The images were independently analyzed by two researchers and only the matching results from both observers were used.The study was conducted from September 2017 to April 2018, and included 157 puerperal women admitted for childbirth care at the Obstetrics Department of a public maternity hospital of the city of São Paulo (SP), Brazil. The abdomen of subjects was photographed on the first or second day postpartum, with the patient lying symmetrically in dorsal decubitus at a standardized distance. Contrast was slightly adjusted and the morphological pattern of supra and infraumbilical linea nigra, 98 images were analyzed. Supra- and infraumbilical linea nigra were analyzed separately and classified according to three directions . The combination of the supra- and infraumbilical images resulted in the formation of nine distinct patterns, being the most prevalent, in primiparous (72.2%) and multiparous women (50.0%), and the authors named as “anticlockwise spiralization of the linea nigra”.Of the 157 observed cases, 139 (88.5%) images provided concordant results between the two researchers. Excluding 41 cases of absence or poor definition of the linea nigra in puerperal women showed a predominance of what the authors named “anti-clockwise spiralization of the linea nigra sign”.The analysis of supra- and infraumbilical  An independent and similar observation was reported by another author more than two decades ago, but the conclusions differ from the present findings.Clinical practice provides an inexhaustible source of observation and valuable knowledge of physiological phenomena, as well as changes leading to pathological situations. After 35 years of professional practice, the senior author of this article noticed what could be a repetitive pattern of the  It is characterized by darkening of areas that are already pigmented , melasma and darkening of the linea alba, which leads to the formation of a linear brownish band, along the abdomen midline, called linea nigra.(–)Hyperpigmentation is the most common physiological skin alteration in pregnancy and is more frequent in women with darker skin.linea nigra is longitudinally located between the pubic symphysis and the umbilical scar, and it may extend up to the xiphoid appendix, although there are some particularities regarding its morphology. There is very scarce research reporting the details of the pattern of the linea nigra in pregnant and puerperal women.In general, the linea nigra in its proximity to the umbilical scar, in puerperal women.This article reports the observational study of the morphology of the supra- and infraumbilical pattern of the linea nigra in puerperal women.To describe the morphology of the supra- and infraumbilical Hospital Municipal de Vila Santa Catarina, a public maternity hospital of the city of São Paulo (SP), Brazil. After approval by the Research Ethics Committee of the organization , data collection was performed. Subjects were randomly approached during admission for childbirth at the obstetrics ward, regardless of the presence or absence of linea nigra. The study was explained, and those who agreed to participate, had their pictures taken after signing an Informed Consent Form. No exclusion criteria were applied at this point. The study followed the principles set forth by the Helsinki Declaration of 1975, as revised in 2013.The study was conducted from September 2017 to April 2018, and included 157 puerperal women admitted for childbirth care at the Obstetrics Department of the linea nigra in the proximity of the umbilical scar. The images were independently analyzed by two researchers and only the matching results from both observers were used.Demographic data (age and reported skin color) and number of previous deliveries were collected from hospital records. Puerperal abdomens were photographed, by the same observer on the first or second day postpartum, at the obstetrics ward of the hospital. The patients laid symmetrically in dorsal decubitus, for the photographs to be taken using a Backlit Sony Exmor RS 12 MP (1.22μm), f/2.2 aperture, approximately 30cm away from the patient's abdomen. To ensure the equidistant visualization of the supra- and infraumbilical lines, and the analysis of both in relation to the umbilical scar, the photographs were taken perpendicularly to the abdomen of the patients. Later, contrast was slightly adjusted to allow a better characterization of the morphological pattern of the supra- and infraumbilical linea nigra were analyzed separately and classified according to three directions, as shown in Supra- and infraumbilical The supra- and infraumbilical lines were classified in relation to the umbilical scar  and their combinations presented nine figurative patterns .Of the 157 observed cases, 139 (88.5%) images provided concordant results between two researchers.linea nigra.Of the 139 selected images, 41 (29.5%) presented an absent line or a line with poor sharpness; of these, 37 were supraumbilical lines, 17 infraumbilical and 13 both. The highest frequency of supraumbilical images with low sharpness was due to the presence of piercing scarring . After the exclusion of these patients, we ended up with 98 quality images to assess the direction of the The age of the study population ranged from 14 to 45 years, mean of 26.9 years. The study included 36 women pregnant for the first time , 58 women who had previous pregnancies  and four women whose parity information was not available (4.1%) .Among the 94 women with parity information, the predominant directions  were D-3 for the supra line (73.4%) and D-1 for the infra line (72.3%), and were more prevalent in primiparous .linea nigra”  and analyzed the abdomen with women in dorsal decubitus, in cephalad direction, which did not enable an adequate visibility of the supraumbilical portion of the linea nigra. In addition, the authors analyzed the linea nigra and umbilical scar in relation only to the abdominal midline of the pregnant women. Our analysis was based on photographs taken perpendicularly to the abdomen of the patients, which allowed the equidistant visualization of the supra- and infraumbilical lines, and the analysis of both in relation to the umbilical scar. With this method, we avoided biases, such as parallax effects, which may have impaired the analysis of Beischer et al.According to Beischer et al.,Importantly, all images were analyzed by two separate researchers, and we only used those in which the rotation direction was consistent between the two researchers. By doing this we minimized the bias associated with observer-dependent subjectivity. analyzed only primiparous women, since they believed previous pregnancies could cause flaccidity of the abdomen, being a confounding factor on the results. In fact, we observed a greater dispersion of the patterns in multiparous women (50.0% of pattern I) than in primiparous (72.2% of pattern I), possibly due to a “blurring” effect on the linea nigra after several pregnancies. However, other causes, such as obesity and the presence of stretch marks , should be considered.Beischer et al.,linea nigra sign”, may be due to the 270° anti-clockwise rotation of the mesentery, which occurs during the return of the physiological omphalocele to the abdominal cavity, around the 10th week of embryonic life.The authors suggest that the higher occurrence of pattern I, which we named “anti-clockwise spiralization of the linea nigra in puerperal women showed a predominance of what the authors named “the anti-clockwise spiralization of the linea nigra sign”.The analysis of the supra and infraumbilical  linea nigra, a formação de um espiralamento no sentido anti-horário em torno da cicatriz umbilical. Uma observação independente e semelhante foi reportada por outro autor, há mais de duas décadas, mas as conclusões foram diferentes dos achados deste estudo.A prática clínica é uma fonte importante de geração de conhecimento, por propiciar fonte inesgotável de observação dos fenômenos fisiológicos, bem como alterações em situações patológicas. Após 35 anos de prática profissional, o autor principal deste artigo constatou algo que poderia ser um padrão repetitivo da  Caracteriza-se pelo escurecimento de áreas já pigmentadas , melasma e escurecimento da linha alba, que leva à formação de uma faixa linear acastanhada, ao longo da linha média do abdome, denominada linea nigra.(–)A hiperpigmentação é a alteração cutânea fisiológica mais comum na gestação e mais frequente em mulheres de pele mais escura.linea nigra localiza-se longitudinalmente entre a sínfise púbica e a cicatriz umbilical, e pode se estender até o processo xifoide, mas há algumas particularidades sobre sua morfologia. Há poucos estudos descrevendo em detalhes o padrão da linea nigra em gestantes e puérperas.Em geral, a linea nigra na proximidade da cicatriz umbilical em puérperas.Este artigo reporta um estudo observacional da morfologia do padrão supra e infraumbilical da linea nigra supra e infraumbilical em puérperas.Descrever a morfologia da linea nigra. O estudo foi explicado, e aquelas que concordaram em participar assinaram um Termo de Consentimento Livre e Esclarecido permitindo a captura de imagens. Nenhum critério de exclusão foi aplicado neste momento. O estudo seguiu os princípios estabelecidos na Declaração de Helsinki de 1975, conforme a revisão de 2013.O estudo foi realizado no período de setembro de 2017 a abril de 2018 e incluiu 157 puérperas admitidas para o parto no Serviço de Obstetrícia do Hospital Municipal de Vila Santa Catarina, uma maternidade pública da cidade de São Paulo (SP). Após a aprovação pelo Comitê de Ética em Pesquisa da instituição , foi realizada a coleta de dados. As participantes foram abordadas aleatoriamente durante a internação para o parto na enfermaria de obstetrícia, independentemente da presença ou ausência da linea nigra supra e infraumbilical na proximidade da cicatriz umbilical. As imagens foram analisadas independentemente por dois pesquisadores, e foram utilizados apenas os resultados congruentes nas avaliações individuais.Dados demográficos (idade e cor da pele reportada) e o número de partos anteriores foram coletados dos registros hospitalares. O abdome das puérperas foi fotografado pelo mesmo observador no primeiro ou segundo dia pós-parto, na enfermaria de obstetrícia do hospital. As fotos foram obtidas com as pacientes deitadas simetricamente, em decúbito dorsal, com uma câmera Sony Exmor RS 12 MP  com retroiluminação, abertura f/2.2, a cerca de 30cm do abdome da paciente. As fotografias foram tiradas perpendicularmente ao abdome das pacientes, permitindo a visualização equidistante das linhas supra e infraumbilicais e a análise de ambas em relação à cicatriz umbilical. Depois, o contraste foi ligeiramente ajustado para permitir uma melhor caracterização do padrão morfológico da linea nigra supra e infraumbilical foram analisadas separadamente e classificadas de acordo com três direções, conforme mostrado na As As linhas supra e infraumbilical foram classificadas em relação à cicatriz umbilical , e suas combinações apresentaram nove padrões figurativos .Dos 157 casos observados, 139  imagens apresentaram resultados concordantes entre os dois pesquisadores.piercing . Após a exclusão dessas pacientes, restaram 98 imagens de boa qualidade para avaliação da direção da linea nigra.Das 139 imagens selecionadas, 41  apresentaram ausência ou má definição da linha; destas, 37 eram linhas supraumbilicais, 17 infraumbilicais e 13 ambas. A frequência mais alta de imagens supraumbilicais com má definição da linha decorreu da presença de cicatrizes de A idade da população