. Results The overall score out of 69 slightly increased for females/males (61.28/59.42) and (61.18/59.49) in the 2022/2023 and 2023/2024 academic years, respectively, but the differences were not statistically significant. In the 2022/2023 academic year, female students scored significantly higher than male students in pre-operative procedures, as evaluated by both evaluators (p = 0.001), and in time management, as assessed by both evaluators (p = 0.031). The Kappa test demonstrated a moderate to substantial level of agreement between the two evaluators in both academic years. Strong and significant correlations were noted between students’ CGPA and some tested parameters (p = 0.000). Conclusion The overall performance was very good and high among both genders, but it was marginally higher among females than among males. This study found some differences in performance between male and female students and variability in the evaluations by the two raters ranging from moderate to substantial agreement and similar performances for students with different CGPA.

Background The present in vitro study aimed to evaluate the fatigue behavior of teeth filled with a calcium silicate-based sealer (Bio-C Sealer, BC) or an epoxy resin-based sealer (AH Plus, AH), in bulk or associated with gutta-percha as main core material. Methods Seventy-two sound human maxillary anterior teeth were initially selected. Sixty of them, were randomly chosen, and had their root canals prepared using nickel-titanium reciprocating instruments, being again randomly assigned to five experimental groups (n = 12): C+ (control + prepared but not filled); BC-B (BC in bulk); BC-GP (BC+ gutta-percha); AP-B (AH in bulk); AP-GP (AH+ gutta-percha). An additional negative control group (C−) was considered (n = 12), consisting only on sound teeth, without preparation and filling. The specimens were submitted to a survival analysis after the cyclic fatigue test. Results Sound teeth (C−) presented the best fatigue performance (P < 0.05), being similar only to the AP-GP group (P > 0.05). Despite that, all experimental groups showed similar fatigue behavior (P > 0.05) to C+ (BC-B = BC-GP = AP-B = AP-GP = C+). Based on that, it can be seen that the use of gutta-percha, as a main core material, associated with the AH Plus sealer, reestablished the mechanical fatigue performance of endodontically treated teeth comparable to sound teeth, still consisting on the most promising approach to rehabilitate such scenario. Teeth filled in bulk, had discreetly higher risk of premature failures and inferior fatigue performance.

Toll-like receptors (TLRs) play a key role in the response of innate and adaptive immune system to microbial and endogenous ligands. Inflammation is a common feature in end-stage renal disease (ESRD) patients; however, the mechanisms/factors triggering the inflammatory process are still poorly clarified. Our aim was to analyze the impact of the c.-1486T>C and c.896A>G polymorphisms in TLR9 and TLR4 genes, respectively, on the inflammatory response of ESRD patients. Clinical and laboratory evaluation was carried out on 184 ESRD patients. Polymerase chain reaction followed by restriction fragmens length polymorphisms (PCR-RFLP) was employed for genotyping of TLR-4 c.896A>G and TLR-9 c.-1486T>C polymorphisms. The prevalence of AA and AG of TLR4 c.896A>G polymorphism in ESRD patients was 97.8% and 2.2%, respectively. None of the individuals showed a homozygous TLR4 polymorphism. Concerning the TLR9 c.-1486T>C polymorphism, we found that ESRD patients showed a prevalence of TC and CC genotypes of 57.1% and 20.6%, respectively. We found that the heterozygous patients for the TLR4 c.896A>G polymorphism presented an increased level in lymphocyte count, a decrease in neutrophil/lymphocyte ratio and in serum levels of hepcidin. Regarding the TLR9 c.-1486T>C polymorphism, we found that it is associated with decreased white blood cell and neutrophil counts, ferritin and CRP serum levels, and with an increase in serum levels of creatinine. Our data suggest that the presence of the studied polymorphisms is associated with a decreased inflammatory response in ESRD patients under hemodialysis, and, thus its presence might have beneficial effects in ESRD patients. Moreover, our data provide new insights in the role of TLR polymorphisms in renal disease, which might have impact in the near future for the development of innovative therapies.

