Scielo RSS <![CDATA[Revista Panamericana de Salud Pública]]> http://www.scielosp.org/rss.php?pid=1020-498920110001&lang=en vol. 29 num. 1 lang. en <![CDATA[SciELO Logo]]> http://www.scielosp.org/img/en/fbpelogp.gif http://www.scielosp.org <![CDATA[<b>Cost-effectiveness in the detection of influenza H1N1</b>: <b>clinical data versus rapid tests</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892011000100001&lng=en&nrm=iso&tlng=en OBJETIVO: Evaluar el desempeño de los datos clínicos y la prueba rápida (PR) en el diagnóstico de influenza H1N1, y analizar el costo-beneficio que representa el uso de esta herramienta diagnóstica. MÉTODOS: Se aplicó la PR a pacientes que acudieron a cuatro hospitales en la ciudad de México con sintomatología similar a influenza (SSI) durante el período octubre y noviembre de 2009. Se comparó el desempeño diagnóstico de la SSI más la PR contra el de la reacción en cadena de la polimerasa en transcripción reversa en tiempo real (rRT-PCR). La rRT-PCR fue procesada en un laboratorio de referencia y cegado al resultado de la PR. Además, se llevó a cabo una evaluación económica a partir de la cual se estimó el impacto presupuestal relacionado con la utilización de la PR RESULTADOS: Se incluyó a 78 pacientes, de los cuales 39 fueron positivos para influenza H1N1 y 6 para influenza A estacional, de acuerdo al resultado de la rRT-PCR. La SSI mostró una sensibilidad de 96% y una especificidad de 21%, la PR de 76% y 82% y el conjunto de SSI más PR de 96% y 100%, respectivamente. El Cociente de Verosimilitud positivo de la SSI-cefalea fue de 31,5 y el de SSI-odinofagia fue de 330. El uso de PR mostró un ahorro de US$ 12,6 por cada caso sospechoso. CONCLUSIONES: El uso de la PR como auxiliar en el diagnóstico de influenza H1N1 incrementa la certeza y reduce el costo promedio por paciente sospechoso e infectado.<hr/>OBJECTIVE: Evaluate the performance of clinical data and the rapid influenza diagnostic test (RIDT) in diagnosing influenza H1N1, and analyze the cost-benefit of using this diagnostic tool. METHODS: The RIDT was used for patients who came to four hospitals in Mexico City with an influenza-like illness (ILI) in October and November 2009. The diagnostic performance of the ILI clinical data and the RIDT was compared to that of the real-time reverse transcription polymerase chain reaction (rRT-PCR) test. The rRT-PCR test was conducted in a reference laboratory and blinded to the results of the RIDT. An economic evaluation also was conducted to estimate the budgetary impact of using the RIDT. RESULTS: The study included 78 patients, 39 of whom tested positive for influenza H1N1 and 6 tested positive for seasonal influenza A, according to the results of the rRT-PCR. The ILI clinical data yielded a sensitivity of 96% and specificity of 21%; the RIDT yielded a sensitivity of 76% and specificity of 82%; and the ILI clinical data and RIDT together yielded a sensitivity of 96% and specificity of 100%. The positive likelihood quotient for ILI-headaches was 31.5 and that of ILI-odynophagia, 330. The use of RIDT yielded savings of US$12.6 per each suspected case. CONCLUSIONS: Use of the RIDT to aid in the diagnosis of influenza H1N1 increases certainty and lowers the average cost per suspected and infected patient. <![CDATA[<b>Criticisms of chlorination</b>: <b>social determinants of drinking water beliefs and practices among the Tz'utujil Maya</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892011000100002&lng=en&nrm=iso&tlng=en OBJECTIVE: To explore social determinants of drinking water beliefs and practices among the Tz'utujil Maya of Santiago Atitlán, Guatemala, through analysis of demographics, socioeconomic status, memory of historical events, sensory experience, and water attitudes. METHODS: Parallel mixed (qualitative and quantitative) methods, including participant observation, in-depth interviews based on a purposive sample, and 201 semi-structured interviews based on a regional quota sample, were used to collect data from March 2007 to August 2008. Data analysis included the use of grounded theory methodology and Pearson's chi-square test for independence. RESULTS: Qualitative results based on grounded theory highlighted how memory of the Guatemalan Civil War and Hurricane Stan, attitudes about Lake Atitlán water, and the taste and smell of chlorine influenced Tz'utujil Maya drinking water beliefs. Quantitative survey results revealed that differences in ethnicity, literacy, years of schooling, distrust of the water supply during the Civil War and Hurricane Stan, and current beliefs about Lake Atitlán and tap water quality were associated with significantly different water self-treatment practices. CONCLUSIONS: In accordance with social determinants of health paradigms, demographic, socioeconomic, social, cultural, political, and historical factors continue to be significant determinants of water-related health. Public health water interventions must address inequalities related to these underlying factors in order to achieve maximum effectiveness.