The jugular foramen remains one of the most complex regions of the human body. Approaching lesions in this area requires extensive anatomical knowledge and experience, due to the many critical neurovascular structures passing through or around the jugular foramen. Here, we present a concise review of the microsurgical anatomy of the jugular foramen in relation to the craniocervical approach.
Volume 7 - 2020 | https://doi.org/10.3389/fsurg.2020.00027
This article is part of the Research TopicMicrosurgical Anatomy of the Central Nervous System and Skull BaseView all 6 articles
The jugular foramen remains one of the most complex regions of the human body
Approaching lesions in this area requires extensive anatomical knowledge and experience
due to the many critical neurovascular structures passing through or around the jugular foramen
we present a concise review of the microsurgical anatomy of the jugular foramen in relation to the craniocervical approach
Since the beginning of modern neurosurgery, tumors of the jugular foramen have been regarded as inaccessible due to the complex bony and neurovascular anatomy, and significant deficits associated with attempted resection (1). Nonetheless, several otologists and neurosurgeons from the early twentieth century have described different approaches to this region, with varying success (2)
and have further contributed to the anatomical basis for modern approaches
The objective of this article is to present this complex anatomy as simply as possible
and to apply this anatomy to surgically approach the jugular foramen
Figure 1. Osseous jugular foramen (JF) and related structures [Modified from Ramina and Tatagiba (3)]
The deep end of the pyramidal fossa lodges the opening of the canaliculus cochleae
Figure 2. Schematic view of the structures of the jugular foramen. Carotid artery in red, sigmoid sinus and jugular bulb in blue (3). IX: glossopharyngeal nerve. X, vagus nerve. XI, accessory nerve. [Modified from Ramina and Tatagiba (3)]
Figure 3. Parts of the roof of the jugular foramen (right intracranial view) [Modified from Ramina and Tatagiba (3)]
On its extracranial surface, the jugular foramen has an oblique course from medial to lateral and from posterior to anterior, and it is located posterior to the carotid canal, anterolateral to the occipital condyle, and medial to the styloid process (Figure 1B)
Most of the jugular foramen is occupied by the jugular bulb, formed by the union of the sigmoid sinus and the inferior petrosal sinus, and is continued as the internal jugular vein in the cervical compartment (Figure 4). The jugular bulb has a size of approximately 15 mm wide and 20 mm high (9), though there is a notorious asymmetry of both sides, with the right side being wider in most patients (10)
Larger jugular bulbs may erode through the middle ear or internal auditory canal
which have important implications for surgery of vestibular schwannoma and other lesions of the internal auditory canal
Figure 4. Lateral extradural exposure of a right jugular foramen (3). IJV, internal jugular vein. Jug, jugular. SPS, superior petrosal sinus. SS, sigmoid sinus. VII, facial nerve. [Modified from Ramina and Tatagiba (3)]
and its extradural segment is routinely exposed (and sometimes transposed) in approaches to the jugular foramen
Figure 5. (A) Schematic showing the three portions of the petrous segment of the internal carotid artery [Modified from Ramina and Tatagiba (3)]
(B) Horizontal segment of the carotid artery in the petrous bone and its relationship with the facial nerve and caroticotympanic branches (CTB)
Figure 6. Left lateral cerebellopontine angle view showing the intradural relationships of the nerves of the jugular foramen, internal auditory canal, and vertebral artery and its branches (3). V, trigeminal nerve; VII, facial nerve; VIII, vestibulocochlear nerve; IX, glossopharyngeal nerve; X, vagus nerve; XI, accessory nerve. [Modified from Ramina and Tatagiba (3)]
The tympanic branch of the glossopharyngeal nerve (Jacobson's nerve) branches off at the level of the inferior ganglion
entering the inferior tympanic canaliculus to form the tympanic plexus to form the lesser petrosal nerve in the middle fossa
The auricular branch of the vagus nerve (Arnold's nerve) is also formed at the level of the jugular foramen
from the superior ganglion of the vagus and inferior ganglion of the glossopharyngeal nerves
passing through the mastoid canaliculus in direction to the external auditory canal
crossing the mastoid segment of the facial nerve (and giving off a small branch)
Figure 7. Schematic (A) and cadaveric (B) views of the jugular foramen with its vascular relationships and the facial nerve in the fallopian canal [dashed lines in (A), green in (B)]. Transverse and sigmoid sinuses are blue in (B) [Modified from Ramina and Tatagiba (3)]
Figure 8. Landmarks to identify the facial nerve [Modified from Ramina and Tatagiba (3)]
(A) Extracranial facial nerve location in relation to the tragal pointer
mastoid tip (MT) and digastric muscle (DM)
with the incus pointing toward the transition between the tympanic and mastoid segment of the facial nerve (arrow)
the hypoglossal nerve lays inferior and lateral to the IX-X-XI complex
