Acute murine-betacoronavirus infection impairs testicular steroidogenesis and the quality of sperm production.

Although several testicular alterations promoted by coronavirus infection have been demonstrated, the extent, causes, and players of testicular pathogenesis are not totally understood. The present study aimed to investigate the short-term effects on male fertility of intranasally administered murine hepatitis virus strain 3 (MHV-3), a member of the genus Betacoronavirus, which causes a severe systemic acute infection. This mouse model might be used as a in vivo prototype for investigating the impact of betacoronavirus on the endocrine and exocrine testicular functions with the advantage to be performed in a biosafety level 2 condition. Herein, we performed virological, histopathological, and molecular studies regarding the testicular spermatogenesis and the spermatic quality analyses in an MHV-3-infected C57BL/6 mice. The main outcomes showed that MHV-3 infects mouse testis and induces a testicular inflammatory state, impairing the steroidogenic pathway. The infection led to several alterations in the testicular parenchyma, such as: seminiferous epithelium sloughing, retention of residual bodies, germ cell apoptosis, alterations in intercellular junction proteins, and worse spermatogenic parameters. Moreover, the levels of plasmatic testosterone as well as the quality of sperm production reduced. Therefore, the present data suggest that the viral/inflammatory impairment of the steroidogenic pathway and the consequent imbalance of androgen levels is critical in testicular pathology, disturbing the SC barrier function and the germ cell differentiation. Our study is important for comprehending the effects of beta coronavirus infections on testis function in order to develop treatments that could prevent virus-mediated male infertility.

Photoanthropometric craniofacial parameters in individuals with osteogenesis imperfecta.

BACKGROUND: This study aimed to evaluate facial photoanthropometric parameters in patients with OI. MATERIAL AND METHODS: We selected 20 Brazilian patients diagnosed with OI treated at the Extension Service for Minors in Need of Specialized Treatment of the Dentistry Course at the Federal University of Ceará (Fortaleza, Brazil), of both sexes, without age restriction, and able to understand and sign the informed consent form (ICF). As a control group, 38 non-syndromic Brazilian individuals, categorized as ASA I, able to understand and sign the ICF, matched by sex, age, and Legan and Burstone facial profile were selected. The exclusion criteria were: previous orthodontic treatment, craniofacial trauma and/or surgery, and the presence of any other systemic diseases. Photoanthropometric analysis of the 18 facial parameters proposed by Stengel-Rutkowski et al. (1984), previously established in the literature for craniofacial syndromes, were conducted. A single examiner digitally performed all effective and angular measurements with the CorelDRAWX7® software. RESULTS: Horizontally shortened ears (p<0.001) but larger in height in relation to the face (p=0.012) were shown to be alterations belonging to individuals with OI. CONCLUSIONS: OI patients present distinct photoanthropometric parameters inherent in this condition.

Protective effects of the angiotensin type 1 receptor antagonist losartan in infection-induced and arthritis-associated alveolar bone loss.

BACKGROUND AND OBJECTIVE: The angiotensin type 1 (AT1) receptor has been implicated in the pathogenesis of inflammatory bone disorders. This study aimed to investigate the effect of an AT1 receptor antagonist in infection-induced and arthritis-associated alveolar bone loss in mice. MATERIAL AND METHODS: Mice were subjected to Aggregatibacter actinomycetemcomitans oral infection or antigen-induced arthritis and treated daily with 10 mg/kg of the prototype AT1 antagonist, losartan. Treatment was conducted for 30 d in the infectious condition and for 17 d and 11 d in the preventive or therapeutic regimens in the arthritic model, respectively. The mice were then killed, and the maxillae, serum and knee joints were collected for histomorphometric and immunoenzymatic assays. In vitro osteoclast assays were performed using RAW 264.7 cells stimulated with A. actinomycetemcomitans lipopolysacharide (LPS). RESULTS: Arthritis and A. actinomycetemcomitans infection triggered significant alveolar bone loss in mice and increased the levels of myeloperoxidase and of TRAP(+) osteoclasts in periodontal tissues. Losartan abolished such a phenotype, as well as the arthritis joint inflammation. Both arthritis and A. actinomycetemcomitans conditions were associated with the release of tumor necrosis factor alpha (TNF-α), interferon-gamma, interleukin-17 and chemokine (C-X-C motif) ligand 1 and an increased RANKL/osteoprotegerin ratio in periodontal tissues, but such expression decreased after losartan treatment, except for TNF-α. The therapeutic approach was as beneficial as the preventive one. In vitro, losartan prevented LPS-induced osteoclast differentiation and activity. CONCLUSION: The blockade of AT1 receptor exerts anti-inflammatory and anti-osteoclastic effects, thus protecting periodontal tissues in distinct pathophysiological conditions of alveolar bone loss.

The relevance of leukotrienes for bone resorption induced by mechanical loading.

5-Lipoxygenase (5-LO) metabolites are important pro-inflammatory lipid mediators. However, much still remains to be understood about the role of such mediators in bone remodeling. This study aimed to investigate the effect of 5-LO metabolites, LTB4 and CysLTs, in a model of mechanical loading-induced bone remodeling. Strain-induced tooth movement and consequently alveolar bone resorption/apposition was achieved by using a coil spring placed on molar and attached to incisors of C57BL6 (wild-type-WT), 5-LO deficient mice (5-LO(-/-)) and mice treated with 5-LO inhibitor (zileuton-ZN) or with antagonist of CysLTs receptor (montelukast-MT). The amount of bone resorption and the number of osteoclasts were determined morphometrically. The expression of inflammatory and bone remodeling markers in periodontium was analyzed by qPCR. Osteoclast differentiation and TNF-α production were evaluated in vitro using RAW 264.7 cells treated with LTB4 or LTD4. Bone resorption, TRAP(+) cells and expression of Tnfa, Il10 and Runx2 were significantly diminished in 5-LO(-/-), ZN- and MT-treated mice. The expression of Rank was also reduced in 5-LO(-/-) and MT-treated mice. Accordingly, LTB4 and LTD4 in association with RANKL promoted osteoclast differentiation and increased TNF-α release in vitro. These data demonstrate that the absence of 5-LO metabolites, LTB4 and CysLTs reduces osteoclast recruitment and differentiation, consequently diminishing bone resorption induced by mechanical loading. Thus, 5-LO might be a potential target for controlling bone resorption in physiological and pathological conditions.

Comportamento ingestivo de cordeiros em confinamento, alimentados com dieta exclusiva de concentrado com diferentes porcentagens de proteína / Ingestive behavior of feedlot lambs feed with exclusive diet of concentrate with different percentages of protein

O experimento foi realizado com o objetivo de avaliar o comportamento ingestivo de cordeiros em confinamento, alimentados com dieta exclusiva de concentrado com diferentes porcentagens de proteína (14, 16, 18 e 20%). Foram utilizados 24 cordeiros mestiços da raça Santa Inês, não castrados, com aproximadamente 180 dias de idade, peso vivo médio de 25kg, confinados, num delineamento experimental inteiramente ao acaso, com quatro tratamentos e seis repetições. O tempo despendido na atividade de alimentação decresceu linearmente em 0,20 hora/dia para cada 1% de aumento na porcentagem de proteína na dieta; o de ócio aumentou linearmente em 0,25 hora/dia; e o de mastigação total reduziu linearmente em 0,25 hora/dia. A elevação da porcentagem de proteína na dieta elevou linearmente a eficiência de alimentação (kg MS e FDN/hora), em 0,038 e 0,005kg/hora, respectivamente, para as frações MS e FDN. Contudo, os consumos de matéria seca (MS) e fibra em detergente neutro (FDN), a eficiência de ruminação (kg MS e FDN/hora), assim como o período (nº/dia) e o tempo (min) gasto por período de alimentação, ruminação e ócio não foram influenciados pelas diferentes porcentagens de proteína na dieta.

The experiment was conducted to evaluate the ingestive behavior of feedlot lambs fed with an exclusive diet of concentrate with different percentages of protein (14, 16, 18, and 20%). A total of twenty four Santa Inês crossbred lambs, not castrated, with approximately 180 days of age, average live weight of 25kg, confined, in a completely randomized design, with four treatments and six repetitions. The time spent on feeding decreased linearly in 0.20 hours/day for each 1% increasing in protein percentage in the diet, the idleness increased linearly in 0.25 hours/day, and the total chewing decreased linearly in 0.25 hours/day. The increase in the protein percentage in the diet increased the feed efficiency linearly (kg DM and NDF/hour) in 0.038 and 0.005kg/hour, respectively, for DM and NDF fractions. However, the intake of dry matter (DM) and neutral detergent fiber (NDF), the rumination efficiency (kg DM and NDF/hour), as well as the period (nº /day) and the time (min) spent on feeding, ruminating and idling were not influenced by different protein percentages in the diet.

MyD88 is essential for alveolar bone loss induced by Aggregatibacter actinomycetemcomitans lipopolysaccharide in mice.

Aggregatibacter actinomycetemcomitans is a Gram-negative bacteria highly associated with localized aggressive periodontitis. The recognition of microbial factors, such as lipopolysaccharide from A. actinomycetemcomitans ((Aa)LPS), in the oral environment is made mainly by surface receptors known as Toll-like receptors (TLR). TLR4 is the major LPS receptor. This interaction leads to the production of inflammatory cytokines by myeloid differentiation primary-response protein 88 (MyD88) -dependent and -independent pathways, which may involve the adaptor Toll/interleukin-1 receptor-domain-containing adaptor inducing interferon-ß (TRIF). The aim of this study was to assess the involvement of MyD88 in alveolar bone loss induced by (Aa)LPS in mice. C57BL6/J wild-type (WT) mice, MyD88, TRIF or TRIF/MyD88 knockout mice received 10 injections of Aa LPS strain FDC Y4 (5 µg in 3 µl), in the palatal gingival tissue of the right first molar, every 48 h. Phosphate-buffered saline was injected in the opposite side and used as control. Animals were sacrificed 24 h after the 10th injection and the maxillae were removed for macroscopic and biochemical analyses. The injections of Aa LPS induced significant alveolar bone loss in WT mice. In the absence of MyD88 or TRIF/MyD88 no bone loss induced by (Aa)LPS was observed. In contrast, responses in TRIF(-/-) mice were similar to those in WT mice. Diminished bone loss in the absence of MyD88 was associated with fewer TRAP-positive cells and increased expression of osteoblast markers, RUNX2 and osteopontin. There was also reduced tumor necrosis factor-α production in MyD88(-/-) mice. There was less osteoclast differentiation of hematopoietic bone marrow cells from MyD88(-/-) mice after (Aa)LPS stimulation. Hence, the signaling through MyD88 is pivotal for (Aa)LPS-induced osteoclast formation and alveolar bone loss.

Desempenho de cordeiros em confinamento alimentados com dieta exclusiva de concentrado com diferentes porcentagens de proteína / Performance of feedlot lambs feed with exclusive concentrate diet with different percentages of protein

O presente experimento foi realizado com o objetivo de avaliar o desempenho de cordeiros em confinamento alimentados com dieta exclusiva de concentrado com diferentes porcentagens de proteína. Foram utilizados 24 cordeiros mestiços da raça Santa Inês, não castrados, com aproximadamente 180 dias de idade, peso vivo médio de 25kg, confinados, num delineamento experimental inteiramente ao acaso, com quatro tratamentos e seis repetições. O consumo voluntário de matéria seca, matéria orgânica, proteína bruta e nutrientes digestíveis totais, além do ganho de peso diário e total, da conversão e da eficiência alimentar dos cordeiros, não foram influenciados (P>0,05) pela porcentagem de proteína na dieta. As dietas com 18 e 20% de proteína bruta apresentaram menores custos de produção, entretanto o menor custo foi obtido com a ração contendo 18% de PB.

The experiment was conducted to evaluate the performance of feedlot lambs feed with exclusive concentrate diet with different percentages of protein. A total of twenty four confined, not castrated Santa Inês crossbred lambs, with approximately 180 days of age, average live weight of 25kg, in a completely randomized design, with four treatments and six repetitions were used. Voluntary intake of dry matter, organic matter, crude protein and total digestible nutrient, besides the daily and total gains, conversion and feed efficiency of feedlot lambs were not affected (P>0.05) by percentage of dietary crude protein. Diets with 18 and 20% crude protein had lower production costs, however, the lowest cost was obtained with a diet containing 18% CP.

Gastroprotective and toxicological evaluation of the Lithothamnion calcareum algae.

Lithothamnion calcareum is a red alga of the Corallinacea family whose main feature is the formation of calcium carbonate precipitate in its cell walls. L. calcareum is marketed as a nutritional supplement for calcium and other minerals in Brazil and other countries under the pharmaceutical name of Vitality 50+. In this study, gastroprotective and pre-clinical toxicity assays were performed on this product. Doses of 30, 120 and 480 mg/kg were used in the gastroprotective study on Wistar rats. A dose of 2000 mg/kg was used in the preclinical acute toxicity study and oral doses of 1000 and 2000 mg/kg were used in the subchronic toxicity evaluation. L. calcareum played no significant role in the protection of the rats' gastric mucosa, nor did it cause increase in gastric irritation. No impact on the acute toxicity test was identified. In the subchronic toxicity test, serum levels of albumin, total protein and calcium decreased, and creatinine levels increased, suggesting hypercalcemia and possible kidney damage associated with liver damage, given that the majority of these parameters were irreversible. Thus, this work aims to discuss the relationship of the high concentration of calcium in the product with the observed effects.

Cryopreservation of swine ovarian tissue: effect of different cryoprotectants on the structural preservation of preantral follicle oocytes.

The present study aimed to test different cryoprotectants on cryopreservation of pig ovarian tissue. Pig ovaries (n=3) were collected at a local slaughterhouse. From each ovary, ten cortex samples were taken. One was immediately fixed (control) and another placed in short-term tissue incubation (STTI control). The other 8 samples were cryopreserved, in pairs, using 4 different cryoprotectants: dimethyl sulphoxide (Me2SO - 1.5M), ethylene glycol (EG - 1.5M), propanediol (PROH - 1.5M) and glycerol (GLY - 10%), all with 0.4% sucrose. Samples were slow cooled and stored in liquid nitrogen for 7 days. After thawing and cryoprotectant removal, one sample from each treatment was immediately fixed and the other was placed in short-term tissue incubation (STTI) for 2h and then fixed. Samples were processed for histology and transmission electron microscopy. The percentages of morphologically normal follicles (MNF) in cryopreserved tissue using Me2SO (67.0+/-4.9), EG (81.8+/-1.4) and PROH (55.9+/-9.9) were significantly lower (P<0.05) than observed in fresh control tissue (97.7+/-1.2). When ovarian tissue was cryopreserved with GLY, no morphologically normal follicles could be found (0%). After STTI, PROH showed a significantly lower percentage of MNF when compared with all other treatments and the control. After ultrastructural analysis, follicles cryopreserved with Me2SO and EG showed some small alterations, but no signs of advanced degeneration. Overall, these were similar to follicles from the control group. In conclusion, it is possible to cryopreserve preantral follicles from pig ovarian tissue using Me2SO or EG.

Detection of nontuberculous mycobacteria from water buffalo raw milk in Brazil.

Milk is an important nutritional source to man and water buffalo raw milk is used to produce mozzarella cheese. Products from unpasteurized milk have been associated with certain infectious diseases and can carry pathogenic mycobacteria. Nontuberculous mycobacteria (NTM) are emerging pathogens causing opportunistic infections in humans and animals. The objectives of this study were to demonstrate the presence of mycobacteria in water buffaloes' milk and to determine their role as possible sources of NTM infections. In this study, raw milk samples from dairy water buffaloes (Bubalus bubalis) (N = 23) were decontaminated by Petroff method and inoculated on to Löwenstein-Jensen and Stonebrink medium. After confirming positive colonies for acid fast bacilli (AFB) by Ziehl-Neelsen technique, the isolated mycobacteria were identified by PCR-Restriction Enzyme Analysis (PRA) and mycolic acids analysis by thin-layer chromatography (TLC). Mycobacterium simiae (2 isolates), Mycobacterium kansasii (2 isolates), Mycobacterium flavescens (2 isolates), Mycobacterium gordonae (3 isolates) and Mycobacterium lentiflavum (1 isolate) were identified by these techniques. The isolation of opportunistic pathogens such as M. kansasii, M. simiae and M. lentiflavum from raw milk represent a risk for the consumers of mozzarella cheese made by this milk.

Role of systemic and local administration of selective inhibitors of cyclo-oxygenase 1 and 2 in an experimental model of periodontal disease in rats.

BACKGROUND AND OBJECTIVE: Periodontal disease is an inflammatory condition of tooth-supporting tissues. Arachidonic acid metabolites have been implicated in development of periodontal disease, especially those derived from the cyclo-oxygenase (COX) pathway. This study investigated the role of inhibitors of cyclo-oxygenases (COX-1 and COX-2) in a model of periodontal disease in rats. MATERIAL AND METHODS: A ligature was placed around the molar of rats. Losses of fiber attachment and of alveolar bone were measured morphometrically in histologically prepared sections. Infiltration of cells into gingival tissue surrounding the ligated tooth was also determined. RESULTS: Systemic and local administration of non-selective and selective COX-2 inhibitors, preventively, resulted in significant reduction of the losses of fiber attachment and alveolar bone, as well as decreased leukocyte numbers in gingival tissue. Preventive selective inhibition of COX-1 was as effective as COX-2 inhibition in reducing local fiber attachment loss and cell migration, but did not prevent alveolar bone loss. CONCLUSION: Our results provide evidence for participation of COX-1 and COX-2 in early stages of periodontal disease in rats. Furthermore, local administration of COX inhibitors reduced the signs of periodontal disease to the same extent as systemic treatment. Therapeutic approaches incorporating locally delivered anti-inflammatory drugs could be of benefit for patients suffering from periodontal disease.

Growth and differentiation factor-9 stimulates activation of goat primordial follicles in vitro and their progression to secondary follicles.

The aim of the present study was to investigate the effects of growth and differentiation factor-9 (GDF-9) on the survival and activation of preantral follicles, as well as their subsequent progression to secondary follicles, using goat ovarian cortical culture in vitro. Pieces of ovarian cortex were cultured for 1 and 7 days in minimum essential medium (MEM) with or without different concentrations of GDF-9 (1-200 ng mL(-1)). On Day 0 and after 1 and 7 days of culture, cortical pieces were fixed for histological and transmission electron microscopy evaluation. Preantral follicles were classified according to their development stage (primordial, intermediate, primary and secondary) and on the basis of morphological features (normal or degenerated). In addition, follicular and oocyte diameters were determined before and after culture. The results showed that, compared with non-cultured cortical tissue (Day 0), the culture of ovarian tissue significantly reduced (P < 0.05) the percentage of normal follicles in all media tested, except for tissue cultured in the presence of 200 ng mL(-1) GDF-9. Furthermore, in all media tested, the percentage of primordial follicles was significantly reduced (P < 0.05), with a concomitant increase in the percentage of developing follicles. The highest percentage of secondary follicles was observed after 7 days of culture in MEM plus 200 ng mL(-1) GDF-9. At all concentrations of GDF-9 tested, follicular diameter increased significantly after 7 days of culture compared with non-cultured cortical tissue. In conclusion, the results of the present study indicate that 200 ng mL(-1) GDF-9 maintains the survival of preantral follicles and promotes activation of primordial follicles. Furthermore, GDF-9 stimulates the transition from primary to secondary follicles, maintaining ultrastructural integrity of the follicles.

Crucial role of peripheral kappa-opioid receptors in a model of periodontal disease in rats.

BACKGROUND AND OBJECTIVE: Periodontal disease is a chronic inflammatory condition of the tooth supporting tissues, the periodontium. Opioids have been shown to account for the relief of various chronic and acute inflammatory conditions. The aim of the present study was to investigate the participation of peripheral opioid receptors in development of periodontal disease. MATERIAL AND METHODS: Morphine and selective agonists and antagonists of opioid receptors were used in an experimental model of ligature-induced periodontal disease in rats. To evaluate the development of disease, the loss of fiber attachment, alveolar bone and number of cells in periodontal tissues were assessed. Measurements of these indicators were obtained by morphometric analysis of histological sections of periodontal-diseased tissues stained with hematoxylin and eosin. RESULTS: Local administration of either morphine or a selective kappa-opioid agonist for three consecutive days from the onset of periodontal disease reduced the loss of periodontal tissues, without changing the number of leukocytes in inflamed periodontium. Nor-binaltorphimine, a selective kappa-antagonist, reversed the beneficial effects of both morphine and the compound U-50,488 in this model. The use of either an agonist or an antagonist of delta-opioid receptors, however, did not affect disease progression. CONCLUSION: Our results showed that the beneficial effect of opioids in periodontal disease depended mainly on the activation of specific kappa-opioid receptors located in the periphery. Activation of such receptors could be considered in the management of periodontal disease, since it would not present the classical central side-effects associated with opioid use.

Ação do extrato metanólico e etanólico de Davilla elliptica St. Hill. (Malpighiaceae) na resposta imune / Action of Davilla elliptica St. Hill. (Malpighiaceae) methanolic and ethanolic extracts in the immune response

Plantas têm contribuído no tratamento da maioria das doenças. Considerando a importância terapêutica das plantas medicinais, foi avaliada a atividade imunológica dos extratos metanólico e etanólico de Davilla elliptica. Macrófagos estão envolvidos em todos estágios da resposta imune, podendo liberar componentes como: peróxido de hidrogênio (H2O2), óxido nítrico (NO) e fator de necrose tumoral-alfa (TNF-alfa). A estimulação dos macrófagos foi avaliada pela determinação de H2O2, NO e TNF-alfa em culturas de macrófagos peritoneais de camundongos na presença dos extratos da D. elliptica. IC50 foi determinado através de ensaio utilizando MTT. Os estudos fitoquímicos realizados mostraram a presença de flavonóides derivados da quercetina e miricetina entre outros compostos. A produção de H2O2 não foi muito expressiva em ambos extratos, contudo a de NO foi significativa. Os dois extratos induziram a produção de TNF-alfa, sendo que a liberação dessa citocina pelo extrato metanólico foi quase cinco vezes maior do que pelo extrato etanólico. Uma relação entre as sínteses de NO e TNF-alfa foi observada. O aumento na produção de NO está relacionado com a indução de citocinas pró-inflamatórias como TNF-alfa. Analisando os resultados, sugere-se que os extratos metanólico e etanólico de D. elliptica podem modular a ativação de macrófagos.

Plants have contributed in a significant way to the treatment of most of the diseases. Considering the therapeutic importance of the medicinal plants, the immunological activity of the methanolic and ethanolic extract of Davilla elliptica was evaluated. In every stage of the immune response macrophages are involved and they can release many compounds such as hydrogen peroxide (H2O2), nitric oxide (NO) and tumor necrosis factor-alpha (TNF-alpha). Macrophages stimulation was evaluated by the determination of H2O2, NO and TNF-alpha in peritoneal macrophages cultures of mice in the presence of the D. elliptica extracts. IC50 was determined by MTT assay. The phytochemical study showed flavonoids derived from quercetin and myricetin and other compounds. The production of H2O2 was not very expressive in both extracts, but they presented a significant effect on NO production. The two extracts induced TNF-alpha production, although the methanolic liberated almost five times more TNF-alpha than the ethanolic one. A relationship among the synthesis of NO and TNF-alpha was observed. The increase of NO production is related with the induction of proinflammatory cytokines like TNF-alpha. Analyzing the results, it is suggested that methanolic and ethanolic extract of D. elliptica can modulate macrophage activation.

Induction of micronuclei by alkaloids extracted from Senecio brasiliensis and stored for 23 years.

In the present study, we report the results of an investigation on pyrrolizidine alkaloids extracted from Senecio brasiliensis (Sprengel) Less., which were stored for more than 23 years under variable conditions of temperature and humidity and exposed to light. Both the crude alkaloid (integerrimine+retrorsine+impurities) and pure integerrimine conserved the ability to induce acute toxicity in mice, leading to the death of the animals in less than 24h. The alkaloids also conserved the potential to induce significant increases in micronucleus frequencies in polychromatic erythrocytes of mouse bone marrow compared to the negative control. The administration of alkaloids to lymphocyte cultures blocked with cytochalasin-B showed no significant increase in micronucleus frequency in binucleated cells, probably due to the lack of a metabolic activation mechanism. However, an antimitotic effect was observed.

O estudante de medicina e o paciente terminal. / The medical student and the terminal patient

O autor, apos discutir as dificuldade emocionais vividas pelo estudante de medicina nos seus primeiros contactos com os pacientes, relata uma experiencia pessoal de acompanhamento psicologico de um doente em insuficiencia hepatica terminal, sob supervisao de professores do Curso de Psicologia Medica. Ilustra com relatos de dialogos que teve com o paciente sobre o modo como lidou com as dificeis questoes levantadas pelos mesmo em relacao a sua irrecuperabilidade e perspectiva de morte.Comentando o trabalho, o Prof. Julio de Mello Filho enfatiza a importancia da intuicao, empatia e sensibilidade do aluno, que lhe permitiram levar a cabo tao dificil tarefa Faz consideracoes sobre os trabalhos praticos que os estudantes podem realizar com os pacientes durante o periodo de aprendizado, aliviando-os, ao mesmo tempo do sentimento de apenas usa-los como se fossem cobaias