do estudo variou de 14 a 45 anos, com média de 26,9 anos. O estudo incluiu 36 mulheres na primeira gestação , 58 com gestações anteriores  e quatro sem informações de paridade disponíveis  .Dentre as 94 puérperas com informações de paridade, as direções predominantes  foram D-3 para a linha supra  e D-1 para a linha infra , que foram mais prevalentes em primíparas .linea nigra”  e analisaram os abdomes com as mulheres deitadas em decúbito dorsal, do ponto de vista podocefálico, o que não proporcionou visibilidade adequada da porção supraumbilical da linea nigra. Além disso, os autores analisaram a linea nigra e a cicatriz umbilical em relação apenas à linha média abdominal da gestante. Nossa análise baseou-se em fotografias realizadas perpendicularmente ao abdome das pacientes, o que permitiu a visualização equidistante das linhas supra e infraumbilicais, e a análise de ambas em relação à cicatriz umbilical. Com esse método, evitamos vieses como, por exemplo, efeitos de paralaxe, que podem ter prejudicado a análise de Beischer et al.De acordo com Beischer et al.,Muito importante também, todas as imagens foram analisadas separadamente por dois pesquisadores, e usamos somente aquelas cuja direção de rotação foi concordante entre os dois observadores. Dessa forma, minimizou-se o viés associado à subjetividade dependente do observador. analisaram apenas primíparas, pois acreditavam que gestações anteriores poderiam causar flacidez abdominal, um possível fator de confusão dos resultados. De fato, observamos uma maior dispersão dos padrões em multíparas  do que em primíparas , possivelmente devido a um efeito de “borramento” da linea nigra após múltiplas gestações. No entanto, outras causas, como obesidade e presença de estrias (que também resultam da multiparidade) devem ser consideradas.Beischer et al.,linea nigra”, pode ser explicado pela rotação anti-horária de 270° do mesentério, que ocorre durante o retorno da onfalocele fisiológica à cavidade abdominal, próximo à 10ª semana de vida embrionária.Os autores sugerem que a maior ocorrência do padrão I, denominado “espiralamento da linea nigra supra e infraumbilical em puérperas mostrou predominância do que os autores denominaram “sinal do espiralamento anti-horário da linea nigra”.A análise das


To assess the quality of adolescent friendly health services.Qualitative assessment using the simulated user technique in first level clinics of Health Services of Morelos, Mexico, during 2018. Ten out of 17 facilities with non-exclusive adolescent friendly services were randomly selected. An additional facility with exclusive adolescent friendly services was included as an intensive subsample. Four adolescents served as simulated users interpreting different cases in the clinics. The total of 43 semi-structured exit interviews were conducted, and two nominal groups were made to assess the perceived quality from the adolescents’ perception of friendliness and experience. Thematic analysis of the data obtained was performed.Staff attitude was highlighted as a key element in the adolescents’ experience. Failures were found, such as the existence of bureaucratic barriers to access, lack of signage in clinics, lack of privacy and confidentiality, failure of physical examination during the appointment and lack of monitoring of the reasons for appointment. The exclusive clinic for adolescents offered more appropriate friendly services compared with nonexclusive clinics.Although the service is accessible in most of the clinics visited, it is still far from being friendly according to international recommendations. The exclusive clinic for adolescents stood out for having better structured mechanisms that can be implemented in nonexclusive clinics to improve the care process. In Mexico, where 18.4% of the population is made up of adolescents 2 , it is essential to address the sexual and reproductive health (SRH) needs of this population group.Globally, adolescents face problems such as pregnancy, early sexual activity, lack of knowledge and use of contraceptive methods, as well as an increased incidence of sexually transmitted infections (STI) that affect their well-being 3 . Adolescent pregnancy is associated with school dropout, few job opportunities, early marriage, predisposition to poverty and can place young people in situations of insecurity and abuse. These conditions limit their personal, occupational and social development 4 . Although the problem of adolescent reproductive health affects both women and men in this age group, the consequences of adolescent pregnancy and the experience of the phenomenon itself are differentiated according to genre. Maternity has a disproportionate and very negative impact on adolescent women, which is directly related to gender inequalities and socio-cultural factors 5 .Prevention of teenage pregnancy is central, because during this stage the likelihood of dying from obstetric events increases 6 . The adolescent fertility rate in 2016 was 61 births per 1,000 adolescents from 15 to 19 years old, ranking first among countries of the Organization for Economic Cooperation and Development (OECD) 7 . In addition, the incidence rate of STI among adolescents increased between 2006 and 2012: Human Papilloma Virus (HPV) (from 5.01 to 7.97); HIV (from 0.76 to 1.63) and herpes (from 0.56 to 1.03) 8 .In Mexico, although 98.2% of adolescents between the ages of 15 and 19 reported knowing some contraceptive methods, 69.2% of women who began sexual life before the age of 20 did not use any contraceptive method in their first intercourse 10 . The World Health Organization (WHO) proposes the adolescent friendly health service (AFHS) model, which provides a space where adolescents feel safe and confident to come for advice and care, primarily in the area of sexual and reproductive health (SRH) 11 . This space should have empathetic staff trained in SRH and adolescent development issues 12 . Following these recommendations and given the importance of adolescent health, the AFHS model was adopted in Mexico in 2000. In 2017, there were 1,494 units with AFHS in the Ministry of Health (MH) nationwide, while in the state of Morelos there were 17 13 . Despite the implementation of AFHS, the health indicators for this population group lead us to consider their effectiveness, since they do not meet the needs of the target population 8 . Programs that promote access and acceptance of SRH services for adolescents are more effective when the friendly approach is combined with their needs and expectations 14 . Strategies are needed to bridge the gap between the adolescent population and the health system, especially by making the male adolescent visible. Health programs are mainly focused on women in relation to reproductive issues 15 .Adolescents have been considered a healthy subset of the population. However, the increase in sexual and reproductive problems in this population has shown the need to provide adolescents with effective, appropriate and quality health services to assert their sexual and reproductive rights 8 . Few studies assess these services 19 , as most are quantitative and were conducted from the perspective of providers. Therefore, a qualitative assessment, from the adolescents’ perspective, would allow us to understand their experience and identify barriers in the access, use and supply of services. However, adolescents are not always informed about the quality standards in AFHS.To assess the implementation of AFHS is relevant and necessary for measuring quality and establishing the impact on adolescent health 20 . The objective of the study was to assess the quality of AFHS based on the dimensions of accessibility, opportunity, acceptability/adaptability, safety and continuity.There are various approaches to measure the quality of health services. TheCentro de Atención Integral a la Salud del Adolescente), a clinic dedicated to serving the adolescent population exclusively and considered standard in AFHS, was included as an intensive type subsample 21 . A total sample of 11 clinics was obtained.Qualitative assessment using simulated user methodology. The study scope was health centers located in Morelos, Mexico, that offered the AFHS model. Ten of the 17 MH clinics with AFHS in 2017 were randomly selected. The selection of nonexclusive centers for adolescents was adjusted by unit size, geographic location and volume of services in the last year. The Center for Comprehensive Adolescent Health Care . To achieve theoretical data saturation Four adolescents aged 18 were selected and trained. They were chosen in late adolescence because they should have reached the legal age in order to obtain a paid job in the research project. The following criteria were considered for selection: ease of speech, good memory, ability to improvise and adapt to unexpected situations, that none of them had children, nor had used the AFHS before, seeking to create a homogeneous group and minimizing bias due to previous experience in the AFHS.The training lasted 16 hours, addressing technical and ethical aspects of the study, additionally offering information about SRH in order to provide the four simulated users with homogeneous knowledge to assess the quality of the information offered in the clinics.The semi-structured exit interview (SSI) was used to collect the data. The interview guide explored the dimensions of friendliness and contained specific case questions at the end. Interviews were conducted after each clinic visit and were carried out via telephone. They lasted approximately 30 minutes, were audiotaped and conducted by a member of the research team.23 were formed with the simulated users as a mechanism for rigor and data quality, as well as to involve adolescents in the data analysis process. The groups were moderated, and audios were recorded by members of the research team.Two nominal groups verbatim(that is word for word). Thematic analysis was done 24 . We looked for themes, within the categories of analysis that allowed us to understand the phenomenon studied and that contained detailed and articulated explanations to the research questions.The information collected via SSI and the nominal groups was transcribedThe research protocol was approved by the ethics and research committee of the National Institute of Public Health, Mexico. Informed consent form was obtained from health authorities and health care providers. The study was totally anonymous, the names assigned were fictitious to protect confidentiality.Psychological support was provided to adolescents to minimize the potential for emotional bias resulting from the development of their role and to minimize any unintended consequences of their participation.The total of 43 exit SSI were collected, the results found are presented in the five dimensions analyzed, the central findings with theoretical saturation and the exceptional or deviant ones are pointed out.In general, easy access was reported due to the geographical location and wide availability of public transport with access to the units. Clinics with adequate internal signage made it easy to locate the service. This was perceived as pleasant since they did not have to ask the staff about the service, while safeguarding the confidentiality of the visit. In most facilities, free care was provided only for the AFHS .The waiting time was less than 30 minutes in most units. Despite this, a clinic was found where they waited approximately four hours for care. One participant pointed out that she only waited because she was playing the role of a simulated user, making it clear that she would have left