Abstract INTRODUCTION: The diagnostic accuracy of Xpert MTB/RIF (Xpert) in pulmonary tuberculosis (PTB) in children is lower than in adults. In Brazil, the diagnosis of PTB is based on a diagnostic score system (DSS). This study aims to study the role of Xpert in children and adolescents with PTB symptoms. METHODS: A cross-sectional study was conducted in 3 referral centers to TB. Children and adolescents (0-19 years old) whose respiratory samples were submitted to Xpert were included. Statistical analysis (bivariate and logistic regression) to assess the simultaneous influence of TB-related variables on the occurrence of Xpert detectable in TB cases was done. To evaluate the agreement or disagreement between Xpert results with acid-fast bacillus (AFB) and cultures, κ method was used (significancy level of 5%). RESULTS: Eighty-eight patients were included in the study and PTB occurred in 43 patients (49%) and Xpert was detectable in 21 patients (24%). Adolescents and positive culture results were independent predictive variables of Xpert positivity. DSS sensitivity compared with the final diagnosis of TB was 100% (95% CI, 88.1-100%), specificity was 97.2% (95% CI, 85.5-99.9%). The accuracy of the method was 98.5% (95% CI, 91.7-99.9%). CONCLUSIONS: Xpert contributed to diagnosis in 9% of patients with AFB and in culture negative cases. DSS indicated relevance for this diagnostic approach of intrathoracic TB (ITB) in reference centers for presenting data both with high sensitivity and specificity.

Resumo Alasdair MacIntyre é um filósofo contemporâneo de ética e política, mais conhecido por seu livro “Depois da virtude”, 1981. A originalidade e a relevância deste trabalho estão na apresentação de artigos escritos por ele nos anos 1970 sobre medicina e ética médica, inexplorados no campo da bioética. Nestes artigos, MacIntyre critica as mudanças na sociedade que transformam a relação médico-paciente: visões morais fragmentárias, individualismo, a incompreensão da cientificidade e falibilidade da prática, além das perdas do embasamento em valores comuns e da autoridade médica. Em perspectiva teleológica, MacIntyre define bens internos à medicina e virtudes que os médicos devem possuir: confiabilidade, justiça, coragem, humildade e até amizade.

Abstract Alasdair MacIntyre is a contemporary philosopher of Ethics and Politics best known for his book “After virtue”, 1981. The originality and relevance of this work lie in the presentation of his articles from the 1970’s about medicine and medical ethics, which are unexplored in Bioethics. In these articles, MacIntyre criticizes changes in society transforming the physician-patient relationship: fragmentary moral views, individualism, misunderstanding of scientism and fallibility of the practice, as well as the lost background of common values and medical authority. From a teleological perspective, MacIntyre describes internal goods of medicine and physician’s virtues: reliability, fairness, courage, humility and even, friendship.

Resumen Alasdair MacIntyre es un filósofo contemporáneo de Ética y Política, mejor conocido por su libro “Tras la virtud”, de 1981. La originalidad y relevancia de este trabajo se encuentran en la presentación de sus artículos de la década de 1970 sobre medicina y ética médica, que no han sido explorados en Bioética. En estos artículos, MacIntyre critica los cambios en la sociedad que transforman la relación médico-paciente: visiones morales fragmentarias, individualismo, incomprensión del cientificismo y la falibilidad de la práctica, además de las pérdidas de la base en valores comunes y la autoridad médica. En una perspectiva teleológica, MacIntyre describe los bienes internos de la medicina y las virtudes de los médicos: fiabilidad, justicia, coraje, humildad e incluso amistad.

