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Clinical Sciences
Assessing screening practices among health care workers at a tertiary-care hospital in Sao Paulo, Brazil
Ana Claudia Gonçalves-SilvaI, Cristiane Murta-NascimentoII, José Eluf-NetoI
I Departamento de Medicina Preventiva, Faculdade de Medicina da Univer-sidade de São Paulo - Sao Paulo/SP, Brazil
II Servei d’Avaluació i Epidemiologia Clínica, Hospital del Mar-IMAS - Barcelona, Spain, Tel.: 55 11 3061.8278
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para170" class="elsevierStylePara elsevierViewall">Interest in using screening procedures to identify diseases in asymptomatic individuals began to increase in the late 1950s&#46; However&#44; it was only in the early 1980s that health authorities began to set up task forces charged with devising criteria to assess the effectiveness of these and other procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;2</a></p><p id="para180" class="elsevierStylePara elsevierViewall">The potential benefits of screening include the early detection of disease&#44; the prevention of serious illness or disability and improved survival&#46;<a class="elsevierStyleCrossRefs" href="#bib3">3&#44;4</a> However&#44; not all screening procedures have shown benefits&#44; and some may cause harm to the health of the individual&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a></p><p id="para190" class="elsevierStylePara elsevierViewall">Various studies have shown that certain screening practices are performed in an inappropriate manner&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib9">9</a> For instance&#44; although many females in developing countries undergo an annual Papanicolaou &#40;Pap&#41; smear&#44; there are also many who have never had one&#46; In addition&#44; urine tests&#44; electrocardiography &#40;ECG&#41; and blood workups are frequently carried out as screening procedures&#44; despite the fact that there is no evidence that these tests provide benefits&#46; In contrast&#44; other procedures that are known to be effective&#44; such as the fecal occult blood test &#40;FOBT&#41; for colorectal cancer in individuals 50 years of age or older&#44; are rarely performed&#46;</p><p id="para200" class="elsevierStylePara elsevierViewall">Physicians and other health care workers &#40;HCWs&#41; are a direct source of health information for the population&#46; Therefore&#44; it is important that the information they disseminate be accurate and that the screening procedures they recommend be appropriate&#46; In addition&#44; previous studies have reported that the personal health habits of physicians are major predictors of their counseling practices&#46;<a class="elsevierStyleCrossRefs" href="#bib8">8&#44;10</a></p><p id="para210" class="elsevierStylePara elsevierViewall">Brazil lacks a nationwide screening program&#44; and the guidelines regarding this issue are conflicting&#46; In addition&#44; little is known about the personal health habits of HCWs in Brazil&#46; Therefore&#44; the aim of the present study was to ascertain the extent to which screening procedures &#40;with and without evidence of effectiveness&#41; are practiced among HCWs at a tertiary-care hospital in Sao Paulo&#44; Brazil&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">METHODS</span><p id="para220" class="elsevierStylePara elsevierViewall">From February 2001 to September 2003&#44; a cross-sectional study involving HCWs was carried out at the largest tertiary-care facility &#40;with approximately 2&#44;200 beds&#41; in Latin America&#44; located in the city of Sao Paulo&#44; Brazil&#46; The study population was composed of physicians&#44; nurses and nursing assistants who worked at three institutes and who together included 82&#46;5&#37; &#40;4&#44;333&#41; of the HCWs employed by the hospital&#46;</p><p id="para230" class="elsevierStylePara elsevierViewall">The inclusion criteria were being 40&#8211;69 years of age and an employee of the hospital&#46; Individuals on leave were ineligible&#46; Subjects were randomly selected from a list of physicians&#44; nurses and nursing assistants&#46; Sample size was calculated based on the expected frequency of three screening procedures&#58; Pap smear &#40;among females&#41;&#59; breast self-examination &#40;among females&#41;&#59; cholesterol screening &#40;among both genders&#41;&#46;</p><p id="para240" class="elsevierStylePara elsevierViewall">The selected sample comprised 170 nursing assistants &#40;162 females and 8 males&#41;&#44; 26 nurses &#40;all female&#41; and 137 physicians &#40;40 females and 97 males&#41;&#46; Face-to-face interviews were conducted by trained personnel&#46; A structured questionnaire was developed specifically for use in the present study&#46; The questionnaire was designed to collect data related to sociodemographic characteristics&#44; medical history and family history of certain diseases&#44; as well as a list of screening procedures&#46; For each procedure&#44; respondents were asked to provide the age at which they were first tested&#44; the number of times they had undergone the test and the time elapsed since