La fatigue post-accident vasculaire cérébral (FPAVC) est fréquente et invalidante. Pour autant, elle reste à ce jour un phénomène mal connu et reconnu. Dans ce travail de thèse, nous avons réalisé une synthèse exhaustive de la littérature scientifique sur les facteurs associés à la FPAVC. Il en ressort qu’elle est fréquemment reliée aux symptômes dépressifs et anxieux mais que ses mécanismes physiopathologiques sont encore peu compris. Nous avons conduit une étude de la FPAVC sur 153 patients de la cohorte hospitalière STROKDEM (NCT01330160) ayant été suivis 6 mois après leur AVC ischémique. Dans une première étude, nous avons montré que la FPAVC n’était pas un effet secondaire des médicaments utilisés par les patients à la sortie de l’hôpital et à 6 mois. Elle reflèterait plutôt la présence de troubles fréquemment observés après un AVC comme la dépression, l’anxiété et les troubles du sommeil. Dans une deuxième étude, nous avons mis au jour une association forte entre FPAVC et plaintes cognitives subjectives des patients qui contrastait avec l’absence d’association avec les performances cognitives objectives lors de l’évaluation neuropsychologique, quel que soit le domaine cognitif considéré. Dans une troisième étude, nous avons exploré les mécanismes neuronaux sous-jacents à la FPAVC. Avec une analyse exploratoire et sans a priori, nous n’avons pas montré de différence de connectivité fonctionnelle au repos entre les patients avec ou sans FPAVC. L’ensemble de ces données nous apporte des éléments permettant d’avancer dans la compréhension du phénomène complexe qu’est la FPAVC. / Post-stroke fatigue (PSF) is frequent and debilitating. However, PSF is up to date a poorly understood and unrecognized phenomenon. In this thesis, we have done an exhaustive synthesis of scientific literature on factors associated with PSF. It indicates that PSF is frequently related with depressive and anxious symptoms but there is a lack of understanding of its physiopathological mechanisms. We conducted a study of PSF on 153 patients from the hospital-based cohort study STROKDEM (NCT01330160), followed-up for 6 months after an ischemic stroke. In a first study, we have shown that PSF was not a side effect of drugs use. PSF more reflects presence of disturbances frequently observed after stroke such as depression, anxiety, or sleep disturbances. In a second study, we have observed a strong association between PSF and subjective cognitive complaints that contrasted with the absence of association with objective cognitive performances during the neuropsychological evaluation, regardless of the considered cognitive domain. In a third study, we explored neuronal mechanisms underlying PSF. With an exploratory analysis, without a priori, we did not demonstrate any difference in functional connectivity at rest between patients with or without PSF. As a whole, these data give us pieces to progress in the understanding of the complex phenomenon named PSF.