Abstract Background: To date there are no specific classification criteria for childhood-onset systemic lupus erythematosus (cSLE). This study aims to compare the performance among the American College of Rheumatology (ACR) 1997, the Systemic Lupus International Collaborating Clinics criteria (SLICC) and the new European League Against Rheumatism (EULAR)/ACR criteria, in a cSLE cohort. Methods: We conducted a medical chart review study of cSLE cases and controls with defined rheumatic diseases, both ANA positive, to establish each ACR1997, SLICC and EULAR/ACR criterion fulfilled, at first visit and 1-year-follow-up. Results: Study population included 122 cSLE cases and 89 controls. At first visit, SLICC criteria had higher sensitivity than ACR 1997 (89.3% versus 70.5%, p < 0.001), but similar specificity (80.9% versus 83.2%, p = 0.791), however performance was not statistically different at 1-year-follow-up. SLICC better scored in specificity compared to EULAR/ACR score ≥ 10 at first visit (80.9% versus 67.4%, p = 0.008) and at 1-year (76.4% versus 58.4%, p = 0.001), although sensitivities were similar. EULAR/ACR criteria score ≥ 10 exhibited higher sensitivity than ACR 1997 (87.7% versus 70.5%, p < 0.001) at first visit, but comparable at 1-year, whereas specificity was lower at first visit (67.4% versus 83.2%, p = 0.004) and 1-year (58.4% versus 76.4%, p = 0.002). A EULAR/ACR score ≥ 13 against a score ≥ 10, resulted in higher specificity, positive predictive value, and cut-off point accuracy. Compared to SLICC, a EULAR/ACR score ≥ 13 resulted in lower sensitivity at first visit (76.2% versus 89.3%, p < 0.001) and 1-year (91% versus 97.5%, p = 0.008), but similar specificities at both assessments. When compared to ACR 1997, a EULAR/ACR total score ≥ 13, resulted in no differences in sensitivity and specificity at both observation periods. Conclusions: In this cSLE population, SLICC criteria better scored at first visit and 1-year-follow-up. The adoption of a EULAR/ACR total score ≥ 13 in this study, against the initially proposed ≥10 score, was most appropriate to classify cSLE. Further studies are necessary to address if SLICC criteria might allow fulfillment of cSLE classification earlier in disease course and may be more inclusive of cSLE subjects for clinical studies.

Abstract Introduction: Although it is an essential component of the treatment of acute lymphoid leukemia in children, asparaginase causes adverse reactions that sometimes make it impossible to use it fully. Hypersensitivity reactions are the most frequent and may lead to early discontinuation of treatment. The present study aimed to investigate suspicions of adverse reactions during the infusion of asparaginase in a pediatric cohort. Methods: A retrospective observational study was carried out at a university pediatric institute in the state of Rio de Janeiro. Information regarding clinical features and characteristics of adverse reactions was collected from hospital medical records. Suspicions of adverse reactions were classified regarding causality and severity. Results: Seventy-three suspicions of adverse reactions were recorded during asparaginase infusion in 72 children in the study period. Allergic hypersensitivity reactions were suspected in 60.5% of the cases. Of these, 25% of the reactions occurred during induction and 61.1% in concomitant use with vincristine, findings that diverge from other studies. High-risk classification and younger age were considered risk factors for these reactions. A total of 72.4% of the reactions were classified as grade 1 or 2, which suggest that not all are related to antibody formation; this highlights the importance of differential diagnosis with other reactions, such as non-allergic hypersensitivity and hyperammonemia. Conclusion: The implementation of the differential diagnosis of reactions related to infusion of asparaginase with ammonia dosage and classification of the grade of reactions is crucial to facilitate the identification and proper management of each type of reaction.

Resumo Fundamento: Existe uma preocupação crescente com o impacto econômico das doenças cardiovasculares (DCV) no Brasil e no mundo. Objetivo: Estimar o impacto econômico das DCV no Brasil nos últimos cinco anos. Métodos: As informações para estimar os custos em DCV foram retiradas de bancos de dados nacionais, somando os custos diretos com hospitalizações, atendimentos ambulatoriais e benefícios concedidos pela previdência. Custos indiretos foram acrescidos ao cálculo, como a perda de renda causada pela morbidade ou pela mortalidade da DCV. Resultados: A mortalidade por DCV representa 28% do total de óbitos ocorridos no Brasil nos últimos cinco anos e atinge 38% dos óbitos na faixa etária produtiva (18 a 65 anos). Os custos estimados por DCV foram de R$ 37,1 bilhões de reais no ano de 2015, um aumento percentual de 17% no período de 2010 a 2015. Os custos estimados pela morte prematura por DCV representam 61% do total de custo por DCV, os custos diretos com internações e consultas foram de 22% e os custos pela perda da produtividade relacionados à doença foram de 15% do total. Os gastos com saúde no Brasil são estimados em 9,5% do PIB e o custo médio das DCV foi estimado em 0,7% do PIB. Conclusão: Os custos com DCV vêm aumentando significativamente nos últimos cinco anos. Estima-se que os custos por DCV aumentem à medida que a população brasileira envelhece e que a prevalência de DCV aumenta.