the last test&#46; We defined a screening procedure as any procedure to which subjects had been submitted of their own volition or as part of prenatal care or a work-related medical examination&#46; We attempted to clarify the differences between screening practices and diagnostic tests for the participants&#46; The questionnaire included procedures with grades of recommendation of A&#44; B&#44; C&#44; D or E&#44; in accordance with the 1996 edition of the United States Preventive Services Task Force &#40;USPSTF&#41; guidelines for routine screening &#40;<a class="elsevierStyleCrossRef" href="#t3-cln_65p151">Chart 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> The 17 procedures analyzed were divided into three groups&#58;</p><elsevierMultimedia ident="t3-cln_65p151"></elsevierMultimedia><p id="para250" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="celist60"><li class="elsevierStyleListItem" id="celistitem170"><span class="elsevierStyleLabel">1&#46;</span><p id="para260" class="elsevierStylePara elsevierViewall">screening for diabetes and cardiovascular diseases&#44; as well as for their risk factors&#58; serum glucose measurement&#59; blood pressure measurement&#59; cholesterol measurement&#59; resting ECG&#59;</p></li><li class="elsevierStyleListItem" id="celistitem180"><span class="elsevierStyleLabel">2&#46;</span><p id="para270" class="elsevierStylePara elsevierViewall">screening for cancer&#58; FOBT&#44; digital rectal examination and sigmoidoscopy &#40;for colorectal cancer&#41;&#59; mammography&#44; breast self-examination and clinical breast examination &#40;for breast cancer&#41;&#59; Pap smear &#40;for cervical cancer&#41;&#59; prostate-specific antigen &#40;PSA&#41; test and digital rectal examination &#40;for prostate cancer&#41;&#59;</p></li><li class="elsevierStyleListItem" id="celistitem190"><span class="elsevierStyleLabel">3&#46;</span><p id="para280" class="elsevierStylePara elsevierViewall">screening for other diseases&#58; urine test&#59; tuberculin skin test &#40;the Mantoux test&#41;&#59; chest X-ray&#59; bone densitometry&#46;</p></li></ul></p><p id="para290" class="elsevierStylePara elsevierViewall">Data were entered twice&#44; by two different operators&#44; into a database using the Epi Info program&#46; For each screening procedure&#44; we estimated the proportion of HCWs who had undergone the procedure at least once&#44; and we calculated the corresponding 95&#37; confidence intervals&#46;</p><p id="para300" class="elsevierStylePara elsevierViewall">The present study was approved by the local research ethics committee&#46; All participants provided written informed consent prior to the initiation of the interview process&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">RESULTS</span><p id="para310" class="elsevierStylePara elsevierViewall">Of the 364 randomly selected HCWs&#44; 22 &#40;6&#37;&#41; could not be located after three attempts and 9 &#40;2&#37;&#41; declined to participate&#46; Therefore&#44; the final sample consisted of 333 HCWs&#44; of whom 228 &#40;68&#46;5&#37;&#41; were female&#46; The mean age was 48&#46;8 years &#40;SD 6&#46;6 years&#41;&#46; Sociodemographic characteristics of the participants are summarized in <a class="elsevierStyleCrossRef" href="#t1-cln_65p151">Table 1</a>&#46;</p><elsevierMultimedia ident="t1-cln_65p151"></elsevierMultimedia><p id="para320" class="elsevierStylePara elsevierViewall">The prevalence of screening practices is shown in <a class="elsevierStyleCrossRef" href="#t2-cln_65p151">Table 2</a>&#46; For 204 &#40;61&#46;3&#37;&#41; of the respondents&#44; the determination of serum cholesterol levels had been performed as a screening procedure at least once&#46; Five males and 95 females began to monitor their cholesterol levels before the ages of 35 and 45 years&#44; respectively&#46; Resting ECG as a screening procedure was reported by 159 &#40;47&#46;7&#37;&#41; subjects&#44; and 25&#37; reported having undergone ECG more than six times&#46;</p><elsevierMultimedia ident="t2-cln_65p151"></elsevierMultimedia><p id="para330" class="elsevierStylePara elsevierViewall">Regarding screening for colorectal cancer&#44; only 6 subjects reported having been screened with the FOBT or sigmoidoscopy &#40;<a class="elsevierStyleCrossRef" href="#t2-cln_65p151">Table 2</a>&#41;&#46; Of the 228 females&#44; 164 &#40;71&#46;9&#37;&#41; had undergone a mammography as a screening procedure&#44; 219 &#40;96&#46;1&#37;&#41; had undergone their first mammography before the age of 50 and 216 &#40;94&#46;7&#37;&#41; had experienced a Pap smear at least once &#40;<a class="elsevierStyleCrossRef" href="#t2-cln_65p151">Table 2</a>&#41;&#46; Of the 105 males&#44; 70 &#40;66&#46;7&#37;&#41; had undergone PSA testing and 34 &#40;32&#46;4&#37;&#41; had been submitted to a digital rectal examination&#46;</p><p id="para340" class="elsevierStylePara elsevierViewall">More than 50&#37; of the subjects reported having undergone other screening procedures&#44; such as a chest X-ray and urine test&#46; For 75 &#40;32&#46;9&#37;&#41; of the females &#40;all of whom were &#8804; 64 years of age at the time of the test&#41;&#44; bone