Sabemos que a grande maioria dos casos de deficiência na infância pode ser evitada ou atenuada e que embora suas causas sejam multifatoriais, muitas vezes, eles são decorrentes da falta de acesso, qualidade ou organização das práticas e dos serviços de saúde. Este estudo sobre a prevenção de deficiências na infância a partir da atenção à saúde -materno – infantil, no Programa Saúde da Família, pelas Equipes Saúde da Família, do Distrito Sanitário Cabula - Beiru, em Salvador-BA, teve como objetivos: analisar as ações desenvolvidas pelas Equipes Saúde da Família (ESF) desenvolvidas no pré-natal e no Acompanhamento do Crescimento e Desenvolvimento (ACD) infantil para a prevenção de deficiências na infância e apontar seus limites e possibilidades. Trata-se de uma pesquisa qualitativa, tendo como técnicas de coletas de dados: a entrevista com roteiro semiestruturado e a observação sistemática. Os sujeitos do estudo foram os 15 profissionais que compõem as ESF (médicos, enfermeiros, técnicos e auxiliares de enfermagem e agentes comunitários de saúde) e 10 usuárias (genitoras em serviços de pré-natal e mães das crianças do ACD). Para a análise dos dados utilizamos a técnica de análise de conteúdo de Bardin. O estudo sinaliza que embora seguindo os mesmos princípios e orientações de organização dos serviços e das práticas, as equipes se distinguem no modo de organização das práticas e nas atividades desenvolvidas em atenção à saúde materno-infantil, destarte para o trabalho multiprofissional, colaborativo, com antecipação das demandas e intervenções articuladas nas ações de promoção, prevenção, assistência e recuperação da saúde a partir das necessidades da população. Como limites para a prevenção de deficiências são apontados a necessidade de uma organização da rede de serviços, a corresponsabilidade, a necessidade de Educação Permanente, a falta de unicidade da ESF e o contexto sócio-econômico das famílias. Já como possibilidades são apontados os Testes do Pezinho, do Olhinho e da Orelhinha, as ações de educação em saúde, o vínculo e o trabalho dos agentes comunitários de saúde (ACS). Concluímos o estudo, reafirmando a existência de possibilidade de prevenção de deficiências na infância e destacando que a integralidade constitui-se no maior desafio para que de fato deficiências na infância possam ser prevenidas perpassando pela prática, organização do trabalho e organização das políticas públicas de saúde, mediante ações intersetoriais._________________________________________________________________________________________ ABSTRACT: It is known that most cases of deficiency in childhood can be avoided or attenuated and, although the causes are related to several factors, most of the times, they are due to lack of access, quality or organization of health practices and services . This study about deficiency prevention on childhood from attention to maternal - infant health, in the Family Health Program, by Family Health Teams (FHT) of Sanitary District Cabula - Beiru, in Salvador, Bahia, has the purpose of analyze the actions developed by Family Health teams in prenatal and infant Growing and Development Accompaniment (GDA) to prevent childhood deficiencies and point their limits and possibilities. It is a qualitative research that uses as techniques of data collection interviews with semistructured guide and systematic observation. The subjects of the study were the fifteen professionals that form the FHTs (doctors, nurses, nurse technicians and auxiliary and communitary health agents) and sixteen users (genitors in prenatal services and mothers from the GDA children). The technique of content analysis from Bardin was used to the analysis of data. The study signals that although the teams follow the same principles and orientations to the services and practices organization, they distinguish from each other in the manner they organize practices and in the activities developed in attention to maternal - infant health, this manner multiprofessional work, collaborative, with demand anticipation and articulated interventions in health promotion, prevention, assistance and recovery actions from people needs. The limits to deficiency prevention pointed out are the need of organization of services network, coresponsibility, the need of permanent education, the lack of unity of FHT and the socioeconomic context of families. The possibilities pointed out are the foot, eye and ear tests, the actions of health education, the community health agents link and work. The study finishes reaffirming the existence of possibility of prevention of childhood deficiencies and pointing that integrality constitutes the major challenge in order to make effective childhood deficiencies prevention, traversing practices, work and public health politics organization, from intersectoral actions.

