Critical appraisal beyond clinical guidelines for intraabdominal candidiasis.

BACKGROUND: Regardless of the available antifungals, intraabdominal candidiasis (IAC) mortality continues to be high and represents a challenge for clinicians. MAIN BODY: This opinion paper discusses alternative antifungal options for treating IAC. This clinical entity should be addressed separately from candidemia due to the peculiarity of the required penetration of antifungals into the peritoneal cavity. Intraabdominal concentrations may be further restricted in critically ill patients where pathophysiological facts alter normal drug distribution. Echinocandins are recommended as first-line treatment in guidelines for invasive candidiasis. However, considering published data, our pharmacodynamic analysis suggests the required increase of doses, postulated by some authors, to attain adequate pharmacokinetic (PK) levels in peritoneal fluid. Given the limited evidence in the literature on PK/PD-based treatments of IAC, an algorithm is proposed to guide antifungal treatment. Liposomal amphotericin B is advocated as first-line therapy in patients with sepsis/septic shock presenting candidemia or endophthalmitis, or with prior exposure to echinocandins and/or fluconazole, or with infections by Candida glabrata. Other situations and alternatives, such as new compounds or combination therapy, are also analysed. CONCLUSION: There is a critical need for more robust clinical trials, studies examining patient heterogeneity and surveillance of antifungal resistance to enhance patient care and optimise treatment outcomes. Such evidence will help refine the existing guidelines and contribute to a more personalised and effective approach to treating this serious medical condition. Meanwhile, it is suggested to broaden the consideration of other options, such as liposomal amphotericin B, as first-line treatment until the results of the fungogram are available and antifungal stewardship could be implemented to prevent the development of resistance.

Plasma-induced nanoparticle aggregation for stratifying COVID-19 patients according to disease severity.

Stratifying patients according to disease severity has been a major hurdle during the COVID-19 pandemic. This usually requires evaluating the levels of several biomarkers, which may be cumbersome when rapid decisions are required. In this manuscript we show that a single nanoparticle aggregation test can be used to distinguish patients that require intensive care from those that have already been discharged from the intensive care unit (ICU). It consists of diluting a platelet-free plasma sample and then adding gold nanoparticles. The nanoparticles aggregate to a larger extent when the samples are obtained from a patient in the ICU. This changes the color of the colloidal suspension, which can be evaluated by measuring the pixel intensity of a photograph. Although the exact factor or combination of factors behind the different aggregation behavior is unknown, control experiments demonstrate that the presence of proteins in the samples is crucial for the test to work. Principal component analysis demonstrates that the test result is highly correlated to biomarkers of prognosis and inflammation that are commonly used to evaluate the severity of COVID-19 patients. The results shown here pave the way to develop nanoparticle aggregation assays that classify COVID-19 patients according to disease severity, which could be useful to de-escalate care safely and make a better use of hospital resources.

Micro- and nanosensors for detecting blood pathogens and biomarkers at different points of sepsis care.

Severe infections can cause a dysregulated response leading to organ dysfunction known as sepsis. Sepsis can be lethal if not identified and treated right away. This requires measuring biomarkers and pathogens rapidly at the different points where sepsis care is provided. Current commercial approaches for sepsis diagnosis are not fast, sensitive, and/or specific enough for meeting this medical challenge. In this article, we review recent advances in the development of diagnostic tools for sepsis management based on micro- and nanostructured materials. We start with a brief introduction to the most popular biomarkers for sepsis diagnosis (lactate, procalcitonin, cytokines, C-reactive protein, and other emerging protein and non-protein biomarkers including miRNAs and cell-based assays) and methods for detecting bacteremia. We then highlight the role of nano- and microstructured materials in developing biosensors for detecting them taking into consideration the particular needs of every point of sepsis care (e.g., ultrafast detection of multiple protein biomarkers for diagnosing in triage, emergency room, ward, and intensive care unit; quantitative detection to de-escalate treatment; ultrasensitive and culture-independent detection of blood pathogens for personalized antimicrobial therapies; robust, portable, and web-connected biomarker tests outside the hospital). We conclude with an overview of the most utilized nano- and microstructured materials used thus far for solving issues related to sepsis diagnosis and point to new challenges for future development.