Despite the advancements in indirect monolithic restorations, technical complications may occur during function. To overcome this issues, intraoral repair using resin composite is a practical and low-cost procedure, being able to increase the restoration’s longevity. This review aimed to evaluate the need for repair and suggest a standardized repair protocol to the main indirect restorative materials. For this, studies were surveyed from PubMed with no language or date restriction, to investigate the scientific evidence of indirect monolithic restoration repair with direct resin composite. A classification to guide clinical decisions was made based on the FDI World Dental Federation criteria about defective indirect restorations considering esthetic and functional standards, along with the patient’s view, to decide when polishing, repairing or replacing a defective restoration. Based on 38 surveyed studies, different resin composite intraoral repair protocols, that included mechanical and chemical aspects, were defined depending on the substrate considering resin-based, glass-ceramic or zirconia restorations. The presented criteria and protocols were developed to guide the clinician’s decision-making process regarding defective indirect monolithic restorations, prolonging longevity and increasing clinical success.

Hydrogels consist of a network of highly porous polymeric chains with the potential for use as a wound dressing. Propolis is a natural product with several biological properties including anti-inflammatory, antibacterial and antioxidant activities. This study was aimed at synthesizing and characterizing a polyacrylamide/methylcellulose hydrogel containing propolis as an active ingredient, to serve as a wound dressing alternative, for the treatment of skin lesions. The hydrogels were prepared using free radical polymerization, and were characterized using scanning electron microscopy, infrared spectroscopy, thermogravimetry, differential scanning calorimetry, swelling capacity, mechanical and rheological properties, UV-Vis spectroscopy, antioxidant activity by the DPPH, ABTS and FRAP assays and biocompatibility determined in Vero cells and J774 macrophages by the MTT assay. Hydrogels showed a porous and foliaceous structure with a well-defined network, a good ability to absorb water and aqueous solutions simulating body fluids as well as desirable mechanical properties and pseudoplastic behavior. In hydrogels containing 1.0 and 2.5% propolis, the contents of total polyphenols were 24.74 ± 1.71 mg GAE/g and 32.10 ± 1.01 mg GAE/g and those of total flavonoids 8.01 ± 0.99 mg QE/g and 13.81 ± 0.71 mg QE/g, respectively, in addition to good antioxidant activity determined with all three methods used. Therefore, hydrogels containing propolis extract, may serve as a promising alternative wound dressing for the treatment of skin lesions, due to their anti-oxidant properties, low cost and availability.

Abstract Chronic inflammation plays an important role in the progression and outcome of chronic kidney disease (CKD). The circulating levels of the inflammatory biomarkers interleukin 6 (IL6) and pentraxin 3 (PTX3) are enhanced in CKD patients, and are associated with the progression of the disease and with higher risk for cardiovascular events, the major cause of death in CKD patients. Our aim was to study how specific polymorphisms of IL6 and PTX3 encoding genes affect the inflammatory response and outcome of end-stage renal disease (ESRD) patients on dialysis. Methodology included the analysis of two single nucleotide polymorphisms (SNP), namely the IL6 (rs1800795) polymorphism in the promoter region (-174G > C), and the PTX3 (rs2305619) polymorphism in the intron 1 (+ 281A > G), which were analyzed in ESRD patients on dialysis and in a group of heathy individuals. The allelic frequencies, genotype distribution and their association with circulating levels of the inflammatory markers C-reactive protein (CRP), IL6, growth differentiation factor 15 (GDF15) and PTX3, were determined in ESRD patients. Events of death were recorded along one year, to assess the association of the studied SNPs with all-cause mortality and the inflammatory biomarkers, in ESRD patients. Results showed that the allelic frequencies and genotype distribution for IL6 and PTX3 SNPs in the control group and ESRD patients were similar and in agreement with other European reports. For the IL6 polymorphism, we found a trend towards higher levels of high-sensitivity (hs) CRP, IL6 and PTX3 in the homozygous genotypes; the CC genotype also showed the highest levels of GDF15. The mortality rate after the 1-year follow-up was 10.4%. The CC genotype (IL6 SNP) was associated to a higher risk of mortality and deceased patients carrying this genotype also showed the highest levels of hsCRP. Regarding the studied PTX3 SNP, the AA genotype was linked to an enhanced inflammatory response, showing the highest values of hsCRP and IL6. Nevertheless, this genotype had no significant impact on the mortality rate. In conclusion, both studied SNPs seem to modulate the inflammatory response in ESRD and may, therefore, be determinant on disease progression and patients’ outcome. Our data also highlights the importance of research on genetic variants that, although less frequent, may have significant biological value.