densitometry had been performed at least once&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">DISCUSSION</span><p id="para350" class="elsevierStylePara elsevierViewall">This is the first study to investigate personal screening practices in a random sample of HCWs at a tertiary-care hospital in Brazil&#46; We observed great variability in these screening practices&#46;</p><p id="para360" class="elsevierStylePara elsevierViewall">According to the 1996 USPSTF guidelines&#44; the recommended methods of screening for cardiovascular diseases are measurement of blood pressure &#40;for adults over 20 years of age&#41; and determination of serum cholesterol levels &#40;for males &#8805; 35 years of age and for females &#8805; 45 years of age&#41;&#46; More than 70&#37; of the HCWs investigated in the present study reported having had their blood pressure measured as a screening procedure&#46; It should be noted that this prevalence might have been underestimated given that the measurement of blood pressure in routine clinical appointments might not have been perceived as a screening practice&#46; However&#44; more than 38&#37; of the HCWs of both genders had never undergone serum cholesterol measurement as a screening procedure&#46; This is somewhat higher than the 23&#37; reported by the Behavioral Risk Factor Surveillance System for HCWs in the United States in 2001&#46;<a class="elsevierStyleCrossRef" href="#bib11">11</a> Although resting ECG is not recommended in asymptomatic individuals without risk factors for cardiovascular diseases&#44; we observed that nearly 50&#37; of the participants had been submitted to this test&#46; The exercise stress test&#44; for which there is also no evidence of a benefit in terms of a reduction in mortality&#44; had been performed on 8&#37; of the respondents &#40;data not shown&#41;&#46;</p><p id="para370" class="elsevierStylePara elsevierViewall">The USPSTF recommends the FOBT as a screening tool for colorectal cancer in all individuals &#8805; 50 years of age&#46; Of the 333 HCWs evaluated in the present study&#44; 131 &#40;39&#37;&#41; were in this age group&#46; However&#44; only 3 &#40;1&#37;&#41; reported having undergone this test as a screening procedure&#46; The 2008 Behavioral Risk Factor Surveillance System report<a class="elsevierStyleCrossRef" href="#bib11">11</a> showed that 20&#46;9&#37; of the participants aged &#8805; 50 years had undergone the FOBT within the past two years and that 61&#46;8&#37; had undergone sigmoidoscopy or colonoscopy&#46;</p><p id="para380" class="elsevierStylePara elsevierViewall">The 1996 USPSTF recommendation for breast cancer screening is mammography &#40;with or without clinical breast examination&#41; for females &#8805;50 years of age&#44;<a class="elsevierStyleCrossRef" href="#bib2">2</a> although an update of the guidelines recommends that the age range be expanded to females &#8805; 40 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib12">12</a> In our sample&#44; 28&#37; of the females reported that they had never undergone this test&#46; Although the evidence is insufficient to recommend breast self-examination as a screening practice&#44; 88&#37; of the female HCWs reported performing this examination on themselves&#44; routinely&#46;</p><p id="para390" class="elsevierStylePara elsevierViewall">Among the female HCWs evaluated&#44; the prevalence of having had at least one Pap smear was 95&#37;&#46; This prevalence was much higher than the 69&#37; and 86&#37; reported&#44; respectively&#44; by Nascimento et al&#46;<a class="elsevierStyleCrossRef" href="#bib7">7</a> and Pinho et al&#46;<a class="elsevierStyleCrossRef" href="#bib13">13</a> for females in the city of S&#227;o Paulo&#46;</p><p id="para400" class="elsevierStylePara elsevierViewall">Although the 1996 and 2008 USPSTF guidelines do not recommend PSA testing as a screening procedure&#44; 67&#37; of the male HCWs who participated in the present study reported having had the test&#46; A high prevalence of PSA testing &#40;78&#46;6&#37;&#41; was also reported among 135 lecturers and professors &#8805; 51 years of age at a medical school in Belo Horizonte&#44; Brazil&#46;<a class="elsevierStyleCrossRef" href="#bib14">14</a></p><p id="para410" class="elsevierStylePara elsevierViewall">Regarding the other screening procedures investigated in the present study &#40;urine test&#44; Mantoux test&#44; chest X-ray and bone densitometry&#41;&#44; a large proportion of HCWs reported having undergone these tests several times&#46; However&#44; except for bone densitometry &#40;recently given a grade B recommendation among females &#8805; 65 years of age&#41;&#44; the other tests are not recommended&#46;</p><p id="para420" class="elsevierStylePara elsevierViewall">The present study has several limitations&#46; First&#44; it was conducted at a public&#44; tertiary-care teaching hospital&#46; Therefore&#44; it is not possible to generalize the results to HCWs at other institutions&#46; Second&#44; our sample was composed of a heterogeneous group of HCWs and physicians in various specialties&#46; It has previously been reported that the beliefs