Le mouvement des organes durant l’acquisition et la réponse impulsionnelle (RI) du système dégradent les images obtenues par Tomographie par Emission de Positons (TEP). Récemment, les scanners simultanés TEP-Imagerie par Résonance Magnétique (IRM) ont été introduits, offrant une solution au problème du mouvement qui peut être estimé grâce à l’IRM pour corriger les images TEP. Néanmoins, pour profiter pleinement de ces nouvelles possibilités, il est également important de corriger les images des effets de la RI. L’objectif de ce travail est de proposer des méthodes TEP-IRM permettant d’améliorer la qualité des images TEP. Pour ce faire, nous avons développé des techniques d’acquisitions/traitement de données IRM permettant de mesurer le mouvement des organes. Nous avons modélisé la RI non-stationnaire du système grâce à des mesures de sources ponctuelles. Nous avons ensuite intégré l’information de mouvement IRM -au niveau des cartes d’émission et d’atténuation- et le modèle de la RI dans un algorithme de reconstruction TEP permettant d’obtenir des images corrigées des effets du mouvement et de la RI. Ces méthodes ont été évaluées pour des applications oncologiques et cardiaques sur des acquisitions de fantômes, d’animaux et de patients, qui ont montré une amélioration de la caractérisation des tumeurs abdominales et des lésions du myocarde. De plus, nous avons développé des méthodes permettant d’améliorer l’imagerie TEP de plaques athéromateuses fragiles dans les coronaires et les avons évaluées avec des simulations réalistes TEP-IRM. Les résultats obtenus montrent que les techniques proposées améliorent la qualité des images TEP par rapport aux méthodes conventionnelles. / The physiologic motion of organs during the data acquisition and the finite system’s Point Spread Function (PSF) both limit the image quality of Positron Emission Tomography (PET). Recently, whole-body (WB) simultaneous PET-Magnetic Resonance (MR) scanners have become available. This modality offers an elegant solution to the motion problem since MR-based motion information can be used to correct the PET images for motion. Nevertheless, to fully benefit from the new capabilities offered by PET-MR, it is essential to also compensate the images for PSF-related degradations. The goal of this thesis was to develop methods allowing to improve PET image quality using PET-MR. In that perspective, we have developed MRI acquisition/processing techniques to measure organs’ motion. We have modeled the spatially-varying PSF using point source measurements. We have then incorporated MR-based motion information (of both emission and attenuation maps) and PSF modeling into fully-3D iterative PET reconstruction, yielding images virtually free of motion artifacts while reducing PSF-related effects. These methods were evaluated for two key applications of WB PET-MR, oncology and cardiology, using phantom, animal and patient studies, demonstrating improved image quality and assessment of tumors and myocardial defects. In addition, we have developed methods allowing to improve PET imaging of small coronary atherosclerotic plaques, a promising pre-clinical application of PET-MR, which were evaluated using a realistic PET-MR simulation study. Overall, the results obtained demonstrate that the developed methodology can substantially improve PET image quality as compared to standard methods.

Cette thèse propose trois contributions principales pour l'imagerie en microscopie à fluorescence. (1) Modélisation du système optique : nous avons étudié les approximations gaussiennes des moindres carrés pour les réponses impulsionnelles optiques (PSFs) limitées par la diffraction du microscope en champ large (WFFM), du microscope confocal (LSCM), et du microscope confocal à disque rotatif (DSCM). Les situations paraxiales/non-paraxiales et 2D/3D sont toutes considérées. Les PSFs sont décrites par les intégrales de diffraction de Debye. Nous avons dérivé les paramètres gaussiens optimaux pour la PSF 2D paraxiale du WFFM, sous les normalisations Linf et L1. Pour les autres PSFs, avec la normalisation Linf, des paramètres quasi-optimaux sont explicitement dérivés par l'appariement des séries de Maclaurin. Ces modèles approximatifs gaussiens peuvent être calculés rapidement, et facilitent considérablement la modélisation des objets biologiques. (2) Débruitage des images de fluorescence : les images issues des LSCM et DSCM ont des statistiques purement poissoniennes ou poissoniennes et gaussiennes mélangées (MPG) selon les différents modes d'acquisition du microscope. Deux approches sont proposées pour restaurer une image poissonienne. La première méthode, basée sur les tests d'hypothèses dans le domaine de Haar biorthogonale, est particulièrement appropriée à estimer rapidement les intensités poissoniennes régulières dans des données de grandes tailles. Notre deuxième méthode, basée sur une transformée stabilisatrice de variance (VST), permet de gaussianiser et stabiliser un processus poissonien filtré. Cette VST peut être combinée avec de nombreuses transformées multi-échelles, ce qui conduit aux VSTs multi-échelles (MS-VSTs). Nous montrons que les MS-VSTs permettent de restaurer efficacement des structures saillantes de diverses formes (isotropes, linéiques et curvilignes) avec un (très) faible flux photonique. La MS-VST est également généralisée pour débruiter les données MPG et pour extraire les taches fluorescentes dans les données MPG. (3) Détection super-résolutive : nous avons revu et étendu les résultats des limites de la résolution pour les sources ponctuelles issus des théories de la détection, de l'estimation, et de l'information. En particulier, nous avons proposé d'appliquer la VST pour étudier les limites de la résolution dans le cas d'observations poissoniennes ou MPG. Les résultats sont asymptotiquement consistants et les expressions sont de formes closes. Nous avons également généralisé une approche de super-résolution qui est basée sur l'ajustement de modèle paramètrique et la sélection de l'ordre de modèle pour localiser un nombre inconnu de spots ou de bâtonnets. Cette méthode permet non seulement de localiser les sources ayant des configurations spatiales complexes, mais aussi d'extraire les objets séparés par des distances inférieures à la résolution optique de Rayleigh (super-résolution).