Fabrication and characterization of low-shrinkage dental composites containing montmorillonite nanoclay.

Dental composites are aesthetic materials widely used in Dentistry for replacing hard dental tissues lost due to caries or traumas. The aim of this study was to fabricate low-shrinkage dental composite charged with nanoclay fillers (montmorillonite Cloisite®-MMT) and evaluate their cytotoxicity and physicomechanical properties. Four dental composites were produced from the same organic matrix: Bis-GMA/TEGDMA (30 wt.%). The filler system was constituted of BaSi, SiO2, and MMT in the following concentrations (wt.%): 93.8/6.2/0, 89.1/5.9/5, 86.7/5.8/7.5, and 84.4/5.6/10 (E0: 0; E5: 5%; E7.5: 7.5%; E10: 10% of MMT nanoclays). The following properties were tested: in vitro cytotoxicity, flexural strength, elastic modulus, volumetric shrinkage, water sorption, water solubility, and hygroscopic expansion. Scanning electron microscopy was used to characterize composites' topography. Data were analyzed by one-way ANOVA and Tukey's HSD post hoc test (p < 0.05). MMT nanoclays did not affect the cytotoxicity. E5 and E7.5 groups showed a significant decrease in polymerization shrinkage while maintained the overall physicomechanical properties. The inclusion of 5 and 7.5 wt.% of MMT nanoclays allowed the fabrication of dental composites with low cytotoxicity and low polymerization shrinkage, without jeopardizing the overall behaviour of their physicomechanical properties (flexural strength, elastic modulus, water sorption, water solubility, and hygroscopic expansion). These aspects suggest that the usage of MMT nanoclays could be an effective strategy to formulate new dental composites with clinical applicability.

Immunodetection of Lung IgG and IgM Antibodies against SARS-CoV-2 via Enzymatic Liquefaction of Respiratory Samples from COVID-19 Patients.

Lung-secreted IgG and IgM antibodies are valuable biomarkers for monitoring the local immune response against respiratory infections. These biomarkers are found in lower airway secretions that need to be liquefied prior to analysis. Traditional methods for sample liquefaction rely on reducing disulfide bonds, which may damage the structure of the biomarkers and hamper their immunodetection. Here, we propose an alternative enzymatic method that uses O2 bubbles generated by endogenous catalase enzymes in order to liquefy respiratory samples. The proposed method is more efficient for liquefying medium- and high-viscosity samples and does not fragment the antibodies. This prevents damage to antigen recognition domains and recognition sites for secondary antibodies that can decrease the signal of immunodetection techniques. The suitability of the enzymatic method for detecting antibodies in respiratory samples is demonstrated by detecting anti-SARS-CoV-2 IgG and IgM to viral N-protein with gold standard ELISA in bronchial aspirate specimens from a multicenter cohort of 44 COVID-19 patients. The enzymatic detection sharply increases the sensitivity toward IgG and IgM detection compared to the traditional approach based on liquefying samples with dithiothreitol. This improved performance could reveal new mechanisms of the early local immune response against respiratory infections that may have gone unnoticed with current sample treatment methods.

Optimized detection of lung IL-6 via enzymatic liquefaction of low respiratory tract samples: application for managing ventilated patients.

Lung IL-6 is a promising biomarker for predicting respiratory failure during pulmonary infections. This biomarker is found in respiratory samples which need to be liquefied prior to analysis. Traditional liquefying methods use reducing agents such as dithiothreitol (DTT). However, DTT impairs immunodetection and does not liquefy highly viscous samples. We propose an enzymatic method that liquefies samples by means of generating O2 bubbles with endogenous catalase. Low respiratory tract specimens from 48 mechanically ventilated patients (38 with SARS-CoV-2 infection) were treated with DTT or with the enzymatic method. We used turbidimetry to compare the liquefaction degree and IL-6 was quantified with ELISA. Finally, we used AUC-ROC, time-to-event and principal component analysis to evaluate the association between respiratory compromise or local inflammation and IL-6 determined with both methods. Enzymatically treated samples were better liquefied than those reduced by DTT, which resulted in higher ELISA signals. Lung IL-6 levels obtained with the enzymatic procedure were negatively correlated with the oxygenation index (PaO2/FiO2) and the time of mechanical ventilation. The proposed enzymatic liquefaction method improves the sensitivity for lung IL-6 detection in respiratory samples, which increases its predictive power as a biomarker for evaluating respiratory compliance.