of HCWs concerning the effectiveness of different screening practices may vary by specialty&#46;<a class="elsevierStyleCrossRef" href="#bib15">15</a> Finally&#44; we used the 1996 USPSTF recommendations as the gold standard because there are no Brazilian guidelines for many of these screening procedures&#46; However&#44; there are guidelines established by other foreign institutions that differ from the USPSTF guidelines&#46;</p></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">CONCLUSIONS</span><p id="para430" class="elsevierStylePara elsevierViewall">The present study investigated screening practices among HCWs at a tertiary-care hospital&#46; Findings showed that a great proportion of the subjects had undergone tests that are considered unnecessary or for which there is insufficient evidence of their usefulness as screening tools&#44; whereas certain recommended tests had been neglected&#46; Because there are no standardized screening programs in Brazil and individuals are&#44; therefore&#44; submitted to screening tests without sufficient knowledge of their effectiveness&#44; it is important that the public authorities in Brazil review the scientific evidence regarding the benefits and hazards of screening procedures&#44; develop guidelines that address these issues and disseminate the information among HCWs&#46;</p></span></span>"
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            2 => "Health personnel"
            3 => "Hospitals"
            4 => "Brazil"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVE</span><p id="spara50" class="elsevierStyleSimplePara elsevierViewall">To ascertain the extent to which screening procedures &#40;with and without evidence of effectiveness&#41; are practiced among health care workers at a tertiary-care hospital in Sao Paulo&#44; Brazil&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHODS</span><p id="spara60" class="elsevierStyleSimplePara elsevierViewall">From February 2001 to September 2003&#44; a cross-sectional study involving physicians&#44; nurses and nursing assistants &#40;aged 40 to 69 years&#41; was carried out at a tertiary-care hospital in the city of Sao Paulo&#44; Brazil&#46; Subjects were interviewed using a questionnaire that addresses 17 procedures with grades of recommendation of A&#44; B&#44; C&#44; D or E&#44; in accordance with the 1996 United States Preventive Services Task Force guidelines for routine screening&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS</span><p id="spara70" class="elsevierStyleSimplePara elsevierViewall">Of the 333 health care workers included&#44; 228 &#40;68&#46;5&#37;&#41; were female&#46; The mean age was 48&#46;8 &#40;SD 6&#46;6 years&#41;&#46; Most subjects had undergone screening for hypertension &#40;blood pressure measurement&#41; and lipid abnormalities &#40;cholesterol testing&#41;&#46; Screening for breast and cervical cancer was common among females&#46; Resting electrocardiography&#44; serum glucose testing&#44; urine tests&#44; chest X-rays and serum prostate-specific antigen testing were also quite common&#46; However&#44; only 6 &#40;1&#46;8&#37;&#41; of the subjects had undergone screening for colorectal cancer &#40;fecal occult blood test or sigmoidoscopy&#41;&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSIONS</span><p id="spara80" class="elsevierStyleSimplePara elsevierViewall">A sizeable proportion of health care workers underwent screening procedures that are not recommended or for which there was insufficient evidence of a benefit&#46; Conversely&#44; certain recommended procedures were performed on a small proportion of such workers&#46; These results indicate that the Brazilian National Ministry of Health must develop nationwide evidence-based screening recommendations and disseminate such recommendations among health care professionals in Brazil&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "ceabs10"
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            "identificador" => "ceabs40"
            "titulo" => "CONCLUSIONS"
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      ]
    ]
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Characteristic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="middle" scope="col">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="middle" scope="col">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">333&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="middle">Gender</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">228&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">68&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">31&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="middle">Age group &#40;years&#41;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>40&#8211;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">202&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">60&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>50&#8211;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">30&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>60&#8211;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">9&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="middle">Level