Bar code stores information in the form of series of bars and gaps with various widths, and therefore can be considered as an example of bilevel (square) signal. Magnetic bar codes are created by applying slightly ferromagnetic material to a substrate. Sensing is done by reading oscillator, whose frequency is modulated by presence of the mentioned ferromagnetic material. Signal from the oscillator is then subjected to frequency demodulation. Due to temperature drift of the reading oscillator, the demodulated signal is accompanied by DC drift. Method for removal of the drift is introduced. Also, drift-insensitive detection of presence of a bar code is described. Reading bar codes is complicated by convolutional distortion, which is result of spatially dispersed sensitivity of the sensor. Effect of the convolutional distortion is analogous to low-pass filtering, causing edges to be smoothed and overlapped, and making their detection difficult. Characteristics of convolutional distortion can be summarized into point-spread function (PSF). In case of magnetic bar codes, the shape of the PSF can be known in advance, but not its width of DC transfer. Methods for estimation of these parameters are discussed. The signal needs to be reconstructed (into original bilevel form) before decoding can take place. Variational methods provide effective way. Their core idea is to reformulate reconstruction as an optimization problem of functional minimization. The functional can be extended by other functionals (regularizations) in order to considerably improve results of reconstruction. Principle of variational methods will be shown, including examples of use of various regularizations. All algorithm and methods (including frequency demodulation of signal from reading oscillator) are digital. They are implemented as a program for a microcontroller from the PIC32 family, which offers high computing power, so that even blind deconvolution (when the real PSF also needs to be found) can be finished in a few seconds. The microcontroller is part of magnetic bar code reader, whose hardware allows the read information to be transferred to personal computer via the PS/2 interface or USB (by emulating key presses on virtual keyboard), or shown on display.

Fluorescence microscopy is an essential tool in biomedical sciences that allows specific molecules to be visualized in the complex and crowded environment of cells. The continuous introduction of new imaging techniques makes microscopes more powerful and versatile, but there is more than meets the eye. In addition to develop- ing new methods, we can work towards getting the most out of existing data and technologies. By harnessing unused potential, this work aims to increase the richness, reliability, and power of fluorescence microscopy data in three key ways: through standardization, evaluation and innovation. A universal standard makes it easier to assess, compare and analyze imaging data – from the level of a single laboratory to the broader life sciences community. We propose a data-standard for fluorescence microscopy that can increase the confidence in experimental results, facilitate the exchange of data, and maximize compatibility with current and future data analysis techniques. Cutting-edge imaging technologies often rely on sophisticated hardware and multi-layered algorithms for reconstruction and analysis. Consequently, the trustworthiness of new methods can be difficult to assess. To evaluate the reliability and limitations of complex methods, quantitative analyses – such as the one present here for the 3D SPEED method – are paramount. The limited resolution of optical microscopes prevents direct observation of macro- molecules like DNA and RNA. We present a multi-color, achromatic, cryogenic fluorescence microscope that has the potential to produce multi-color images with sub-nanometer precision. This innovation would move fluorescence imaging beyond the limitations of optics and into the world of molecular resolution.

A Estratégia Saúde da Família, caracterizada inicialmente como Projeto QUALIS no município de São Paulo, iniciou as suas atividades em 1996 na zona leste da cidade, através da Casa de Saúde Santa Marcelina. O Programa de Saúde Bucal da estratégia Saúde da Família Santa Marcelina está atuando no território desde 1998, tendo como principal ponto de reivindicações dos gestores a ampliação do número de equipes para garantir a ampliação do acesso à população. Atualmente, a preocupação está focada nos resultados das ações do programa na saúde bucal da população assistida. Porém, avaliar os resultados das ações de saúde de um programa sem conhecer as bases e o contexto em que foi implantado, torna-se uma tarefa muito complicada. O objetivo geral do estudo é avaliar a implantação do Programa de Saúde Bucal da Estratégia Saúde da Família da Casa de Saúde Santa Marcelina/Organização Social Santa Marcelina, na zona leste do município de São Paulo e os objetivos específicos são: verificar o conhecimento dos profissionais do programa sobre as leis, normas e diretrizes estabelecidas para a saúde bucal na Atenção Básica; verificar a adequação dos processos de trabalho às leis, normas e diretrizes propostas pelo Ministério da Saúde e Secretaria Municipal de Saúde; e, verificar se a estrutura estabelecida, nos consultórios odontológicos das unidades de saúde, permite a operacionalização do trabalho de acordo com as leis, normas e diretrizes. Metodologia: Estudo descritivo/analítico através de pesquisa documental e do arcabouço legal que estabelece as bases para a Saúde Bucal na Atenção Básica e de dados primários coletados em instrumento apropriado, aplicado para o levantamento de informações sobre o conhecimento dos profissionais em relação às normas, diretrizes e a legislação específica, e, em relação ao desenvolvimento dos processos de trabalho. O universo de estudo é composto por 14 UBS que desenvolvem a estratégia Saúde da Família na região, assim como todas as ESB habilitadas no Ministério da Saúde pela instituição. A avaliação dos dados foi feita considerando as variáveis em três Eixos de Análises, que correspondem aos objetivos específicos da proposta. Assim foram criados os eixos: 1 Conhecimento dos profissionais; 2 Adequação dos processos de trabalho; e, 3 Estrutura. A hipótese a ser verificada foi, que o Programa de Saúde Bucal está implantado satisfatoriamente considerando os eixos de avaliação propostos. Resultados: o eixo Conhecimento dos profissionais teve um percentual de implantação de 87,7%, o eixo Adequação dos processos de trabalho teve um percentual de implantação de 82,0% e o eixo Estrutura teve um percentual de implantação de 80,5%. Conclusão: O Programa de Saúde Bucal da estratégia Saúde da Família está Satisfatoriamente Implantado (83,4%) na zona leste do município de São Paulo, considerando o conhecimento dos profissionais envolvidos sobre as leis, normas e diretrizes para a Saúde Bucal na Atenção Básica, a adequação do processo de trabalho às leis, normas e diretrizes, e a estrutura oferecida nos consultórios odontológicos para o desenvolvimento das ações. / The Family Healthcare Strategy, characterized initially as Project QUALIS in the municipality of São Paulo, started its activities in 1996 in the eastern area of the city, through the Casa de Saúde Santa Marcelina. The Program of oral healthcare of the Family Health strategy Santa Marcelina is acting in the territory since 1998, the main point of claims of managers the enlargement of the number of teams to ensure the expansion of access to the population. Currently, the concern is focused on the results of the actions of the program in oral health of the population assisted. However, to assess the results of health actions of a program without knowing the bases and the context in which was implemented, becomes a difficult task. The general objective of the study is to assess the implementation of the Program of oral healthcare of the Family Health Strategy of Casa de Saúde Santa Marcelina/Social Organization Santa Marcelina, in the eastern region of the municipality of S Paulo and specific objectives are: to verify the knowledge of professionals of the program about the laws, rules and guidelines established for oral healthcare in primary health; to verify the adequacy of work processes to the laws, rules and guidelines proposed by the Ministry of Health and Municipal Department of Health; and, to verify whether the structure established in dental clinics of public health units allows the structuring of the work in accordance with the laws, rules and guidelines. Methodology: descriptive study/analytical through documental research and the legal framework which lays the foundations for the Oral Health Care in Primary Health and primary data collected in appropriate instrument, applied for setting up information on the knowledge of professionals in relation to standards, guidelines and specific legislation, and, in relation to the development of work processes. The universe of study is composed by 14 public health primary care units which develop the family health strategy in the region as well as all oral health teams empowered in the Health Ministry by the institution. Data evaluation was performed considering the variables in three axles of analyzes, which correspond to specific objectives of the proposal. So were created the axles: 1-Knowledge of professionals; 2- Adequacy of work processes; and, 3- Structure. The hypothesis to be verified was that the Program of Oral healthcare is implemented satisfactorily whereas the axles of evaluation proposed. Results: the axis of knowledge of professionals had a percentage of implementing of 87.7%, the axis Adequacy of the processes of work had a percentage of implementing of 82.0% and the axis Structure had a percentage of implementing of 80.5%. Conclusion: Concerning knowledge of involved professionals about laws, rules and guidelines for the Oral Health in basic care, the adequacy of work processes to the laws, rules and guidelines and structure offered in public dental clinics for clinical procedures it is legitimate that the Program of oral healthcare of the Family Health strategy is satisfactorily implemented (83.4%) in the eastern region of the city of São Paulo.

L'instrument SNIFS a été conçu pour l'observation des Supernovae de type Ia à bas redshit afin de mieu connaître et caractériser ces objets. Le but étant de savoir si ces objets peuvent être utilisés comme des chandelles standards afin de contraindre les paramètres cosmologiques. La première partie de cette thèse porte sur le développement d'une simulation numérique détaillée de l'instrument SNIFS. Cette simulation reproduit les données issues de l'instrument de la manière la plus réaliste possible en tenant compte de toutes les aberrations présentes, ce qui inclut l'instrument mais aussi l'atmosphère. A terme ces images pourront être utilisées pour préparer la calibration de l'instrument. Le seconde partie tente d'établir une méthode capable d'analyser les résultats produits par l'instrument SNIFS. En se basant sur des outils morphométriques, cette méthode montrera comment l'on peut comparer des séries temporelles de spectre de supernovae et extraire des informations statistiques de celles ci.

Hepatitis delta virus (HDV) is the smallest known mammalian RNA virus, containing a genome of ~ 1700 nt. Replication of HDV is extremely dependent on the host transcription machinery. Previous studies indicated that RNA polymerase II (RNAPII) directly binds to and forms an active preinitiation complex on the right terminal stem-loop fragment (R199G) of HDV genomic RNA, and that the polypyrimidine tract-binding protein-associated splicing factor (PSF) directly binds to the same region. Further studies demonstrated that PSF also binds to the carboxyl-terminal domain (CTD) of RNAP II. In my thesis, co-immunoprecipitation assays were performed to show that PSF stimulates the interaction of RNAPII with R199G. Results of co-immunoprecipitation experiments also suggest that both the RNA recognition motif 2 (RRM2) and N-terminal proline-rich region (PRR) of PSF are required for the interaction between PSF and RNAPII, while the two RNA recognition motifs (RRM1 and RRM2) might be required for the interaction of PSF with R199G. Furthermore, in vitro run-off transcription assays suggest that PSF facilitates the HDV RNA transcription from the R199G template. Together, the above experiments suggest that PSF might act as a transcription factor for the RNAPII transcription of HDV RNA by linking the CTD of RNAPII and the HDV RNA promoter. My experiments provide a better understanding of the mechanism of HDV RNA-dependent transcription by RNAP II.

Made available in DSpace on 2016-06-02T19:00:23Z (GMT). No. of bitstreams: 1 3824.pdf: 2658470 bytes, checksum: 5e7861897a19147035f7c37972ec6fa0 (MD5) Previous issue date: 2011-02-18 / Universidade Federal de Minas Gerais / The purpose of this research was originally the anthropological study of multidisciplinary teams of Family Health Program (PSF), realized from ethnography in a city of São Paulo, in which I intend to observe the interaction between different discursive fields and professional practices. It was noted, however, that the multidisciplinary teams studied could be divided into two types of teams: a hierarchical, formed by all legitimate health professionals (doctors, nurses and nursing assistants), and a more egalitarian, just conformed by Community Health Agents (ACS). Moreover, by exploring the theme through ethnographic research, was also shown that knowledge and health practices in the field were crossed by the paradigm of health promotion, which not only sought to reorient the demand of users of public health, but sought to transform them, through educational processes, in subjects of citizenship. For this, an analysis of this process was made, focusing particularly on the role and training of ACS, since they emerged not only as mediators between biomedical knowledge and popular knowledge, but also showed themselves capable of switching between these two roles: the interventionist state and the interlocutor of the community. Thus, if the ambiguity of the ACS reveal, on hand, the normative character of the strategy, on the other hand, showed an opening for the emergence of citizenship, which allowed the problematization of the health citizention project implicit in public health politics, as the coexistence of contradictory models within the same program and the same health equipment. Then we saw that the Family Health Strategy presents paradoxes and inconsistencies in the operationalization of the program, some of which may bind that it consolidates as a guideline of SUS and must be object of reflection, in order that the program does not become just a model manager without the effective care counterparty expected of a health care service in public health. / O objetivo desta pesquisa foi, originalmente, o estudo antropológico das equipes multiprofissionais do Programa de Saúde da Família (PSF), realizado a partir da etnografia em um município do Estado de São Paulo, na qual se procurou observar a interação entre diferentes campos discursivos e práticas profissionais. Constatou-se, entretanto, que as equipes multiprofissionais estudadas podiam ser divididas em dois tipos de equipe: uma hierárquica, conformada por todos os profissionais de saúde legitimados (médicos, enfermeiros, técnicos e auxiliares de enfermagem), e outra, mais igualitária, conformada apenas pelos Agentes Comunitários de Saúde (ACS). Além disso, ao explorar o tema por meio da pesquisa etnográfica, foi também evidenciado que os saberes e as práticas de saúde em campo eram atravessados pelo paradigma da promoção da saúde, a qual não só buscava reorientar a demanda dos usuários da saúde pública, mas visava a transformá-los, por meio de processos pedagógicos, em sujeitos de cidadania. Para tanto, foi feita uma análise desse processo, focando-se, particularmente, na atuação e formação dos ACS, dado que eles surgiam não só como mediadores entre o saber biomédico e o saber popular, mas também se mostravam capazes de transitar entre estes dois papéis: o de interventor do Estado e o de interlocutor da comunidade. Assim, se por um lado a ambigüidade do ACS revelava o caráter normatizador da estratégia, por outro, mostrava uma brecha para a emergência da cidadania, o que permitiu tanto a problematização do projeto de cidadanização na saúde implícito nas políticas públicas de saúde, quanto da coexistência de modelos contraditórios dentro de um mesmo programa e de um mesmo equipamento de saúde. Vimos, então, que a Estratégia de Saúde da Família apresenta paradoxos e incongruências na operacionalização do programa, algumas das quais podem comprometer sua consolidação como eixo norteador do SUS e devem ser objeto de reflexão, a fim de que o programa não se transforme apenas em um modelo gestor sem a contraparte assistencial efetiva que se espera de um serviço de atenção em saúde pública.