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assist&#234;ncia m&#233;dica mais frequentemente identificados foram <span class="elsevierStyleItalic">Staphylococcus coagulase negativo</span> &#40;SCoN&#41; &#40;15&#37;&#41;&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;15&#37;&#41;&#44; <span class="elsevierStyleItalic">Enterococcus sp&#46;</span> &#40;12&#37;&#41;&#44; <span class="elsevierStyleItalic">Candida sp&#46;</span> &#40;11&#37;&#41;&#44; seguidos por diversos bacilos gram&#8208;negativos&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> Essas infec&#231;&#245;es relacionadas &#224; assist&#234;ncia m&#233;dica representam um importante desafio para o sistema de sa&#250;de e est&#227;o associadas com significativo custo&#44; morbidade e mortalidade&#46; Estima&#8208;se que a cada 100 pacientes hospitalizados a qualquer momento&#44; sete em pa&#237;ses desenvolvidos e dez em pa&#237;ses em desenvolvimento adquirir&#227;o pelo menos uma infec&#231;&#227;o relacionada a esses cuidados&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Poucos estudos avaliaram a contamina&#231;&#227;o de microrganismos em dermatosc&#243;pios e n&#227;o h&#225; estudos em adaptadores para <span class="elsevierStyleItalic">smartphones</span>&#46; Um estudo feito na Su&#237;&#231;a analisou a presen&#231;a bacteriana em lentes dos dermatosc&#243;pios de 10 dermatologistas &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41; envolvidos com o atendimento de pacientes do Ambulat&#243;rio de Dermatologia em dois hospitais su&#237;&#231;os&#46; Dos 112 <span class="elsevierStyleItalic">swabs</span> feitos&#44; 65&#37; dos aparelhos mostraram o crescimento de bact&#233;rias n&#227;o patog&#234;nicas &#40;inclusive todos os SCoN&#44; <span class="elsevierStyleItalic">Streptococcus</span> &#945; e &#947;&#8208;hemol&#237;ticos&#44; <span class="elsevierStyleItalic">Corynebacterium</span>&#44; <span class="elsevierStyleItalic">Bacillus</span> e <span class="elsevierStyleItalic">Lactobacillus</span>&#41;&#46; <span class="elsevierStyleItalic">S&#46; aureus</span> sens&#237;vel &#224; meticilina &#40;MSSA&#41; foi encontrado em tr&#234;s ocasi&#245;es &#40;nos tr&#234;s <span class="elsevierStyleItalic">swabs</span> foi usado &#243;leo de imers&#227;o no aparelho e n&#227;o &#225;lcool isoprop&#237;lico para a dermatoscopia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> Na &#193;ustria estudaram o espectro de microrganismos em 4 dermatosc&#243;pios &#40;lente e corpo&#41; do Departamento de Dermatologia em um hospital de Viena ap&#243;s a dermatoscopia de 39 pacientes e encontraram <span class="elsevierStyleItalic">S&#46; epidermidis</span> em 74&#37; dos aparelhos e <span class="elsevierStyleItalic">S&#46; aureus</span> em 7&#37;&#46; Na Inglaterra&#44; Chattopadhyay et al&#46; avaliaram 9 lentes de dermatosc&#243;pios em 60 ocasi&#245;es &#40;30 antes do exame e 30 ap&#243;s a dermatoscopia&#41; para monitoramento de crescimento bacteriano&#46; Um &#225;lcool&#8208;gel com etanol 70&#37; foi usado como l&#237;quido de imers&#227;o&#46; Os autores encontraram <span class="elsevierStyleItalic">S&#46; aureus</span> resistente &#224; meticilina &#40;MRSA&#41; em 10&#37; dos experimentos &#40;todos de <span class="elsevierStyleItalic">swabs</span> feitos depois da dermatoscopia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Os investigadores quiseram identificar os cocos gram&#8208;positivos mais frequentemente encontrados nos dermatosc&#243;pios e adaptadores para <span class="elsevierStyleItalic">smartphones</span> e avaliar os fatores associados com um maior risco de contamina&#231;&#227;o bacteriana na lente e no bot&#227;o liga&#47;desliga dos dermatosc&#243;pios&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudo de delineamento transversal&#44; feito entre setembro de 2017 e julho de 2018&#46; Foram convidados para participar do estudo dermatologistas e residentes em dermatologia que atendiam em ambulat&#243;rio hospitalar&#44; em ambulat&#243;rio n&#227;o hospitalar e em consult&#243;rios privados&#46; Os m&#233;dicos responderam a um question&#225;rio an&#244;nimo com informa&#231;&#245;es demogr&#225;ficas e sobre os h&#225;bitos de uso do dermatosc&#243;pio e forneceram os seus aparelhos para an&#225;lise bacteriol&#243;gica atrav&#233;s da t&#233;cnica de <span class="elsevierStyleItalic">swab</span>&#46; Foram exclu&#237;dos os m&#233;dicos que n&#227;o desejaram participar do preenchimento do question&#225;rio ou da coleta de <span class="elsevierStyleItalic">swab</span> dos dermatosc&#243;pios e dos adaptadores de celulares&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Para coleta&#44; foram usados <span class="elsevierStyleItalic">swabs</span> em dois ou tr&#234;s locais previamente definidos dos dermatosc&#243;pios&#58; na lente&#44; no bot&#227;o liga&#47;desliga e no adaptador &#40;para os profissionais que usavam esse equipamento&#41;&#46; Os <span class="elsevierStyleItalic">swabs</span> foram selados&#44; etiquetados e encaminhados para an&#225;lise&#46; No laborat&#243;rio&#44; os <span class="elsevierStyleItalic">swabs</span> foram colocados em tubos com o meio enriquecido BHI &#40;Infus&#227;o C&#233;rebro&#8208;Cora&#231;&#227;o&#41; &#40;Sigma Aldrich&#44; Merck&#44; Alemanha&#41; e deixados na estufa a 35&#176;&#177;2<span class="elsevierStyleHsp" style=""></span>&#176;C por 24 horas&#46; Na presen&#231;a de turva&#231;&#227;o &#40;nesse caso o teste &#233; considerado positivo&#44; ou seja&#44; houve crescimento bacteriano&#41;&#44; os caldos foram semeados em placas de &#225;gar sangue de carneiro a 5&#37; &#40;biomeri&#233;ux&#44; Marcy L&#8217;Etoile&#44; Fran&#231;a&#41; com o aux&#237;lio de uma al&#231;a est&#233;ril&#46; Na sequ&#234;ncia&#44; as placas foram deixadas na estufa a 35&#176;&#177;2<span class="elsevierStyleHsp" style=""></span>&#176;C por 24 horas&#46; As placas em que foram observadas crescimento bacteriano foram colocadas em <span class="elsevierStyleItalic">skim milk</span> e congeladas para posterior identifica&#231;&#227;o&#46; As amostras que turvaram no caldo BHI foram&#44; posteriormente&#44; descongeladas e&#44; novamente&#44; semeadas em placas de &#225;gar sangue para identifica&#231;&#227;o por MALDI&#8208;TOF MS&#46; No estudo foi usada a plataforma da Bruker Daltonics &#40;microflex LT&#59; Bruker Daltonik GmbH&#44; Bremen&#44; Germany&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Para os testes de suscetibilidade&#44; as col&#244;nias com 24 horas de cultivo em &#225;gar sangue de carneiro eram incubadas a 35&#176;&#177;2<span class="elsevierStyleHsp" style=""></span>&#176;C por 18&#8211;24 horas e foram testadas para os seguintes antibi&#243;ticos&#58; penicilina &#40;10U&#41;&#44; cefoxitina &#40;30 &#956;g&#41;&#44; eritromicina &#40;15 &#956;g&#41;&#44; clindamicina &#40;2 &#956;g&#41;&#44; levofloxacina &#40;5 &#956;g&#41;&#44; sulfametoxazol&#8208;trimetropim &#40;1&#44;25&#47;23&#44;75 &#956;g&#41;&#44; linezolida &#40;30 &#956;g&#41;&#44; tetraciclina &#40;30 &#956;g&#41;&#44; gentamicina &#40;10 &#956;g&#41; e rifampicina &#40;5 &#956;g&#41;&#46; As placas foram analisadas conforme as recomenda&#231;&#245;es do <span class="elsevierStyleItalic">Clinical and Laboratory Standards Institute</span> &#40;CLSI&#44; 2018&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> Conforme o di&#226;metro do halo de inibi&#231;&#227;o&#44; as amostras foram classificadas como sens&#237;vel&#44; resist&#234;ncia intermedi&#225;ria ou resistente&#46; <span class="elsevierStyleItalic">S&#46;aureus</span> ATCC 25923 foi usado para o controle de qualidade dos discos de antibi&#243;ticos&#44; de acordo com os procedimentos padronizados no teste de disco difus&#227;o&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A pesquisa foi aprovada pelo Comit&#234; de &#201;tica em Pesquisa da Irmandade da Santa Casa de Porto Alegre &#40;protocolo n&#176; 69396017&#46;5&#46;0000&#46;5335&#41;&#44; Universidade Federal de Ci&#234;ncias da Sa&#250;de de Porto Alegre &#40;protocolo n&#176; 69396017&#46;5&#46;0001&#46;5345&#41; e Secretaria Estadual de Sa&#250;de do Rio Grande do Sul &#40;protocolo n&#176; 69396017&#46;5&#46;3002&#46;5312&#41;&#46; Todos os participantes inclu&#237;dos no estudo assinaram Termo de Consentimento Informado&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Os dados foram digitados no programa Excel e posteriormente exportados para o programa SPSS v&#46; 20&#46;0 para an&#225;lise estat&#237;stica&#46; Foram descritas as vari&#225;veis qualitativas por frequ&#234;ncias e percentuais&#46; As vari&#225;veis quantitativas com distribui&#231;&#227;o sim&#233;trica foram descritas pela m&#233;dia e o desvio padr&#227;o e as com distribui&#231;&#227;o assim&#233;trica pela mediana e o intervalo interquartil&#46; As vari&#225;veis categ&#243;ricas foram comparadas pelo teste de qui&#8208;quadrado ou exato de Fisher&#46; O teste de Mann&#8208;Whitney foi usado para as vari&#225;veis num&#233;ricas&#44; com exce&#231;&#227;o da vari&#225;vel &#8220;idade&#8221;&#44; para a qual foi usado o teste <span class="elsevierStyleItalic">t</span> de Student&#46; Foi considerado um n&#237;vel de signific&#226;ncia de 5&#37; para as compara&#231;&#245;es estabelecidas&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Para o c&#225;lculo do tamanho da amostra&#44; com aproximadamente 59 dermatologistas para cada um dos dois grupos &#40;um com dermatologistas que atendiam em ambiente hospitalar e o outro com dermatologistas que atendiam em consult&#243;rio&#41;&#44; conseguir&#237;amos detectar uma diferen&#231;a de 20 pontos percentuais na frequ&#234;ncia de coloniza&#231;&#227;o por bact&#233;rias&#46; Consideramos um valor basal de coloniza&#231;&#227;o de 5&#37; &#40;no referencial te&#243;rico foi citado um valor que oscila entre 2&#44;7&#37; a 10&#37;&#41;&#44; um poder de 80&#37; e uma signific&#226;ncia de 5&#37;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Foram convidados a participar da pesquisa 138 dermatologistas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; As caracter&#237;sticas dos 118 dermatologistas que tiveram seus aparelhos analisados est&#227;o descritas na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Dos dermatosc&#243;pios analisados&#44; 46&#44;6&#37; tiveram crescimento de cocos gram&#8208;positivos na lente e 37&#44;3&#37; no bot&#227;o liga&#47;desliga &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Houve uma maior frequ&#234;ncia de crescimento de cocos gram&#8208;positivos no sexo masculino&#44; mas essa diferen&#231;a n&#227;o teve signific&#226;ncia estat&#237;stica &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46; Ser residente&#44; atender em hospital ou n&#227;o exclusivamente em consult&#243;rio&#44; guardar o dermatosc&#243;pio no jaleco&#44; usar o dermatosc&#243;pio no hospital&#44; em pacientes internados e na Unidade de Terapia Intensiva foram significantemente associados com a presen&#231;a de cocos gram&#8208;positivos &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Usar adaptador para <span class="elsevierStyleItalic">smartphone</span> n&#227;o foi associado com contamina&#231;&#227;o dos dermatosc&#243;pios&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Dermatologistas mais jovens &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41; e com menos tempo de profiss&#227;o &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a>&#41; tinham maior presen&#231;a bacteriana&#44; assim como foi observado uma rela&#231;&#227;o estatisticamente significativa entre o n&#250;mero de pacientes atendidos por dia e o n&#250;mero de vezes que usava o dermatosc&#243;pio ao dia &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Os microrganismos mais frequentemente encontrados foram <span class="elsevierStyleItalic">S&#46; epidermidis</span>&#44; <span class="elsevierStyleItalic">S&#46; hominis</span> e <span class="elsevierStyleItalic">S&#46; warneri</span>&#46; <span class="elsevierStyleItalic">S&#46; aureus</span> foi detectado apenas na lente &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">As maiores taxas de resist&#234;ncia dos cocos gram&#8208;positivos foram observadas frente &#224; penicilina&#44; eritromicina&#44; sulfametoxazol&#8208;trimetoprima &#40;SMT&#8208;TMP&#41; e clindamicina &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabela 5</a>&#41;&#46; A resist&#234;ncia dos cocos gram&#8208;positivos &#224; cefoxitina foi de 6&#44;6&#37; e nenhum microrganismo apresentava resist&#234;ncia &#224; linezolida&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S&#46; epidermidis</span> apresentou alta taxa de resist&#234;ncia &#224; penicilina&#44; eritromicina e SMP&#8208;TMP&#44; enquanto <span class="elsevierStyleItalic">S&#46; hominis</span> apresentou maior resist&#234;ncia &#224; eritromicina em rela&#231;&#227;o &#224; penicilina&#46; <span class="elsevierStyleItalic">S&#46; capitis</span> apresentou altas taxas de resist&#234;ncia a diversos antibi&#243;ticos&#44; mas nenhum caso de resist&#234;ncia &#224; clindamicina e gentamicina&#46; As maiores taxas de resist&#234;ncia &#224; penicilina foram verificadas com <span class="elsevierStyleItalic">S&#46; warneri</span> e <span class="elsevierStyleItalic">S&#46; haemolyticus</span>&#46; Todos os isolados de <span class="elsevierStyleItalic">S&#46; haemolyticus</span> eram resistentes &#224; penicilina&#44; al&#233;m de apresentar as maiores frequ&#234;ncias relativas de resist&#234;ncia &#224; clindamicina&#44; tetraciclina&#44; SMT&#8208;TMP e gentamicina &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">tabela 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discuss&#227;o</span><p id="par0095" class="elsevierStylePara elsevierViewall">Os dermatosc&#243;pios foram colonizados principalmente por bact&#233;rias da microbiota cut&#226;nea &#40;SCoN&#41;&#44; <span class="elsevierStyleItalic">S&#46; epidermidis</span> foi o mais frequentemente encontrado&#44; o que est&#225; de acordo com a literatura&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;10</span></a> Esse microrganismo tornou&#8208;se a causa mais comum de bacteremia prim&#225;ria e infec&#231;&#227;o de dispositivos m&#233;dicos&#44; como cateteres&#44; particularmente em indiv&#237;duos imunocomprometidos e neonatos&#46; Em contraste com <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; que &#233; muito mais virulento e sintetiza uma matriz de toxinas e outros fatores de virul&#234;ncia&#44; o principal fator de virul&#234;ncia definido associado a <span class="elsevierStyleItalic">S&#46; epidermidis</span> &#233; sua capacidade de formar biofilme e colonizar biomateriais&#46; Em contraste com o <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; cujo principal s&#237;tio s&#227;o as narinas&#44; o <span class="elsevierStyleItalic">S&#46; epidermidis</span> pode ser facilmente transferido para a pele de outros indiv&#237;duos atrav&#233;s do simples contato&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Tanto <span class="elsevierStyleItalic">S&#46; hominis</span> &#8211; o segundo microrganismo mais encontrado em nosso estudo e que na literatura &#233; citado como um dos tr&#234;s SCoN mais encontrados em hemoculturas de neonatos e em pacientes imunossuprimidos<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> &#8211; quanto <span class="elsevierStyleItalic">S&#46; warneri</span> &#8211; o terceiro mais frequente nos dermatosc&#243;pios do nosso estudo e citado em alguns artigos como o segundo mais frequente dos SCoN<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;14</span></a> &#8211; t&#234;m capacidade de formar biofilme<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">15&#44;16</span></a> e t&#234;m sido associados com bacteremia&#44; septicemia e endocardite&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S&#46; capitis</span> raramente causa infec&#231;&#227;o em adultos&#44; mas tem sido relatada uma suscetibilidade decrescente &#224; vancomicina e uma popula&#231;&#227;o clonal de <span class="elsevierStyleItalic">S&#46; capitis</span> resistente &#224; meticilina com heterorresist&#234;ncia &#224; vancomicina se espalhou entre v&#225;rias UTIs neonatais na Fran&#231;a e em outros pa&#237;ses&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> Ehlersson et al&#46; avaliaram isolados de <span class="elsevierStyleItalic">S&#46; capitis</span> de hemoculturas de neonatos na Su&#233;cia e acharam uma taxa de resist&#234;ncia &#224; cefoxitina e gentamicina de 75&#37;&#44; apenas 3&#37; de resist&#234;ncia &#224; eritromicina e nenhum caso de resist&#234;ncia &#224; norfloxacina e