of education<a class="elsevierStyleCrossRef" href="#tfn1-cln_65p151">&#42;</a></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Elementary school&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">10&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>High school &#40;incomplete&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">10&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>High school &#40;complete&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">24&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>College &#40;incomplete&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">4&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>College &#40;complete&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">166&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">50&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="middle">Marital status</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Married&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">177&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">53&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">23&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Separated&#47;divorced&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">16&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Widowed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">6&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="middle">Occupation</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Physician&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">137&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">41&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Nurse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle" style="border-bottom: 2px solid black"><span class="elsevierStyleHsp" style=""></span>Nursing Assistant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle" style="border-bottom: 2px solid black">170&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle" style="border-bottom: 2px solid black">51&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tfn1-cln_65p151"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">No data for 3 subjects&#46;</p>"
            ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Distribution of health care workers according to sociodemographic characteristics&#44; Sao Paulo&#44; Brazil&#44; 2001&#8211;2003</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "t2-cln_65p151"
        "etiqueta" => "Table 2"
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        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="3" align="left" valign="middle" scope="col">Screening procedur</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="middle" scope="col">Screening practice</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="middle" scope="col">N &#40;&#37;&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="middle" scope="col">Never&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="middle" scope="col">At least once&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Serum glucose measurement &#40;for diabetes mellitus&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">73 &#40;21&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">260 &#40;78&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Blood pressure measurement &#40;for hypertension&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">97 &#40;29&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">236 &#40;70&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Serum cholesterol determination &#40;for lipid abnormality&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">129 &#40;38&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">204 &#40;61&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Resting electrocardiography &#40;for asymptomatic coronary artery disease&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">174 &#40;52&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">159 &#40;47&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Fecal occult blood test &#40;for colorectal cancer&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">329 &#40;98&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">4 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Sigmoidoscopy &#40;for colorectal cancer&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">331 &#40;99&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">2 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Digital rectal examination &#40;for colorectal cancer&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">330 &#40;99&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">3 &#40;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Mammography<a class="elsevierStyleCrossRef" href="#tfn2-cln_65p151">&#42;</a> &#40;for breast cancer&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">64 &#40;28&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">164 &#40;71&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Breast self-examination<a class="elsevierStyleCrossRef" href="#tfn2-cln_65p151">&#42;</a> &#40;for