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Iron is a transition metal used as a cofactor in many biochemical reactions. In bacteria, iron homeostasis involves Fur-mediated de-repression of iron uptake systems, such as the iron-chelating compounds siderophores. In this work, we identified and characterized novel regulatory systems that control siderophores in the environmental opportunistic pathogen Chromobacterium violaceum. Screening of a 10,000-transposon mutant library for siderophore halos identified seven possible regulatory systems involved in siderophore-mediated iron homeostasis in C. violaceum. Further characterization revealed a regulatory cascade that controls siderophores involving the transcription factor VitR acting upstream of the quorum-sensing (QS) system CviIR. Mutation of the regulator VitR led to an increase in siderophore halos, and a decrease in biofilm, violacein, and protease production. We determined that these effects occurred due to VitR-dependent de-repression of vioS. Increased VioS leads to direct inhibition of the CviR regulator by protein-protein interaction. Indeed, insertion mutations in cviR and null mutations of cviI and cviR led to an increase of siderophore halos. RNA-seq of the cviI and cviR mutants revealed that CviR regulates CviI-dependent and CviI-independent regulons. Classical QS-dependent processes (violacein, proteases, and antibiotics) were activated at high cell density by both CviI and CviR. However, genes related to iron homeostasis and many other processes were regulated by CviR but not CviI, suggesting that CviR acts without its canonical CviI autoinducer. Our data revealed a complex regulatory cascade involving QS that controls siderophore-mediated iron homeostasis in C. violaceum.IMPORTANCEThe iron-chelating compounds siderophores play a major role in bacterial iron acquisition. Here, we employed a genetic screen to identify novel siderophore regulatory systems in Chromobacterium violaceum, an opportunistic human pathogen. Many mutants with increased siderophore halos had transposon insertions in genes encoding transcription factors, including a novel regulator called VitR, and CviR, the regulator of the quorum-sensing (QS) system CviIR. We found that VitR is upstream in the pathway and acts as a dedicated repressor of vioS, which encodes a direct CviR-inhibitory protein. Indeed, all QS-related phenotypes of a vitR mutant were rescued in a vitRvioS mutant. At high cell density, CviIR activated classical QS-dependent processes (violacein, proteases, and antibiotics production). However, genes related to iron homeostasis and type-III and type-VI secretion systems were regulated by CviR in a CviI- or cell density-independent manner. Our data unveil a complex regulatory cascade integrating QS and siderophores in C. violaceum.

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Objetivo: analisar a percepção de gestores municipais paraibanos sobre o tema da judicialização da saúde. Metodologia: trata-se de uma pesquisa descritiva e analítica, com delimitação transversal, realizada em 2018. Foram aplicados questionários a 31 gestores de saúde municipais, que representam proporcionalmente à 75% da população do estado da Paraíba. Resultados: os resultados apontam a judicialização como fenômeno mais fortemente ligado a fatores externos à gestão do Sistema Único de Saúde (SUS). O processo de discussão da judicialização tem mais ressonância nos espaços das Comissões Intergestores, e os órgãos representativos e o Ministério Público são os maiores aliados no enfrentamento. Identifica-se fragilidades na construção dos instrumentos de gestão e, entre as soluções possíveis, estão o maior conhecimento desse fenômeno pelos órgãos e setores de gestão do SUS, bem como na qualificação das ações de regulação. Conclusão: percebe-se a complexidade da judicialização da saúde, desde a sua compreensão até a forma desafiadora de gerenciá-la. É fundamental estabelecer estratégias que promovam a comunicação e a informação, ampliando o conhecimento dos órgãos de controle e dos setores de gestão do SUS, a fim de lidar de forma mais eficaz com esse fenômeno.

Objective: to analyze the perceptions of municipal leaders in the state of Paraíba, Brazil, on the topic of health judicialization. Methodology: it is a descriptive and analytical study of a cross-sectional nature, carried out in 2018. Questionnaires were administered to 31 municipal health managers, proportionately representing 75% of the population of the state of Paraíba, Brazil. Results: judicialization is a phenomenon more associated with factors outside the management of the Brazilian Unified Health System (SUS). The discussion process about judicialization tends to take place in the Inter-institutional Commissions.The representative bodies and the Public Ministry are the main allies in the dispute. Weaknesses in the construction of administrative instruments have been identified, and solutions include better knowledge of this phenomenon by the SUS administrative bodies and sectors, and in the qualification of regulatory measures. Conclusion: the complexity of health judicializationis perceived, from its understanding to the difficulties of managing it. It is important to develop strategies that promote communication and information and improve the knowledge of regulatory bodies and SUS administrative sectors to better deal with this phenomenon.