SMT&#8208;TMP&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Verificamos que o dermatosc&#243;pio pode carrear <span class="elsevierStyleItalic">S&#46; aureus</span>&#46; Essa bact&#233;ria coloniza a camada superficial da pele&#44; sobrevive por curto per&#237;odo e &#233; frequentemente adquirida por profissionais de sa&#250;de durante contato direto com o paciente &#40;colonizado ou infectado&#41;&#44; ambiente&#44; superf&#237;cies pr&#243;ximas ao paciente&#44; produtos e equipamentos contaminados&#44;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20&#44;21</span></a> tanto que foi detectado em nosso estudo justamente na lente e n&#227;o no adaptador ou no bot&#227;o liga&#47;desliga&#44; locais esses que poderiam estar mais relacionados ao contato direto com a pele do profissional de sa&#250;de&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">As m&#227;os dos profissionais de sa&#250;de podem ser persistentemente colonizadas por microrganismos patog&#234;nicos &#40;como <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; bacilos gram&#8208;negativos ou leveduras&#41; que&#44; em &#225;reas cr&#237;ticas como unidades de terapia intensiva e unidades com pacientes imunocomprometidos ou cir&#250;rgicos&#44; podem ter um importante papel adicional como causa de infec&#231;&#227;o relacionada &#224; assist&#234;ncia &#224; sa&#250;de&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">No nosso estudo&#44; a resist&#234;ncia &#224; cefoxitina foi considerada baixa&#46; Resist&#234;ncia &#224; eritromicina foi destacadamente alta nos isolados de <span class="elsevierStyleItalic">S&#46; hominis</span> do nosso estudo &#40;83&#44;3&#37;&#41;&#44; fato j&#225; citado em outros trabalhos&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> Szczuka et al&#46; encontraram uma taxa de resist&#234;ncia &#224; eritromicina de 75&#37; em isolados oriundos de sangue e ferida cir&#250;rgica de pacientes hospitalizados&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> As maiores taxas de resist&#234;ncia a diversos antibi&#243;ticos foram observadas no <span class="elsevierStyleItalic">S&#46; haemolyticus</span>&#44; o que j&#225; foi observado em outras publica&#231;&#245;es&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> Alguns estudos recentes t&#234;m citado <span class="elsevierStyleItalic">S&#46; haemolyticus</span> como o segundo SCoN&#44; depois do <span class="elsevierStyleItalic">S&#46; epidermidis</span>&#44; mais frequentemente isolado de casos cl&#237;nicos&#44; inclusive de pacientes em sepse&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">25&#8211;27</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Este &#233; o primeiro estudo na literatura que avalia resist&#234;ncia antimicrobiana de SCoN em dermatosc&#243;pios e em adaptadores para smarphones&#46; Conhecer o padr&#227;o de resist&#234;ncia dos SCoN dos dermatosc&#243;pios&#44; e da nossa pr&#243;pria pele&#44; passa a ser importante quando consideramos que esse grupo bacteriano pode agir como reservat&#243;rio de genes de resist&#234;ncia antimicrobiana por transfer&#234;ncia horizontal entre esp&#233;cies estafiloc&#243;cicas&#44; at&#233; serem adquiridos por <span class="elsevierStyleItalic">S&#46;</span> aureus<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">26&#44;28&#44;29</span></a> e&#44; posteriormente&#44; serem transferidos entre o dermatologista e seus pacientes&#44; especialmente m&#233;dicos que atendem em ambiente hospitalar&#44; em que as taxas de resist&#234;ncia antimicrobiana s&#227;o maiores&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> Segundo uma coorte com 2&#46;518 pacientes&#44; feita em Israel&#44; os padr&#245;es de resist&#234;ncia de SCoN obtidos por hemoculturas&#44; mesmo quando contaminantes&#44; poderiam ajudar a prever a mortalidade e corrigir a antibioticoterapia emp&#237;rica&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Uma das limita&#231;&#245;es do nosso estudo inclui a n&#227;o pesquisa de bact&#233;rias gram&#8208;negativas&#44; fungos e v&#237;rus&#46; Al&#233;m disso&#44; o pequeno n&#250;mero de adaptadores n&#227;o permitiu definir melhor se as diferen&#231;as de frequ&#234;ncias tivessem signific&#226;ncia estat&#237;stica&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclus&#227;o</span><p id="par0140" class="elsevierStylePara elsevierViewall">N&#243;s identificamos uma alta frequ&#234;ncia de cocos gram&#8208;positivos nos equipamentos testados&#46; <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> foi o mais observado&#44; tanto na lente&#44; no bot&#227;o liga&#47;desliga quanto no adaptador&#46; <span class="elsevierStyleItalic">S&#46; aureus</span> foi detectado apenas na lente&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Este estudo reflete a associa&#231;&#227;o entre o examinador dermatologista e a contamina&#231;&#227;o dos dermatosc&#243;pios&#46; Os profissionais devem adotar medidas para prevenir a contamina&#231;&#227;o de seus aparelhos e a coloniza&#231;&#227;o cruzada com seus pacientes&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Suporte financeiro</span><p id="par0150" class="elsevierStylePara elsevierViewall">Coordena&#231;&#227;o de Aperfei&#231;oamento de Pessoal de N&#237;vel Superior &#40;Capes&#41;&#44; Conselho Nacional de Pesquisa e Desenvolvimento Tecnol&#243;gico &#40;CNPq&#41; e Funda&#231;&#227;o de Amparo &#224; Pesquisa do Rio Grande do Sul &#40;Fapergs&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Contribui&#231;&#227;o dos autores</span><p id="par0155" class="elsevierStylePara elsevierViewall">Maur&#237;cio de Quadros&#58; An&#225;lise estat&#237;stica&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Roberto Carlos Freitas Bugs&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Renata de Oliveira Soares&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Adriana Medianeira Rossato&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Lisiane da Luz Rocha&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Pedro Alves d&#8217;Azevedo&#58; An&#225;lise estat&#237;stica&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflitos de interesse</span><p id="par0185" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">47 &#40;39&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Em hospital&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25 &#40;21&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Em consult&#243;rio e hospital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">46 &#40;39&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">N&#250;mero de vezes de uso do dermatosc&#243;pio por dia&#8211;mediana &#40;intervalo interquartil&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">15 &#40;10&#8211;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tempo de uso do dermatosc&#243;pio por consulta&#44; em minutos&#8211;mediana &#40;intervalo interquartil&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5 &#40;3&#8211;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Modelo do dermatosc&#243;pio&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DL100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 &#40;5&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DL200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;1&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DL3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">24 &#40;20&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DL4&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="\n
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                  \t\t\t\t">34 &#40;28&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hybrid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">42 &#40;35&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MiniHeine ou Heine&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="\n
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                  \t\t\t\t">8 &#40;6&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Wellch Allyn&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;0&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Veos Canfield&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;0&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">O aparelho toca a pele do paciente durante o exame&#63; &#8211; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">92 &#40;78&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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
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                  \t\t\t\t">26 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Onde guarda o dermatosc&#243;pio&#63; &#8211; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Jaleco&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">68 &#40;57&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mesa de trabalho&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">76 &#40;64&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Arm&#225;rio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21 &#40;17&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Estojo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;12&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Usa o dermatosc&#243;pio no consult&#243;rio&#63; &#8211; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">102 &#40;86&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;13&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Usa o dermatosc&#243;pio no hospital&#63; &#8211; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">64 &#40;54&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">54 &#40;45&#44;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
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Usa o dermatosc&#243;pio em pacientes internados&#63; &#8211; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
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                  \t\t\t\t">39 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
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                  \t\t\t\t">79 &#40;67&#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
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Usa o dermatosc&#243;pio em UTI&#63; &#8211; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98 &#40;83&#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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Atendeu paciente internado em isolamento por bact&#233;ria multirresistente nos &#250;ltimos 30 dias&#63; &#8211; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;12&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103 &#40;87&#44;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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Usou o dermatosc&#243;pio em paciente internado em isolamento por bact&#233;ria multirresistente nos &#250;ltimos 30 dias&#63; &#8211; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">116 &#40;98&#44;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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Usa algum produto de limpeza para o dermatosc&#243;pio&#63;</span> &#8211; <span class="elsevierStyleItalic">n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92 &#40;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;22&#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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Usa adaptador para smartphone&#63;</span> &#8211; <span class="elsevierStyleItalic">n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;22&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91 &#40;77&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vari&#225;vel&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n&#47;total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Frequ&#234;ncia &#40;&#37;&#41;&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="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; IC&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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Crescimento bacteriano no dermatosc&#243;pio &#40;lente ou bot&#227;o liga&#47;desliga&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#47;118&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#44;3&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&#44;9&#8211;68&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Crescimento bacteriano na lente&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&#47;118&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#44;6&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#44;4&#8211;56&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Crescimento bacteriano no bot&#227;o liga&#47;desliga&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#47;118&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#44;3&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#44;6&#8211;46&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Crescimento bacteriano no adaptador para <span class="elsevierStyleItalic">smartphone</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#47;27&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#44;4&#8211;57&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Frequ&#234;ncia de coloniza&#231;&#227;o bacteriana por cocos gram&#8208;positivos em dermatosc&#243;pios e adaptadores para <span class="elsevierStyleItalic">smartphones</span></p>"
        ]
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vari&#225;vel&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Frequ&#234;ncia&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37; de contamina&#231;&#227;o por cocos gram&#8208;positivos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valor p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sexo</span>&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="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;581<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Masculino&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#46;8&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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Feminino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">59&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">57&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Residente</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;013<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">33&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">75&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Onde atende&#63;</span>&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;010<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consult&#243;rio&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="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">42&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospital&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="\n
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                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">72&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consult&#243;rio e hospital&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="\n
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                  \t\t\t\t">32&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="\n
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                  \t\t\t\t">69&#44;6&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Onde atende&#63;</span>&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="" valign="\n
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                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;005<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Apenas consult&#243;rio&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="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">42&#44;6&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Apenas hospital ou consult&#243;rio mais hospital&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="\n
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                  \t\t\t\t">50&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="\n
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                  \t\t\t\t">70&#44;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Modelo do Dermatosc&#243;pio</span>&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="" valign="\n