otherwise .Most units did not have a mechanism for appointments or rescheduling, leaving open the possibility of treatment when they require the service, but not guaranteeing assistance when they return (Testimony O5).The staff tried to find a way to provide care or information that would solve the adolescent’s problem. Inadequate practices in detecting risky sexual behavior were recorded. Simulated users found that questioning was incomplete and observed that some providers were not comfortable interrogating adolescents about their sexual behavior (Testimony O3).Although a minority, there were clinics where care was not provided for reasons such as: unavailability of AFHS, service saturation, lack of professionals, inadequate hours, or it was simply alleged that care could not be provided, suggesting patients to return another day (Testimony O5).The exclusive center for adolescents had extended opening hours (morning and afternoon). In addition, they had mechanisms for scheduling and controlling appointments, different from the nonexclusive centers, where the service was offered only in the morning, with no appointment control.All the services had clinics that provided care to adolescents (Testimony B2). Most of the simulated users were treated in a clinic, but they were not always exclusive to AFHS, or provided a privacy environment (Testimony B1).The attitude of the staff was considered central to the care process. A good attitude was defined as friendly, respectful, trustworthy, smiling, listening without interruption and showing interest. These elements generated trust and confidence in the adolescents, who stated they would recommend the service. A bad attitude was defined as unfriendly, rude, uncouth gestures, uncomfortable looks or judgments about the users’ sexual practices, making they feel reprehended, misunderstood and therefore not willing to return.The confidentiality policy was presented to teenagers in an exceptional way (Testimony B3). However, the adolescents expressed the belief that when staff showed a good attitude, their information would be protected, or threatened when staff showed a bad attitude. Both privacy and confidentiality were violated by waiting room care, simultaneous care of patients in the same office, interruptions during appointment, and leaving the door open during care (Testimony B1).At the exclusive center, the confidentiality policy was regularly mentioned, it was explained that information would only be revealed in cases in which their lives were at risk. Their sexual rights were also discussed; in nonexclusive services it did not happen.The training of the users allowed them to identify errors or omissions in the information provided, which was not always truthful, useful or timely . There was variability according to the topic consulted, with contraceptive method and condom use being best explained, while STI/HIV counseling was the worst (Testimony S1). The use of didactic material such as models, audiovisual material and plastic models was perceived as positive, since it facilitated learning.The offer of diagnostic studies depended on the case of appointment, mainly on the case of suspected HIV, in which rapid tests were more frequently offered. The information provided about diagnostic studies was unclear and confusing. Physical examination was an unusual practice (Testimony S2). In cases when it was done, it consisted of weight, height and blood pressure measurements. On rare occasions, ears and eyes were checked. The physical examination was more complete in the center exclusive for adolescents.Health care providers, regardless of the reason for appointment, emphasized condom use with the partner as the only method that prevents unwanted pregnancy and STI/HIV (Testimony S3).There was no continuity in the reason for appointment via follow-up appointments, although the opportunity was left open to return when they needed care (Testimony C1). Clinics did not offer services in addition to SRH, and few of them invited users to attend SRH talks or workshops. At the exclusive center, monitoring was provided and services such as nutrition and dental care were offered.There were two exceptional cases in which providers, concerned about the health of users, provided a personal telephone number or information about their working hours to follow the case. This element was highly appreciated by the adolescents (Testimony C2).The continuity dimension presented one of the important differences between nonexclusive and exclusive clinics for adolescents. In the exclusive clinics, the supply of other services in the health unit was consistently observed (Testimony C3).25 . Most units do not have signs with schedules, days, cost of service, or signage of the service, resulting in users receiving indications from staff, in line with other studies that report lack of signage and unclear indications from staff 17 .There are areas for improvement to ensure that the quality of care in AFHS is optimal and effective, particularly in nonexclusive AFHS. Based on the experience of simulated users, services are geographically accessible. However, our study does not present disaggregations by type of locality, so it differs from other studies that point to difficult access in rural areas, as noted by Regmi et al. 16 . If adolescents incur costs for using services, this reduces the chances of them returning to use the service or applying for contraception. In addition, adolescents avoid services using family health insurance for fear that their parents will find out 5 .In Mexico, the friendly service is free. However, there were cases in which procedures such as charging and health insurance requirements were a barrier. Charging for the service is a significant and documented barrier to accessing health services 26 , a barrier that may be even more critical for male adolescents, for whom the need for quick and direct service is important 27 . There were few cases when care was denied, as found by De Castro et al. and Sykes, who point out that professionals denied care to adolescents and invited them to return another day 28 . The clinics do not have clear mechanisms for scheduling visits, which is a central problem for continuity. Inviting adolescents to return does not guarantee that they will be assisted when they return, further wasting the opportunity to provide information and meet the health needs of adolescents.Waiting time was not a barrier for most clinics. However, there were exceptions that caused adolescents to want to leave and not return to a clinic. Schriver points out that waiting time needs to be optimized because it is one of the main constraints on attending services 31 . Users prefer units with an exclusive space for adolescents, but most clinics do not have it. Villalobos et al. specify that 78.3% of the clinics do not have exclusive spaces, and this element is registered in the literature as central 32 , especially for males, who fear their masculinity will be impaired by being exposed to their community, because of SRH care 5 .Lack of privacy is the main barrier users faced when they use the services. The units have spaces designed to provide care, but the infrastructure is not always optimal to guarantee privacy 28 . Therefore, they constitute crucial elements in the satisfaction perceived by adolescents, since an atmosphere of distrust is generated when these characteristics are not present.Privacy and confidentiality are key to avoid that users feel embarrassed or unmotivated to express their doubts 9 .Physical examination is not a common practice, an element that diminishes the quality of AFHS, which must provide comprehensive care and systematize clinical examination during counseling 28 . The importance given by staff to condom use as a method of preventing STI and unplanned pregnancies and the use of educational materials were important for counseling. This favored a dynamic appointment and facilitated the understanding of adolescents as pointed out by De Castro 28 .Users point the need to provide clear, truthful and specific information, as found in a previous study There was no monitoring after appointments in most units, even when diagnostic tests for STI/HIV were required, although the user was invited to return when needed. With the exception of the exclusive center, the rest of the facilities do not promote complementary services among users.31 .A key finding for the quality perceived by adolescents is the staff’s attitude. Most had a respectful attitude, but we found cases when staff were critical, made moral judgments or showed an unprofessional behavior. Negative staff attitudes have been identified as one of the main barriers to service quality Although the exclusive services were perceived as successful, by providing friendly care, infrastructure and resource requirements limit their replication in a general way. Friendly services in public clinics to people without social security are the predominant model in the state. The findings of this study point out areas of opportunity for these adolescents and document good care practices, according to the resources available in each clinic.33 . The experiences of the simulated users during the search and obtaining of health services generated evaluative data, the result of a comparison and contrast exercise that can be differentiated from the poor knowledge about quality standards of real users. This generates valuable evidence for the discussion of quality studies from the perspective of the users 34 .In this study, the simulated user methodology enabled us to obtain objective information from a trained and standardized fictitious client 35 .Our findings and the analyses presented are observational and do not seek to identify causality among the phenomena studied. The methodology carried out a critical assessment and facilitated observation without altering the behavior of the service provider when being examined No differentiation was made between urban and rural areas, due to the geographical location of the centers, and all possible cases of appointment were not addressed. Although there were two male and two female simulated users, no specific attempt was made to understand differences related to sex or sexual preference of users, but to the dimensions of the quality of the service. This study contributed by identifying findings that may go unnoticed by a common user, due to lack of knowledge about the topic consulted.Although most of the establishments visited by the simulated users refer to having a friendly service, they are still far from meeting the characteristics of friendliness according to international recommendations. This study reports important findings about quality during the care process. Services do not always provide integral care to adolescents, forgetting prevention and continuity of care once the immediate reason for appointment is addressed. In addition, although there were few cases, care is still conditioned on payment for services. Due to the evidence in the literature about disparities in the experiences and consequences of adolescent pregnancy, it is necessary for services to incorporate a gender focus that allows the active use of sexual and reproductive health services by males.Differences were found between adolescent-only and non-exclusive clinic-based facilities. The perception of the simulated users showed that the care in the exclusive centers is better and more complete, offering various services, regardless of the reason for appointment. Although it is not possible for the health system to have exclusive friendly services in all