Objetivo: analizar la percepción de los gestores municipales del estado de Paraíba, en Brasil, sobre la judicialización de la salud. Metodología: se trata de una investigación descriptiva y analítica, con delimitación transversal, realizada en 2018. Se aplicaron cuestionarios a 31 gestores municipales de salud, que representan proporcionalmente el 75% de la población del estado de Paraíba, en Brasil. Resultados: los resultados apuntan a la judicialización como un fenómeno más fuertemente ligado a factores externos a la gestión del Sistema Único de Salud (SUS) brasileño. Los órganos de representación y el Ministerio Público son los principales aliados in el enfrentamiento, y el proceso de discusión de la judicialización tiene mayor resonancia en los espacios de las Comisiones Interinstitucionales. Fue posible identificar debilidades en la construcción de instrumentos de gestióny, entre las posibles soluciones se encuentran un mayor conocimiento de este fenómeno por parte de los órganos y sectores gestores del SUS, así como en la calificación de las acciones normativas. Conclusión: se reconoce la complejidad de la judicialización de la salud, desde cómo se entiende hasta cómo se maneja. Para enfrentar con mayor eficacia este fenómeno, es necesario establecer estrategias que promuevan la comunicación y la información, ampliando el conocimiento de los órganos de control y de los sectores de gestión del SUS.

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Chromobacterium violaceum is an environmental Gram-negative beta-proteobacterium that causes systemic infections in humans. C. violaceum uses siderophore-based iron acquisition systems to overcome the host-imposed iron limitation, but its capacity to use other iron sources is unknown. In this work, we characterized ChuPRSTUV as a heme utilization system employed by C. violaceum to explore an important iron reservoir in mammalian hosts, free heme and hemoproteins. We demonstrate that the chuPRSTUV genes comprise a Fur-repressed operon that is expressed under iron limitation. The chu operon potentially encodes a small regulatory protein (ChuP), an outer membrane TonB-dependent receptor (ChuR), a heme degradation enzyme (ChuS), and an inner membrane ABC transporter (ChuTUV). Our nutrition growth experiments using C. violaceum chu deletion mutants revealed that, with the exception of chuS, all genes of the chu operon are required for heme and hemoglobin utilization in C. violaceum. The mutant strains without chuP displayed increased siderophore halos on CAS plate assays. Significantly, we demonstrate that ChuP connects heme and siderophore utilization by acting as a positive regulator of chuR and vbuA, which encode the TonB-dependent receptors for the uptake of heme (ChuR) and the siderophore viobactin (VbuA). Our data favor a model of ChuP as a heme-binding post-transcriptional regulator. Moreover, our virulence data in a mice model of acute infection demonstrate that C. violaceum uses both heme and siderophore for iron acquisition during infection, with a preference for siderophores over the Chu heme utilization system.

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Objetivo: a judicialização da saúde é um fenômeno multifacetado e requer a construção de caminhos que possibilitem a análise de fatores que, isolada ou conjuntamente, influenciam em sua constituição; assim, torna-se necessário identificar quais são os fatores apontados pela literatura científica nacional como causas da judicialização no campo da saúde. Metodologia: foi feita uma revisão integrativa de literatura, fundamentada no estudo exploratório-descritivo e bibliográfico de 101 publicações contidas na base de dados da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, usando cinco descritores compatíveis com a pesquisa, a saber: judicialização e saúde e Brasil; judicialização da saúde e Direito; judicialização e saúde e causas; judicialização e saúde e consequências; e judicialização e direito à saúde. Resultados: dos 101 artigos catalogados, 30 foram selecionados; tal amostra foi organizada em três categorias, a partir de sua temática: 14 artigos discutiam a judicialização da assistência farmacêutica; 10 artigos abordavam a judicialização do direito à saúde; e 6 artigos debatiam sobre a judicialização com ênfase nas práticas de gestão. Conclusão: ainda é incipiente a produção intelectual brasileira para a identificação e sistematização dos determinantes da judicialização. Contudo, foi possível identificar caminhos que permitiram uma leitura preliminar sobre a temática, que foram divididos em três categorias: judicialização da assistência farmacêutica; judicialização do direito à saúde; e judicialização e práticas de gestão