breast cancer&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">28 &#40;12&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">200 &#40;87&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Clinical breast examination<a class="elsevierStyleCrossRef" href="#tfn2-cln_65p151">&#42;</a> &#40;for breast cancer&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">58 &#40;25&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">170 &#40;74&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Papanicolaou smear<a class="elsevierStyleCrossRef" href="#tfn2-cln_65p151">&#42;</a> &#40;for cervical cancer&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">12 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">216 &#40;94&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Prostate-specific antigen test<a class="elsevierStyleCrossRef" href="#tfn3-cln_65p151">&#42;&#42;</a> &#40;for prostate cancer&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">36 &#40;34&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">69 &#40;65&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Digital rectal examination &#40;for prostate cancer&#41;<a class="elsevierStyleCrossRef" href="#tfn3-cln_65p151">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">71 &#40;67&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">34 &#40;32&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Chest X-ray &#40;for lung cancer&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">143 &#40;42&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">190 &#40;57&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Urine test &#40;for asymptomatic bacteriuria&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">164 &#40;49&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">169 &#40;50&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Bone densitometry<a class="elsevierStyleCrossRef" href="#tfn2-cln_65p151">&#42;</a> &#40;for osteoporosis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">153 &#40;67&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">75 &#40;32&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle" style="border-bottom: 2px solid black">Mantoux test &#40;for infection with <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle" style="border-bottom: 2px solid black">250 &#40;75&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle" style="border-bottom: 2px solid black">83 &#40;24&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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              "identificador" => "tfn2-cln_65p151"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="cenpara20">Females only&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tfn3-cln_65p151"
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              "nota" => "<p class="elsevierStyleNotepara" id="cenpara30">Males only&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Screening practices among health care workers in a tertiary-care hospital in Sao Paulo&#44; Brazil&#44; 2001&#8211;2003</p>"
        ]
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          "leyenda" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Source&#58; United States Preventive Services Task Force &#40;USPSTF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="middle" scope="col">Grade<a class="elsevierStyleCrossRef" href="#tfn5-cln_65p151">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="middle" scope="col">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="middle" scope="col">Test or procedure evaluated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><ul class="elsevierStyleList" id="celist10"><li class="elsevierStyleListItem" id="celistitem10"><p id="para10" class="elsevierStylePara elsevierViewall">- to screen for hypertension&#44; blood pressure measurement for all persons &#8805; 21 years of age</p></li><li class="elsevierStyleListItem" id="celistitem20"><p id="para20" class="elsevierStylePara elsevierViewall">- to screen for breast cancer&#44; mammography alone or mammography with clinical breast examination for females 50&#8211;69 years of age</p></li><li class="elsevierStyleListItem" id="celistitem30"><p id="para30" class="elsevierStylePara elsevierViewall">- to screen for cervical cancer&#44; Papanicolaou smear</p></li><li class="elsevierStyleListItem" id="celistitem40"><p id="para40" class="elsevierStylePara elsevierViewall">- to screen for infection with <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>&#44; tuberculin skin testing for all persons at increased risk &#40;including health care workers&#41;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><ul class="elsevierStyleList" id="celist20"><li class="elsevierStyleListItem" id="celistitem50"><p id="para50" class="elsevierStylePara elsevierViewall">- to screen for lipid abnormality&#44; serum cholesterol determination for all males 35&#8211;65 years of age and all females 45&#8211;65 years of age</p></li><li class="elsevierStyleListItem" id="celistitem60"><p id="para60" class="elsevierStylePara elsevierViewall">- to screen for colorectal cancer&#44; fecal occult blood