Objetivo: evidenciar a aplicação de scaffolds para promover a reabilitação periodontal dos tecidos de suporte do dente. Materiais e Métodos: trata-se de uma revisão da literatura através da base de dados PubMed, utilizado o Boleano and e os descritores ''3D printing'' e ''periodontal regeneration''. Os critérios de inclusão foram: artigos completos e disponíveis na íntegra. Foram encontrados 35 artigos, sendo analisados títulos e resumos e excluídos 10 artigos. Após a leitura dos artigos selecionados na íntegra restaram 13 artigos que foram incluídos nesta revisão de literatura. Resultados: o periodonto se refere aos tecidos que sustentam e circundam os dentes, como o cemento, ligamento periodontal, e osso alveolar. A destruição desses tecidos pode ser causada pela periodontite, levando a perda dental. O tratamento dessa condição tem como objetivo principal evitar a progressão da doença e aliviar os sintomas. Apesar da existência de vários tratamentos nenhum é capaz de permitir a regeneração do periodonto. Para suprir tal necessidade à engenharia tecidual desenvolveu andaimes que são constituídos de metais, cerâmicas e polímeros, o que permite seu desenvolvimento funcional e mecânico quando inseridos na cavidade oral. Os scaffolds são projetados baseados em imagens colhidas e processadas com reconstrução tridimensional e modelagem CAD, depois da impressão a fabricação de modelos personalizados é realizada, criando um ambiente ideal para o crescimento celular e angiogênese. O objetivo dos andaimes está em promover a osteogênese, a formação do ligamento periodontal e cemento além de proporcionar a integração entre eles. Conclusão: diante do que foi encontrado nesta revisão é possível inferir que o scaffold apresenta impacto positivo na reconstrução do periodonto, podendo ser usado como modalidade de tratamento.

Background: The antifungal drug itraconazole exerts in vitro activity against SARS-CoV-2 in Vero and human Caco-2 cells. Preclinical and clinical studies are required to investigate if itraconazole is effective for the treatment and/or prevention of COVID-19. Methods: Due to the initial absence of preclinical models, the effect of itraconazole was explored in a clinical, proof-of-concept, open-label, single-center study, in which hospitalized COVID-19 patients were randomly assigned to standard of care with or without itraconazole. Primary outcome was the cumulative score of the clinical status until day 15 based on the 7-point ordinal scale of the World Health Organization. In parallel, itraconazole was evaluated in a newly established hamster model of acute SARS-CoV-2 infection and transmission, as soon as the model was validated. Findings: In the hamster acute infection model, itraconazole did not reduce viral load in lungs, stools or ileum, despite adequate plasma and lung drug concentrations. In the transmission model, itraconazole failed to prevent viral transmission. The clinical trial was prematurely discontinued after evaluation of the preclinical studies and because an interim analysis showed no signal for a more favorable outcome with itraconazole: mean cumulative score of the clinical status 49 vs 47, ratio of geometric means 1.01 (95% CI 0.85 to 1.19) for itraconazole vs standard of care. Interpretation: Despite in vitro activity, itraconazole was not effective in a preclinical COVID-19 hamster model. This prompted the premature termination of the proof-of-concept clinical study.Funding: KU Leuven, Research Foundation - Flanders (FWO), Horizon 2020, Bill and Melinda Gates Foundation

Khat (Catha edulis) is a recreational, chewed herbal drug that has been used as a psychostimulant for centuries in East Africa and the Arabian Peninsula, namely in Somalia, Ethiopia, and Yemen. However, the growing worldwide availability of khat has produced widespread concern. The plant comprises a large number of active substances, among which cathinone, cathine, and norephedrine are the main constituents, which can be included in the group of sympathomimetics of natural origin. In fact, these compounds are amphetamine analogues, and, as such, they have amphetamine-like nervous system stimulant effects. Chewing the leaves gives people a sensation of well-being and increases energy, alertness, and self-confidence. The chronic use of khat is, however, associated with severe cardiac, neurological, psychological, and gastrointestinal complications. The psychological dependence and withdrawal symptoms of khat are the reasons for its prolonged use. The aim of this paper is to review current knowledge on the khat plant with toxicokinetic and toxicodynamic perspectives. Namely, this review paper addresses in vitro, in vivo, and human studies. The models used, as well as the concentrations and doses with the respective biological effects, are discussed. Additionally, the main drug interactions involved with khat are described.