Objective: health judicialization is a multifaceted phenomenon; thus, it is necessary to identify what are the factors that cause this phenomenon in Brazilian scientific literature. Methods: it was conducted an integrative literature review, based on an exploratory-descriptive and bibliographic study of 101 publications available in Capes database. The search used 5 descriptors: judicialization and health and Brazil; health judicialization and law; judicialization and health and causes; judicialization and health and consequences; and judicialization and the right to health. Results: of a corpus of 101 articles, the authors selected 30, which were organized into three categories based on its theme: 14 articles discussed the judicialization of pharmaceutical assistance; 10 articles addressed the judicialization of the right to health; and 6 articles discussed judicialization with emphasis on management practices. Conclusion: Brazilian intellectual production is still incipient to identify and systematize the determinants of health judicialization. However, it was possible to have a preliminary understanding of the main themes, which were divided into three categories: the judicialization of pharmaceutical assistance, the judicialization of the right to health and the judicialization and management practices.

Objetivo: la judicialización de la salud es un fenómeno multifacético y requiere la construcción de caminos que permitan analizar los factores que, individualmente o en conjunto, inciden en su constitución; por tanto, se hace necesario identificar cuáles son los factores señalados por la literatura científica nacional como causas de judicialización en el campo de la salud. Metodología: se realizó una revisión integradora de la literatura, a partir de un estudio exploratorio-descriptivo y bibliográfico de 101 publicaciones contenidas en la base de datos de la Coordinación para el Perfeccionamiento del Personal de Educación Superior, utilizando cinco descriptores compatibles con la investigación, a saber: judicialización y salud. y Brasil; judicialización de la salud y el derecho; judicialización y salud y causas; judicialización y salud y consecuencias; y judicialización y derecho a la salud. Resultados: de los 101 artículos catalogados, se seleccionaron 30; esta muestra se organizó en tres categorías, en función de su temática: 14 artículos discutieron la judicialización de la asistencia farmacéutica; 10 artículos abordaron la judicialización del derecho a la salud; y 06 artículos discutieron la judicialización con énfasis en las prácticas de gestión. Conclusión: la producción intelectual brasileña es aún incipiente para la identificación y sistematización de los determinantes de la judicialización. Sin embargo, fue posible identificar caminos que permitieron una lectura preliminar sobre el tema, que se dividió en tres categorías: la primera, judicialización de la asistencia farmacéutica, seguida de la judicialización del derecho a la salud y finalmente, judicialización y prácticas de gestión.

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Iron is a highly reactive metal that participates in several processes in prokaryotic and eukaryotic cells. Hosts and pathogens compete for iron in the context of infection. Chromobacterium violaceum, an environmental Gram-negative bacterial pathogen, relies on siderophores to overcome iron limitation in the host. In this work, we studied the role of the ferric uptake regulator Fur in the physiology and virulence of C. violaceum A Δfur mutant strain showed decreased growth and fitness under regular in vitro growth conditions and presented high sensitivity to iron and oxidative stresses. Furthermore, the absence of fur caused derepression of siderophore production and reduction in swimming motility and biofilm formation. Consistent with these results, the C. violaceum Δfur mutant was highly attenuated for virulence and liver colonization in mice. In contrast, a manganese-selected spontaneous fur mutant showed only siderophore overproduction and sensitivity to oxidative stress, indicating that Fur remained partially functional in this strain. We found that mutations in genes related to siderophore biosynthesis and a putative CRISPR-Cas locus rescued the Δfur mutant growth defects, indicating that multiple Fur-regulated processes contribute to maintaining bacterial cell fitness. Overall, our data indicated that Fur is conditionally essential in C. violaceum mainly by protecting cells from iron overload and oxidative damage. The requirement of Fur for virulence highlights the importance of iron in the pathogenesis of C. violaceumIMPORTANCE Maintenance of iron homeostasis, i.e., avoiding both deficiency and toxicity of this metal, is vital to bacteria and their hosts. Iron sequestration by host proteins is a crucial strategy to combat bacterial infections. In bacteria, the ferric uptake regulator Fur coordinates the expression of several iron-related genes. Sometimes, Fur can also regulate several other processes. In this work, we performed an in-depth phenotypic characterization of fur mutants in the human opportunistic pathogen Chromobacterium violaceum We determined that fur is a conditionally essential gene necessary for proper growth under regular conditions and is fully required for survival under iron and oxidative stresses. Fur also controlled several virulence-associated traits, such as swimming motility, biofilm formation, and siderophore production. Consistent with these results, a C. violaceumfur null mutant showed attenuation of virulence. Therefore, our data established Fur as a major player required for C. violaceum to manage iron, including during infection in the host.