<hr/>OBJETIVO: Explorar los factores sociales determinantes de las creencias y prácticas con respecto al agua potable de la población maya tz'utujil, que habita en Santiago Atitlán (Guatemala), mediante el análisis de la información demográfica, la situación socioeconómica, la memoria de hechos históricos, la experiencia sensorial y las actitudes con respecto al agua. MÉTODOS: De marzo del 2007 a agosto del 2008, se recopilaron datos por medio de métodos paralelos mixtos (tanto cualitativos como cuantitativos), como la observación de participantes, entrevistas en profundidad basadas en un muestreo intencionado y 201 entrevistas semiestructuradas basadas en un muestreo por cuota regional. En el análisis de los datos se usó el método de la teoría fundamentada o muestreo teórico y la prueba de la chi al cuadrado de Pearson para la independencia. RESULTADOS: Los resultados cualitativos basados en la teoría fundamentada pusieron de relieve que los recuerdos de la guerra civil guatemalteca y del huracán Stan, las actitudes acerca del agua del Lago Atitlán, y el gusto y el olor del cloro influían las creencias de los tz'utujiles con respecto al agua potable. Los resultados cuantitativos de la encuesta indicaron que las diferencias a raíz del grupo étnico, el alfabetismo, los años de escolaridad, la desconfianza del abastecimiento de agua durante la guerra civil y el huracán Stan, y las creencias actuales acerca de la calidad del agua del Lago Atitlán y del agua de grifo estaban asociadas con prácticas de autotratamiento del agua sumamente diferentes. CONCLUSIONES: En consonancia con el paradigma de los factores sociales determinantes de la salud, los factores demográficos, socioeconómicos, sociales, culturales, políticos e históricos siguen siendo determinantes significativos de la salud en relación con el agua. Para que puedan lograr la mayor eficacia posible, las intervenciones de salud pública con respecto al agua deben abordar las desigualdades relacionadas con estos factores fundamentales. <![CDATA[<b>Decline in homicide rates in São Paulo, Brasil</b>: <b>a descriptive analysis</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892011000100003&lng=en&nrm=iso&tlng=en OBJETIVO: Descrever a evolução da mortalidade por homicídios no Município de São Paulo segundo tipo de arma, sexo, raça ou cor, idade e áreas de exclusão/inclusão social entre 1996 e 2008. MÉTODOS: Estudo ecológico de série temporal. Os dados sobre óbitos ocorridos no Município foram coletados da base de dados do Programa de Aprimoramento das Informações sobre Mortalidade, seguindo a Classificação Internacional de Doenças, Décima Revisão (CID-10). Foram calculadas as taxas de mortalidade por homicídio (TMH) para a população total, por sexo, raça ou cor, faixa etária, tipo de arma e área de exclusão/inclusão social. As TMH foram padronizadas por idade pelo método direto. Foram calculados os percentuais de variação no período estudado. Para as áreas de exclusão/inclusão social foram calculados os riscos relativos de morte por homicídio. RESULTADOS: As TMH apresentaram queda de 73,7% entre 2001 e 2008. Foi observada redução da TMH em todos os grupos analisados, mais pronunciada em homens (-74,5%), jovens de 15 a 24 anos (-78,0%) e moradores de áreas de exclusão social extrema (-79,3%). A redução ocorreu, sobretudo, nos homicídios cometidos com armas de fogo (-74,1%). O risco relativo de morte por homicídio nas áreas de exclusão extrema (tendo como referência áreas com algum grau de exclusão social) foi de 2,77 em 1996, 3,9 em 2001 e 2,13 em 2008. Nas áreas de alta exclusão social, o risco relativo foi de 2,07 em 1996 e 1,96 em 2008. CONCLUSÕES: Para compreender a redução dos homicídios no Município, é importante considerar macrodeterminantes que atingem todo o Município e todos os subgrupos populacionais e microdeterminantes que atuam localmente, influenciando de forma diferenciada os homicídios com armas de fogo e os homicídios na população jovem, no sexo masculino e em residentes em áreas de alta exclusão social.