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                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;361<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DL100 e DL200&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DL3&#44; DL4&#44; Veos Canfield&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#44;7&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hybrid&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#44;9&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Wellch Allyn ou Heine&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#44;3&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Toca a pele&#63;</span>&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="" valign="\n
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                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;676<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
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                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">60&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#44;8&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Guarda o dermatosc&#243;pio no jaleco</span>&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="" valign="\n
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                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;019<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#44;1&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Guarda o dermatosc&#243;pio na mesa de trabalho</span>&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="" valign="\n
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                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;819<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">57&#44;9&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#44;9&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="" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Guarda o dermatosc&#243;pio no arm&#225;rio</span>&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="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;999<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#44;1&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#44;8&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="" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Guarda o dermatosc&#243;pio no estojo</span>&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="" valign="\n
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                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;735<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#44;7&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="" valign="\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&#44;3&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="" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Usa o dermatosc&#243;pio no consult&#243;rio&#63;</span>&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="" valign="\n
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                  \t\t\t\t">&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="" valign="\n
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                  \t\t\t\t">&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;272<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&#44;9&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="" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#44;0&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="" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Usa o dermatosc&#243;pio no hospital&#63;</span>&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="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Usa o dermatosc&#243;pio em pacientes internados&#63;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Usa o dermatosc&#243;pio em UTI&#63;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Atendeu pacientes em isolamento por bact&#233;ria multirresistente nos &#250;ltimos 30 dias&#63;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;143<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">56&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Usou o dermatosc&#243;pio em paciente em isolamento por bact&#233;ria multirresistente nos &#250;ltimos 30 dias&#63;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;348<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Usa adaptador para smartphone&#63;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" 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><td class="td" title="\n
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                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;999<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&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="\n
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                  \t\t\t\t">59&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">54&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">59&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" 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></tbody></table>
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                  <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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vari&#225;vel&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="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Aus&#234;ncia de cocos gram&#8208;positivos&#8208; Mediana &#40;intervalo interquartil&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valor&#8208;p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Tempo como dermatologista&#44; em anos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;1&#8211;11&#44;25&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;4&#44;25&#8211;18&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#250;mero de vezes de uso do dermatosc&#243;pio por dia&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;10&#8211;20&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;10&#8211;16&#44;5&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#250;mero de pacientes atendidos&#44; por dia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;15&#8211;25&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#44;5 &#40;12&#44;25&#8211;20&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;035&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tempo de dermatoscopia por consulta&#44; em minutos&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;3&#8211;7&#44;25&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;3&#8211;5&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;881&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Quantas vezes voc&#234; acessa o celular por dia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;4&#44;75&#8211;15&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;5&#8211;15&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;862&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\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" style="border-bottom: 2px solid black">Antibi&#243;tico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Penicilina&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#44;2&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eritromicina&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#44;6&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clindamicina&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&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="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">SMT&#8208;TMP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Rifampicina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&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
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                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Tetraciclina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">25&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="\n
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                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SMT&#8208;TMP&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="\n
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                  \t\t\t\t">45&#44;9&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="\n
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                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cefoxitina&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="\n
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                  \t\t\t\t">6&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gentamicina&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="\n
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                  \t\t\t\t">5&#44;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rifampicina&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="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Levofloxacina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">75&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Linezolida&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Perfil de resist&#234;ncia antimicrobiana dos isolados dos cocos gram&#8208;positivos mais frequentes obtidos de dermatosc&#243;pios e adaptadores para <span class="elsevierStyleItalic">smartphones</span></p>"
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        0 => array:2 [
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            0 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "iPads&#44; droids&#44; and bugs&#58; Infection prevention for mobile handheld devices at the point of care"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;L&#46; Manning"
                            1 => "J&#46; Davis"
                            2 => "E&#46; Sparnon"
                            3 => "R&#46;M&#46; Ballard"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ajic.2013.03.304"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Infect Control&#46;"
                        "fecha" => "2013"
                        "volumen" => "41"
                        "paginaInicial" => "1073"
                        "paginaFinal" => "1076"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23816356"
                            "web" => "Medline"
                          ]
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            1 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Increasing clinical presence of mobile communication technology&#58; avoiding the pitfalls"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Visvanathan"
                            1 => "A&#46;P&#46; Gibb"
                            2 => "R&#46;R&#46; Brady"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1089/tmj.2011.0018"
                      "Revista" => array:6 [
                        "tituloSerie" => "Telemed J E Health&#46;"
                        "fecha" => "2011"
                        "volumen" => "17"
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                        "paginaFinal" => "661"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21780941"
                            "web" => "Medline"
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              ]
            ]
            2 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;P&#46; Wenzel"
                            1 => "T&#46;M&#46; Perl"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/0195-6701(95)90079-9"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hosp Infect&#46;"
                        "fecha" => "1995"
                        "volumen" => "31"
                        "paginaInicial" => "13"
                        "paginaFinal" => "24"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7499817"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "NHSN annual update&#58; antimicrobial&#8208;resistant pathogens associated with healthcare&#8208;associated infections&#58; annual summary of data reported to the national healthcare safety network at the centers for disease control and prevention&#44; 2006&#8208;2007"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;I&#46; Hidron"
                            1 => "J&#46;R&#46; Edwards"
                            2 => "J&#46; Patel"
                            3 => "T&#46;C&#46; Horan"
                            4 => "D&#46;M&#46; Sievert"
                            5 => "D&#46;A&#46; Pollock"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/591861"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol&#46;"
                        "fecha" => "2008"
                        "volumen" => "29"
                        "paginaInicial" => "996"
                        "paginaFinal" => "1011"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18947320"
                            "web" => "Medline"
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            4 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "World Health Organization &#91;Internet&#93;&#46; Geneva&#59; c2016 &#91;cited 2018 Jun 30&#93;&#46; Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level&#46; Availabre from&#58; http&#58;&#47;&#47;www&#46;who&#46;int&#47;infection&#8208;prevention&#47;publications&#47;ipc&#8208;components&#8208;guidelines&#47;en&#47;&#46;"
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            5 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dermatoscope as Vector for Transmissible Diseases &#8208; No Apparent Risk of Nosocomial Infections in Outpatients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46; H&#228;usermann"
                            1 => "A&#46; Widmer"
                            2 => "P&#46; Itin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000089018"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatology&#46;"
                        "fecha" => "2006"
                        "volumen" => "212"
                        "paginaInicial" => "27"
                        "paginaFinal" => "30"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16319470"
                            "web" => "Medline"
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            6 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Are dermatoscopes a potential source of nosocomial infection in dermatology clinics&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Chattopadhyay"
                            1 => "M&#46; Blackman Northwood"
                            2 => "B&#46; Ward"
                            3 => "J&#46; Sule"
                            4 => "N&#46;P&#46; Burrows"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ced.12277"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Exp Dermatol&#46;"
                        "fecha" => "2014"
                        "volumen" => "39"
                        "paginaInicial" => "401"
                        "paginaFinal" => "403"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24635085"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "CLSI&#46; Performance Standards for Antimicrobial Susceptibility Testing&#46; 28th ed&#46; CLSI supplement M100&#46; Wayne&#44; PA&#58; Clinical and Laboratory Standards Institute&#44; 2018&#46;"
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The dermatoscope&#58; a potential source of nosocomial infection&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "F&#46; Stauffer"
                            1 => "H&#46; Kittler"
                            2 => "C&#46; Forstinger"
                            3 => "M&#46; Binder"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/00008390-200104000-00010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Melanoma Res&#46;"
                        "fecha" => "2001"
                        "volumen" => "11"
                        "paginaInicial" => "153"
                        "paginaFinal" => "156"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11333125"
                            "web" => "Medline"
                          ]
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                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antimicrobial susceptibility and body site distribution of community isolates of coagulase&#8208;negative staphylococci"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;P&#46; Cavanagh"
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Vol. 95. Núm. 3.
Páginas 298-306 (1 maio 2020)
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Vol. 95. Núm. 3.
Páginas 298-306 (1 maio 2020)
Investigação
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Identificação de cocos gram‐positivos em dermatoscópios e adaptadores para smartphones por MALDI‐TOF MS: estudo transversal
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Maurício de Quadrosa,b,
Autor para correspondência
mdquadros@gmail.com