Nanoparticle transfer biosensors for the non-invasive detection of SARS-CoV-2 antigens trapped in surgical face masks.

Detecting SARS-CoV-2 antigens in respiratory tract samples has become a widespread method for screening new SARS-CoV-2 infections. This requires a nasopharyngeal swab performed by a trained healthcare worker, which puts strain on saturated healthcare services. In this manuscript we describe a new approach for non-invasive COVID-19 diagnosis. It consists of using mobile biosensors for detecting viral antigens trapped in surgical face masks worn by patients. The biosensors are made of filter paper containing a nanoparticle reservoir. The nanoparticles transfer from the biosensor to the mask on contact, where they generate colorimetric signals that are quantified with a smartphone app. Sample collection requires wearing a surgical mask for 30 min, and the total assay time is shorter than 10 min. When tested in a cohort of 27 patients with mild or no symptoms, an area under the receiving operating curve (AUROC) of 0.99 was obtained (96.2 % sensitivity and 100 % specificity). Serial measurements revealed a high sensitivity and specificity when masks were worn up to 6 days after diagnosis. Surgical face masks are inexpensive and widely available, which makes this approach easy to implement anywhere. The excellent sensitivity, even when tested with asymptomatic patient samples, along with the mobile detection scheme and non-invasive sampling procedure, makes this biosensor design ideal for mass screening.

Paper biosensors for detecting elevated IL-6 levels in blood and respiratory samples from COVID-19 patients.

Decentralizing COVID-19 care reduces contagions and affords a better use of hospital resources. We introduce biosensors aimed at detecting severe cases of COVID-19 in decentralized healthcare settings. They consist of a paper immunosensor interfaced with a smartphone. The immunosensors have been designed to generate intense colorimetric signals when the sample contains ultralow concentrations of IL-6, which has been proposed as a prognosis biomarker of COVID-19. This is achieved by combining a paper-based signal amplification mechanism with polymer-filled reservoirs for dispensing antibody-decorated nanoparticles and a bespoken app for color quantification. With this design we achieved a low limit of detection (LOD) of 10-3 pg mL-1 and semi-quantitative measurements in a wide dynamic range between 10-3 and 102 pg mL-1 in PBS. The assay time is under 10 min. The low LOD allowed us to dilute blood samples and detect IL-6 with an LOD of 1.3 pg mL-1 and a dynamic range up to 102 pg mL-1. Following this protocol, we were able to stratify COVID-19 patients according to different blood levels of IL-6. We also report on the detection of IL-6 in respiratory samples (bronchial aspirate, BAS) from COVID-19 patients. The test could be easily adapted to detect other cytokines such as TNF-α and IL-8 by changing the antibodies decorating the nanoparticles accordingly. The ability of detecting cytokines in blood and respiratory samples paves the way for monitoring local inflammation in the lungs as well as systemic inflammation levels in the body.

Update of the treatment of nosocomial pneumonia in the ICU.

In accordance with the recommendations of, amongst others, the Surviving Sepsis Campaign and the recently published European treatment guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), in the event of a patient with such infections, empirical antibiotic treatment must be appropriate and administered as early as possible. The aim of this manuscript is to update treatment protocols by reviewing recently published studies on the treatment of nosocomial pneumonia in the critically ill patients that require invasive respiratory support and patients with HAP from hospital wards that require invasive mechanical ventilation. An interdisciplinary group of experts, comprising specialists in anaesthesia and resuscitation and in intensive care medicine, updated the epidemiology and antimicrobial resistance and established clinical management priorities based on patients' risk factors. Implementation of rapid diagnostic microbiological techniques available and the new antibiotics recently added to the therapeutic arsenal has been reviewed and updated. After analysis of the categories outlined, some recommendations were suggested, and an algorithm to update empirical and targeted treatment in critically ill patients has also been designed. These aspects are key to improve VAP outcomes because of the severity of patients and possible acquisition of multidrug-resistant organisms (MDROs).