<hr/>OBJECTIVE: To describe homicide mortality in the municipality of São Paulo according to type of weapon, sex, race or skin color, age, and areas of socioeconomic inequalities, between 1996 and 2008. METHOD: For this ecological time-series study, data about deaths in the municipality of São Paulo were collected from the municipal program for improvement of mortality information, using International Classification of Diseases, 10th revision (ICD-10) codes. Homicide mortality rates (HMR) were calculated for the overall population and specifically for each sex, race or skin color, age range, type of weapon, and occurrence in social deprivation/affluence areas. HMR were adjusted for age using the direct method. The percentage age of variation in HMR was calculated for the study period. For areas of socioeconomic inequalities, the relative risk of death from homicide was calculated. RESULTS: HMR fell 73.7% between 2001 and 2008. A reduction in HMR was observed in all groups, especially males (-74.5%), young men between 15 and 24 years of age (-78.0%), and residents in areas of extreme socioeconomic deprivation (-79.3%). The reduction occurred mostly in firearm homicide rates (-74.1%). The relative risk of death from homicide in areas of extreme socioeconomic deprivation, as compared to areas with some degree of socioeconomic deprivation, was 2.77 in 1996, 3.9 in 2001, and 2.13 in 2008. In areas of high socioeconomic deprivation, the relative risk was 2.07 in 1996 and 1.96 in 2008. CONCLUSIONS: To understand the reduction in homicide rates in the municipality of São Paulo, it is important to take into consideration macrodeterminants that affect the entire municipality and all population subgroups, as well as micro/local determinants that have special impact on homicides committed with firearms and on subgroups such as the young, males, and residents of areas of high socioeconomic deprivation. <![CDATA[<b>Trends in hip fracture rates in Ecuador and projections for the future</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892011000100004&lng=en&nrm=iso&tlng=en OBJECTIVE: To examine recent trends in hip fracture rates in Ecuador and predict the number of hip fractures over the next decades. METHODS: The Anuario de Egresos Hospitalarios, the national database of annual hospital discharges, was analyzed to determine the incidence of hip fractures among those 50 years of age and older in 1999-2008. Census estimates of the population were used as the denominator to calculate hip fracture rates per 100 000 persons. Hip fracture rates were then standardized by the direct method. The annual percentage change in hip fracture rates observed in the different age groups over the study period were used to predict the numbers of hip fractures among older adults by the years 2020, 2030, and 2050. RESULTS: The number of hip fractures increased from 703 in 1999 to 1 315 in 2008. After controlling for age, hip fracture rates increased by 3.9% annually (95% Confidence Interval, 1.4-6.5), from 46.4/100 000 in 1999 to 62.4/100 000 in 2008. This increase in age-adjusted rates was mainly attributed to an increase in hip fractures among those 80 years of age or older. If the annual percentage change in age-specific rates continues, the total number of hip fractures among older adults in Ecuador will be about 3 909, 8 980, and 47 275 by the years 2020, 2030, and 2050, respectively. CONCLUSIONS: Hip fracture rates increased substantially among persons 50 years of age and older in Ecuador during the study period. As the population of Ecuador ages, the number of hip fractures is expected to increase considerably among those 80 years of age and older.<hr/>OBJETIVO: Examinar las tendencias recientes de las tasas de fractura de cadera en el Ecuador y predecir el número de casos que se presentará en los próximos decenios. MÉTODOS: Se analizó el Anuario de Egresos Hospitalarios para determinar la incidencia de fractura de cadera en las personas a partir de los 50 años de edad entre 1999 y el 2008. Con el fin de obtener las tasas de fractura de cadera por 100-000 habitantes se utilizaron en el denominador los cálculos del censo de población. Las tasas de fractura de cadera se ajustaron luego mediante el método directo. La variación porcentual por año de las tasas de fractura de cadera observada en los diferentes grupos de edad en el período del estudio permitió la predicción del número de casos que se presentará en los adultos mayores para los años 2020, 2030 y 2050. RESULTADOS: El número de fracturas de cadera aumentó de 703 en 1999 a 1 315 en el 2008. Después de controlar la variable edad, se encontró que las tasas de fractura de cadera aumentaron en 3,9% anualmente (intervalo de confianza de 95%: 1,4-6,5), de 46,4 casos por 100 000 habitantes en 1999 a 62,4 casos por 100 000 habitantes en el 2008. Este aumento de las tasas ajustadas por edad se atribuyó principalmente a una mayor frecuencia de las fracturas a partir de los 80 años de edad. En caso de que el porcentaje de variación anual de las tasas específicas en función de la edad permanezca estable, el número total de fracturas de cadera en los ancianos en el Ecuador será cercano a 3-909 en el año 2020, a 8-980 en el 2030 y a 47-275 en el 2050. CONCLUSIONES: Durante el período de estudio las tasas de fractura de cadera aumentaron