Autor para correspondência.
, Roberto Carlos Freitas Bugsa, Renata de Oliveira Soaresa, Adriana Medianeira Rossatoa, Lisiane da Luz Rochaa, Pedro Alves d’Azevedoa
a Laboratório de Cocos Gram‐Positivos, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
b Departamento de Dermatologia, Hospital Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil
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Informação do artigo
Resume
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Estatísticas
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Tabelas (6)
Tabela 1. Características dos dermatologistas da amostra e do uso do dermatoscópio
Tabela 2. Frequência de colonização bacteriana por cocos gram‐positivos em dermatoscópios e adaptadores para smartphones
Tabela 3. Variáveis categóricas e sua relação com a presença de contaminação bacteriana na lente ou no botão liga/desliga
Tabela 4. Variáveis numéricas e sua relação com a presença ou ausência de contaminação bacteriana na lente ou no botão liga/desliga
Tabela 5. Perfil de resistência antimicrobiana dos isolados de cocos gram‐positivos obtidos de dermatoscópios e adaptadores para smartphones
Tabela 6. Perfil de resistência antimicrobiana dos isolados dos cocos gram‐positivos mais frequentes obtidos de dermatoscópios e adaptadores para smartphones
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Resumo
Fundamentos

O uso cada vez mais frequente da dermatoscopia pode constituir‐se em risco para a transferência de microrganismos, através do dermatoscópio, entre médico e pacientes.

Objetivos

Identificar os cocos gram‐positivos mais frequentes em dermatoscópios e adaptadores para smartphones, bem como o perfil de resistência, e avaliar os fatores associados com um maior risco de contaminação bacteriana dos dermatoscópios.

Métodos

Estudo transversal com 118 dermatologistas de Porto Alegre/ Brasil entre setembro de 2017 e julho de 2018. Os cocos gram‐positivos foram identificados por MALDI‐TOF MS e os hábitos de uso do dermatoscópio foram avaliados através de um questionário anônimo.

Resultados

Dos dermatoscópios analisados, 46,6% tiveram crescimento de cocos gram‐positivos na lente e 37,3% no botão liga/desliga. Os microrganismos mais frequentemente identificados foram S. epidermidis, S. hominis e S. warneri. Atender em hospital, pacientes internados e pacientes em unidade de terapia intensiva foram significantemente associados com a presença de cocos gram‐positivos nos dermatoscópios (p<0,05). As maiores taxas de resistência foram observadas frente à penicilina, eritromicina e sulfametoxazol‐trimetoprim.

Limitações do estudo

A não inclusão de bacilos gram‐negativos, fungos e vírus. Além disso, o pequeno número de adaptadores não permitiu avaliar diferenças estatísticas.

Conclusão

Estafilococos coagulase negativos foram frequentemente identificados. S. aureus foi detectado apenas na lente.

Palavras‐chave:
Cocos gram‐positivos
Dermoscopia
Espectrometria de massas
Testes de sensibilidade microbiana
Texto Completo
Introdução

A dermatoscopia é uma excelente ferramenta diagnóstica na prática diária do dermatologista. E, nos últimos anos, os adaptadores para smartphones têm sido usados para fotografar lesões cutâneas, como nevos melanocíticos, e permitir o seu acompanhamento, bem como possibilitar a discussão de casos entre grupos de dermatologistas.

Toda essa inovação tecnológica trouxe aos profissionais da saúde uma maior agilidade no acesso às informações: smartphones e tablets permitem buscar artigos, fazer consultas rápidas em livros ou aplicativos, discutir casos em grupos com experts, além de ter um papel no ensino de futuros profissionais da saúde, como um dos possíveis facilitadores de aprendizagem.1,2 O uso indiscriminado desses objetos trouxe um novo desafio: a possibilidade de transferência de microrganismos, com ou sem potencial patogênico, desses aparelhos para as mãos dos profissionais, ou vice‐versa, ou ainda, transferir de pessoa a pessoa. Para exemplificar, pacientes com colonização nasal por Staphylococcus aureus têm entre 2 a 9 vezes mais risco de ter uma infecção por S. aureus.3 Os patógenos associados com infecções associadas à assistência médica mais frequentemente identificados foram Staphylococcus coagulase negativo (SCoN) (15%), S. aureus (15%), Enterococcus sp. (12%), Candida sp. (11%), seguidos por diversos bacilos gram‐negativos.4 Essas infecções relacionadas à assistência médica representam um importante desafio para o sistema de saúde e estão associadas com significativo custo, morbidade e mortalidade. Estima‐se que a cada 100 pacientes hospitalizados a qualquer momento, sete em países desenvolvidos e dez em países em desenvolvimento adquirirão pelo menos uma infecção relacionada a esses cuidados.5

Poucos estudos avaliaram a contaminação de microrganismos em dermatoscópios e não há estudos em adaptadores para smartphones. Um estudo feito na Suíça analisou a presença bacteriana em lentes dos dermatoscópios de 10 dermatologistas (n=10) envolvidos com o atendimento de pacientes do Ambulatório de Dermatologia em dois hospitais suíços. Dos 112 swabs feitos, 65% dos aparelhos mostraram o crescimento de bactérias não patogênicas (inclusive todos os SCoN, Streptococcus α e γ‐hemolíticos, Corynebacterium, Bacillus e Lactobacillus). S. aureus sensível à meticilina (MSSA) foi encontrado em três ocasiões (nos três swabs foi usado óleo de imersão no aparelho e não álcool isopropílico para a dermatoscopia).6 Na Áustria estudaram o espectro de microrganismos em 4 dermatoscópios (lente e corpo) do Departamento de Dermatologia em um hospital de Viena após a dermatoscopia de 39 pacientes e encontraram S. epidermidis em 74% dos aparelhos e S. aureus em 7%. Na Inglaterra, Chattopadhyay et al. avaliaram 9 lentes de dermatoscópios em 60 ocasiões (30 antes do exame e 30 após a dermatoscopia) para monitoramento de crescimento bacteriano. Um álcool‐gel com etanol 70% foi usado como líquido de imersão. Os autores encontraram S. aureus resistente à meticilina (MRSA) em 10% dos experimentos (todos de swabs feitos depois da dermatoscopia).7

Os investigadores quiseram identificar os cocos gram‐positivos mais frequentemente encontrados nos dermatoscópios e adaptadores para smartphones e avaliar os fatores associados com um maior risco de contaminação bacteriana na lente e no botão liga/desliga dos dermatoscópios.

Métodos

Estudo de delineamento transversal, feito entre setembro de 2017 e julho de 2018. Foram convidados para participar do estudo dermatologistas e residentes em dermatologia que atendiam em ambulatório hospitalar, em ambulatório não hospitalar e em consultórios privados. Os médicos responderam a um questionário anônimo com informações demográficas e sobre os hábitos de uso do dermatoscópio e forneceram os seus aparelhos para análise bacteriológica através da técnica de swab. Foram excluídos os médicos que não desejaram participar do preenchimento do questionário ou da coleta de swab dos dermatoscópios e dos adaptadores de celulares.

Para coleta, foram usados swabs em dois ou três locais previamente definidos dos dermatoscópios: na lente, no botão liga/desliga e no adaptador (para os profissionais que usavam esse equipamento). Os swabs foram selados, etiquetados e encaminhados para análise. No laboratório, os swabs foram colocados em tubos com o meio enriquecido BHI (Infusão Cérebro‐Coração) (Sigma Aldrich, Merck, Alemanha) e deixados na estufa a 35°±2°C por 24 horas. Na presença de turvação (nesse caso o teste é considerado positivo, ou seja, houve crescimento bacteriano), os caldos foram semeados em placas de ágar sangue de carneiro a 5% (biomeriéux, Marcy L’Etoile, França) com o auxílio de uma alça estéril. Na sequência, as placas foram deixadas na estufa a 35°±2°C por 24 horas. As placas em que foram observadas crescimento bacteriano foram colocadas em skim milk e congeladas para posterior identificação. As amostras que turvaram no caldo BHI foram, posteriormente, descongeladas e, novamente, semeadas em placas de ágar sangue para identificação por MALDI‐TOF MS. No estudo foi usada a plataforma da Bruker Daltonics (microflex LT; Bruker Daltonik GmbH, Bremen, Germany).

Para os testes de suscetibilidade, as colônias com 24 horas de cultivo em ágar sangue de carneiro eram incubadas a 35°±2°C por 18–24 horas e foram testadas para os seguintes antibióticos: penicilina (10U), cefoxitina (30 μg), eritromicina (15 μg), clindamicina (2 μg), levofloxacina (5 μg), sulfametoxazol‐trimetropim (1,25/23,75 μg), linezolida (30 μg), tetraciclina (30 μg), gentamicina (10 μg) e rifampicina (5 μg). As placas foram analisadas conforme as recomendações do Clinical and Laboratory Standards Institute (CLSI, 2018).8 Conforme o diâmetro do halo de inibição, as amostras foram classificadas como sensível, resistência intermediária ou resistente. S.aureus ATCC 25923 foi usado para o controle de qualidade dos discos de antibióticos, de acordo com os procedimentos padronizados no teste de disco difusão.

A pesquisa foi aprovada pelo Comitê de Ética em Pesquisa da Irmandade da Santa Casa de Porto Alegre (protocolo n° 69396017.5.0000.5335), Universidade Federal de Ciências da Saúde de Porto Alegre (protocolo n° 69396017.5.0001.5345) e Secretaria Estadual de Saúde do Rio Grande do Sul (protocolo n° 69396017.5.3002.5312). Todos os participantes incluídos no estudo assinaram Termo de Consentimento Informado.

Os dados foram digitados no programa Excel e posteriormente exportados para o programa SPSS v. 20.0 para análise estatística. Foram descritas as variáveis qualitativas por frequências e percentuais. As variáveis quantitativas com distribuição simétrica foram descritas pela média e o desvio padrão e as com distribuição assimétrica pela mediana e o intervalo interquartil. As variáveis categóricas foram comparadas pelo teste de qui‐quadrado ou exato de Fisher. O teste de Mann‐Whitney foi usado para as variáveis numéricas, com exceção da variável “idade”, para a qual foi usado o teste t de Student. Foi considerado um nível de significância de 5% para as comparações estabelecidas.

Para o cálculo do tamanho da amostra, com aproximadamente 59 dermatologistas para cada um dos dois grupos (um com dermatologistas que atendiam em ambiente hospitalar e o outro com dermatologistas que atendiam em consultório), conseguiríamos detectar uma diferença de 20 pontos percentuais na frequência de colonização por bactérias. Consideramos um valor basal de colonização de 5% (no referencial teórico foi citado um valor que oscila entre 2,7% a 10%), um poder de 80% e uma significância de 5%.

Resultados

Foram convidados a participar da pesquisa 138 dermatologistas (fig. 1). As características dos 118 dermatologistas que tiveram seus aparelhos analisados estão descritas na tabela 1.

Figura 1.

Fluxograma dos dermatologistas da amostra.

(0.08MB).
Tabela 1.

Características dos dermatologistas da amostra e do uso do dermatoscópio

Variável  Medidas descritivas 
Idade em anos – média±DP  36,4±8,4 
Sexo, n (%)
Masculino  16 (13,5) 
Feminino  102 (86,5) 
Tempo que atua como dermatologista, em anos–mediana (intervalo interquartil)  6,5 (2–15) 
Onde atende pacientes?n (%)
Em consultório  47 (39,8) 
Em hospital  25 (21,2) 
Em consultório e hospital  46 (39,0) 
Número de vezes de uso do dermatoscópio por dia–mediana (intervalo interquartil)  15 (10–20) 
Tempo de uso do dermatoscópio por consulta, em minutos–mediana (intervalo interquartil)  5 (3–7) 
Modelo do dermatoscópio, n (%)
DL100  6 (5,1) 
DL200  2 (1,7) 
DL3  24 (20,3) 
DL4  34 (28,8) 
Hybrid  42 (35,6) 
MiniHeine ou Heine  8 (6,8) 
Wellch Allyn  1 (0,8) 
Veos Canfield  1 (0,8) 
O aparelho toca a pele do paciente durante o exame? – n (%)
Sim  92 (78) 
Não  26 (22) 
Onde guarda o dermatoscópio? – n (%)
Jaleco  68 (57,6) 
Mesa de trabalho  76 (64,4) 
Armário  21 (17,8) 
Estojo  15 (12,7) 
Usa o dermatoscópio no consultório? – n (%)
Sim  102 (86,4) 
Não  16 (13,6) 
Usa o dermatoscópio no hospital? – n (%)
Sim  64 (54,2) 
Não  54 (45,8) 
Usa o dermatoscópio em pacientes internados? – n (%)
Sim  39 (33) 
Não  79 (67) 
Usa o dermatoscópio em UTI? – n (%)
Sim  20 (17) 
Não  98 (83) 
Atendeu paciente internado em isolamento por bactéria multirresistente nos últimos 30 dias? – n (%)
Sim  15 (12,7) 
Não  103 (87,3) 
Usou o dermatoscópio em paciente internado em isolamento por bactéria multirresistente nos últimos 30 dias? – n (%)
Sim  2 (1,7) 
Não  116 (98,3) 
Usa algum produto de limpeza para o dermatoscópio?n (%)
Sim  92 (78) 
Não  26 (22) 
Usa adaptador para smartphone?n (%)
Sim  27 (22,9) 
Não  91 (77,1) 

Dos dermatoscópios analisados, 46,6% tiveram crescimento de cocos gram‐positivos na lente e 37,3% no botão liga/desliga (tabela 2).

Tabela 2.

Frequência de colonização bacteriana por cocos gram‐positivos em dermatoscópios e adaptadores para smartphones

Variável  n/total  Frequência (%)  95% IC 
Crescimento bacteriano no dermatoscópio (lente ou botão liga/desliga)  70/118  59,3  49,9–68,3 
Crescimento bacteriano na lente  55/118  46,6  37,4–56,0 
Crescimento bacteriano no botão liga/desliga  44/118  37,3  28,6–46,7 
Crescimento bacteriano no adaptador para smartphone  10/27  37  19,4–57,6 

IC, intervalo de confiança.

Houve uma maior frequência de crescimento de cocos gram‐positivos no sexo masculino, mas essa diferença não teve significância estatística (tabela 3). Ser residente, atender em hospital ou não exclusivamente em consultório, guardar o dermatoscópio no jaleco, usar o dermatoscópio no hospital, em pacientes internados e na Unidade de Terapia Intensiva foram significantemente associados com a presença de cocos gram‐positivos (p<0,05). Usar adaptador para smartphone não foi associado com contaminação dos dermatoscópios.

Tabela 3.

Variáveis categóricas e sua relação com a presença de contaminação bacteriana na lente ou no botão liga/desliga

Variável  Frequência  % de contaminação por cocos gram‐positivos  Valor p 
Sexo      0,581a 
Masculino  11  68.8   
Feminino  59  57,8   
Residente      0,013a 
Sim  33  75   
Não  37  50   
Onde atende?      0,010a 
Consultório  20  42,6   
Hospital  18  72,0   
Consultório e hospital  32  69,6   
Onde atende?      0,005a 
Apenas consultório  20  42,6   
Apenas hospital ou consultório mais hospital  50  70,4   
Modelo do Dermatoscópio      0,361a 
DL100 e DL200  50   
DL3, DL4, Veos Canfield  37  62,7   
Hybrid  26  61,9   
Wellch Allyn ou Heine  33,3   
Toca a pele?      0,676a 
Sim  56  60,9   
Não  14  53,8   
Guarda o dermatoscópio no jaleco      0,019a 
Sim  47  69,1   
Não  23  46   
Guarda o dermatoscópio na mesa de trabalho      0,819a 
Sim  44  57,9   
Não  26  61,9   
Guarda o dermatoscópio no armário      0,999a 
Sim  12  57,1   
Não  58  59,8   
Guarda o dermatoscópio no estojo      0,735a 
Sim  10  66,7   
Não  60  58,3   
Usa o dermatoscópio no consultório?      0,272a 
Sim  58  56,9   
Não  12  75,0   
Usa o dermatoscópio no hospital?      0,001a 
Sim  47  73,4   
Não  23  42,6   
Usa o dermatoscópio em pacientes internados?      0,001a 
Sim  33  84,6   
Não  37  46,8   
Usa o dermatoscópio em UTI?      <0,001a 
Sim  20  100   
Não  50  51   
Atendeu pacientes em isolamento por bactéria multirresistente nos últimos 30 dias?      0,143a 
Sim  12  80   
Não  58  56,3   
Usou o dermatoscópio em paciente em isolamento por bactéria multirresistente nos últimos 30 dias?      0,513 
Sim  100   
Não  68  58,6   
Limpeza      0,348a 
Sim  52  56,5   
Não  18  69,2   
Usa adaptador para smartphone?      0,999a 
Sim  16  59,3   
Não  54  59,3   

UTI, Unidade de Terapia Intensiva.

a

Teste do qui‐quadrado.

Dermatologistas mais jovens (fig. 2) e com menos tempo de profissão (tabela 4) tinham maior presença bacteriana, assim como foi observado uma relação estatisticamente significativa entre o número de pacientes atendidos por dia e o número de vezes que usava o dermatoscópio ao dia (tabela 4).

Figura 2.

Idade média dos dermatologistas e sua relação com a presença ou ausência de cocos gram‐positivos no dermatoscópio. Teste estatístico t de Student.

Desvio‐padrão no grupo com cocos gram‐positivo 6,4.

Desvio‐padrão no grupo sem cocos gram‐positivo 9,8.

(0.04MB).
Tabela 4.

Variáveis numéricas e sua relação com a presença ou ausência de contaminação bacteriana na lente ou no botão liga/desliga

Variável  Presença de cocos gram‐positivos‐ Mediana (intervalo interquartil)  Ausência de cocos gram‐positivos‐ Mediana (intervalo interquartil)  Valor‐p 
Tempo como dermatologista, em anos  4 (1–11,25)  11 (4,25–18)  <0,001 
Número de vezes de uso do dermatoscópio por dia  15 (10–20)  10 (10–16,5)  0,004 
Número de pacientes atendidos, por dia  20 (15–25)  15,5 (12,25–20)  0,035 
Tempo de dermatoscopia por consulta, em minutos  5 (3–7,25)  5 (3–5)  0,881 
Quantas vezes você acessa o celular por dia  10 (4,75–15)  10 (5–15)  0,862 

Teste estatístico usado: Mann‐Whitney.

Os microrganismos mais frequentemente encontrados foram S. epidermidis, S. hominis e S. warneri. S. aureus foi detectado apenas na lente (fig. 3).

Figura 3.

Cocos gram‐positivos identificados por MALDI‐TOF MS.

(0.15MB).

As maiores taxas de resistência dos cocos gram‐positivos foram observadas frente à penicilina, eritromicina, sulfametoxazol‐trimetoprima (SMT‐TMP) e clindamicina (tabela 5). A resistência dos cocos gram‐positivos à cefoxitina foi de 6,6% e nenhum microrganismo apresentava resistência à linezolida.

Tabela 5.

Perfil de resistência antimicrobiana dos isolados de cocos gram‐positivos obtidos de dermatoscópios e adaptadores para smartphones

  Cocos gram‐positivos
  SensibilidadeResistência
Antibiótico 
Penicilina  26  23,2  86  76,8 
Eritromicina  32  28,6  80  71,4 
Clindamicina  78  69,6  34  30,4 
Tetraciclina  97  86,6  15  13,4 
SMT‐TMP  66  58,9  46  41,1 
Cefoxitina  105  93,7  6,3 
Gentamicina  106  94,6  5,4 
Rifampicina  107  95,5  4,5 
Levofloxacina  105  93,7  6,3 
Linezolida  112  100 

SMT‐TMP, sulfametoxazol‐trimetoprima.

S. epidermidis apresentou alta taxa de resistência à penicilina, eritromicina e SMP‐TMP, enquanto S. hominis apresentou maior resistência à eritromicina em relação à penicilina. S. capitis apresentou altas taxas de resistência a diversos antibióticos, mas nenhum caso de resistência à clindamicina e gentamicina. As maiores taxas de resistência à penicilina foram verificadas com S. warneri e S. haemolyticus. Todos os isolados de S. haemolyticus eram resistentes à penicilina, além de apresentar as maiores frequências relativas de resistência à clindamicina, tetraciclina, SMT‐TMP e gentamicina (tabela 6).

Tabela 6.

Perfil de resistência antimicrobiana dos isolados dos cocos gram‐positivos mais frequentes obtidos de dermatoscópios e adaptadores para smartphones

Antibiótico  Frequência de resistência dos cocos gram‐positivos (%)
  S. epidermidis  S.hominis  S. warneri  S. capitis  S. haemolyticus 
Penicilina  79,7  50  90  75  100 
Eritromicina  74,3  83,3  50  50  80 
Clindamicina  35,1  25  10  40 
Tetraciclina  14,9  8,3  25  40 
SMT‐TMP  45,9  25  30  50  60 
Cefoxitina  6,8  25  20 
Gentamicina  5,4  40 
Rifampicina  25 
Levofloxacina  5,4  75 
Linezolida 

SMT‐TMP, sulfametoxazol‐trimetoprima.

Discussão

Os dermatoscópios foram colonizados principalmente por bactérias da microbiota cutânea (SCoN), S. epidermidis foi o mais frequentemente encontrado, o que está de acordo com a literatura.9,10 Esse microrganismo tornou‐se a causa mais comum de bacteremia primária e infecção de dispositivos médicos, como cateteres, particularmente em indivíduos imunocomprometidos e neonatos. Em contraste com S. aureus, que é muito mais virulento e sintetiza uma matriz de toxinas e outros fatores de virulência, o principal fator de virulência definido associado a S. epidermidis é sua capacidade de formar biofilme e colonizar biomateriais. Em contraste com o S. aureus, cujo principal sítio são as narinas, o S. epidermidis pode ser facilmente transferido para a pele de outros indivíduos através do simples contato.11

Tanto S. hominis – o segundo microrganismo mais encontrado em nosso estudo e que na literatura é citado como um dos três SCoN mais encontrados em hemoculturas de neonatos e em pacientes imunossuprimidos12 – quanto S. warneri – o terceiro mais frequente nos dermatoscópios do nosso estudo e citado em alguns artigos como o segundo mais frequente dos SCoN13,14 – têm capacidade de formar biofilme15,16 e têm sido associados com bacteremia, septicemia e endocardite.16,17

S. capitis raramente causa infecção em adultos, mas tem sido relatada uma suscetibilidade decrescente à vancomicina e uma população clonal de S. capitis resistente à meticilina com heterorresistência à vancomicina se espalhou entre várias UTIs neonatais na França e em outros países.18 Ehlersson et al. avaliaram isolados de S. capitis de hemoculturas de neonatos na Suécia e acharam uma taxa de resistência à cefoxitina e gentamicina de 75%, apenas 3% de resistência à eritromicina e nenhum caso de resistência à norfloxacina e SMT‐TMP.19

Verificamos que o dermatoscópio pode carrear S. aureus. Essa bactéria coloniza a camada superficial da pele, sobrevive por curto período e é frequentemente adquirida por profissionais de saúde durante contato direto com o paciente (colonizado ou infectado), ambiente, superfícies próximas ao paciente, produtos e equipamentos contaminados,20,21 tanto que foi detectado em nosso estudo justamente na lente e não no adaptador ou no botão liga/desliga, locais esses que poderiam estar mais relacionados ao contato direto com a pele do profissional de saúde.

As mãos dos profissionais de saúde podem ser persistentemente colonizadas por microrganismos patogênicos (como S. aureus, bacilos gram‐negativos ou leveduras) que, em áreas críticas como unidades de terapia intensiva e unidades com pacientes imunocomprometidos ou cirúrgicos, podem ter um importante papel adicional como causa de infecção relacionada à assistência à saúde.22

No nosso estudo, a resistência à cefoxitina foi considerada baixa. Resistência à eritromicina foi destacadamente alta nos isolados de S. hominis do nosso estudo (83,3%), fato já citado em outros trabalhos.23 Szczuka et al. encontraram uma taxa de resistência à eritromicina de 75% em isolados oriundos de sangue e ferida cirúrgica de pacientes hospitalizados.24 As maiores taxas de resistência a diversos antibióticos foram observadas no S. haemolyticus, o que já foi observado em outras publicações.23 Alguns estudos recentes têm citado S. haemolyticus como o segundo SCoN, depois do S. epidermidis, mais frequentemente isolado de casos clínicos, inclusive de pacientes em sepse.25–27

Este é o primeiro estudo na literatura que avalia resistência antimicrobiana de SCoN em dermatoscópios e em adaptadores para smarphones. Conhecer o padrão de resistência dos SCoN dos dermatoscópios, e da nossa própria pele, passa a ser importante quando consideramos que esse grupo bacteriano pode agir como reservatório de genes de resistência antimicrobiana por transferência horizontal entre espécies estafilocócicas, até serem adquiridos por S. aureus26,28,29 e, posteriormente, serem transferidos entre o dermatologista e seus pacientes, especialmente médicos que atendem em ambiente hospitalar, em que as taxas de resistência antimicrobiana são maiores.26 Segundo uma coorte com 2.518 pacientes, feita em Israel, os padrões de resistência de SCoN obtidos por hemoculturas, mesmo quando contaminantes, poderiam ajudar a prever a mortalidade e corrigir a antibioticoterapia empírica.30

Uma das limitações do nosso estudo inclui a não pesquisa de bactérias gram‐negativas, fungos e vírus. Além disso, o pequeno número de adaptadores não permitiu definir melhor se as diferenças de frequências tivessem significância estatística.

Conclusão

Nós identificamos uma alta frequência de cocos gram‐positivos nos equipamentos testados. Staphylococcus epidermidis foi o mais observado, tanto na lente, no botão liga/desliga quanto no adaptador. S. aureus foi detectado apenas na lente.

Este estudo reflete a associação entre o examinador dermatologista e a contaminação dos dermatoscópios. Os profissionais devem adotar medidas para prevenir a contaminação de seus aparelhos e a colonização cruzada com seus pacientes.

Suporte financeiro

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes), Conselho Nacional de Pesquisa e Desenvolvimento Tecnológico (CNPq) e Fundação de Amparo à Pesquisa do Rio Grande do Sul (Fapergs).

Contribuição dos autores

Maurício de Quadros: Análise estatística; aprovação da versão final do manuscrito; concepção e planejamento do estudo; elaboração e redação do manuscrito; obtenção, análise e interpretação dos dados; participação efetiva na orientação da pesquisa; revisão crítica da literatura; revisão crítica do manuscrito.

Roberto Carlos Freitas Bugs: Aprovação da versão final do manuscrito; concepção e planejamento do estudo; obtenção, análise e interpretação dos dados; revisão crítica da literatura.

Renata de Oliveira Soares: Aprovação da versão final do manuscrito; concepção e planejamento do estudo; obtenção, análise e interpretação dos dados; participação efetiva na orientação da pesquisa.

Adriana Medianeira Rossato: Aprovação da versão final do manuscrito; concepção e planejamento do estudo; elaboração e redação do manuscrito; obtenção, análise e interpretação dos dados; participação efetiva na orientação da pesquisa; revisão crítica da literatura; revisão crítica do manuscrito.

Lisiane da Luz Rocha: Aprovação da versão final do manuscrito; concepção e planejamento do estudo; elaboração e redação do manuscrito; obtenção, análise e interpretação dos dados; revisão crítica da literatura.

Pedro Alves d’Azevedo: Análise estatística; aprovação da versão final do manuscrito; concepção e planejamento do estudo; elaboração e redação do manuscrito; obtenção, análise e interpretação dos dados; participação efetiva na orientação da pesquisa; revisão crítica da literatura; revisão crítica do manuscrito.

Conflitos de interesse

Nenhum.

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Como citar este artigo: Quadros M, Bugs RCF, Soares RO, Rossato AM, Rocha LL, d’Azevedo PA. Identifying gram‐positive cocci in dermatoscopes and smartphone adapters using MALDI‐TOF MS: a cross‐sectional study. An Bras Dermatol. 2020;95:298–306.

Trabalho realizado no Laboratório de Cocos Gram‐Positivos, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil.

Copyright © 2020. Sociedade Brasileira de Dermatologia
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