cases, adaptations are necessary to allow current services to adopt strategies that make it possible for nonexclusive services to provide a service comparable to that of the exclusive center. It was best evaluated by the adolescents when indicated that they could return if they required care. It is a fact that the number of clinics providing adolescent health services has increased, but improvements are needed to achieve quality care.Strategies are needed to improve good practices and quality of health care for adolescents, including the development of activities in communities, involving schools and parents, to attract and engage adolescents before they become sexually active. In addition, awareness raising and training for administrators and health personnel in the care of adolescents are essential, so that prejudices and social norms do not permeate the care offered to this population. Globalmente, los/as adolescentes enfrentan problemas como embarazo, inicio de vida sexual a edad temprana, desconocimiento y falta de uso de métodos anticonceptivos, así como incremento de la incidencia de infecciones de transmisión sexual (ITS) que afectan su bienestarLa prevención del embarazo adolescente es central, debido a que se incrementa la probabilidad de morir por eventos obstétricos en esta etapa6. La tasa de fecundidad en adolescentes para 2016 fue de 61 nacimientos por cada 1,000 adolescentes de 15 a 19 años, ocupando el primer lugar entre países de la Organización para la Cooperación y el Desarrollo Económico (OCDE)7. Adicionalmente, se incrementó la tasa de incidencia de ITS en adolescentes entre el 2006 y 2012, principalmente: Virus de Papiloma Humano (VPH) (de 5.01 a 7.97); VIH (de 0.76 a 1.63) y herpes (de 0.56 a 1.03)8.En México, aun cuando el 98.2% de los adolescentes entre 15 y 19 años declaran conocer algún método anticonceptivo, 69.2% de las mujeres que iniciaron vida sexual antes de los 20 años no utilizó ningún método anticonceptivo en su primera relación sexual10. La Organización Mundial de la Salud (OMS) propone el modelo de servicio de salud amigable para adolescentes (SSAA), que brinda un espacio en donde los adolescentes se sienten seguros y en un ambiente de confianza para acudir a recibir asesoría y atención, primordialmente en materia de salud sexual y reproductiva (SSR)11. Ese espacio debe tener personal empático y capacitado en temas de SSR y desarrollo adolescente1,12. Siguiendo estas recomendaciones y dada la importancia que tiene la salud de los adolescentes, se adoptó el modelo SSAA en México desde el año 2000. En 2017, existían 1,494 unidades con SSAA en la Secretaría de Salud (SSA) a nivel nacional, mientras en el estado de Morelos existían 1713. Pese a la implementación de SSAA, los indicadores en salud para este grupo poblacional nos conducen a reflexionar sobre la efectividad de los mismos, al no lograr resolver las necesidades de la población objetivo6. Los programas que promueven el acceso y la aceptación de los servicios de SSR para adolescentes son más efectivos cuando el enfoque amigable se combina con las necesidades y expectativas de la demanda14. Se requieren desarrollar estrategias que acorten las distancias entre la población adolescente y el sistema de salud, particularmente haciendo visible al adolescente masculino. Los programas de salud están enfocados principalmente hacia las mujeres en relación a temáticas reproductivas15.Los adolescentes han sido considerados como un subconjunto saludable de la población. Sin embargo, el incremento de problemas sexuales y reproductivos en esta población ha mostrado la necesidad de otorgar a los adolescentes servicios de salud efectivos, apropiados y de calidad para hacer valer sus derechos sexuales y reproductivos8. Son pocos los estudios que evalúan estos servicios16, y la mayoría es de tipo cuantitativo y se realiza desde la perspectiva de los prestadores. Por lo tanto, realizar una evaluación cualitativa, desde la perspectiva adolescente, permitiría comprender la experiencia e identificar barreras en el acceso, utilización y oferta de servicios. Sin embargo, los adolescentes no siempre conocen los estándares de calidad en los SSAA.Evaluar la implementación de los SSAA es relevante y necesario para medir la calidad y establecer el impacto en la salud de los adolescentes20. El objetivo del estudio fue evaluar la calidad de los SSAA con base en las dimensiones de accesibilidad, oportunidad, aceptabilidad/adaptabilidad, seguridad y continuidad.Existen diversas aproximaciones para medir la calidad de los servicios de salud. La21al Centro de Atención Integral a la Salud del Adolescente (CAISA), clínica dedicada a atender población adolescente de forma exclusiva y considerada como estándar de oro en los SSAA. Se obtuvo una muestra total de 11 clínicas.Evaluación cualitativa utilizando metodología de usuario simulado. El universo de estudio fueron establecimientos de salud en el estado de Morelos, México, que ofertaran el modelo de SSAA. Del universo de 17 clínicas de la SSA con SSAA en el 2017, se eligieron 10 de forma aleatoria. La selección de centros no exclusivos para adolescentes se ajustó por el tamaño de la unidad, ubicación geográfica y volumen de servicios en el último año. Se incluyó como submuestra de tipo intensivo20. Permite identificar factores que hacen que los usuarios decidan regresar o no a un establecimiento de salud, debido a la percepción de la calidad del servicio recibido21. Mediante ella se evaluó la calidad percibida en cinco dimensiones de amigabilidad de los servicios: accesibilidad, oportunidad, seguridad, aceptabilidad/adaptabilidad y continuidad . Para lograr la saturación teórica de datosSe seleccionaron y capacitaron cuatro adolescentes de 18 años. Se escogieron en la etapa tardía de la adolescencia debido a que, al obtener un trabajo remunerado en el proyecto de investigación, debían contar con la mayoría de edad. Se consideraron los siguientes criterios para el reclutamiento: facilidad de palabra, buena memoria, capacidad de improvisar y adaptarse a situaciones no previstas, que ninguno tuviera hijos, ni hubiera utilizado antes los SSAA, buscando crear un grupo homogéneo y minimizando sesgos debido a la previa experiencia en los SSAA.La capacitación duró 16 horas, abordando aspectos técnicos y éticos del estudio, ofreciendo adicionalmente información sobre SSR para que los cuatro usuarios simulados contaran con conocimientos homogéneos para poder evaluar la calidad de la información ofertada en las clínicas.Se utilizó la entrevista semiestructurada (ESE) de salida para recolectar los datos. La guía de entrevista exploró las dimensiones de amigabilidad y contenía preguntas específicas del caso al final. Las entrevistas se llevaron a cabo después de cada visita a las clínicas y fueron realizadas vía telefónica. Duraron aproximadamente 30 minutos, fueron audio-grabadas y dirigidas por un miembro del equipo de investigación.23con los usuarios simulados como mecanismos de rigor y calidad de datos, así como para lograr la participación de los adolescentes en el proceso de análisis de datos. Los grupos fueron facilitados y audio-grabados por miembros del equipo de investigación.Se realizaron dos grupos nominalesverbatim. Se llevó a cabo análisis temático24. Al interior de las categorías de análisis, se buscaron temas que permitieron comprender el fenómeno estudiado y contenían explicaciones detalladas y articuladas frente a las preguntas de investigación.La información recabada mediante las ESE y los grupos nominales fue transcritaEl protocolo de investigación fue aprobado por el comité de ética e investigación del Instituto Nacional de Salud Pública, México. Se obtuvo el consentimiento informado de autoridades de salud y prestadores de los servicios de salud. El estudio fue totalmente anónimo, los nombres asignados eran ficticios para resguardar la confidencialidad.Se brindó apoyo psicológico a los adolescentes para minimizar el potencial sesgo derivado de aspectos emocionales, consecuencia del desarrollo de su rol, y minimizar cualquier consecuencia no intencionada de su participación.Se recolectaron 43 ESE de salida, los resultados encontrados se presentan en las cinco dimensiones analizadas, se señalan los hallazgos centrales con saturación teórica y los excepcionales o desviantes. Los testimonios que ilustran los resultados se presentan en laEn general, se reportó fácil acceso debido a la ubicación geográfica y amplia disponibilidad de transporte público con acceso a las unidades. Las clínicas con señalización interna adecuada permitieron ubicar fácilmente el servicio. Eso se percibió como agradable ya que no tuvieron que preguntar al personal por el servicio, cuidándose la confidencialidad de la visita. En la mayoría de los establecimientos, se brindó atención gratuita sólo para el SSAA .El tiempo de espera resultó menor a 30 minutos en la mayoría de las unidades. Pese a ello, se encontró una clínica donde esperaron aproximadamente cuatro horas para recibir atención. Una participante señaló que ella sólo esperó porque estaba desempeñando el rol de usuaria simulada, aclarando que, de otra forma se hubiera retirado .La mayoría de las unidades no contaban con un mecanismo para citas o reprogramación de consultas, dejando abierta la posibilidad de volver cuando requieran el servicio, pero sin garantizar que al regresar serán atendidos (Testimonio O5).El personal buscó la forma de brindar atención o dar información que solucionara el motivo de consulta del adolescente. Se registraron prácticas inadecuadas de detección de conductas sexuales de riesgo. Los usuarios simulados detectaron que el interrogatorio resulta incompleto y percibieron que algunos prestadores no se sienten cómodos al hacer preguntas sobre el comportamiento sexual a los adolescentes (Testimonio O3).Aunque fueron minoría, hubo clínicas donde no se brindó atención aludiendo a razones como: no disponibilidad del SSAA, saturación del servicio, falta de personal, horario inadecuado o, simplemente, se dijo que no se podía brindar atención sugiriendo que regresaran otro día (Testimonio O5).El centro exclusivo para adolescentes tenía un horario de atención ampliado (matutino y vespertino). Además, contaban con mecanismos de programación y control de citas, a diferencia de los centros no exclusivos, donde sólo se ofertaba el servicio por la mañana, no existiendo control de citas.Todos los servicios contaban con consultorios para dar atención a los adolescentes (Testimonio B2). La mayoría de los usuarios simulados fueron atendidos en un consultorio, pero no siempre eran exclusivos del SSAA, o proporcionaban un ambiente de privacidad (Testimonio B1).La actitud del personal resultó central para el proceso de atención. Una buena actitud fue definida como: amable, respetuosa, confiable, sonriente, escuchaban sin interrumpir y mostraban interés. Esto generó confianza y seguridad en los adolescentes, quienes afirmaron que recomendarían el servicio. Una mala actitud se definió como: poco cordial, grosera, hicieron gestos, miradas incómodas o emitieron juicios sobre las prácticas sexuales de los usuarios, se sintieron regañados, incomprendidos y, por lo tanto, no volverían.La política de confidencialidad fue dada a conocer a los adolescentes de manera excepcional (Testimonio B3). Pese a ello, los adolescentes expresaron la creencia de que, cuando el personal mostraba buena actitud, su información sería resguardada, o amenazada cuando el personal mostraba una mala actitud. Tanto la privacidad como la confidencialidad se vieron vulneradas por la atención en sala de espera, atención simultánea de pacientes en un mismo