sustancialmente en las personas de 50 años de edad y mayores en el Ecuador. Se prevé que a medida que la población del país envejezca, el número de fracturas de cadera aumentará en forma considerable en las personas a partir de los 80 años de edad. <![CDATA[<b>Residential typologies in Chilean irregular settlements with precarious housing conditions</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892011000100005&lng=en&nrm=iso&tlng=en OBJETIVO: Identificar dimensiones residenciales que caractericen el ambiente físico y social en los campamentos de Chile y construir tipologías que permitan elaborar perfiles con esos atributos residenciales distintivos. MÉTODOS: Se estudió el universo de campamentos (n = 122) de la Región Metropolitana (Chile) a partir del Catastro Nacional de Campamentos realizado por la fundación "Un Techo para Chile" en 2007. Se recolectó información proveniente de informantes clave sobre las comunidades y los lugares de emplazamiento, variables que fueron modeladas empleando un análisis factorial para identificar dimensiones residenciales, las que a su vez fueron refinadas con la técnica de agrupamientos de k-medias. RESULTADOS: El análisis factorial destacó tres dimensiones subyacentes: respuesta social local, ambiente extracomunitario y servicios básicos. Las variables centrales en la formación de esas categorías fueron la existencia de proyectos habitacionales, el área urbana y el acceso a electricidad, respectivamente. El análisis de agrupamientos generó cuatro perfiles que combinaron las tres dimensiones: perfil urbano con baja precariedad de servicios básicos (n = 30), perfil urbano-rural con alto potencial de respuesta social local (n = 32), perfil urbano con alta amenaza ambiental (n = 43) y perfil rural con bajo potencial de respuesta social local (n = 17). CONCLUSIONES: Las dimensiones residenciales formadas son consistentes con el modelo teórico revisado y sugieren indicadores relevantes para el seguimiento de estas comunidades. La identificación de perfiles permite dimensionar la heterogeneidad de realidades residenciales contribuyendo a la priorización de dominios de déficit o riesgos que pueden estar presentes en cada grupo, para con ello profundizar en su investigación y oportunidades de acción.<hr/>OBJECTIVE: To identify residential parameters that characterize the physical and social environment in Chile's irregular settlements, and to construct typologies that will allow to develop profiles with those distinctive residential attributes. METHODS: The study examined the universe of irregular settlements (n = 122) in Chile's Metropolitan Region, based on the 2007 national inventory of irregular settlements conducted by the "Un Techo para Chile" foundation. Information about the communities and their locations was obtained from key informants, and these variables were modeled using factor analysis to identify residential parameters, which were then refined by k-means clustering. RESULTS: The factor analysis pointed to three underlying parameters: local social response, the environment beyond the community, and basic services. The key variables shaping these categories were the existence of housing projects, the urban area involved, and access to electricity. The cluster analysis generated four profiles that combined the three parameters: an urban profile with relatively reliable basic services (n = 30), an urban-rural profile with high potential for local social response (n = 32), an urban profile with a high level of environmental threat (n = 43), and a rural profile with low potential for local social response (n = 17). CONCLUSIONS: The residential parameters formed are consistent with the revised theoretical model and suggest relevant indicators for monitoring these communities. Definition of the profiles facilitates assessment of the heterogeneity of residential situations, which helps in the prioritization of areas with deficits or risks that may be present in each cluster. This, in turn, opens the door to further investigation and to exploring opportunities for action. <![CDATA[<b>Prevalence of metabolic syndrome in indigenous people over 40 years of age in Rio Grande do Sul, Brazil</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892011000100006&lng=en&nrm=iso&tlng=en OBJETIVO: Estudar a prevalência da síndrome metabólica (SM) em indígenas com idade maior do que 40 anos em duas cidades no Rio Grande do Sul, Brasil. MÉTODOS: Este estudo transversal, descritivo e analítico foi realizado nos municípios de Porto Alegre e Nonoai entre julho e agosto de 2009. Participaram 150 indígenas com idade entre 40 e mais de 70 anos (idade mínima 40 e máxima 104 anos). A prevalência da SM foi determinada pelos critérios do National Cholesterol Education Program-Adult Treatment Panel III. Foram coletadas