and the hypoglossal canal is separated from the jugular foramen by the jugular tubercle
where is usually not exposed during surgery
in the cervical region the nerve has intimate relationship with the nerves of the jugular foramen
Figure 9. Neck dissection [Modified from Ramina and Tatagiba (3)]
(A) Exposition of the skull base and vascular structures
(B) Course of the vagus nerve in the proximal cervical region (arrows)
(C) Relationship of the carotid artery and venous system on the lateral skull base
Arrows represent the space between both structures where the glossopharyngeal
The common, internal and external carotid arteries run medial to the internal jugular vein. In the carotid triangle of the neck—bounded posteriorly by the sternocleidomastoid muscle and superiorly by the stylohyoideus and digastric muscles—the internal carotid artery is posterolateral to the external carotid artery and the internal jugular vein is lateral to both (Figure 9)
It is worth noting that the vertebral artery is surrounded by a venous plexus that is largest in the region of the C1-C2 joint
Figure 10. Vertebral artery in the skull base [Modified from Ramina and Tatagiba (3)]
(A) Schematic drawing of the course of the cranial vertebral artery before perforating the atlanto-occipital membrane
(B) Cadaveric view of the vertebral artery entering the skull
limited by the rectus capitis posterior major
This dissection is tailored to expose the inferior pole of the tumor
The superior and inferior capitis obliquus muscles are cut at the insertion in the transverse process of C1 and the
Figure 11. Left-sided craniocervical approach [Modified from Ramina and Tatagiba (3)]
(B) Suprafascial dissection exposing the temporalis muscle fascia and cervical fascia
(C) Creating the temporo-cervical-SCM flap to close the surgical defect after surgery
Figure 12. Neck dissection [Modified from Ramina and Tatagiba (3)]
(A) Left lateral mass of C1 as landmark to identify the accessory nerve and vertebral artery
Figure 13. Skull base after neck dissection and transposition of the vertebral artery (3). IJV, internal jugular vein; VA, vertebral artery. [Modified from Ramina and Tatagiba (3)]
Figure 14. After radical mastoidectomy, the facial nerve is left protected by bone inside the fallopian canal, with a hook passing below the canal to show the working space to resect tumor in the hypotympanum (3)
facial nerve in the fallopian canal (black) and entering the parotid gland (white)
Figure 15. Jugular foramen opened after neck dissection, radical mastoidectomy and retrosigmoid craniectomy (3). IJV, internal jugular vein; JB, jugular bulb; TU, tumor; SS, sigmoid sinus; VII, facial nerve in the fallopian canal (black) and entering the parotid gland (white). [Modified from Ramina and Tatagiba (3)]
Precise knowledge of the anatomy of the jugular foramen allows skull base surgeons to access the jugular foramen with minimum morbidity and mortality
The complex anatomy of this region demands a dedicated team with experience to tailor the approach to the morphology of the tumor
FC and MC contributed to the conception and design of the manuscript
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest
CrossRef Full Text | Google Scholar
Surgical approaches to jugular foramen schwannomas
Google Scholar
Structural variations in the jugular foramen of the human skull
PubMed Abstract | Google Scholar
Microsurgical anatomy of the jugular foramen
CrossRef Full Text | Google Scholar
The interperiosteodural concept applied to the jugular foramen and its compartmentalization
How I Do It: Retrosigmoid suprajugular approach to the jugular foramen
Its anatomic and clinical considerations in contemporary otology
PubMed Abstract | CrossRef Full Text | Google Scholar
Skull base and brain in children and adults
Google Scholar
Effects of preoperative embolization on glomus jugulare tumors
Jugular foramen: microscopic anatomic features and implications for neural preservation with reference to glomus tumors involving the temporal bone
Tumors of the jugular foramen: diagnosis and management
Reconstruction of the cranial base in surgery for jugular foramen tumors
Nogueira GF and Ramina R (2020) Microsurgical Anatomy of the Jugular Foramen Applied to Surgery of Glomus Jugulare via Craniocervical Approach
Received: 25 February 2020; Accepted: 24 April 2020; Published: 15 May 2020
Copyright © 2020 Constanzo, Coelho Neto, Nogueira and Ramina. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY)
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provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited
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*Correspondence: Felipe Constanzo, Y29uc3RhbnpvLm1kQGdtYWlsLmNvbQ==
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In a rare two-hour television appearance, Campos Neto, 53, took a battery of tough questions from six reporters and walked a diplomatic tightrope. He expressed a desire for good relations with Lula’s economic team while refusing to cave on two of its central demands: to cut interest rates and raise the inflation target. Based on the positive market reaction the following morning, his gamble paid off.
Systematic review registration: PROSPERO, identifier CRD42021233219, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021233219.