consultorio, interrupciones durante la consulta y dejar la puerta abierta durante la atención (Testimonio B1).En el centro exclusivo se hizo regularmente mención de la política de confidencialidad, se explicó que la información sólo sería revelada en los casos donde se pusiese en riesgo su vida, además se les habló sobre sus derechos sexuales, mientras que en los servicios no exclusivos esto no ocurrió.El entrenamiento de los usuarios les permitió identificar errores u omisiones en la información proporcionada, la cual no siempre fue veraz, útil u oportuna (Testimonios S4 y S5). Hubo variabilidad de acuerdo con el tema consultado, siendo mejor explicado el uso de métodos anticonceptivos y del condón, mientras que el más pobre fue la consejería sobre ITS/VIH (Testimonio S1). El uso de material didáctico como maquetas, material audiovisual y maniquís se percibió positivo, ya que facilitó el aprendizaje.La oferta de estudios diagnósticos dependió del caso de consulta, principalmente para el caso de sospecha de VIH, en donde se ofertó con mayor frecuencia la realización de pruebas rápidas. La información proporcionada sobre estudios diagnósticos fue poco entendible y resultó confusa. La exploración física fue una práctica poco habitual (Testimonio S2). En los casos donde se realizó, constó de toma de peso, talla y presión arterial. En raras ocasiones, se revisaron oídos y ojos. La exploración física fue más completa en el centro exclusivo para adolescentes.Los prestadores salud, independientemente del motivo de consulta, hacían énfasis a los usuarios en el uso de condón con la pareja como único método que evita embarazos no deseados e ITS/VIH (Testimonio S3).No existió continuidad del motivo de consulta a través de consultas de seguimiento, aunque se dejó abierta la oportunidad de regresar cuando ellos necesitaran atención (Testimonio C1). Los establecimientos no ofertaron servicios adicionales a los de SSR, pocos invitaron a los usuarios a acudir a pláticas o talleres de SSR. En el centro exclusivo, se brindó seguimiento y oferta de servicios como nutrición y atención dental.Se presentaron dos casos de excepción donde los prestadores, preocupados por la salud de los usuarios, brindaron un número telefónico personal o información sobre sus horarios laborales para dar seguimiento al caso. Ese elemento fue altamente apreciado por los adolescentes (Testimonio C2).La dimensión de continuidad presentó una de las diferencias importantes entre las clínicas no exclusivas y exclusivas para adolescentes, en las segundas se observó la oferta de otros servicios en la unidad de salud de manera consistente (Testimonio C3). En la25. La mayoría de unidades no tienen letreros con horarios, días, costo de atención, ni señalización del servicio, provocando que los usuarios recibieran indicaciones del personal, concordante con otros estudios que reportan falta de señalización e indicaciones poco claras del personal17.Existen áreas de mejora para lograr que la calidad de la atención en los SSAA sea óptima y efectiva, particularmente en los SSAA no exclusivos. De acuerdo con la experiencia de los usuarios simulados, los servicios son accesibles geográficamente. Sin embargo, nuestro estudio no presenta desagregaciones por tipo de localidad, por lo que difiere de otros estudios que señalan difícil acceso en áreas rurales, como es señalado por Regmi et al16. Si los adolescentes incurren en costos por el uso de los servicios, esto reduce las probabilidades de que vuelvan a utilizar el servicio o a solicitar métodos anticonceptivos. Adicionalmente, los adolescentes evitan utilizar servicios a través del seguro médico familiar, por temor a que sus padres se enterenEn México, el servicio amigable es gratuito. Sin embargo, se presentaron casos en que trámites como, cobro y requisitos de afiliación representaron una barrera. El cobro por el servicio es una barrera importante muy documentada para el acceso a los servicios de salud26, barrera que puede ser aún más determinante para los varones, para quienes la necesidad de un servicio rápido y directo es importante27. Fueron pocos los casos donde se negó la atención, como lo encontrado por De Castro et al y Sykes quienes señalan que los profesionales negaron la atención a los adolescentes y se les invitó a volver otro día28. Las clínicas no cuentan con mecanismos claros para programar citas, constituyendo un problema central para la continuidad. Invitar a regresar a los adolescentes no garantiza que sean atendidos al regresar, desaprovechando adicionalmente la oportunidad de ofrecer información y satisfacer las necesidades de salud de los adolescentes.El tiempo de espera no constituyó una barrera para la mayoría de las clínicas. Sin embargo, hubo excepciones que motivaron que los adolescentes quisieran retirarse y no regresar a esa clínica. Schriver señala que es necesario optimizar la espera pues constituye una de las principales limitantes para acudir a los servicios29. Los usuarios prefieren unidades con espacios exclusivos para adolescentes, pero la mayoría de las clínicas no los tiene. Villalobos et al especifican que el 78.3% de las clínicas no tiene espacios exclusivos siendo este elemento registrado en la literatura como central29, especialmente para los varones, quienes temen que su masculinidad sea menoscabada al ser expuestos ante su comunidad, respecto a la atención de SSRLa falta de privacidad es la principal barrera que enfrentaron los usuarios al acudir a los servicios. Las unidades tienen espacios destinados para brindar atención, pero la infraestructura no siempre es óptima para garantizar la privacidad28. Por ello, constituyen elementos cruciales en la satisfacción que perciben los adolescentes, ya que se genera un ambiente de desconfianza cuando no están presentes estas características.La privacidad y confidencialidad son claves para evitar que los usuarios sintieran pena o falta de motivación de expresar sus dudas9.La exploración física no es una práctica habitual, elemento que demerita la calidad de los SSAA los cuales deben brindar atención integral, y sistematizar la exploración clínica durante la consejería28. La importancia dada por el personal al uso del condón como un método de prevención de ITS y embarazos no planeados y el uso de material didáctico fueron importantes para la consejería. Eso favoreció una consulta dinámica y facilitó la comprensión de los adolescentes como lo ha señalado De Castro28.Los usuarios señalan la necesidad de brindar información clara, veraz y específica, así como en un estudio previoNo existió seguimiento al motivo de consulta en la mayoría de las unidades, aun cuando se requería hacer pruebas diagnósticas de ITS/VIH, aunque se invitó a regresar al usuario cuando lo necesitara. Salvo el caso del centro exclusivo, el resto de los establecimientos no promueve servicios complementarios entre sus usuarios.31.Un hallazgo fundamental para la calidad percibida por los adolescentes es la actitud del personal. La mayor parte tuvo una actitud respetuosa, pero se encontraron casos donde el personal emitió juicios, críticas o tuvo conductas poco profesionales. Las actitudes negativas del personal han sido señaladas como una de las principales barreras para la calidad del servicioSi bien los servicios exclusivos fueron percibidos como exitosos, al brindar atención amigable, los requerimientos de infraestructura y recursos limitan su réplica de forma generalizada. Los servicios amigables anidados en clínicas de población sin seguridad social son el esquema que prevalece en el estado. Los hallazgos del presente estudio señalan las áreas de oportunidad para éstos y documenta buenas prácticas de atención, de acuerdo con los recursos disponibles en cada clínica.33. Las experiencias de los usuarios simulados durante la búsqueda y obtención de servicios de salud generaron datos evaluativos, resultado de un ejercicio de comparación y contraste que puede diferenciarse del pobre conocimiento sobre los estándares de calidad de los usuarios reales. Eso genera evidencia valiosa para la discusión de los estudios de calidad desde la perspectiva de los usuarios34.En este estudio, la metodología de usuario simulado permitió obtener información objetiva, a partir de un cliente ficticio capacitado y estandarizado35.Nuestros hallazgos y los análisis expuestos son observacionales y no buscan identificar causalidad entre los fenómenos estudiados. La metodología realizó una valoración crítica y facilitó la observación sin alterar el comportamiento del prestador al saberse evaluadoNo se hizo diferenciación por áreas urbanas y rurales, debido a la ubicación geográfica de los establecimientos y no se abordaron todos los casos posibles de consulta. Aunque se contó con dos usuarios simulados varones y dos mujeres, no se buscó específicamente comprender las diferencias relacionadas al género o a la preferencia sexual de los usuarios, sino a las dimensiones de la calidad del servicio. Este estudio contribuyó al identificar hallazgos que pueden pasar desapercibidos para un usuario común, debido a la falta de conocimiento sobre el tema consultado.Si bien, la mayoría de los establecimientos visitados por los usuarios simulados refieren tener un servicio amigable, aun distan de cumplir con las características de amigabilidad de acuerdo con las recomendaciones internacionales. Este estudio reporta hallazgos importantes de la calidad durante el proceso de atención. Los servicios no siempre brindan una atención integral a los adolescentes, olvidándose de la prevención y continuidad de la atención una vez atendido el motivo inmediato de consulta. Además, aunque fueron pocos casos, aún se condiciona la atención al pago de los servicios. Debido a la evidencia en la literatura sobre disparidades en las experiencias y consecuencias del embarazo adolescente, es necesario que los servicios incorporen un enfoque de género que permita el uso activo de los servicios de salud sexual y reproductiva por parte de los varones.Se encontraron diferencias entre los centros exclusivos para adolescentes y los anidados en clínicas no exclusivas. La percepción de los usuarios simulados reveló que la atención en los centros exclusivos es de mayor calidad y más completa al ofertar diversos servicios, independientemente del motivo de consulta. Si bien no es posible para el sistema de salud contar con servicios amigables exclusivos en todos los casos, es necesario hacer adecuaciones que permitan que los servicios actuales adopten estrategias que hagan posible que los servicios no exclusivos brinden un servicio comparable con los del centro exclusivo. Este fue mejor valorado por los adolescentes señalando que regresarían en caso de requerir atención. Es un hecho que ha aumentado el número de clínicas que brindan a los adolescentes servicios de salud, pero es necesario hacer mejoras para lograr una atención de calidad.Se requieren estrategias para mejorar las buenas prácticas y la calidad de la atención en salud para adolescentes. Entre ellas, el desarrollo de actividades en las comunidades, involucrando a las escuelas y padres de familia, para atraer y captar a las y los adolescentes antes de que inicien la actividad sexual. Además, la sensibilización y capacitación a administrativos y al personal de salud, en la atención a los adolescentes, de forma que los prejuicios y normas sociales no permeen la atención que se le ofrece a esta población.


The affiliations for the second and fifth author are incorrect. Filipe C. Serrano and Marcio Martins are not affiliated with #2 but with #3: Departamento de Ecologia, Instituto de Biociências, Universidade de São Paulo, São Paulo, São Paulo, Brazil.