amostras de sangue e medidas antropométricas. Além disso, os participantes responderam a um questionário sobre hábitos alimentares, analisado posteriormente conforme os 40 passos para uma alimentação saudável propostos pela Organização Mundial de Saúde e endossados pelo Ministério da Saúde. RESULTADOS: A prevalência da SM foi de 65,3%, mais prevalente no sexo feminino (P < 0,001). Alterações na circunferência abdominal, glicemia de jejum e HDL-colesterol e presença de hipertensão arterial sistêmica, hipertrigliceridemia e obesidade foram associados à SM. Faixa etária, tabagismo e sedentarismo não foram associados à SM. Os indígenas com SM tinham uma dieta pouco saudável, com baixo consumo de vegetais, frutas e legumes e nível de atividade física, alto consumo de doces e refrigerantes e alta prevalência de obesidade. CONCLUSÕES: Os indígenas pesquisados apresentaram alta prevalência de SM, especialmente as mulheres. A educação e a motivação para a saúde dos indígenas é possivelmente o melhor caminho para o controle da SM e para a promoção da saúde nessa população ainda ignorada pelas políticas de saúde pública.<hr/>OBJECTIVE: To investigate the prevalence of the metabolic syndrome (MS) among indigenous people older than 40 years of age from two cities in the State of Rio Grande do Sul, southern Brazil. METHODS: A descriptive, analytic, cross-sectional study was conducted in two municipalities, Porto Alegre and Nonoai, between July and August 2009. A total of 150 indigenous people older than 40 years of age (range: 40-104 years), participated in the study. MS prevalence was determined based on National Cholesterol Education Program - Adult Treatment Panel III criteria. Blood samples and anthropometric data were collected. The participants also answered a questionnaire on eating habits, which was then contrasted to the 10 steps to healthy eating proposed by the World Health Organization and recommended by the Brazilian Ministry of Health. RESULTS: MS prevalence was 65.3%, affecting women more than men (P < 0.001). Changes in waist circumference, fasting glucose, and HDL-cholesterol and presence of hypertension, hypertriglyceridemia, and obesity were associated with MS. Age, smoking, and sedentary lifestyle were not associated with MS. Indigenous people with MS had a poor diet, with low intake of fruit and vegetables, low levels of physical activity, high consumption of sweets and soft drinks, and high prevalence of obesity. CONCLUSIONS: A high prevalence of MS was observed among the indigenous people surveyed, especially in women. Education and motivation for healthy behaviors is possibly the best way to manage MS and promote health in a population that is still neglected by public health policies. <![CDATA[<b>International drug price comparisons</b>: <b>quality assessment</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892011000100007&lng=en&nrm=iso&tlng=en OBJECTIVE: To quantitatively summarize results (i.e., prices and affordability) reported from international drug price comparison studies and assess their methodological quality. METHODS: A systematic search of the most relevant databases-Medline, Embase, International Pharmaceutical Abstracts (IPA), and Scopus, from their inception to May 2009-was conducted to identify original research comparing international drug prices. International drug price information was extracted and recorded from accepted papers. Affordability was reported as drug prices adjusted for income. Study quality was assessed using six criteria: use of similar countries, use of a representative sample of drugs, selection of specific types of prices, identification of drug packaging, different weights on price indices, and the type of currency conversion used. RESULTS: Of the 1 828 studies identified, 21 were included. Only one study adequately addressed all quality issues. A large variation in study quality was observed due to the many methods used to conduct the drug price comparisons, such as different indices, economic parameters, price types, basket of drugs, and more. Thus, the quality of published studies was considered poor. Results varied across studies, but generally, higher income countries had higher drug prices. However, after adjusting drug prices for affordability, higher income countries had more affordable prices than lower income countries. CONCLUSIONS: Differences between drug prices and affordability in different countries were found. Low income countries reported less affordability of drugs, leaving room for potential problems with drug access, and consequently, a negative impact on health. The quality of the literature on this topic needs improvement.