Human noroviruses (HuNoVs) are the most common cause of viral gastroenteritis resulting in ~219,000 deaths annually and a societal cost of ~USD60 billion. There are no antivirals or vaccines available to treat and/or prevent HuNoV. In this study, we performed a large-scale phenotypical antiviral screening using the mouse norovirus (MNV), which included ~1000 drug-like small molecules from the Drug Design and Synthesis Centre (Sapienza University, Rome). Compound 3-((3,5-dimethylphenyl)sulfonyl)-5-chloroindole-N-(phenylmethanol-4-yl)-2.carboxamide (compound 1) was identified as an inhibitor of MNV replication with an EC50 of 0.5 ± 0.1 µM. A series of 10 analogs were synthesized of which compound 6 showed an improved potency/selectivity (EC50 0.2 ± 0.1 µM) against MNV; good activity was also observed against the HuNoV GI replicon (EC50 1.2 ± 0.6 µM). Time-of-drug-addition studies revealed that analog 6 acts at a time point that coincides with the onset of viral RNA replication. After six months of selective pressure, two compound 6res variants were independently selected, both harboring one mutation in VPg and three mutations in the RdRp. After reverse engineering S131T and Y154F as single mutations into the MNV backbone, we did not find a markedly compound 6res phenotype. In this study, we present a class of novel norovirus inhibitors with a high barrier to resistance and in vitro antiviral activity.

Previous studies have shown that the negative effects of density of Ae. albopictus on Ae. aegypti exceed those of Ae. aegypti on Ae. albopictus for population growth, adult size, survivorship, and developmental rate. This competitive superiority has been invoked to explain the displacement of Ae. aegypti by Ae. albopictus in the southeastern USA. In Brazil, these species coexist in many vegetated suburban and rural areas. We investigated a related, but less-well-studied question: do effects of Ae. albopictus on Ae. aegypti larval development and survival occur under field conditions at realistic densities across multiple seasons in Brazil? We conducted additive competition experiments in a vegetated area of Rio de Janeiro where these species coexist. We tested the hypothesis that Ae. aegypti (the focal species, at a fixed density) suffers negative effects on development and survivorship across a gradient of increasing densities of Ae. albopictus (the associate species) in three seasons. The results showed statistically significant effects of both season and larval density on Ae. aegypti survivorship, and significant effects of season on development rate, with no significant season-density interactions. Densities of Aedes larvae in these habitats differed among seasons by a factor of up to 7x. Overall, Spring was the most favorable season for Ae. aegypti survivorship and development. Results showed that under natural conditions the negative competitive effects of Ae. albopictus on Ae. aegypti were expressed primarily as lower survivorship. Coexistence between Ae. aegypti and Ae. albopictus in vegetated areas is likely affected by seasonal environmental differences, such as detrital resource levels or egg desiccation, which can influence competition between these species. Interactions between these Aedes are important in Brazil, where both species are well established and widely distributed and vector dengue, Zika and chikungunya viruses.

Fish farming in the Amazon has been stimulated as a solution to increase economic development. However, poorly managed fish ponds have been sometimes associated with the presence of Anopheles spp. and consequently, with malaria transmission. In this study, we analyzed the spatial and temporal dynamics of malaria in the state of Acre (and more closely within a single county) to investigate the potential links between aquaculture and malaria transmission in this region. At the state level, we classified the 22 counties into three malaria endemicity patterns, based on the correlation between notification time series. Furthermore, the study period (2003-2013) was divided into two phases (epidemic and post-epidemic). Higher fish pond construction coincided both spatially and temporally with increased rate of malaria notification. Within one malaria endemic county, we investigated the relationship between the geolocation of malaria cases (2011-2012) and their distance to fish ponds. Entomological surveys carried out in these ponds provided measurements of anopheline abundance that were significantly associated with the abundance of malaria cases within 100 m of the ponds (P < 0.005; r = 0.39). These results taken together suggest that fish farming contributes to the maintenance of high transmission levels of malaria in this region.