Volume 10 - 2022 | https://doi.org/10.3389/fpubh.2022.963841
This article is part of the Research TopicGlobal Excellence in Public Health and Nutrition: Latin America and the CaribbeanView all 8 articles
Electronic Health Records (EHR) are critical tools for advancing digital health worldwide
EHR development must follow specific standards
and guidelines that contribute to implementing beneficial resources for population health monitoring
This paper presents an audit of the main approaches used for EHR development in Brazil
We applied a systematic review protocol to search for articles published from 2011 to 2021 in seven databases (Science Direct
we analyzed 14 articles that met the inclusion and quality criteria and answered our research questions
78.58% (11) of the articles state that interoperability between systems is essential for improving patient care
many resources are being designed and deployed to achieve this communication between EHRs and other healthcare systems in the Brazilian landscape
the articles report other considerable elements: (i) the need for increased security with the deployment of permission resources for viewing patient data
(ii) the absence of accurate data for testing EHRs
and (iii) the relevance of defining a methodology for EHR development
Our review provides an overview of EHR development in Brazil and discusses current gaps
and technological solutions that could potentially address the related challenges
our study also addresses primary elements that could contribute to relevant components of EHR development in the context of Brazil's public health system
Systematic review registration: PROSPERO, identifier CRD42021233219, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021233219
the main goal of EHRs is to provide health care providers
with the patient's clinical data systematized
Data fragmentation due to legacy systems (non-interoperable) also hampers epidemiological assessment, which is critically important under outbreak, epidemic, and pandemic scenarios (13). Albeit standards to maintain optimal interoperability with EHRs have been defined, achieving a satisfactory level of integration remains a demanding task (34, 35). Pfeuffer et al. (36) claim that interoperability
and issues alike constitute the main obstacles to implementing an EHR
we conducted a Systematic Literature Review (SLR) on the main approaches applied to EHR development in Brazil
Our paper presents (i) the technological resources
(ii) the organization and structuring of EHRs for data collection; (iii) a brief discussion of the contributions and evolution of EHRs development in Brazil
HIS are powerful tools that allow for timely decision-making by the several management levels; however
data must be first qualified by robust models of integrity
The Federal Government's support has greatly underpinned this digital transformation by making available large-scale HIS used by state and local health departments. The Health Information System for Primary Care (SISAB, its Portuguese acronym) (46)
established through a 2013 ministerial decree
electronically records data on consultations and activities
SISAB constitutes the predominant HIS in Primary Health Care (PHC) in Brazil
Available in virtually every Brazilian municipality
it has been used for funding and adherence purposes concerning the programs and strategies laid out in the National Primary Care Policy (PNAB
To overcome this issue, the MoH has established technological and semantic standards. Hence, Ministerial Order No. 2,073 of 2011 (49) regulates the use of interoperability standards and health information for those systems, indicating the main standards that can or should be adopted. Table 1 lists such standards and their respective descriptions (50)
Interoperability standards set forth in the Ministerial Order No
Other Brazilian organizations are also interested in and contribute to developing and implementing EHRs
These include the Brazilian Health System Informatics Department (DATASUS
its Portuguese acronym) of the Brazil's MoH
the National Council of Health Secretaries (CONASS
the National Council of Municipal Health Secretariats (CONASEMS
such organizations have been engaged in discussions about the impact and importance of adopting EHRs for advancing digital public health in the country
And “Connect SUS” is a case in point
Connect SUS is a national health platform for citizens, health practitioners, and managers (55). Its purpose is to integrate the citizen's health information into an extensive data network, thus providing health practitioners and managers with access to a wide range of health data with the potential to improve the continuity of care and decision-making (42, 56)
It is a platform for citizens to access their health information based on their health care records in the SUS and private services
Connect SUS implementation is expected to improve health services delivered to the population
This SLR is based on the systematic review guidelines proposed by Kitchenham (60) and follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (61). Moreover, we registered this review in the International prospective register of systematic reviews (PROSPERO) (62), under registration No. CRD42021233219 (63)
This study sought to investigate EHR development in Brazil and identify major approaches and gaps in this context. Given this premise, we designed Research Questions (RQs) (see Table 2) to compile relevant information
We searched and selected papers published between 2011 and 2021 in Science Direct
and SciELO databases using the search terms (“electronic medical record” OR “electronic patient record” OR “electronic health record”) AND (Brazil OR Brasil)
it consisted of three steps: (i) paper identification and organization
(ii) paper triage through quality screening (inclusion and exclusion criteria)
and (iii) paper analysis according to quality criteria
we selected the first set of articles the database search returned
all articles were reviewed by three authors
In step (iii), the eligible articles were fully read according to the Quality Assessment (QA) protocol and its criteria (see Table 4)
a score measuring the paper's relevance to this review was assigned for each criterion
This score is distributed in weights for possible answers to the QA criteria included in the primary studies
with 1.0 being the most relevant weight and 0 being the least
For each paper, a score (Equation 1) was calculated using the arithmetic mean of the QA criteria scores (Table 4)
all papers scoring greater than or equal to 0.5 (0.5 ≤ score) were selected for this research and now comprise the last set of papers
along with the data extracted from the papers
were adequately registered in a spreadsheet and stored on Rayyan