Atrial fibrillation in a patient with Zika virus infection.

BACKGROUND: Zika virus is an emerging arbovirus of the family Flaviviridae and genus Flavivirus that until 2007 was restricted to a few cases of mild illness in Africa and Asia. CASE PRESENTATION: We report a case of atrial fibrillation disclosed during an acute Zika virus infection in a 49-year-old man. Different biological samples were analyzed for the molecular diagnosis of Zika by real-time PCR, however only the saliva specimen was positive. The patient's wife tested positive in the serum sample, although she was an asymptomatic carrier. Moreover, a complete overview of patient's biomarkers, including cytokines, chemokines, and growth-factors levels, was analyzed and compared to gender and age matching non-infected controls, as well as other Zika infected patients, considering the 95%CI of the mean values. Elevated levels of CXCL8, CCL11, CCL2, CXCL10, IL-1ß, IL-6, TNF-α, IFN-γ, IL-17, IL-1Ra, IL-4, IL-9, FGF-basic, PDGF, G-CSF, and GM-CSF were observed in the Atrial fibrillation patient, in contrast to uninfected controls. Furthermore, increased levels of CCL5, IL-1ß, TNF-α, IFN-γ, IL-9, G-CSF, and GM-CSF were observed only in the atrial fibrillation patient, when compared to other Zika patients. CONCLUSIONS: To our knowledge, this is the first description of this type of cardiac disorder in Zika patients which may be considered another atypical manifestation during Zika virus infection.

Improved empirical antibiotic treatment of sepsis after an educational intervention: the ABISS-Edusepsis study.

BACKGROUND: Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality. METHODS: We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs. RESULTS: We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period. CONCLUSIONS: Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.

Survival of hematological patients after discharge from the intensive care unit: a prospective observational study.

INTRODUCTION: Although the survival rates of hematological patients admitted to the ICU are improving, little is known about the long-term outcome. Our objective was to identify factors related to long-term outcome in hematological patients after ICU discharge. METHODS: A prospective, observational study was carried out in seven centers in Spain. From an initial sample of 161 hematological patients admitted to one of the participating ICUs during the study period, 62 were discharged alive and followed for a median time of 23 (1 to 54) months. Univariate and multivariate analysis were performed to identify the factors related to long term-survival. Finally, variables that influence the continuation of the scheduled therapy for the hematological disease were studied. RESULTS: Mortality after ICU discharge was 61%, with a median survival of 18 (1 to 54) months. In the multivariate analysis, an Eastern Cooperative Oncology Group score (ECOG) >2 at ICU discharge (Hazard ratio 11.15 (4.626 to 26.872)), relapse of the hematological disease (Hazard ratio 9.738 (3.804 to 24.93)) and discontinuation of the planned treatment for the hematological disease (Hazard ratio 4.349 (1.286 to 14.705)) were independently related to mortality. Absence of stem cell transplantation, high ECOG and high Acute Physiology and Chronic Health Evaluation II (APACHE II) scores decreased the probability of receiving the planned therapy for the hematological malignancy. CONCLUSIONS: Both ICU care and post-ICU management determine the long-term outcome of hematological patients who are discharged alive from the ICU.

A Qualitative Analysis of Treatment Patterns for Mild and Severe Molar Hypomineralization in Permanent Teeth: A Systematic Review.

Purpose: Using a systematic review to answer the following question: What are the treatment patterns for mild and severe molar hypomineralization in permanent teeth? Methods: Electronic searches were conducted to identify randomized clinical trials (RCT) that related treatment to molar hypomineralization- (MH) affected permanent molars in children from five to 16 years old. Data extraction and risk of bias evaluation, using the Cochrane risk of bias tool, were performed for all included studies. Studies were selected according to PICOS criteria. RCTs relating mild and severe MH to treatments on permanent molars were included. Studies analyzing clinical techniques, whether single or any association of tech- niques for restorative and desensitizing treatments, were included. Studies involving another disease or comparing different types of enamel defects related to trauma and hereditary were excluded. The certainty of the evidence was evaluated using the GRADE approach. Results: The electronic search was performed on MEDLINE via PubMed, Embase, Cochrane Library, and Grey literature up to May 9, 2022. Of the 5,201 studies initially identified, 88 were fully assessed and 14 RCTs were included. A total of 2,399 interventions were analyzed in 576 patients. Certainty of evidence was found to be of low quality for the outcomes remineralization, structural integrity maintenance, and decay prevention, and very low quality for hypersensitivity decrease and retention. Conclusions: Mild molar hypomineralization needs remineralization, desensitization, sealants, and close follow-up. Severe MH requires restoration both to treat hypersensitivity and reconstruct the affected teeth. Yellow-brown defects have a poor prognosis.

Ten Issues for Updating in Community-Acquired Pneumonia: An Expert Review.

Community-acquired pneumonia represents the third-highest cause of mortality in industrialized countries and the first due to infection. Although guidelines for the approach to this infection model are widely implemented in international health schemes, information continually emerges that generates controversy or requires updating its management. This paper reviews the most important issues in the approach to this process, such as an aetiologic update using new molecular platforms or imaging techniques, including the diagnostic stewardship in different clinical settings. It also reviews both the Intensive Care Unit admission criteria and those of clinical stability to discharge. An update in antibiotic, in oxygen, or steroidal therapy is presented. It also analyzes the management out-of-hospital in CAP requiring hospitalization, the main factors for readmission, and an approach to therapeutic failure or rescue. Finally, the main strategies for prevention and vaccination in both immunocompetent and immunocompromised hosts are reviewed.

Ventilatory support in critically ill hematology patients with respiratory failure.

INTRODUCTION: Hematology patients admitted to the ICU frequently experience respiratory failure and require mechanical ventilation. Noninvasive mechanical ventilation (NIMV) may decrease the risk of intubation, but NIMV failure poses its own risks. METHODS: To establish the impact of ventilatory management and NIMV failure on outcome, data from a prospective, multicenter, observational study were analyzed. All hematology patients admitted to one of the 34 participating ICUs in a 17-month period were followed up. Data on demographics, diagnosis, severity, organ failure, and supportive therapies were recorded. A logistic regression analysis was done to evaluate the risk factors associated with death and NIVM failure. RESULTS: Of 450 patients, 300 required ventilatory support. A diagnosis of congestive heart failure and the initial use of NIMV significantly improved survival, whereas APACHE II score, allogeneic transplantation, and NIMV failure increased the risk of death. The risk factors associated with NIMV success were age, congestive heart failure, and bacteremia. Patients with NIMV failure experienced a more severe respiratory impairment than did those electively intubated. CONCLUSIONS: NIMV improves the outcome of hematology patients with respiratory insufficiency, but NIMV failure may have the opposite effect. A careful selection of patients with rapidly reversible causes of respiratory failure may increase NIMV success.

Current Positioning against Severe Infections Due to Klebsiella pneumoniae in Hospitalized Adults.

Infections due to Klebsiella pneumoniae have been increasing in intensive care units (ICUs) in the last decade. Such infections pose a serious problem, especially when antimicrobial resistance is present. We created a task force of experts, including specialists in intensive care medicine, anaesthesia, microbiology and infectious diseases, selected on the basis of their varied experience in the field of nosocomial infections, who conducted a comprehensive review of the recently published literature on the management of carbapenemase-producing Enterobacterales (CPE) infections in the intensive care setting from 2012 to 2022 to summarize the best available treatment. The group established priorities regarding management, based on both the risk of developing infections caused by K. pneumoniae and the risk of poor outcome. Moreover, we reviewed and updated the most important clinical entities and the new antibiotic treatments recently developed. After analysis of the priorities outlined, this group of experts established a series of recommendations and designed a management algorithm.

[Guidelines for the treatment of invasive fungal disease by Aspergillus spp. and other fungi issued by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). 2011 Update]. / Recomendaciones sobre el tratamiento de la enfermedad fúngica invasiva por Aspergillus spp. y otros hongos filamentosos de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC). Actualización 2011.

The guidelines on the treatment of invasive fungal disease by Aspergillus spp. and other fungi issued by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) are presented. These recommendations are focused on four clinical categories: oncology-haematology patients, solid organ transplant recipients, patients admitted to intensive care units, and children. An extensive review is made of therapeutical advances and scientific evidence in these settings. These guidelines have been prepared according the SEIMC consensus rules by a working group composed of specialists in infectious diseases, clinical microbiology, critical care medicine, paediatrics and oncology-haematology. Specific recommendations on the prevention of fungal infections in these patients are included.

Colorimetric Detection of Sepsis-Derived Hyperdegranulation with Plasmonic Nanosensors.

Hyperdegranulation of neutrophilic granulocytes is a common finding in sepsis that directly contributes to the heightened immune response leading to organ dysfunction. Currently, cell degranulation is detected by flow cytometry, which requires large infrastructure that is not always available at the point of care. Here, we propose a plasmonic assay for detecting the degranulation status of septic cells colorimetrically. It is based on triggering the aggregation of gold nanoparticles with cationic granule proteins. Cells from septic patients contain fewer granules and therefore release less cationic proteins than healthy cells. This results in red-colored assays than can be easily detected by eye. The assay can selectively detect cationic granule proteins even in the presence of an excess of unrelated proteins, which is key to detect degranulation with high specificity. Coupling this signal generation mechanism with a magnetic purification step enabled the identification of septic cells with the same performance as flow cytometry. This makes the proposed method a promising alternative for diagnosing sepsis in decentralized healthcare schemes.

Occupational stress and work engagement among military police officers. / Estresse ocupacional e engajamento no trabalho entre policiais militares.

This paper investigates the levels of occupational stress and work engagement among military police officers. This cross-sectional, descriptive, and analytical study was conducted with 268 police officers from the 3rd Military Police Battalion of Paraná state. We observed significant levels of occupational stress in 125 (46.7%) police officers. The main stressors were lack of career growth prospects (3.7; ±1.3); inadequate training (3.4; ±1.2); discrimination/favoritism in the work environment (3.1; ±1.4); long working hours (3.0; ±1.4); distribution of tasks (2.7; ±1.1); control type (2.7; ±1.1); gaps in disclosing information about organizational decisions (2.7; ±1.2); low valuation (2.7; ±1.2). Levels of work engagement ranged from 3.8 [medium] to 4.1 [high]. The correlation between occupational stress and work engagement was low for the dimensions of Absorption (r: -.284; p<0.001) and Overall Score (r: -0.393; p<0.001) and moderate for the dimensions Vigor (r: -0.422; p<0.001) and Dedication (r: -0.414; p<0.001). We concluded that an important number of police officers had shown occupational stress. However, they displayed good levels of work engagement and are enthusiastic, inspired, and proud of their work.

Este artigo investiga os níveis de estresse ocupacional e engajamento no trabalho entre policiais militares. Estudo transversal, descritivo e analítico, com 268 policiais do 3º Batalhão de Polícia Militar do estado do Paraná. Observou-se níveis importantes de estresse ocupacional em 125 (46,7%) policiais. Os principais estressores foram: falta de perspectivas de crescimento na carreira (3,7; ±1,3); deficiência nos treinamentos (3,4; ±1,2); presença de discriminação/favoritismo no ambiente de trabalho (3,1; ±1,4); longas jornadas de trabalho (3,0; ±1,4); forma de distribuição das tarefas (2,7; ±1,1); tipo de controle (2,7; ±1,1); deficiência na divulgação de informações sobre decisões organizacionais (2,7; ±1,2); baixa valorização (2,7;±1,2). Os níveis de engajamento no trabalho variaram de 3,8 [médio] a 4,1 [alto]. A correlação entre estresse ocupacional e engajamento no trabalho foi baixa para as dimensões 'Absorção' (r: -0,284; p<0,001) e 'Escore geral' (r: -0,393; p<0,001) e moderada para as dimensões 'Vigor' (r: -0,422; p<0,001) e 'Dedicação' (r: -0,414; p<0,001). Concluiu-se que há um importante número de policiais com estresse ocupacional que, no entanto, apresentam bons níveis de engajamento no trabalho e mostram-se entusiasmados, inspirados e orgulhosos com o seu trabalho.