Abstract Background: There is growing concern about the economic impact of cardiovascular diseases (CVD) in Brazil and worldwide. Objective: To estimate the economic impact of CVD in Brazil in the last five years. Methods: The information to estimate CVD costs was taken from national databases, adding the direct costs with hospitalizations, outpatient visits and benefits granted by social security. Indirect costs were added to the calculation, such as loss of income caused by CVD morbidity or mortality. Results: CVD mortality accounts for 28% of all deaths in Brazil in the last five years and for 38% of deaths in the productive age range (18 to 65 years). The estimated costs of CVD were R$ 37.1 billion in 2015, a 17% increase in the period from 2010 to 2015. The estimated costs of premature death due to CVD represent 61% of the total cost of CVD, Direct costs with hospitalizations and consultations were 22%, and costs related to the loss of productivity related to the disease were 15% of the total. Health expenditures in Brazil are estimated at 9.5% of GDP and the average cost of CVD was estimated at 0.7% of GDP. Conclusion: CVD costs have increased significantly in the last five years. It is estimated that CVD costs increase as the Brazilian population ages and the prevalence of CVD increases.

RESUMO Objetivo: A abordagem terapêutica de crianças com múltiplas malformações inclui muitos dilemas, tornando difícil diferenciar um tratamento de benefício duvidoso da obstinação terapêutica. O objetivo deste artigo foi destacar as possíveis fontes de incerteza no processo de tomada de decisão para esse grupo de crianças. Descrição do caso: Lactente de 11 meses de idade, que nasceu com múltiplas malformações congênitas e foi abandonado por seus pais, nunca recebeu alta hospitalar. Ele tem cardiopatia congênita cianótica, estenose do brônquio fonte esquerdo e imperfuração anal. Passou por muitos procedimentos cirúrgicos e permanece sob suporte tecnológico. A correção total do defeito cardíaco parece improvável, e todas as tentativas de desmame do ventilador falharam. Comentários: As duas principais fontes de incerteza no processo de tomada de decisão para crianças com múltiplos defeitos congênitos estão relacionadas ao prognóstico incerto. Dados empíricos escassos são por conta das múltiplas possibilidades de envolvimento (anatômico ou funcional) de órgãos, com poucos casos semelhantes descritos na literatura. O prognóstico é também imprevisível para a evolução da capacidade cognitiva e para o desenvolvimento de outros órgãos. Outra fonte de incertezas é como qualificar uma vida como valendo a pena ser vivida, ponderando custos e benefícios. A quarta fonte de incerteza é quem tem a decisão: os médicos ou os pais? Finalmente, se um tratamento é definido como fútil, então, como limitar o suporte? Na ausência de um método universal para essa tomada de decisão, ficamos com a responsabilidade dos médicos em desenvolver suas habilidades de percepção das necessidades dos pacientes e dos valores familiares.

ABSTRACT Objective: Therapeutic approach of children with multiple malformations poses many dilemmas, making it difficult to build a line between the treatment of uncertain benefit and therapeutic obstinacy. The aim of this paper was to highlight possible sources of uncertainty in the decision-making process, for this group of children. Case description: An 11-month-old boy, born with multiple birth defects and abandoned by his parents, has never been discharged home. He has complex congenital heart disease, main left bronchus stenosis and imperforate anus. He is under technological support and has gone through many surgical procedures. The complete correction of the cardiac defect seems unlikely, and every attempt to wean the ventilator has failed. Comments: The first two main sources of uncertainty in the management of children with multiple birth defects are related to an uncertain prognosis. There is a lack of empirical data, due to the multiple possibilities of anatomic or functional organ involvement, with few similar cases described. Prognosis is also unpredictable for neuro-developmental evolution, as well as the capacity for the development and regeneration of other organs. Another source of uncertainty is how to qualify the present and future life as worth living, by weighing the costs and benefits. The fourth source of uncertainty is who has the decision: physicians or parents? Finally, if a treatment is defined futile then, how to limit support? No single framework exists to help these delicate decision-making processes. We propose, then, that physicians should be committed to develop their own perception skills in order to understand patient’s manifestations of needs and family values.

Resumo: Este estudo visou a caracterizar os ensaios clínicos com medicamentos envolvendo crianças e adolescentes brasileiros, registrados nas bases de dados do Clinical Trials e da Registro Brasileiro de Ensaios Clínicos (ReBEC), entre os anos de 1994 e 2014. Apenas 462 ensaios clínicos envolveram brasileiros nessa faixa etária. A partir de 2003, houve aumento no número de registros, com expressiva queda em 2011. Dentre esses, 35,5% foram sediados no Brasil. Os ensaios clínicos internacionais foram majoritariamente conduzidos por empresas norte-americanas. Em ambos os casos, a indústria multinacional foi a principal fonte de apoio financeiro. Predominaram ensaios clínicos de fase III com antivirais em formas farmacêuticas injetáveis e sólidas orais. Os ensaios clínicos nacionais apresentaram maior variação quanto às formas farmacêuticas e maior porcentual de formulações líquidas investigadas, em comparação aos internacionais. Além da forte dependência externa para a realização dos ensaios clínicos, destacou-se o desafio para o cuidado pediátrico no Brasil, que apresenta peculiaridades epidemiológicas em um ambiente propício ao uso de medicamentos não licenciados para crianças.