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Bacteria use siderophores to scavenge iron from environmental or host sources. The iron acquisition systems of Chromobacterium violaceum, a ubiquitous environmental bacterium that can cause infections in humans, are still unknown. In this work, we demonstrated that C. violaceum produces putative distinct endogenous siderophores, here named chromobactin and viobactin, and showed that they are each required for iron uptake and virulence. An in silico analysis in the genome of C. violaceum revealed that genes related to synthesis and uptake of chromobactin (cba) and viobactin (vba) are located within two secondary-metabolite biosynthetic gene clusters. Using a combination of gene deletions and siderophore detection assays, we revealed that chromobactin and viobactin are catecholate siderophores synthesized from the common precursor 2,3-dihydroxybenzoate (2,3-DHB) on two nonribosomal peptide synthetase (NRPS) enzymes (CbaF and VbaF) and taken up by two TonB-dependent receptors (CbuA and VbuA). Infection assays in mice revealed that both the synthesis and the uptake of chromobactin or viobactin are required for the virulence of C. violaceum, since only the mutant strains that do not produce any siderophores or are unable to take up both of them were attenuated for virulence. In addition, the mutant strain unable to take up both siderophores showed a pronounced attenuation of virulence in vivo and reduced neutrophil extracellular trap (NET) formation in in vitro assays, suggesting that extracellularly accumulated siderophores modulate the host immune response. Overall, our results revealed that C. violaceum uses distinct endogenous siderophores for iron uptake and its establishment in the host.

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Trypanosoma cruzi and Helicobacter pylori (HP) are pathogens that cause chronic diseases and have been associated with hypergastrinemia. The aim of this study was to evaluate the fasting gastrin levels in patients with different clinical forms of Chagas disease (CD), coinfected or not by HP. The enrolled individuals were outpatients attending at the university hospital. HP infection was assessed by serology and 13 C-urea breath test. Fasting serum gastrin concentration was measured by chemiluminescence assay. Gastric endoscopic and histological features were also evaluated. Associations between CD and serum gastrin level were evaluated in a logistical model, adjusting for age, gender and HP status. A total of 113 patients were evaluated (45 with Chagas disease and 68 controls). In the multivariate analysis, increasing serum gastrin levels (OR= 1.02; 95% CI= 1.01-1.12), increasing age (OR= 1.05; 95% CI= 1.02 - 1.09) and HP-positive status (OR = 2.88; 95% CI = 1.10 - 7.51) remained independently associated with CD. The serum gastrin levels were significantly higher in the group of patients with the cardiodigestive form ( P = 0.03) as well as with digestive form ( P = <0.001) of Chagas disease than in the controls. In conclusion, patients with cardiodigestive and digestive clinical forms of CD have increased basal serum gastrin levels in comparison with controls. Moreover, we also demonstrated that H. pylori coinfection contributes to the hypergastrinemia shown in CD.

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Chromobacterium violaceum is an environmental Gram-negative bacterium that causes infections in humans. Treatment of C. violaceum infections is difficult and little is known about the mechanisms of antibiotic resistance in this bacterium. In this work, we identified mutations in the MarR family transcription factor EmrR and in the protein GyrA as key determinants of quinolone resistance in C. violaceum, and we defined EmrR as a repressor of the MFS-type efflux pump EmrCAB. Null deletion of emrR caused increased resistance to nalidixic acid, but not to other quinolones or antibiotics of different classes. Moreover, the ΔemrR mutant showed decreased production of the purple pigment violacein. Importantly, we isolated C. violaceum spontaneous nalidixic acid-resistant mutants with a point mutation in the DNA-binding domain of EmrR (R92H), with antibiotic resistance profile similar to that of the ΔemrR mutant. Other spontaneous mutants with high MIC values for nalidixic acid and increased resistance to fluoroquinolones presented point mutations in the gene gyrA. Using DNA microarray, Northern blot and EMSA assays, we demonstrated that EmrR represses directly a few dozen genes, including the emrCAB operon and other genes related to transport, oxidative stress and virulence. This EmrR repression on emrCAB was relieved by salicylate. Although mutation of the C. violaceum emrCAB operon had no effect in antibiotic susceptibility or violacein production, deletion of emrCAB in an emrR mutant background restored antibiotic susceptibility and violacein production in the ΔemrR mutant. Using a biosensor reporter strain, we demonstrated that the lack of pigment production in ΔemrR correlates with the accumulation of quorum-sensing molecules in the cell supernatant of this mutant strain. Therefore, our data revealed that overexpression of the efflux pump EmrCAB via mutation and/or derepression of EmrR confers quinolone resistance and alters quorum-sensing signaling in C. violaceum, and that point mutation in emrR can contribute to emergence of antibiotic resistance in bacteria.