Empezamos a partir del presupuesto de que existe una estrecha convergencia entre la educación-cuidado-politicidad cuando se desea la garantía a los derechos de las personas en situaciones crónicas de salud. El objetivo de esta reflexión fue evidenciar la imbricación que existe entre el cuidado en la salud y en la enfermería, la educación para la salud y la politicidad que los orienta. Partiendo de la presentación parcial de los datos de una investigación exploratoria junto a personas portadoras de ostomías en un hospital publico del Estado de Mato Grosso, empezamos la discusión acerca de la relación que existe entre la educación, el cuidado y la formación de sujeto político, sea el alumno, el profesional o el usuario de los servicios de la salud.

ObjectivesBilirubin has potential antioxidant and anti-inflammatory properties. The UGT1A1*28 polymorphism (TA repeats in the promoter region) is a major determinant of bilirubin levels and recent evidence suggests that raised adiposity may also be a contributing factor. We aimed to study the interaction between UGT1A1 polymorphism, hematological and anthropometric variables with total bilirubin levels in young individuals.Methods350 obese (mean age of 11.6 years; 52% females) and 79 controls (mean age of 10.5 years; 59% females) were included. Total bilirubin and C-reactive protein (CRP) plasma levels, hemogram, anthropometric data and UGT1A1 polymorphism were determined. In a subgroup of 74 obese and 40 controls body composition was analyzed by dual-energy X-ray absorptiometry.ResultsThe UGT1A1 genotype frequencies were 49.9%, 42.7% and 7.5% for 6/6, 6/7 and 7/7 genotypes, respectively. Patients with 7/7 genotype presented the highest total bilirubin levels, followed by 6/7 and 6/6 genotypes. Compared to controls, obese patients presented higher erythrocyte count, hematocrit, hemoglobin and CRP levels, but no differences in bilirubin or in UGT1A1 genotype distribution. Body fat percentage was inversely correlated with bilirubin in obese patients but not in controls. This inverse association was observed either in 6/7 or 6/6 genotype obese patients. UGT1A1 polymorphism and body fat percentage were the main factors affecting bilirubin levels within obese patients (linear regression analysis).ConclusionIn obese children and adolescents, body fat composition and UGT1A1 polymorphism are independent determinants of total bilirubin levels. Obese individuals with 6/6 UGT1A1 genotype and higher body fat mass may benefit from a closer clinical follow-up.

Estima-se que em 2050, no mundo inteiro, possam existir cerca de 10 milhões de mortes associadas à resistência aos antimicrobianos, superando as mortes atribuíveis a doença neoplásica.1 Em 2015, em Portugal, estimaram-se 24 021 casos de infeção por bactérias multirresistentes, responsáveis por 1158 mortes, das quais 63,5% associadas aos cuidados de saúde.2 Assim, as infeções nosocomiais, a resistência aos antimicrobianos e as doenças infeciosas emergentes são fatores determinantes na qualidade e segurança dos cuidados de saúde, condicionando uma significativa morbimortalidade que impede o seu normal funcionamento. [...] O`Neill J. Tackling Drug-Resistant Infections Globally: Final Report and Recomendations. 2016. [accessed May 2020] Available from: https://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf. Cassini A, Högberg LD, Plachouras D, Quattrocchi A, Hoxha A, Simonsen GS, et al. Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis. Lancet Infect Dis 2019;19:56-66. doi: 10.1016/S1473-3099(18)30605-4.