Abstract: This study aimed to characterize the clinical trials with medicines enrolling Brazilian children and adolescents, registered in the databases of Clinical Trials and the Brazilian Clinical Trials Network (ReBEC) from 1994 to 2014. Only 462 clinical trials enrolled Brazilian children and adolescents. There was an increase in registrations beginning in 2003, with an important drop in 2011. Among these trials, 35.5% were hosted in Brazil. The international clinical trials were mostly conducted by North American companies. In both cases, multinational industry was the principal source of funding. The clinical trials were predominantly phase III with injectable and solid oral pharmaceutical forms of antiviral drugs. Domestic clinical trials showed wider variation in the pharmaceutical forms and higher percentage of liquid formulations, when compared to the international trials. In addition to heavy external dependence for conducting clinical trials, the study emphasized the challenge for pediatric care in Brazil, which presents epidemiological peculiarities in an environment prone to the use of unlicensed medicines for children.

Resumen: Este estudio tuvo como objetivo caracterizar los ensayos clínicos con medicamentos, involucrando a niños y adolescentes brasileños, registrados en las bases de datos de Clinical Trials y de la Red Brasileña de Ensayos Clínicos (ReBEC), entre los años de 1994 y 2014. Solamente 462 ensayos clínicos involucraron a brasileños en esa franja de edad. A partir de 2003, hubo un aumento en el número de registros, con una expresiva caída en 2011. Entre ellos, un 35,5% estuvieron ubicados en Brasil. Los ensayos clínicos internacionales fueron mayoritariamente dirigidos por empresas norteamericanas. En ambos casos, la industria multinacional fue la principal fuente de apoyo financiero. Predominaron ensayos clínicos de fase III con antivirales en formas farmacéuticas inyectables y orales sólidas. Los ensayos clínicos nacionales presentaron una mayor variación, en cuanto a las formas farmacéuticas y mayor porcentaje de formulaciones líquidas investigadas, en comparación con los internacionales. Además de la fuerte dependencia externa para la realización de los ensayos clínicos, se destacó el desafío para el cuidado pediátrico en Brasil, que presenta peculiaridades epidemiológicas en un ambiente propicio al uso de medicamentos sin licencia para niños.

Resumo: Este estudo visou a caracterizar os ensaios clínicos com medicamentos envolvendo crianças e adolescentes brasileiros, registrados nas bases de dados do Clinical Trials e da Registro Brasileiro de Ensaios Clínicos (ReBEC), entre os anos de 1994 e 2014. Apenas 462 ensaios clínicos envolveram brasileiros nessa faixa etária. A partir de 2003, houve aumento no número de registros, com expressiva queda em 2011. Dentre esses, 35,5% foram sediados no Brasil. Os ensaios clínicos internacionais foram majoritariamente conduzidos por empresas norte-americanas. Em ambos os casos, a indústria multinacional foi a principal fonte de apoio financeiro. Predominaram ensaios clínicos de fase III com antivirais em formas farmacêuticas injetáveis e sólidas orais. Os ensaios clínicos nacionais apresentaram maior variação quanto às formas farmacêuticas e maior porcentual de formulações líquidas investigadas, em comparação aos internacionais. Além da forte dependência externa para a realização dos ensaios clínicos, destacou-se o desafio para o cuidado pediátrico no Brasil, que apresenta peculiaridades epidemiológicas em um ambiente propício ao uso de medicamentos não licenciados para crianças.

Abstract: This study aimed to characterize the clinical trials with medicines enrolling Brazilian children and adolescents, registered in the databases of Clinical Trials and the Brazilian Clinical Trials Network (ReBEC) from 1994 to 2014. Only 462 clinical trials enrolled Brazilian children and adolescents. There was an increase in registrations beginning in 2003, with an important drop in 2011. Among these trials, 35.5% were hosted in Brazil. The international clinical trials were mostly conducted by North American companies. In both cases, multinational industry was the principal source of funding. The clinical trials were predominantly phase III with injectable and solid oral pharmaceutical forms of antiviral drugs. Domestic clinical trials showed wider variation in the pharmaceutical forms and higher percentage of liquid formulations, when compared to the international trials. In addition to heavy external dependence for conducting clinical trials, the study emphasized the challenge for pediatric care in Brazil, which presents epidemiological peculiarities in an environment prone to the use of unlicensed medicines for children.