and potential answers to the RQs were extracted from the set of papers selected in step (iii)
Such answers allowed us to perform the final analysis and achieve this systematic review's purpose
totaling 42 articles for the entire reading and evaluation based on the AQs
The detailed analysis and assignment of the AQ values were discarded in 28 papers from the search for not reaching the defined score (≥0.5)
Flowchart adapted from the PRISMA with result of the execution of the systematic review protocol
Regarding the articles excluded, 60.71% (17) did not address technical concepts about the development of EHR, 25% (7) had content related only to the use of EHR, and 10.71% (3) were not associated with research on EHR in Brazil, and 3.58% (1) were not available for reading
14 articles were assessed for this systematic review's final analysis and investigation
Thus, engaging in a more comprehensive analysis of the 14 selected articles, it was possible to highlight four different approaches related to the development of EHR in Brazil, as shown in Figure 2A
Most articles report the need to implement interoperability between EHR and other HIS
the other publications report the need for permission functionalities to visualize patient data
the absence of real data to perform data persistence tests in EHR
and the importance of defining a methodology for the development of EHR
Analysis of accepted articles after performing the systematic review protocol
(A) Approach discussed; (B) Standards and technologies used; (C) Percentage of EHR developed according to the Brazilian Ministry of Health; (D) Percentage of EHR developed using standards established by Brazilian guidelines
The included articles were published during the following years: 2012 (n = 1)
Characteristics of the selected set of article
the authors present the steps of the archetype modeling process to support the construction of an interoperable regional EHR system
The decision to use archetypes was based on the flexibility and easiness these artifacts can offer when reusing medical knowledge
The authors judge that the ISO 13606 reference model
together with the definition of archetypes
is sufficient to meet the specificities for creating a regional EHR system for primary health care in a federative unit of Brazil
These are only examples of possible headings
Please feel free to use different headings to best describe your results
A few years later, Maia et al. (66) presented a similar study
proposing a model for the process of creating archetypes that can subsidize the development of EHR
considering the legislation of the Unified Health System in Brazil
and primary artifacts for the governance process of the archetype to be used in the interoperable EHR of health care networks
quality requirements were defined to address the clinical
and governance information of the archetype development process used when creating the model
This process can significantly increase the coherence between EHR systems and the public policies established in Brazil
supporting the organization of public health information in a scenario with the initial implementation of EHR
Pahl et al. (67) investigated the feasibility of using openEHR for the digital representation of demographic and clinical data required by the Ministry of Health regarding obstetric follow-up in Brazilian health units
were performed on the Clinical Knowledge Manager (CKM) platform using the LinkEHR archetype editor
The study highlights that CKM provides archetypes to represent a particular data snippet and can represent missing information in a given context
The results further reinforce confidence that the openEHR approach is highly usable for international representation of clinical and demographic data and also confirm that openEHR is sufficient for national-level data representation in the context of the digital transformation of primary health care in Brazil
Souza et al. (68) stated that even with the definition of standards
there is still a deficiency when it comes to technical interoperability solutions between EHR systems for public health organizations in Brazil
The authors present an architecture capable of providing technical interoperability between EHR systems in public health organizations based on an evaluation of different interoperability architectures proposed in the literature
The proposed architecture was based on the Social and Health Information System of the Lombardy Region
and some adaptations were made to meet Brazilian requirements and legislation
The adoption of an SOA-based architecture promoted interoperability among electronic record systems
this architecture integrates different applications using the HL7 message exchange standard
The main purpose of this suggestion was to ensure that administrative data at the healthcare organization level is synchronized with a central citizen registry
which contains up-to-date information on all citizens in the region
where it was possible to see the feasibility of applying architecture in organizations using different EHR
The lack of standardization in patient data collection considerably hinders the continuation of adequate care, especially for patients who pass through different levels of care. To improve the quality of this process in the context of tuberculosis, Pellison et al. (69) proposed an architecture that uses semantic web standards recommended by W3C (World Wide Web Consortium) as interoperability tools for reducing the costs of records storage and management
The proposed architecture expects to provide a single
and complete database of the assisted population
The authors intend to evaluate the impact of integration and interoperability methods between systems from e-SUS Primary Care (e-SUS AB
in Portuguese: e-SUS Atenção Básica)
Notification and Monitoring System for Cases of Tuberculosis in the State of São Paulo (TBWEB
its Portuguese acronym) and information systems from other hospitals
The evaluation metrics related to data quality include completeness
The semantic web was also a topic of research in the work conducted by Lima et al. (70)
They presented the implementation of security mechanisms for a semantic API that allows the extraction of health data related to tuberculosis cases from a regional health information system called SisTB
designed to generate notifications and track patients diagnosed with tuberculosis
The proposal establishes access levels for exchanging health data between systems using the semantic API
the authors believe it will be possible to semantically segment the tagged content in SisTB to allow access only to specific systems with an appropriate access level
Systems that do not meet the access level defined by the API will not be allowed to view the information at that level
Systems that do not integrate the ecosystem will be able to access the data through identification and authentication through public/private keys
the proposal presents an alternative for data sharing
considering aspects related to semantic interoperability
and access authorization to the data stored in the system
Crepaldi et al. (71) presented the project of the SisTB ecosystem
which is formed by a set of systems and applications designed to assist in the treatment of tuberculosis and improve the routine of health professionals regarding the monitoring of their patients
The ecosystem was designed based on the need to store and consult information and make it available quickly and easily for reporting
as recommended by the Brazilian Ministry of Health
The SisTB ecosystem has layers to manage and interpret the information available from the other systems
The interoperability and security layers are responsible for the ability to exchange data between SisTB and other systems securely
The interoperability layer has its base on standards recommended by the W3C and the semantic web paradigm
The semantic interoperability can be achieved by defining and using a domain-specific ontology
This ontology represents the concepts and specificities of tuberculosis in the Brazilian context
reaching functional interoperability through communication protocols
The security layer provides robust methods for transferring data between authorized applications over the Internet
the development of the SisTB ecosystem intends to minimize the problem related to the use of several isolated information systems without interoperability
From the perspective of improving access to patient data stored in multiple locations, Roehrs et al. (72) proposed a distributed and interoperable architecture model
which uses blockchain technology and the openEHR interoperability standard to integrate patient health records
One of the main goals of this architecture is to provide interoperability between different healthcare providers by enabling access to patient health records
OmniPHR proposes using a P2P network to represent a hierarchically organized
and distributed Personal Health Record (PHR) in data blocks chained over the network
The proposed architecture contributes to secure sharing since the authors present strategies to promote the unification of patient health data
The evaluation of the information exchange security of the architecture proposed by Roehrs et al. (72) was performed from the implementation of OmniPHR Roehrs et al. (73)
The authors used real data to test the blockchain network implementation to achieve this goal
measuring the architecture's performance in several concurrent access scenarios
The evaluation sought to reflect the splitting
and communication of data blocks in the network
The results indicated that combining the openEHR standard with blockchain technologies created a unified and interoperable view of healthcare data
the implementation of the OmniPHR model showed that it is possible to integrate distributed data into a unified view of patient health records
making up-to-date patient health information available to improve the quality of care
Still using the same proposal, Roehrs et al. (74) evaluate the interoperability and integration structure of the OmniPHR prototype using different healthcare standards currently adopted
The analyzed model has the organizational domain
which aims to maintain the original data contained in the healthcare providers' databases
and the personal domain consists of a middleware with the inclusion of repositories where the PHR is stored
The organizational domain provides for the input of open and legacy standards
The reference model Medical Information Mart for Intensive Care (MIMIC-III) was used to evaluate the legacy standards
The middleware is composed of a translator component in the personal domain
making it possible to receive data in any of the three formats mentioned above
the translator component reads and converts this data into the openEHR ontology through a Natural Language Processing (NLP) algorithm
The authors state that it is possible to integrate different patterns by using the ontology
allowing inferences to be made from this data
The research results demonstrated the possibility of a unified and updated view of PHR data for patients and healthcare professionals
presenting a solution based on artificial intelligence with NLP
and an open healthcare standard to achieve semantic interoperability
this proposal contributes to obtaining original data from different standards in a single format
The main contribution of the platform is the development of an ontology that aligns the healthcare domain (openEHR) with the IoMT technical domain (SSN)
This ontology serves as a model for data storage following a semantic web approach capable of identifying sensors and automatically translating the detected data into Web Ontology Language (OWL) individuals
thus ensuring semantic coherence between the two domains
concerns the semantic extension of the openEHR model to the M2M domain
which enabled definitions of heterogeneous IoMT devices within a single data model
The study favors the development of modern healthcare services
with interoperability between different devices that compose an IoMT platform and the EHR
for retrieving and maintaining medical records
The authors show the feasibility of using devices (smartphones
and tags) for patient monitoring while maintaining secure access to EHR information on a local network
The analyzed architecture uses Near Field Communication (NFC) technology for patient identification
The healthcare professional uses a device to scan the NFC tag under the patient's possession to access patient information
The experiments performed show that the system implemented had high usability among healthcare professionals and demonstrated that the architecture is a viable alternative to prevent intruders from accessing the devices and
the patient's confidential information
coded according to openEHR formalism to promote research and fostering development
offer subsidies for more robust and reliable testing of EHR systems based on the openEHR model
This foundation has the potential to contribute to the engineering
and consequently widespread adoption of openEHR-based electronic health record systems
The insertion of EHR for patient follow-up has been used for a few years now. These systems, considered legacy, have a lot of important information and somehow must keep up with the evolution of technology. França et al. (78) describes the development of an EHR system focused on data integration against a series of legacy systems that store important information about patients
appointments and other data from a public hospital in Brazil