<hr/>OBJETIVO: Resumir cuantitativamente los resultados (p. ej., precios y asequibilidad) presentados en estudios de comparación internacional de precios de medicamentos y evaluar su calidad metodológica. MÉTODOS: Se llevó a cabo una búsqueda sistemática en las bases de datos más importantes -Medline, Embase, International Pharmaceutical Abstracts y Scopus, desde la fecha de inicio hasta mayo del 2009- para identificar artículos de investigación original que comparaban precios de medicamentos entre distintos países. Se obtuvo y se registró la información sobre los precios de los medicamentos de los trabajos que fueron aprobados para ser incorporados en esta revisión. Para evaluar la asequibilidad se consideró la adaptación de los precios en función de los ingresos. Se evaluó la calidad de los estudios tomando como parámetro seis criterios: el uso en países similares, el uso de una muestra representativa de medicamentos, la selección de tipos específicos de precios, la descripción del tipo de envasado, las diferentes ponderaciones aplicadas a los índices de precios y el tipo de cambio empleado. RESULTADOS: De los 1-828 estudios encontrados, se incluyeron 21. Solo un estudio cumplió adecuadamente con todos los criterios de calidad. Se observó una amplia diferencia de calidad entre los estudios a causa de los diversos métodos empleados para comparar los precios de los medicamentos, tales como, diferentes índices, parámetros económicos, tipos de precio y canasta de medicamentos. Por lo tanto, se consideró que la calidad de los estudios publicados era deficiente. Si bien los resultados de los estudios son muy diversos, en general, los medicamentos fueron más costosos en los países de ingresos más altos. Sin embargo, una vez ajustados los precios en función de la asequibilidad, se observa que los países de ingresos más altos tienen precios más asequibles que los países de bajos ingresos. CONCLUSIONES: Se encontraron diferencias en los precios de los medicamentos y la asequibilidad entre los diferentes países. En los países de ingresos bajos, se registró un grado menor de asequibilidad, lo que origina posibles problemas de acceso a los medicamentos y, en consecuencia, tiene repercusiones negativas sobre la salud. Es necesario mejorar la calidad de los estudios dedicados a este tema. <![CDATA[<b>The tobacco dependence dimension in Colombia</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892011000100008&lng=en&nrm=iso&tlng=en This epidemiological study of a sample of smokers from the general population of Colombia examined the population distribution and dimensionality of eight hypothesized inter-correlated clinical features (CFs) associated with tobacco dependence syndrome (TDS). Data were drawn from interviews of 4 426 smokers conducted in a national survey in Colombia as part of the World Mental Health Survey Initiative. Daily smokers completed a Spanish-language TDS module, and the 237 smokers who had begun smoking during the five years prior to the assessment were selected. Confirmatory factor analysis (CFA) for a unidimensional TDS provided discrimination and difficulty parameter estimates. Two CFs that were reported very infrequently among the study sample were dropped from the CFA. Among the six remaining CFs, discrimination (D1) estimates ranged from 1.1 to 6.0 and difficulty (D2) estimates ranged from 1.1 to 2.2, providing evidentiary support for a unidimensional tobacco dependence construct. The Spanish-language TDS module used in this study could serve as a valuable tool in future studies for evaluating public health outreach and early intervention programs directed toward community residents who have begun smoking tobacco.<hr/>En el presente estudio epidemiológico de una muestra de fumadores de la población general de Colombia se examinó la distribución y la magnitud de ocho características clínicas interrelacionadas en forma hipotética, que se asocian con el síndrome de dependencia del tabaco. Los datos se extrajeron de las entrevistas realizadas a 4-426 fumadores en una encuesta nacional en Colombia, que formó parte de la Iniciativa de la Encuesta de Salud Mental Mundial. Los fumadores habituales completaron un módulo de evaluación del síndrome de dependencia del tabaco y se escogieron los 237 fumadores que habían comenzado el consumo de tabaco en los cinco años que precedieron a la evaluación. El análisis factorial confirmatorio del modelo unidimensional del síndrome de dependencia del tabaco proporcionó los índices de discriminación y de dificultad de cada variable. Dos características clínicas que se notificaron con muy poca frecuencia en la muestra del estudio se excluyeron del análisis factorial. El índice de discriminación de las seis características restantes osciló entre 1,1 y 6,0, y el índice de dificultad fluctuó entre 1,1 y 2,2, con lo cual se demostró la validez de un modelo unidimensional de la dependencia. El módulo de evaluación en español del síndrome