Resumen: Este estudio tuvo como objetivo caracterizar los ensayos clínicos con medicamentos, involucrando a niños y adolescentes brasileños, registrados en las bases de datos de Clinical Trials y de la Red Brasileña de Ensayos Clínicos (ReBEC), entre los años de 1994 y 2014. Solamente 462 ensayos clínicos involucraron a brasileños en esa franja de edad. A partir de 2003, hubo un aumento en el número de registros, con una expresiva caída en 2011. Entre ellos, un 35,5% estuvieron ubicados en Brasil. Los ensayos clínicos internacionales fueron mayoritariamente dirigidos por empresas norteamericanas. En ambos casos, la industria multinacional fue la principal fuente de apoyo financiero. Predominaron ensayos clínicos de fase III con antivirales en formas farmacéuticas inyectables y orales sólidas. Los ensayos clínicos nacionales presentaron una mayor variación, en cuanto a las formas farmacéuticas y mayor porcentaje de formulaciones líquidas investigadas, en comparación con los internacionales. Además de la fuerte dependencia externa para la realización de los ensayos clínicos, se destacó el desafío para el cuidado pediátrico en Brasil, que presenta peculiaridades epidemiológicas en un ambiente propicio al uso de medicamentos sin licencia para niños.

Resumo A bioética é vista por muitos médicos como disciplina que deve substanciar decisões e condutas em situações dilemáticas, indicando regras de ação racionais e universais. Nesse cenário, a perspectiva da ética das virtudes propõe substituição da pergunta de “como agir” para “como se constituir”; e, formando o próprio caráter, permitir que a pessoa seja capaz de tomar as decisões da vida, inclusive profissionais, de forma sábia e prudente. Neste ensaio, apresentar-se-á a perspectiva da ética aristotélica, seus autores contemporâneos e as respostas às principais críticas, explicitando vantagens que esse referencial oferece à deliberação médica – suas características valorativa, particularista e teleológica. Mais do que proclamar um paciente autônomo e um profissional que busca regras externamente estabelecidas, a ética das virtudes reconhece que paciente e profissional estão inseridos em comunidades, tradições e culturas, respeitando valores e virtudes, em busca do fim determinado de suas práticas e vidas.

Abstract Many doctors understand bioethics as the discipline that should substantiate decisions and conduct in dilemmatic cases, indicating rational and universal rules of action. In this scenario, the perspective of Virtue Ethics proposes the modification of the question “what to do” to “how to be” and, how to constitute one’s own character in order to take wise and prudent decisions in life, including professional ones. This theoretical essay will present the Aristotelian Ethics perspective, its contemporary authors, the answers to the main criticisms and will underline the advantages this framework offers to medical decision-making processes - its evaluative, particularistic and teleological characteristics. It will lead to a conclusion that more than proclaiming an autonomous patient and a profefssional who seeks externally established rules, Virtue Ethics recognizes that both patient and professional are integrated in communities, traditions and cultures, respecting values and virtues, in the pursuit of a particular purpose for their practices and lives.

Resumen La bioética es vista por muchos médicos como la disciplina que debe justificar las decisiones y conductas en casos dilemáticos indicando reglas de acción racionales y universales. En este escenario, la perspectiva de la Ética de las Virtudes propone la modificación de la cuestión de “qué hacer” al “cómo ser” – cómo construir su propio carácter con el objetivo de tomar decisiones sabias y prudentes, incluyendo las profesionales. En este ensayo teórico, se presentará la perspectiva ética aristotélica, algunos autores contemporáneos, las respuestas a las principales críticas, destacando las ventajas que ofrece este marco para las decisiones médicas – sus características evaluativa, particularista y teleológica. Más que proclamar un paciente autónomo y un profesional que busca reglas establecidas externamente, se concluye que la Ética de las Virtudes reconoce que ambos se insertan en comunidades, tradiciones y culturas, con valores y virtudes, en busca de los fines particulares de sus prácticas y vidas.

Pesquisa que teve como objetivo geral compreender as possibilidades de contribuição da homeopatia na construção de projetos terapêuticos cuidadores, em oficinas multiprofissionais de educação permanente em saúde, no contexto da atenção básica. Como analisadores foram escolhidos os incômodos que os trabalhadores da saúde manifestaram com relação ao seu processo de trabalho e a emergência, nos primeiros encontros com as equipes, do tema da educação em saúde, que motivou a produção deste artigo. Discute-se o território existencial “ser profissional de saúde” como sendo instituído a partir de uma concepção de educação como referente significante, e de certa missão intervencionista como valor transcendente. Observou-se ao longo das oficinas um esvaecimento da importância do tema da educação em saúde, por vezes até desaparecendo das discussões, na medida em que os projetos terapêuticos cuidadores se constituíam. Conclui-se que tal esvaecimento consistiu em um processo de desterritorialização no sentido de uma pactuação com o usuário, tido ao final como um interlocutor válido; e que o cuidado ultrapassa a dimensão estritamente pedagógica.

The general objective of this research was to assess the possible contribution of homeopathy to the development of caregiving therapeutic projects in multidisciplinary workshops of permanent education in health, in the context of primary health care. The chosen points of analysis were the series of inconveniences expressed by health workers with respect to their work processes and it was the emergence of the theme of health education in the first meetings with the teams that led to the production of this article. This study discusses the existential territory of “being a health professional” as understood from a concept of education as a significant benchmark, and of a certain interventionist mission as a transcendent value. A progressive waning of the importance of health education was observed during the workshops, sometimes even disappearing from the discussions, as the caregiving therapeutic projects took shape. The conclusion reached is that this waning involved a process of moving towards a pact with the health system user, eventually considered to be a valid interlocutor; and that health care transcends any strictly pedagogical dimension.

Pesquisa que teve como objetivo geral compreender as possibilidades de contribuição da homeopatia na construção de projetos terapêuticos cuidadores, em oficinas multiprofissionais de educação permanente em saúde, no contexto da atenção básica. Como analisadores foram escolhidos os incômodos que os trabalhadores da saúde manifestaram com relação ao seu processo de trabalho e a emergência, nos primeiros encontros com as equipes, do tema da educação em saúde, que motivou a produção deste artigo. Discute-se o território existencial “ser profissional de saúde” como sendo instituído a partir de uma concepção de educação como referente significante, e de certa missão intervencionista como valor transcendente. Observou-se ao longo das oficinas um esvaecimento da importância do tema da educação em saúde, por vezes até desaparecendo das discussões, na medida em que os projetos terapêuticos cuidadores se constituíam. Conclui-se que tal esvaecimento consistiu em um processo de desterritorialização no sentido de uma pactuação com o usuário, tido ao final como um interlocutor válido; e que o cuidado ultrapassa a dimensão estritamente pedagógica.

The general objective of this research was to assess the possible contribution of homeopathy to the development of caregiving therapeutic projects in multidisciplinary workshops of permanent education in health, in the context of primary health care. The chosen points of analysis were the series of inconveniences expressed by health workers with respect to their work processes and it was the emergence of the theme of health education in the first meetings with the teams that led to the production of this article. This study discusses the existential territory of “being a health professional” as understood from a concept of education as a significant benchmark, and of a certain interventionist mission as a transcendent value. A progressive waning of the importance of health education was observed during the workshops, sometimes even disappearing from the discussions, as the caregiving therapeutic projects took shape. The conclusion reached is that this waning involved a process of moving towards a pact with the health system user, eventually considered to be a valid interlocutor; and that health care transcends any strictly pedagogical dimension.

Chromosome abnormalities that usually define high-risk acute lymphoblastic leukemia are the t(9;22)/ breakpoint cluster region protein-Abelson murine leukemia viral oncogene homolog 1, hypodiploid with < 44 chromosomes and 11q23/ myeloid/lymphoid leukemia gene rearrangements. The spectrum of acute lymphoblastic leukemia genetic abnormalities is nevertheless rapidly expanding. Therefore, newly described chromosomal aberrations are likely to have an impact on clinical care in the near future. Recently, the rare intrachromosomal amplification of chromosome 21 started to be considered a high-risk chromosomal abnormality. It occurs in approximately 2-5% of pediatric patients with B-cell precursor acute lymphoblastic leukemia. This abnormality is associated with a poor outcome. Hence, an accurate detection of this abnormality is expected to become very important in the choice of appropriate therapy. In this work the clinical and molecular cytogenetic evaluation by fluorescence in situ hybridization of a child with B-cell precursor acute lymphoblastic leukemia presenting the rare intrachromosomal amplification of chromosome 21 is described.