and the need for data replication in different systems is recurrent
Due to the restrictions found in this scenario
the proposed solution consists of using Service-Oriented Architecture (SOA) principles and techniques to gather all the important information from the legacy systems and map them into services to be consumed by the EHR system
inspired by ISO/IEC 25010 called Service-Oriented Architecture Quality Model (SOAQM)
with multiple views of architecture and software design to guide the EHR system's development process
The proposed model defines the actual applicability of ISO/IEC 25010 quality characteristics and the essential attributes for applications in the SOA context
the EHR development process is guided by the quality of the SOAQM values attributes in software development from the early stages
The model approached emphasizes the importance of the comprehensive definition of the architecture
enabling the definition of essential artifacts to understand and maintain the developed system
This SLR investigated articles that address technological resources and standards used for EHR development in Brazil
Fourteen articles were included and analyzed after performing the SLR protocol
It was possible to observe the main approaches related to the theme
the technologies and standards used to overcome the existing problems
and guidelines defined by the Brazilian Ministry of Health to develop EHR
a generalization in which several systems bound to this modeling can use this base for testing
reducing problems related to the absence of accurate data for testing
the technology meets those needs related to implementing interoperability in EHR
Another relevant aspect in view of the analyses performed consists in the adoption of a minimum data set with the main information that must be collected from each patient. Pellison et al. (69) show in their work that the ecosystem developed is composed of forms made available by the Ministry of Health for the detailed follow-up of tuberculosis patients
The adoption of a minimum data set assists in the standardization of data and can minimize the difficulty of collecting the essential information for the follow-up and evolution of the disease
This information enables a more comprehensive scenario for the decision-making process
This aspect becomes increasingly necessary
especially by the impositions in the face of digital health transformation in Brazil and global health
storage of health data across different organizations
and standardization of data in health records are important factors to look at for the development of EHRs
the main objective is to make patient health data securely available to promote quality in ongoing clinical care
The lack of implementation of these factors can create challenges for the advancement of digital health
such as the unfeasibility of care provided by a variety of professionals in different health care institutions; the complexity of a unified and comprehensive view of the patient due to data fragmentation among different health care providers; and
the unavailability of data for continuity of care in case of change of health care service
the analyzed characteristics contribute to the need for an interoperability architecture
presenting relevant aspects that can achieve objectives related to the development of EHR
the works studied and analyzed in this systematic review pointed to the interoperability problem in terms of HIS in Brazil—notably
an aspect that directly impacts the fragmentation and quality of health information
This pressing problem poses many challenges to Brazil because the quality
and evaluation of patient data and information plays a pivotal role in guiding public health policies
this phenomenon is directly related to the integration not only of HIS but mainly of two crucial areas for the SUS
which are Health Surveillance and Health Care
In this context, there are numerous obstacles to interoperability. In Brazil, there is currently a large number of health information systems, many of them obsolete. For instance, the Notifiable Diseases Information System (SINAN) is not available in the RNDS, nor has it been integrated with the systems developed by the Brazilian MoH and many others (11, 48)
This scenario is even more critical because the MoH
often does not recognize the conditions of the technological infrastructure in a country where there is enormous cultural
The country's political instability and the lack of stable job positions for information technology professionals is also a big issue and therefore constitutes a strenuous challenge
Such challenges can be overcome over the medium and long term
it is necessary to guarantee the full participation of states and municipalities
It is fundamentally necessary to include them not only in the planning for the use of new technologies after they are ready but in a top-down model
It is essential to develop a logic of incorporating technologies from the territories
states and municipalities must have the autonomy to create
and then integrate their health information systems with the federal government in a down-top model
An important step has already been taken in this direction through the RNDS
it is still necessary to define the minimum data models for the diverse demands of the SUS
this is not a trivial task in a country as complex as Brazil
it is essential to highlight poor communication between information technology professionals
Articulated and synergistic communication within this triad is necessary for including new interoperable technologies that can meet the needs of the SUS more effectively
especially for managing more qualified information
It is noteworthy that the poor communication among these actors is a recurrent problem in the country
however brilliant they may be from a computational perspective
in addition to technical cooperation actions and effective communication
the parties involved also prioritized transparency and social control
which served as inductive mechanisms for adhering (mitigated resistance) to online technologies capable of providing more timely data and information
The study addressed in this paper presented a comprehensive overview of the use and development of EHR in Brazil
highlighted and discussed the problems related to the theme
The results point to interoperability as a necessary aspect
which will require a greater interaction HIS by sharing data safely and reliably
Other important factors for the development of EHRs are related to the application of technology to improve the security of data visualization and sharing
and the appropriate definition of the EHR architecture
these studies present characteristics and the main technologies that can contribute to research on the development of EHR