A dupla antiagregação plaquetária (DAP) é o tratamento fundamental do infarto agudo do miocárdio (IAM). O presente estudo visou investigar a eficácia e a segurança da tripla antiagregação plaquetária (TAP) em pacientes femininas idosas com diabetes e infarto agudo do miocárdio com supradesnível do segmento ST (IAMCSST), que foram submetidas à intervenção coronária percutânea ICP. Trata-se se de um estudo randomizado e mono-cego. O grupo controle A  recebeu aspirina, ticagrelor e tirofibana. Um total de 162 pacientes femininas idosas com diabetes e IAMCSST foram divididas aleatoriamente em dois grupos de acordo com o escore CRUSADE. O grupo B (69 pacientes com escore CRUSADE > 31) recebeu aspirina e ticagrelor. O grupo C (93 pacientes com escore CRUSADE < 30) recebeu aspirina, ticagrelor e tirofibana. Valores de p < 0,05 foram considerados estatisticamente significativos.Thrombolysis in Myocardial Infarction(TIMI) e a perfusão miocárdica TIMI grau 3 foram significativamente menos prevalentes no grupo B, em comparação com o grupo A . Quando comparada aos grupos A e C, a incidência de complicações adversas maiores foi significativamente maior no grupo B . Após a PCI, o fluxo sanguíneo grau 3 A TAP pode efetivamente reduzir a incidência de complicações maiores em pacientes idosas com diabetes e IAMCSST. No entanto, atenção cuidadosa deve ser dada à hemorragia em pacientes que recebem TAP.  Em comparação com o clopidogrel, o efeito inibitório do ticagrelor nas plaquetas no DAPT é rápido e potente, com inibição dupla e combinação reversível. Além disso, pode dilatar as artérias coronárias e é recomendado pelas diretrizes.5 Os inibidores dos receptores da glicoproteína IIb/IIIa, em adição à DAP, podem efetivamente reduzir o aparecimento de complicações, tais como fluxo sanguíneo lento, não-refluxo, trombose aguda e subaguda e eventos cardíacos adversos maiores (ECAM).9 Porém, ainda não se sabe se a combinação de medicamentos da tripla antiagregação plaquetária (TAP), especialmente o ticagrelor, aumentaria o risco de hemorragia. A questão urgente no tratamento de IAM é como equilibrar o risco de eventos isquêmicos e de complicações hemorrágicas. Em relação à DAP (aspirina e ticagrelor), o presente estudo teve como objetivo investigar a eficácia e segurança a curto prazo da TAP , em mulheres idosas com diabetes e IAM.A incidência de fluxo sanguíneo lento, não-refluxo e complicações trombóticas em pacientes do sexo feminino com diabetes e IAM é maior do que em pacientes sem diabetes ou em pacientes do sexo masculino com diabetes e IAM que estão recebendo DAP.Can Rapid Risk Stratification of UnsTabela Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines(CRUSADE)10 dos pacientes de acordo com hematócrito, taxa de depuração da creatinina, frequência cardíaca, pressão arterial, existência de insuficiência cardíaca, diabetes mellitus e doenças vasculares anteriores. Trata-se de um estudo prospectivo. De acordo com o escore CRUSADE, as pacientes foram divididas aleatoriamente em dois grupos: grupo B (pontuação maior que 30) e grupo C (pontuação menor que 30). A DAP (aspirina e ticagrelor) foi administrada às pacientes do grupo B e a TAP  foi administrada às pacientes do grupo C. Pacientes idosos do sexo masculino com diabetes e IAMCSST, que receberam ICP de emergência durante o mesmo período de hospitalização, foram alocados ao grupo A (grupo controle) e receberam a mesma terapia medicamentosa que os pacientes do grupo C. O diagnóstico de IAMCSST foi de acordo com as diretrizes da Sociedade Europeia de Cardiologia11 e o diagnóstico de diabetes mellitus foi de acordo com os critérios da Organização Mundial de Sáude.12 Foram aplicados os seguintes critérios de inclusão: (1) pacientes com início de IAMCSST em ≤ 12 hours, (2) pacientes com diagnóstico conhecido de diabetes mellitus, (3) pacientes que concordaram em receber ICP de emergência e DAP ou TAP e (4) pacientes com idade entre 60 e 79 anos. Os critérios de exclusão foram os seguintes: (1) pacientes com início de IAMCSST > 12 horas, (2) pacientes com pressão arterial ≥ 180/110 mmHg, (3) pacientes com dissecção aórtica suspeita, (4) pacientes com ICP recuperada após trombólise para IAMCSST, (5) pacientes com histórico de hemorragia cerebral e acidente vascular cerebral isquêmico em um ano, (6) pacientes com insuficiência hepática e/ou renal grave e (7) pacientes com histórico de doenças hemorrágicas.9 O presente estudo está de acordo com as normas de ética médica. Com a aprovação do Comitê de Ética do Hospital Popular de Zhengzhou, todos os tratamentos foram realizados com o consentimento esclarecido dos pacientes ou de seus familiares.9Este estudo foi realizado em dois centros, no Hospital Popular de Zhengzhou da Universidade Médica do Sul e no Hospital de Medicina Tradicional Chinesa do Condado de Shenqiu, ambos na província de Henan. Foram incluídas pacientes femininas idosas com diabetes e infarto agudo do miocárdio com supradesnível do segmento ST (IAMCSST), internadas na unidade coronariana e que receberam intervenção coronária percutânea (ICP) de janeiro de 2013 a dezembro de 2018. O estudo foi randomizado e mono-cego. O sangue foi coletado imediatamente após a admissão. Foi calculado o escore7. Foram usados stents farmacológicos em todos os pacientes. Apenas o vaso culpado foi tratado durante a emergência. Quando um vaso não culpado precisava de tratamento, foi realizada ICP seletiva 10 a 14 dias depois. Adicionalmente, 100 mg/d de aspirina e 90 mg/d de ticagrelor foram administrados duas vezes por via oral continuamente em pacientes nos três grupos. Posteriormente, a DAP foi aplicada durante pelo menos 12 meses. Além disso, bloqueadores do receptor, estatinas, agentes hipoglicêmicos e inibidores da enzima de conversão da angiotensina foram administrados continuamente.9Foi registrado eletrocardiograma de dezoito derivações imediatamente após a admissão e os sinais vitais foram verificados. Imediatamente após a admissão, foi coletado o sangue para análise de enzimas cardíacas, troponina e outros itens bioquímicos e de rotina relacionados. Além disso, foram administrados 100 mg de aspirina  e 180 mg de ticagrelor  por via oral aos pacientes nos três grupos. Foram realizadas angiografia coronária e ICP de emergência. Quando trombos foram encontrados, foi utilizado um cateter de aspiração de trombo para aspirá-los . Foi injetado cloridrato de tirofibana (10 µg/kg) na artéria coronária nos pacientes dos grupos A e C. Após a ICP, 0,075 µg/kg·min de cloridrato de tirofibana foi bombeado continuamente na veia durante 24 horas 13 e CRUSADE integral10 foram calculados com base nesses dados. Foi calculado o SYNTAX integral14 de acordo com as características patológicas da angiografia coronária. Subsequentemente, foram determinadas as características do vaso culpado e foram registrados os dados do diâmetro e do comprimento dos stents. Por exemplo, se mais de dois stents eram necessários para mais de dois vasos culpados, o comprimento dos stents separados era somado para obter o comprimento. Se a lesão-alvo foi mais comprida e mais de dois stents foram colocados em série, 4 mm eram subtraídos do comprimento total. O diâmetro e o comprimento dos stents para cirurgia secundária seletiva de vasos não culpados não foram incluídos. Foram registrados os dados de tempo de internação hospitalar e eventos adversos, incluindo ICP seletiva durante a hospitalização, angina pectoris pós-infarto, re-infarto durante a hospitalização, trombose aguda e subaguda do stent, arritmia grave , função cardíaca acima de Killip grau III, choque cardiogênico e mortalidade em 30 dias9 dos pacientes dos três grupos. A classificação de sangramentoThrombolysis in Myocardial Infarction(TIMI) foi registrada da maneira seguinte: (1) hemorragia grave: hemorragia intracraniana ou sangramento clinicamente visível (incluindo diagnóstico por imagem), diminuição da hemoglobina ≥ 5 g/dl e diminuição do hematócrito ≥ 15%); (2) hemorragia moderada: sangramento clinicamente visível (incluindo diagnóstico por imagem), diminuição da hemoglobina entre 3 e 5 g/dl, sangramento leve; (3) hemorragia leve: sangramento clinicamente visível (incluindo diagnóstico por imagem), com diminuição da hemoglobina < 3 g/dl.15 Também foram registrados o grau de fluxo sanguíneo TIMI e o grau de perfusão miocárdica TIMI (TMPG) dos vasos relacionados ao infarto após a ICP.15Foram coletados e contados os dados para tempo primeiro contato médico-balão, tempo porta-balão, idade, sexo, frequência cardíaca, pressão sistólica, creatinina sérica, classificação Killip da função cardíaca, enzimas miocárdicas, troponina, hematócrito, histórico de doença vascular ou diabetes mellitus e a existência de parada cardíaca. Os escores GRACE9Foi usado o software SPSS 17.0 para análise estatística de todos os dados. Os dados de medição, expressos como média ± desvio padrão, apresentaram distribuição normal de acordo com o teste de Kolmogorov-Smirnov. A comparação entre os dois grupos foi realizada pelo teste t de Student não pareado. Os dados de contagem foram expressos em números de casos (razão de constituintes), e a comparação entre os dois grupos foi realizada pelo teste do qui-quadrado. ANOVA de uma via foi utilizada para comparar os três grupos e p < 0,05 foi considerado estatisticamente significativo. > 0,05,O grupo A , que foi o grupo controle, apresentou escore CRUSADE de baixo risco (inferior a 30). O grupo B  apresentou escore CRUSADE de risco moderado e acima de moderado (superior a 31). O grupo C  apresentou escores CRUSADE de baixo risco (escore inferior a 30). Não houve diferenças estatisticamente significativas em relação a idade, tempo primeiro contato médico-balão, tempo porta-balão, hipertensão, hiperlipidemia, índice de massa corporal, história prévia de ICP, histórico familiar de doença cardíaca coronária e pontuação GRACE entre os três grupos . Além disso, o fluxo sanguíneo TIMI grau 3 e o TMPG grau 3 após a ICP foram significativamente menos prevalentes no grupo B do que nos grupos A e C . Além disso, o grupo B teve 14 casos de angina pectoris pós-infarto, enquanto os outros dois grupos tiveram 5 casos cada. Ocorreram 9 casos de arritmia grave no grupo B, o que foi maior do que nos outros dois grupos (2 casos no grupo A e 3 casos no grupo C). Houve 14 casos de insuficiência cardíaca, choque cardiogênico e mortalidade em 30 dias no grupo B, o que foi maior do que nos grupos A e C . Além disso, a incidência de ICP seletiva, re-infarto e trombose de stent durante a internação hospitalar foi significativamente mais alta no grupo B, em comparação com o grupo A . No grupo B, ocorreram 14 casos de angina pectoris pós-infarto, 7 casos de re-infarto e 3 casos de trombose de stent. Em adição a isso, a incidência total de hemorragia e a incidência de hemorragia moderada foram significativamente maiores no grupo C, quando comparados aos grupos A e B  is a cornerstone in the treatment of acute myocardial infarction (AMI). Compared with clopidogrel, the inhibitory effect of ticagrelor on platelets