de dependencia del tabaco usado en este estudio podría constituir un instrumento valioso en estudios futuros destinados a evaluar los programas de salud pública de divulgación y de intervención temprana dirigidos a los residentes de la comunidad que han comenzado a fumar. <![CDATA[<b>Tuberculosis transmission across the United States-Mexico border</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892011000100009&lng=en&nrm=iso&tlng=en In this era of increasing drug resistance among infectious diseases such as tuberculosis (TB), the complex population dynamics of border areas must be monitored more extensively. TB remains a major public health threat; its antimicrobial treatment is long; and the only vaccine licensed in the world, live-attenuated Mycobacterium bovis Bacille Calmette-Guérin (BCG), exhibits varying efficacy. In addition to epidemiological surveillance, the underlying determinants contributing to the health and wellbeing of populations are of key importance. Although it received heightened attention in the past, tuberculosis transmission in the United States-Mexico border area demands renewed interest. Lessons learned should be applied to similar areas around the globe.<hr/>En esta época en la que cada vez es mayor la farmacorresistencia de enfermedades infecciosas como la tuberculosis, es preciso vigilar más ampliamente la compleja dinámica de la población de las zonas fronterizas. La tuberculosis sigue siendo un problema muy importante de salud pública, el tratamiento antimicrobiano es prolongado y la vacuna BCG (Bacilo de Calmette-Guérin) -la única autorizada en el mundo, elaborada con bacilos atenuados de Mycobacterium bovis- tiene eficacia variable. Además de la vigilancia epidemiológica, revisten suma importancia los determinantes fundamentales que inciden en la salud y el bienestar de las poblaciones. Si bien la transmisión transfronteriza de la tuberculosis entre México y los Estados Unidos recibió gran atención en el pasado, la situación actual exige renovar el interés por este tema. Es necesario aplicar las lecciones aprendidas en zonas similares del resto del mundo. <![CDATA[<b>Challenges for the universalization of clinical genetics</b>: <b>the Brazilian case</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892011000100010&lng=en&nrm=iso&tlng=en Este artigo aborda as dificuldades de inserir a genética médica como parte do Sistema Único de Saúde (SUS) no Brasil. Em 2009, foi instituída no Brasil a Política Nacional de Atenção Integral em Genética Médica, cujo pilar central seria o aconselhamento genético. Porém, são problemas estratégicos para a implementação dessa política a falta de programas de formação em aconselhamento genético, o desconhecimento acerca de quantos profissionais existem para prestar esse aconselhamento e o provável baixo número de profissionais disponíveis. É desejável uma atuação conjunta dos Ministérios da Saúde e da Educação para ampliar a educação em genética e a formação em aconselhamento genético para todas as profissões no campo da saúde. Além disso, é essencial a inclusão da genética em programas como o Saúde da Família, que permitirá um mapeamento da incidência das doenças genéticas no país e a implementação de aconselhamento genético apesar do grande território e da heterogeneidade populacional do Brasil. Finalmente, a inserção da genética médica no SUS depende do engajamento de profissionais médicos e não médicos no trabalho em equipes horizontais, com alteração da tradicional hierarquia da atenção à saúde.<hr/>The present article deals with the difficulties of introducing medical genetics as part of the Brazilian public Unified Health System (SUS). A national policy of comprehensive care in medical genetics was established in 2009, having genetic counseling as a central pillar. However, there are strategic limitations to the implementation of this policy: a dearth of genetic counseling training programs, the lack of knowledge concerning the number of professionals available to provide genetic counseling, and the likely low number of professionals available for the job. A joint effort by the ministries of health and education is desirable to foster genetics and genetic counseling training for all health professions. In addition, genetics must be introduced in government programs such as the Family Health Program (Saúde da Família), a measure that would allow a mapping of the incidence of genetic diseases in the country and the implementation of genetic counseling despite the size of the territory and the population heterogeneity. Lastly, the introduction of medical genetics as part of the SUS depends on the engagement of medical and nonmedical professionals in horizontal teamwork, with a change in the hierarchy that has traditionally been at the foundations of health care.