taking into account the Brazilian scenario
the implementation of EHR adhering to the most comprehensive interoperability standards will increase the capacity of health services regarding the basic principles of PHC
Brazil needs to accelerate and support initiatives that are developing actions to promote the deployment of EHR in a coordinated manner
as well as interoperability between public and private services
The original contributions presented in the study are included in the article/supplementary material
further inquiries can be directed to the corresponding author/s
and RV: preparing the manuscript and editing and revision
and AC: manuscript review and modification
All authors contributed to the review of the paper and approved the submitted version
This study was supported by Brazil's Ministry of Health
We kindly thank the Laboratory for Technological Innovation in Health (LAIS) of the Federal University of Rio Grande do Norte (UFRN) and the Brazilian Ministry of Health for supporting the research
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations
Any product that may be evaluated in this article
or claim that may be made by its manufacturer
is not guaranteed or endorsed by the publisher
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Chioro A and Valentim RAM (2022) Electronic health records in Brazil: Prospects and technological challenges
Received: 08 June 2022; Accepted: 18 October 2022; Published: 03 November 2022
Copyright © 2022 Barbalho, Fernandes, Barros, Paiva, Henriques, Morais, Coutinho, Coelho Neto, Chioro and Valentim. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY)
*Correspondence: Ingridy M. P. Barbalho, aW5ncmlkeS5tYXJpbmFAbGFpcy5odW9sLnVmcm4uYnI=
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Volume 7 - 2020 | https://doi.org/10.3389/fmed.2020.00354
Acute respiratory distress syndrome (ARDS) is the main cause of death in COVID-19 patients (1, 2). In recent years the relationship between this respiratory syndrome and inflammatory system dysregulation has been discussed (3). Patients with ARDS could present distinct endophenotypes with respect to immune alterations: hyper- or hypo-inflammatory profiles (4, 5)
In fact, people with COVID-19 present high levels of systemic inflammatory biomarkers (15), and the detection of these forms part of the preliminary guidelines for the diagnosis and treatment of SARS-CoV-2 (12). Accordingly, multiple experimental treatments with immune-suppressing or stimulating drugs have been tested, aiming to reduce the pro-inflammatory cascade and, thus, mortality (16–18)
In this sense, the consequences are systemic and affect the elderly especially, causing changes in body composition and an imbalance between availability and energy demand that can affect the quality of life and functionality of the elderly (28). In addition, the inflammation overload makes the elderly more susceptible to several other diseases, such as cardiovascular disease, diabetes, osteoporosis, and ostearthrosis (29)
In this context, lifestyle and nutraceuticals arise as important prophylactic interventions to reduce the burden of baseline inflammation in older adults and consequently improve quality of life, mobility, cognition, mood, and metabolic and immune balances, especially during the pandemic. It is possible that COVID-19 will be a long pandemic, with multiple infection waves (30); therefore
these strategies are especially important since they can be adopted in the long term and under physical social isolation
The aim of this study is to discuss how diet and nutraceuticals and lifestyle as complementary therapies could help older adults during the COVID-19 pandemic
the vitamin C supplementation did not significantly improve organ dysfunction scores or alter biomarkers of inflammation and vascular injury
controlled trials and large-population studies should be conducted to prove these hypotheses
Sedentary behaviors such as longer screen time and lower physical energy expenditure can aggravate physical and mental conditions (50), especially in this period of social isolation. Therefore, reducing the time spent in sedentary behavior at home is of great importance for maintaining health during lockdown (51)
increasing the time spent engaging in exercise is essential
Lifestyle therapy consists of adopting a health routine that includes a balanced diet, physical exercise, relaxation and meditation techniques, and good sleep (38, 48)
A robust body of evidence has demonstrated the benefits of these modifications of lifestyle for mental health, mainly for mood symptoms (52–55), indicating that lifestyle therapy is an effective strategy for preventing and treating some mental disorders (56–59), including in old adults (45)
Considering the high rate of risk factors being present in older adults as a risk group (67), it is necessary to build tools directed at this group that aim to reduce sedentary behaviors and to keep them active during the COVID-19 pandemic. As well as setting prescribed exercises and encouraging increased levels of daily physical activity, all movements should be stimulated, even simple routine activities such as those related to cleaning the house (68)
Successful mind-body interventions in older adults have shown improvements in different aspects, such as pain control, sleep quality, attention, global cognition, and working memory (77). Additionally, positive results were recently presented for the reduction of depressive symptoms through internet mindfulness therapy in this population (78)
applying relaxation and meditation therapies is urgent
as these can improve mental and physical health in older people who are in isolation
Social physical isolation due to COVID-19 can bring serious risks to health if older adults continue with
which includes a lack of physical activity and a diet low in nutrients and rich in comfort foods
strategies should be encouraged to promote and raise awareness among the older population about the application of lifestyle and nutraceutical tools
These interventions have great potential for insertion in public policies in different contexts due to their low cost
We are aware that it can be difficult to apply all of these suggestions
but every step is important and better than none
a healthy lifestyle should be encouraged as an intervention to prevent frailty among older people
and a multi-professional care system should act in this time of COVID-19 to reduce risks and avoid damage related to inflammation overload in older adults
and writing—original draft preparation
All authors contributed to the article and approved the submitted version
The authors declare that this study was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest
NG-C was supported by the CAPES Foundation of the Brazilian Ministry of Education (Research Fellowship 88887.466701/2019-00) and the National Science and Technology Institute for Translational Medicine (INCT-TM Fapesp 2014/50891-1; CNPq 465458/2014-9)
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Received: 07 May 2020; Accepted: 15 June 2020; Published: 26 June 2020
Copyright © 2020 Neto, Tavares, Galvão-Coelho, Schuch and Lima. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY)
*Correspondence: Leônidas Oliveira Neto, bGVvbmlkYXNvbGl2ZWlyYW5ldG9AZ21haWwuY29t
The writer was committed to literature and the reader
Brazilian literature lost one of its great exponents
the São Paulo writer Lygia Fagundes Telles
Recipient of great national and international literary honors
the São Paulo Association of Art Critics Award (APCA)
She was a member of the Academia Paulista de Letras and
she was nominated for the Nobel Prize in Literature
her short stories were produced over eight decades
bringing together his production in this genre
he avoided adhering to any of the literary trends that he saw succeeding him
becoming unmistakable - and never identified with any of these fashions or trends”
Despite this, the author considered the novel as the starting point of her work. stone circle (1954), with which he would have reached “literary maturity”, according to critic Antonio Candido. In a letter to the author after receiving the Camões Prize, Candido boasted of having been "one of the first to discern in the beginning of 1946 the great writer who was emerging”[1]
to the times when they were both students at the Largo São Francisco Law School
and to a certain literary competition promoted among students
identified by Candido in both short stories and novels
something that few writers manage to achieve
In his presentation to the first edition of During that strange tea (2002)
novels stone circle e The girls (1973) already had more than thirty editions
The positive reception among readers seems to have been important for the author. In a letter to Hilda Hilst, in 1989 (available at the Alexandre Eulálio Documentation Center at Unicamp), Lygia celebrates the sales success of The naked hours (1989)[2]
then on the bestseller list: “I'm happy with the result
Perhaps their surprisingly accessible language
the precision of the words and Machado's bias
This is what we see in the short story "A burning heart" (2012)
tells the narrator about his “burning heart”
The boy decides to regenerate her by marrying her
Without giving away the details of the narrative
gives any indication of an ironic tone; is the set of the character's actions that will transform the idea of the burning heart
becomes something negative in the eyes of the reader
But perhaps it is Telles' characters that really seduce readers
recalls writer Alberto da Costa e Silva (2010)
“at drawing her characters with just a few lines
it is not with the description of her posture and her features [...] that she places them within us
the intonations of speech and the contraction of the lips to a muxoxo”
from which the red fruits of the title hang
the hair that Marcelo held like the mane of one of his horses
Olivia is constructed as a kind of femme fatale
from whose clutches the boy could not escape
sometimes causes Romana and Tigrela to become confused in the story
What we have in these examples are the characters' fundamental traits
their core being revealed fragment after fragment
it is his interior that is revealed in every feature
with the contradictions typical of all human beings
Telles condenses the meanings of his texts into what Walnice Galvão called “pregnant images” - “an extreme synthesis of everything the story insinuates” -
to which we can add the cherries and the burning heart of the other mentioned tales
This way of constructing narratives gives a unique expressive force to his texts
which acquire uniqueness through the writer's words
This is what critic and writer José Castello suggests
in an afterword to the 2009 edition of Seminar the two rats: “Lygia is a writer who works with mysteries and small revelations
don't get it wrong: her writing is neither religious nor mystical
it is in the way it excavates banality in search of its core
it hides in her inclination to value the subterranean zones of existence.”
It is possible that the fragment above is not unknown to the public; In January of this year
he appeared in one of the Unicamp entrance exam questions
the subject of which was precisely “Rat Seminar” (1977)
an allegorical tale about power relations in society
Comvest's choice of the work was well received by the press and teachers
which reiterates Lygia's importance in the panorama of contemporary Brazilian literature and reinforces the topicality of the themes present in her texts
other facets of the writer that still deserve to be explored
In Lygia's letters and photographs that make up the Hilda Hilst and Abílio Ferreira de Almeida Funds
we find mention of the successes she achieved with her work
in Brazil and abroad; the closeness between Lygia and Hilst
whom she called “my sister”; a glimpse of his daily life
or in seasons outside the country; experimentation on stage
with the arduous and lonely job of writing
she confesses that she could not “write with hate”; it was peace
that she sought when creating her texts: “in peace includes work
In peace there is also love.” The “passion for words”
which the author mentions in her letters and in her inauguration speech at ABL
Commitment to literature and to others: “But the writer needs to see himself and others in the transparency of the water
He has to overcome fear to write that fear
*Ana Maria Ferreira Côrtes has a degree in Literature and is a doctoral candidate in the Literary Theory and History Program at the Institute of Language Studies at Unicamp
CANDIDO, Antonio. The new narrative. In: ___. Education at night and other essays. São Paulo: Ática, 1989. Available at: https://is.muni.cz/el/phil/jaro2014/PO0B203/Antonio_Candido_A_nova_narrativa.pdf
_______________. [Master hand that never fails]. Recipient: Lygia Fagundes Telles. São Paulo, May 15, 2005. 1 letter. Available in: https://correio.ims.com.br/carta/mao-de-mestre-que-nunca-falha/
During that strange tea: memory and fiction
Lygia Fagundes Telles – The Person and the Writer
2010.
Inaugural speech at the Brazilian Academy of Letters
Alexandre Eulálio Documentation Center (CEDAE/UNICAMP)
Campinas: Alexandre Eulálio Documentation Center (CEDAE/UNICAMP)
[1] Correspondence available in the Moreira Salles Institute Collection. Available in: https://correio.ims.com.br/carta/mao-de-mestre-que-nunca-falha/
[2] Information present in the description of the CEDAE document
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