in DAPT is rapid and potent, with dual-inhibition and reversible combination. Furthermore, it can dilate coronary arteries, and it is recommended by guidelines.5Glycoprotein IIb/IIIa receptor inhibitors, in addition to DAPT, can effectively reduce the onset of complications, such as slow blood flow, no reflow, acute and subacute thrombosis, and major adverse cardiac events (MACE).9However, it remains unknown whether the combination of triple antiplatelet therapy (TAPT) drugs, especially ticagrelor, would increase the risk of hemorrhage. The urgent issue in the treatment of AMI is how to balance the risk of ischemic events and hemorrhagic complications. In relation to DAPT (aspirin and ticagrelor), the present study aimed to investigate the short-term efficacy and safety of TAPT  in elderly female patients with diabetes and AMI.The incidence of slow blood flow, no-reflow, and thrombotic complications in female patients with diabetes and AMI is higher than in patients without diabetes or in male patients with diabetes and AMI who are receiving DAPT.10was calculated according to patients’ hematocrit, creatinine clearance rate, heart rate, blood pressure, existence of heart failure, diabetes mellitus, and previous vascular diseases. This was a prospective study. According to CRUSADE score, patients were randomly divided into the following two groups: group B (score higher than 30) and group C (score lower than 30). DAPT (aspirin and ticagrelor) was given to the patients in group B, and TAPT  was given to the patients in group C. Elderly male patients with diabetes and STEMI, who received emergency PCI during the same period of hospitalization, were assigned to group A (control group), and they received the same drug therapy as the patients in group C. Diagnosis of STEMI was in accordance with the European Society of Cardiology guidelines,11and diagnosis of diabetes mellitus was in accordance with the World Health Organization criteria.12The inclusion criteria were as follows: (1) patients with the onset of STEMI at ≤ 12 hours, (2) patients with known diagnosis of diabetes mellitus, (3) patients who agreed to receive emergency PCI and DAPT or TAPT, and (4) patients between the ages of 60 and 79 years old. The exclusion criteria were as follows: (1) patients with the onset of STEMI at > 12 hours, (2) patients with blood pressure ≥ 180/110 mmHg, (3) patients with suspected aortic dissection, (4) patients with retrieved PCI after thrombolysis for STEMI, (5) patients with a history of cerebral hemorrhage and ischemic stroke within one year, (6) patients with severe hepatic and/or renal insufficiency, and (7) patients with a history of hemorrhagic diseases.9The present study conforms to the standards of medical ethics. With the approval of the Ethics Committee of Zhengzhou People’s Hospital, all treatments were performed with the informed consent of patients or their families.9This study was conducted in two centers, Zhengzhou People’s Hospital of Southern Medical University and Shenqiu County Hospital of Traditional Chinese Medicine, both in the Henan province. Elderly female patients with diabetes and STEMI, who were admitted to the coronary care unit and who received emergency percutaneous coronary intervention (PCI) treatment from January 2013 to December 2018, were included into this study. This study was randomized and single-blinded. Blood was drawn immediately after admission. The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) score7. Drug-eluting stents were used for all patients. Merely the culprit vessel was treated during the emergency. If a non-culprit vessel needed to be treated, selected PCI was performed 10 to 14 days later. In addition, 100 mg/d of aspirin and 90 mg/d of ticagrelor were given twice orally and continuously in patients in all three groups. Subsequently, DAPT was applied for at least 12 months. Furthermore, -receptor blockers, statins, hypoglycemic agents, and angiotensin converting enzyme inhibitors were continuously administered.9Eighteen-lead electrocardiogram was recorded immediately after admission, and vital signs were checked. Blood was drawn immediately after admission for assay of cardiac enzymes, troponin, and other related biochemical and routine testing items. In addition, 100 mg of aspirin  and 180 mg of ticagrelor  were orally administered to patients in these three groups. Emergency coronary angiography and PCI were performed. If thrombi were found, a thrombus aspiration catheter was used to aspirate them . Tirofiban hydrochloride (10 µg/kg) was injected into the coronary artery in patients in groups A and C. After PCI, 0.075 µg/kg·min of tirofiban hydrochloride was continuously pumped into the vein for 24 hours13and CRUSADE integral10were calculated based on the above data. The SYNTAX integral14was calculated according to the pathological characteristics of coronary angiography. Subsequently, the characteristics of the culprit vessel were determined. Data for diameter and length of stents were recorded. For instance, if more than two stents were needed for more than two culprit vessels, the length of the separate stents was added to obtain the length of stent. If the target lesion was longer and more than two stents were placed in series, the total length of the stent was subtracted by 4 mm. The diameter and length of stents for selective secondary surgery of non-culprit vessels were not included. Data were also recorded for length of stay and adverse events, including selective PCI during hospitalization, post-infarction angina pectoris, re-infarction during hospitalization, acute and sub-acute thrombosis in the stent, severe arrhythmia , cardiac function above Killip grade III, cardiogenic shock, and 30-day mortality9of patients in these three groups. The Thrombolysis in Myocardial Infarction (TIMI) bleeding classification was recorded as follows: (1) severe hemorrhage: intracranial hemorrhage or clinically visible bleeding (including imaging diagnosis), decreased hemoglobin of ≥ 5 g/dl and decreased hematocrit by ≥ 15%); (2) moderate hemorrhage: clinically visible bleeding (including imaging diagnosis), decreased hemoglobin between 3 and 5 g/dl, slight bleeding; (3): mild hemorrhage: clinically visible bleeding (including imaging diagnosis), with decreased hemoglobin < 3 g/dl.15TIMI blood flow grading and TIMI myocardial perfusion grade (TMPG) of the infarction-related vessels after PCI were also recorded.15The data for first-medical-contact-to-balloon time, door-to-balloon time, age, sex, heart rate, systolic pressure, serum creatinine, Killip classification of cardiac function, myocardial enzymes, troponin, hematocrit, past history of vascular disease and diabetes mellitus, and the existence of cardiac arrest were collected and counted. The GRACE scores9SPSS 17.0 software was used for statistical analysis of all data. The measurement data were expressed as mean ± standard deviation. They presented a normal distribution according to Kolmogorov-Smirnov test, and the comparison between the two groups was conducted by unpaired Student’s t test. The count data was expressed as the number of cases (constituent ratio), and the comparison between the two groups was performed by chi-squared test. One-way ANOVA was employed to compare these three groups, and p < 0.05 was considered statistically significant.>0.05,Group A , which was the control group, had low risk CRUSADE scores (less than 30). Group B  had moderate and above moderate risk CRUSADE scores (higher than 31). Group C  had low risk CRUSADE scores (lower than 30). There were no statistically significant differences in age, first-medical-contact-to-balloon time, door-to-balloon time, hypertension, hyperlipidemia, body mass index, previous history of PCI, family history of coronary heart disease, and GRACE score among the three groups (p<0.05). In addition, TIMI grade 3 blood flow and TMPG grade 3 after PCI were significantly less prevalent in group B than in groups A and C . In addition, group B had 14 cases of post-infarction angina pectoris, whereas the other two groups had 5 cases each Nine cases of severe arrhythmia occurred in group B, which was higher than that in other two groups (2 cases in group A and 3 cases in group C). There were 14 cases of heart failure, cardiogenic shock, and 30-day mortality in group B, which was higher than in groups A and C . Furthermore, the incidence of selective PCI, re-infarction, and stent thrombosis during hospitalization was significantly higher in group B, when compared to group A (p<0.05). In group B, there were 14 cases of post-infarction angina pectoris, 7 cases of re-infarction and 3 cases of stent thrombosis. Moreover, the total incidence of hemorrhage and the incidence of moderate hemorrhage were significantly higher in group C, when compared to groups A and B (p<0.05,The average length of hospital stay was significantly higher in group B than in group A and C (p17Timely PCI in female patients with acute coronary syndrome can effectively reduce the incidence of MACE.18However, women, especially elderly women, often have no typical chest pain during ischemic attack, which may delay diagnosis and treatment. In the present study, the incidence of angina pectoris before infarction was significantly lower in women, when compared to men. Furthermore, non-specific symptoms, such as post-sternal discomfort, chest tightness, shortness of breath, nausea, vomiting, and fatigue, were more common in females with AMI. In addition, the sensitivity and specificity of electrocardiogram and exercise electrocardiogram in the diagnosis of coronary heart disease are lower in women. The lack of specific symptoms and the corresponding electrocardiogram changes in the pathophysiological condition of ischemia and the lack of timely and necessary medicines and lifestyle intervention, even in critical conditions, such as complete or subtotal vascular occlusion, often lead to late consultation, missing the most treatable stage and resulting in a lack of early intervention, such as emergency PCI, which is one of the main causes of the higher incidence of complications and mortality in female patients with AMI.18More than 50% of cardiovascular deaths occur in females. Regardless of the positive results of the pathophysiology, complaints, symptoms, signs and results of auxiliary examinations, or the short-term and long-term therapeutic effects, female patients have their own particularities.15This suggests that enhanced antiplatelet therapy is needed for patients with diabetes. Diabetes mellitus is one of the most important risk factors for patients with acute coronary syndrome, regardless of whether the GRACE score is used for evaluating ischemic events or the CRUSADE score is used for predicting the risk of bleeding. DAPT is the cornerstone for preventing ischemia and thrombosis after PCI.19After receiving DAPT, some patients still have serious complications of thrombosis, especially in female patients with diabetes and elderly patients