testing for all persons &#8805; 50 of age</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination&#44; although recommendations may be made on other grounds&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><ul class="elsevierStyleList" id="celist30"><li class="elsevierStyleListItem" id="celistitem70"><p id="para70" class="elsevierStylePara elsevierViewall">- to screen for asymptomatic coronary artery disease&#44; resting electrocardiography for males and females</p></li><li class="elsevierStyleListItem" id="celistitem80"><p id="para80" class="elsevierStylePara elsevierViewall">- to screen for diabetes mellitus&#44; serum or plasma glucose determination in non-pregnant adults</p></li><li class="elsevierStyleListItem" id="celistitem90"><p id="para90" class="elsevierStylePara elsevierViewall">- to screen for breast cancer&#44; clinical breast examination for females 50&#8211;69 years of age</p></li><li class="elsevierStyleListItem" id="celistitem100"><p id="para100" class="elsevierStylePara elsevierViewall">- teaching breast self-examination in the periodic health examination</p></li><li class="elsevierStyleListItem" id="celistitem110"><p id="para110" class="elsevierStylePara elsevierViewall">- to screen for colorectal cancer&#44; digital rectal examination</p></li><li class="elsevierStyleListItem" id="celistitem120"><p id="para120" class="elsevierStylePara elsevierViewall">- to screen for asymptomatic bacteriuria&#44; leukocyte esterase or nitrite testing in urine for ambulatory elderly females or females with diabetes</p></li><li class="elsevierStyleListItem" id="celistitem130"><p id="para130" class="elsevierStylePara elsevierViewall">- to screen for osteoporosis&#44; bone densitometry in asymptomatic&#44; postmenopausal females</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle"><ul class="elsevierStyleList" id="celist40"><li class="elsevierStyleListItem" id="celistitem140"><p id="para140" class="elsevierStylePara elsevierViewall">- to screen for lung cancer&#44; chest X-ray</p></li><li class="elsevierStyleListItem" id="celistitem150"><p id="para150" class="elsevierStylePara elsevierViewall">- to screen for prostate cancer&#44; prostate specific antigen testing or digital rectal examination</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle" style="border-bottom: 2px solid black">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle" style="border-bottom: 2px solid black">There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle" style="border-bottom: 2px solid black"><ul class="elsevierStyleList" id="celist50"><li class="elsevierStyleListItem" id="celistitem160"><p id="para160" class="elsevierStylePara elsevierViewall">- none</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          ]
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              "identificador" => "tfn4-cln_65p151"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="cenpara40">Some of these recommendations have changed in the more recent versions of the USPSTF guidelines&#46; For up-to-date information&#44; access the USPSTF webpage &#40;<span class="elsevierStyleInterRef" id="interrefs10" href="http://www.ahrq.gov/clinic/uspstfix.htm">http&#58;&#47;&#47;www&#46;ahrq&#46;gov&#47;clinic&#47;uspstfix&#46;htm</span>&#41;&#46;</p>"
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            1 => array:3 [
              "identificador" => "tfn5-cln_65p151"
              "etiqueta" => "&#42;&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="cenpara50">Grade of recommendation&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">1996 United States Preventive Services Task Force recommendations<a class="elsevierStyleCrossRef" href="#tfn4-cln_65p151">&#42;</a> and the screening procedures analyzed</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "REFERENCES"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "cebibsec10"
          "bibliografiaReferencia" => array:15 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The periodic health examination"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Canadian Task Force on the Periodic Health Examination"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Can Med Assoc J"
                        "fecha" => "1979"
                        "volumen" => "121"
                        "paginaInicial" => "1193"
                        "paginaFinal" => "1254"
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        "texto" => "<p id="para440" class="elsevierStylePara elsevierViewall">Ana Claudia Camargo Gon&#231;alves da Silva is the recipient of Masters fellowship grants from the <span class="elsevierStyleItalic">Conselho Nacional de Desenvolvimento Cient&#237;fico e Tecnol&#243;gico</span> &#40;CNPq&#44; National Council for Scientific and Technological Development&#59; grant no&#46; 131142&#47;2003-8&#41; and the <span class="elsevierStyleItalic">Funda&#231;&#227;o de Amparo &#224; Pesquisa do Estado de S&#227;o Paulo</span> &#40;FAPESP&#44; Foundation for the Support of Research in the State of S&#227;o Paulo&#59; grant no&#46; 03&#47;05278-5&#41;&#46;</p>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos