Hypercupremia in female munitions workers using taking oral contraceptives: a case series.

Copper is an essential trace element for homeostasis and is mostly obtained through the diet. Copper can also enter the body through occupational and accidental exposure, resulting in the elevation of serum copper levels (hypercupremia). Other factors associated with hypercupremia include smoking, use of oral contraceptives, and several clinical conditions. This case series describes the presence of hypercupremia in workers exposed to copper while also taking oral contraceptives. Serum copper levels of the sample remained high, even after participants spent time away from work, normalizing only after a change in contraceptive methods. The present results underscore the importance of considering oral contraceptives as a possible cause of hypercupremia in women with occupational exposure to copper, regardless of symptomatic status.

Risk factors for the development of hospital-acquired pediatric venous thromboembolism-Dealing with potentially causal and confounding risk factors using a directed acyclic graph (DAG) analysis.

INTRODUCTION: Hospital-acquired venous thromboembolism (HA-VTE) in children comprises multiple risk factors that should not be evaluated separately due to collinearity and multiple cause and effect relationships. This is one of the first case-control study of pediatric HA-VTE risk factors using a Directed Acyclic Graph (DAG) analysis. MATERIAL AND METHODS: Retrospective, case-control study with 22 cases of objectively confirmed HA-VTE and 76 controls matched by age, sex, unit of admission, and period of hospitalization. Descriptive statistics were used to define distributions of continuous variables, frequencies, and proportions of categorical variables, comparing cases and controls. Due to many potential risk factors of HA-VTE, a directed acyclic graph (DAG) model was created to identify confounding, reduce bias, and increase precision on the analysis. The final model consisted of a DAG-informed conditional logistic regression. RESULTS: In the initial conventional univariable model, the following variables were selected as potential risk factors for HA-VTE: length of stay (LOS, days), immobility, ICU admission in the last 30 days, LOS in ICU, infection, central venous catheter (CVC), number of CVCs placed, L-asparaginase, heart failure, liver failure, and nephrotic syndrome. The final model using the set of variables selected by DAG analysis revealed LOS (OR = 1.106, 95%CI = 1.021-1.198, p = 0.013), L-asparaginase (OR = 26.463, 95%CI = 1.609-435.342, p = 0.022), and nephrotic syndrome (OR = 29.127, 95%CI = 1.044-812.508, p = 0.004) as independent risk factors for HA-VTE. CONCLUSION: The DAG-based approach was useful to clarify the influence of confounders and multiple causalities of HA-VTE. Interestingly, CVC placement-a known thrombotic risk factor highlighted in several studies-was considered a confounder, while LOS, L-asparaginase use and nephrotic syndrome were confirmed as risk factors to HA-VTE. Large confidence intervals are related to the sample size; however, the results were significant.

Shared decision making in Brazil: Concrete efforts to empower the patients' voice.

Patient involvement in healthcare decisions has grown in Brazil at three different levels: 1) the macro level, which includes the patient actively influencing legislation and regulation of medical care as well as political changes in the process of care itself; 2) the meso level, which includes institutions that aim to improve information, empowerment and counseling to patients, and 3) the micro level, which focuses on the actual decision-making process that takes place within patient-physician encounter. In Brazil, the macro and meso levels are stronger than the micro one. In this paper, the practical efforts to engage patients in the center of their own care are presented. In order to do that, an overview on the National Humanization Policy and the Brazilian patient's movement is provided.