with diabetes. IIb/IIIa receptor inhibitors in addition to DAPT can effectively reduce the occurrence of slow blood flow and no reflow, the incidence of acute and subacute thrombosis, and the occurrence of MACE.15However, there were no significant differences in general characteristics, coronary lesion characteristics and GRACE scores among the three groups in the present study. These results revealed that TAPT was significantly superior to DAPT in reducing related ischemia-driven events, such as the incidence of post-infarction angina pectoris, severe arrhythmia, heart failure, cardiogenic shock, and 30-day mortality, in both elderly male and female patients with diabetes and STEMI, when compared to women with diabetes and STEMI who received DAPT. Furthermore, compared to patients receiving DAPT, the average hospital stay was shorter in those receiving TAPT. Moreover, the incidence of selective PCI, re-infarction, and stent thrombosis in elderly male patients with diabetes and STEMI who received TAPT was significantly lower, when compared to elderly female patients with diabetes and STEMI who received DAPT. This suggested that TAPT could effectively reduce the onset of ischemic events in elderly patients with diabetes and STEMI. Furthermore, male patients benefit more than female patients.Diabetes mellitus is an isocritical condition of coronary heart disease. The therapeutic effects of antiplatelet drugs in patients with diabetes are worse than in patients without diabetes. Furthermore, the incidence of slow blood flow and no reflow after emergency PCI and MACE are significantly higher than in patients without diabetes.10Older age, the existence of diabetes mellitus, and female sex are all important risk factors for hemorrhage. Due to the strong antiplatelet effect of tirofiban and the combined application of ticagrelor, hemorrhagic complications have always been a matter of concern for cardiovascular physicians.15Close attention should be given to the application of DAPT and TAPT in order to minimize the occurrence of hemorrhagic complications. DAPT has been applied only for elderly female patients with STEMI, whose CRUSADE score was above middle-risk, while TAPT has been applied for patients with low-risk CRUSADE scores. These results revealed that the total incidence of hemorrhage and the incidence of moderate hemorrhage in elderly female patients with diabetes after TAPT was significantly higher, when compared to that of female patients with relatively high risk of hemorrhage and elderly male patients with diabetes receiving TAPT. However, there was no significant difference in the risk of hemorrhage between male and female patients receiving TAPT. This indicated that the risk of hemorrhage is higher for elderly female patients with diabetes and STEMI. It is noteworthy that there are special pathophysiological conditions in antiplatelet therapy for elderly female patients with diabetes and STEMI, which are different from those of males. While preventing ischemia-driven events, close attention must be given to the increased risk of hemorrhage.The CRUSADE score is an important index for evaluating the risk of hemorrhage.The study only compared elderly female patients with diabetes who received TAPT and DAPT, and it did not include male patients receiving DAPT as a control. Furthermore, the sample size was small, and there was a lack of long-term follow-up. The team of authors is conducting further research to address these limitations.The present study showed that the incidence of complications in elderly female patients with diabetes and STEMI receiving TAPT after PCI was significantly lower than in patients receiving DAPT. However, the incidence of hemorrhage in female patients receiving TAPT was significantly higher, when compared to male patients receiving TAPT and female patients receiving DAPT.


No entanto, estudos têm demonstrado o valor dos biomarcadores de fibrose miocárdica na progressão da patogênese da DCh.6A inflamação miocárdica persistente e a fibrose representam as principais características patológicas da DCh que estariam relacionadas com a sua progressão.7 apresentam dados que contribuem para o nosso entendimento relacionado à carga da fibrose miocárdica em diferentes estágios da DCh. Para tanto, os autores avaliaram a presença (ou não) da Galectina-3 , um biomarcador de fibrose miocárdica, em diferentes estágios da doença comparados à um grupo controle e se ela está associada a mortalidade ou necessidade de transplante de coração no estágio mais avançado da doença. Para esse propósito, foram realizados 2 estudos com desenhos distintos. Inicialmente, a fim de estratificar os grupos pelo status de cardiomiopatia chagásica (CC) utilizando um desenho de estudo transversal, 330 pacientes soropositivos para T. cruzi  foram incluídos, além de 153 controles soronegativos (pareados por idade e sexo). Desses pacientes soropositivos, 97 com formas cardíacas mais graves de CC fizeram parte do estudo longitudinal prospectivo censurado até o evento .Nesta edição, Fernandes et al.,s = -0,16, p = 0,001). Foram observados eventos em 28 pacientes (29%). Em pacientes com cardiopatia e FEVE <50%, o modelo de regressão linear ajustado mostrou uma associação significativa entre os níveis de Gal-3 e morte ou transplante cardíaco durante um seguimento de cinco anos .Os resultados foram resumidos e analisados nos diferentes grupos. A mediana de idade foi de 49 ± 9,2 anos, com mediana de seguimento de 58 meses. Pacientes com doença de Chagas sem cardiomiopatia (n = 187) e aqueles com cardiomiopatia e FEVE >50% (n = 46) tinham níveis de Gal-3 semelhantes aos de controles saudáveis (n = 153), mas aqueles com cardiomiopatia e FEVE <50% (n = 97) apresentaram níveis de Gal-3 significativamente maiores do que os controles saudáveis . Uma correlação significativa foi observada entre os níveis de Gal-3 e FEVE ; assim, os resultados das análises multivariadas, que incluíram cinco variáveis independentes, devem ser considerados com cautela devido à provável supersaturação do modelo.A interpretação desses resultados deve considerar o pequeno número de pacientes com seguimento de cinco anos e experiência em centro único já citados pelos autores. No grupo de pacientes com cardiomiopatia e FEVE <50%, possivelmente foram utilizados diferentes graus de comprometimento miocárdico, já que havia um amplo espectro de FEVE (variando de 20% a 40%) levando a diferentes perfis de pacientes incluídos nos grupos.T. cruzi .10 Isso significaria um avanço no manejo da DCh.Um dos maiores desafios da DCh é a dificuldade da identificação, em um estágio inicial, os indivíduos infectados que farão parte dos 20% a 30% que podem desenvolver cardiomiopatia. Infelizmente, no momento, não há como prever essa possível progressão. Assim, encontrar biomarcadores confiáveis de progressão da doença significaria o maior salto na história da DCh desde sua descoberta em 1909 pelo Dr. Carlos Chagas. Por esse motivo, existem inúmeros grupos de pesquisa que se dedicam à busca de biomarcadores derivados do hospedeiro e do  1 In Brazil, to date, it is the neglected disease with the highest burden, of which ~30% of individuals will progress to the symptomatic tissue disruptive stage within 20 – 30 years after being infected2 .3In recent decades, the epidemiology of Chagas disease (Chd) has changed significantly as a consequence of urbanization and migration.5 The use of myocardial fibrosis biomarkers to predict progression in patients with normal or near normal LV function is certainly important in Chd, where traditional risk factors, such as LVEF, may not be as useful. Nevertheless, studies have shown the value of myocardial fibrosis biomarkers in the progression of Chd pathogenesis.6Persistent myocardial inflammation and fibrosis represent the main pathological characteristics of Chd that would be correlated with its progression.7 present data that contributes to our understanding related to the burden of myocardial fibrosis in different stages of Chd. To this end, the authors assessed the presence (or not) of Galectin-3 , a myocardial fibrosis biomarker, in different stages of the disease compared to a control group and whether it is associated with mortality or need for a heart transplant in the most advanced stage of the disease. For this purpose, 2 studies with different designs were carried out. Initially, in order to stratify the groups by the Chagas cardiomyopathy (CC) status using a cross-sectional study design, 330 patients seropositive for T. cruzi  were included, in addition to 153 seronegative controls (matched by age and gender). Of these seropositive patients, 97 with more severe cardiac forms of CC were part of the prospective longitudinal study censored until the event .In this edition, Fernandes et al.s=-0.16, p=0.001). Events were observed in 28 patients (29%). In patients with cardiopathy and LVEF< 50%, the adjusted linear regression model showed a significantly association between Gal-3 levels and death or heart transplantation during a five-year follow-up . The authors concluded that in patients with the cardiac form, higher Gal-3 levels were significantly associated with severe forms of the disease and a higher long-term mortality rate, which means that they can be effectively used to identify high-risk patients.The results were summarized and analysed in the different groups. The median age was 49 ± 9.2 years, with a median follow-up of 58 months. Chagas disease patients without cardiomyopathy (n = 187) and those with cardiomyopathy and LVEF >50% (n = 46) had Gal-3 levels similar to those of healthy controls (n = 153), but those with cardiomyopathy and LVEF <50% (n = 97) had significantly higher Gal-3 levels than the healthy controls (p = 0.0001). A significant correlation was observed between Gal-3 levels and LVEF ; thus, the results from the multivariate analyses, which included 5 independent variables, should be taken with caution due to likely model oversaturation.The interpretation of these results should consider the small number of patients who had a five-year follow-up and single center experience already quoted by the authors. In the group of patients with cardiomyopathy and LVEF <50%, different degrees of myocardial involvement were possibly used, since there was a wide spectrum of LVEF (ranging from 20% to 40%) leading to different patient profiles included in the groups.10 This would mean a breakthrough in the management of ChdOne of the mayor challenges in Chd is the difficulty in identifying at an early stage the infected subjects who will be part of those 20% to 30% who might develop cardiomyopathy. Unfortunately, at present there is no way to predict this possible progression. Thus, finding reliable biomarkers of disease progression would mean the greatest leap forward in the history of Chd since its discovery in 1909 by Dr. Carlos Chagas. For this reason, there are numerous research groups devoted to the search of both host-derived and T. cruzi-derived biomarkers.