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Introdução: A dermatomiosite é uma miopatia inflamatória idiopática rara, cujo principal sintoma é a fraqueza muscular. Objetivo: Descrever os achados fonoaudiológicos em um caso de dermatomiosite. Descrição do histórico e procedimentos: A partir de análise de prontuário de paciente do gênero feminino, 68 anos, com diagnóstico confirmado de dermatomiosite, foi realizada entrevista e avaliação clínica fonoaudiológica, após consentimento livre e esclarecido. Resultados: Limitação na abertura de boca, de mobilidade dos órgãos fonoarticulatórios, dificuldade na deglutição para consistência sólida, com episódios de engasgos, dispneia, necessidade de múltiplas deglutições, ardência (lábios e língua), presença de voz molhada após a deglutição e fraqueza muscular generalizada, indicando gravidade do quadro. Conclusão: a atuação fonoaudiológica em pacientes com dermatomiosite deve ser o mais precoce possível, tendo em vista que alterações na mobilidade e na execução das funções orais, em especial, da deglutição, podem interferir significativamente na condição nutricional e de bem-estar dos sujeitos acometidos.

The Dermatomyositis is a rare idiopathic inflammatory myopathy, which main symptom is muscle weakness. Objective: To describe the speech therapy findings in a case of dermatomyositis. Description of the history and procedures: From patient chart analysis, a female, 68 years old, with confirmed diagnosis of dermatomyositis, an interview and a clinical examination were performed, after free and informed consent. Results: Restriction in mouth opening, of mobility of the speech organs, difficulty in swallowing in a solid consistency, with episodes of choking, dyspnea, a need for multiple swallowing, burning sensation (lips and tongue), presence of wet voice after swallowing and muscle weakness widespread, indicating the severity of the condition. Conclusion: speech therapy performance in patients with dermatomyositis should be as early as possible, considering that changes in mobility and in execution of oral functions, in particular swallowing, can interfere significantly in nutritional condition and in the well-being of affected subjects.

La dermatomiositis es una miopatía inflamatoria idiopática rara, cuyo síntoma principal es la debilidad muscular. Objetivo: Describir los hallazgos fonoaudiologicos en un caso de la dermatomiositis. Descripción de la historia y procedimientos: Desde la análisis de registros médicos de una paciente del género femenino, 68 años, con diagnóstico confirmado de dermatomiositis, se llevó a cabo entrevista y evaluación clínica fonoaudiológica, después de consentimiento libre e informado. Resultados: Restricción en la apertura de la boca, en la movilidad de los órganos fonoarticulatórios, dificultad para tragar consistencia sólida, con episodios de asfixia, falta de aire, necesidad de múltiples degluciones, ardor (labios y lengua), presencia de voz húmeda después de tragar y debilidad muscular generalizada, lo que indica la gravedad de la condición. Conclusión: la actuación fonoaudiología con pacientes con dermatomiositis debe ser lo más precoz posible, teniendo en cuenta que los cambios en la movilidad y en la ejecución de las funciones orales, en particular, la deglución, pueden interferir significativamente en el estado nutricional y en el bienestar de los sujetos afectados.

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Sleep disturbances are a common complaint among patients with epilepsy. Studies assessing the relationship between sleep and epilepsy during childhood are scarce. The purpose of this study was to evaluate sleep habits in children with epilepsy. This cross-sectional study of children with and without epilepsy employed two questionnaires to evaluate sleep habits. Characteristics of both sleep habits and epilepsy (type of seizure, epileptic syndrome, number of seizures, use of anticonvulsant drugs) were collected from parental interviews and medical records. Our results indicate that children with epilepsy have a greater incidence of sleep problems compared with children without epilepsy. In those with epilepsy, we observed that nocturnal seizures, polytherapy, developmental delay, refractory epilepsy, generalized seizures, and epileptic syndromes with an unfavorable outcome are associated with poor sleep habits.

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