Patients with haematological malignancies have a higher incidence of infection compared with the general population. Several factors contribute to this but specially chemotherapy drugs carry different and specific infectious risks. This protocol discusses the prevention of infections in patients who will undergo chemotherapy for the treatment of haematological malignancies. It is divided into: study prior to the initiation of chemotherapy; vaccination and eradication prior to initiation of chemotherapy; antimicrobial prophylaxis during chemotherapy; special situations. The main aims of this protocol are to serve as support to a more systematic and individualized approach to patients undergoing chemotherapy for the treatment of haematological malignancies and by doing so prevent the infectious complications that may arise.

Anemia is a common complication of chronic kidney disease (CKD) that develops early and its severity increases as renal function declines. It is mainly due to a reduced production of erythropoietin (EPO) by the kidneys; however, there are evidences that iron metabolism disturbances increase as CKD progresses. Our aim was to study the mechanisms underlying the development of anemia of CKD, as well as renal damage, in the remnant kidney rat model of CKD induced by 5/6 nephrectomy. This model of CKD presented a sustained degree of renal dysfunction, with mild and advanced glomerular and tubulointerstitial lesions. Anemia developed 3 weeks after nephrectomy and persisted throughout the protocol. The remnant kidney was still able to produce EPO and the liver showed an increased EPO gene expression. In spite of the increased EPO blood levels, anemia persisted and was linked to low serum iron and transferrin levels, while serum interleukin (IL)-6 and high sensitivity C-reactive protein (hs-CRP) levels showed the absence of systemic inflammation. The increased expression of duodenal ferroportin favours iron absorption; however, serum iron is reduced which might be due to iron leakage through advanced kidney lesions, as showed by tubular iron accumulation. Our data suggest that the persistence of anemia may result from disturbances in iron metabolism and by an altered activity/function of EPO as a result of kidney cell damage and a local inflammatory milieu, as showed by the increased gene expression of different inflammatory proteins in the remnant kidney. In addition, this anemia and the associated kidney hypoxia favour the development of fibrosis, angiogenesis and inflammation that may underlie a resistance to EPO stimuli and reduced iron availability. These findings might contribute to open new windows to identify putative therapeutic targets for this condition, as well as for recombinant human EPO (rHuEPO) resistance, which occurs in a considerable percentage of CKD patients.

Se tuvo por objetivo en este estudio indicar el potencial presente en el grupo investigado acerca de sus competencias para promocionar acciones instituyentes en su ambiente de trabajo. La teoría adoptada para el análisis de los datos fue el Análisis Institucional, según el enfoque de Baremblitt. Para la recolección de los datos adoptamos la entrevista semiestructurada, aplicada a 9 trabajadores de enfermería y, posteriormente, se formo 2 grupos focales de discusión con el propósito de profundizar los datos recogidos de las entrevistas. El criterio para la inclusión de los sujetos en la investigación fue de haber vivido la experiencia de internación hospitalaria ellos propios o los familiares en el mismo local donde trabajaban. Como resultados tuvimos que el grupo estudiado tiene un grande potencial para invertir la cultura de la subalternidad aún presente el la enfermería, e instaurar la cultura de la solidaridad altamente propiciadora para el surgimiento de fuerzas productivo-deseantes-revolucionarias, como la primera condición para la emergencia de las acciones instituyentes y las prácticas ciudadanas en el servicio estudiado.

En este artículo nuestro objetivo fue problematizar la carencia socio- económica de los usuarios de un servicio público de la salud como uno de los condicionadores de la precarización de en atención a los derechos de la salud. Dentro de esta perspectiva, trabajamos con la idea de los derechos y las vulnerabilidad, partiendo del presuposto que existen nuevas nociones a ser incorporadas para que la enfermería piense en su praxis teniendo al usuario como un aliado en la reivindicación por los mejores condiciones del trabajo. Así nos parece que la enfermería es una de las categorías profesionales del área de la salud que abriga en sí mayores posibilidades de ampliación en la sensibilidad con aspecto a la noción de la vulnerabilidad del usuario sobre sus cuidados, ya que muchos de sus componentes, también son usuarios de los servicios públicos de la salud, sufriendo los mismos apuros que la grande masa de usuarios, asi tambien agregar esfuerzos y crear sinergias entre usuarios y trabajadores, se hace posible crear un contexto más favorable para el desarrollo de mejores condiciones de trabajo en el servicio público de la salud estudiada.