Perception of newly graduated physicians toward ethical education in medical schools: a Brazilian cross-sectional nationwide study.

OBJECTIVE: The objective of this study was to evaluate fresh medical graduates' perceptions regarding the general aspects of ethics teaching in Brazilian medical schools. METHODS: A structured questionnaire was applied to 4,601 participants among the 16,323 physicians who registered in one of the 27 Regional Medical Councils of Brazil in 2015. Answers to four questions regarding general aspects of ethics education in medical school were analyzed. Sampling procedures involved two stratification variables: legal nature (public vs. private) of medical schools and monthly household income higher than 10 minimum wages. RESULTS: A large percentage of the participants had witnessed unethical behaviors during contact with patients (62.0%), toward coworkers (51.5%), and in relationships with patients' families (34.4%) over the course of their medical training. Even though most of the responders (72.0%) totally agreed that patient-physician relationship and humanities education were part of their medical school curriculum, important topics such as conflicts of interest and end-of-life education were not satisfactorily addressed in the participants' medical training. Statistically significant differences were found between the answers of public and private school graduates. CONCLUSION: Despite great efforts to improve medical ethics education, our findings suggest the persistence of deficits and inadequacies in the ethics training currently given in medical schools in Brazil. Further modifications in ethics training must be made to address the deficiencies shown in this study. This process should be accompanied by continuous evaluation.

Time for change? A systematic review with meta-analysis of leptospires infecting dogs to assess vaccine compatibility in Brazil.

Dogs are thought to be highly exposed to environmental pathogenic leptospires, possibly acting as potential sources of infection for zoonotic transmission. Vaccination stands as the cornerstone strategy to prevent disease and urinary shedding in dogs, yet the success of vaccination is highly dependent on the correspondence of leptospires circulating locally with those used in vaccine compositions. To provide evidence for vaccine compatibility, and to assess whether there are regional differences on serogroup distribution, we conducted a systematic review with meta-analysis on serological data, characterization of leptospiral isolates and risk factors for seropositivity in dogs from Brazil. Studies reporting canine leptospirosis within the Brazilian territory were eligible for inclusion, and methodology was validated by PROSPERO under registration CRD42020204187. Six electronic databases were searched, and data regarding population, methods, and outcomes were extracted. Sixty-one studies were included to access serogroup distribution and risk factors, with a pooled positivity rate of 19.7% in dog population. Serological evidence indicates that Canicola, Icterohaemorrhagiae and Autumnalis are the most frequently found serogroups. Twenty-eight records were included to access leptospiral strains isolated in Brazil, with n = 56 strains characterized as serogroups Canicola, n = 37 as Icterohaemorrhagiae, n = 2 as Pomona, and n = 1 strain as Australis and Sejroe each. Risk factor analysis revealed that stray dogs, puppies or elderly dogs, male dogs and dogs kept by tutors with poor social and economic conditions are at high risk for infection. The present study revealed overall good compatibility of leptospiral strains circulating locally with those used in vaccines against canine leptospirosis in Brazil. The circulation of serovars Pomona and Grippotyphosa has not been consistently demonstrated, and the inclusion of these serovars in local vaccines cannot be supported by our results. The results also provided serological evidence for the circulation of Serogroup Autumnalis among the studied populations.

Perception of newly graduated physicians toward ethical education in medical schools: a Brazilian cross-sectional nationwide study

SUMMARY OBJECTIVE: The objective of this study was to evaluate fresh medical graduates' perceptions regarding the general aspects of ethics teaching in Brazilian medical schools. METHODS: A structured questionnaire was applied to 4,601 participants among the 16,323 physicians who registered in one of the 27 Regional Medical Councils of Brazil in 2015. Answers to four questions regarding general aspects of ethics education in medical school were analyzed. Sampling procedures involved two stratification variables: legal nature (public vs. private) of medical schools and monthly household income higher than 10 minimum wages. RESULTS: A large percentage of the participants had witnessed unethical behaviors during contact with patients (62.0%), toward coworkers (51.5%), and in relationships with patients' families (34.4%) over the course of their medical training. Even though most of the responders (72.0%) totally agreed that patient-physician relationship and humanities education were part of their medical school curriculum, important topics such as conflicts of interest and end-of-life education were not satisfactorily addressed in the participants' medical training. Statistically significant differences were found between the answers of public and private school graduates. CONCLUSION: Despite great efforts to improve medical ethics education, our findings suggest the persistence of deficits and inadequacies in the ethics training currently given in medical schools in Brazil. Further modifications in ethics training must be made to address the deficiencies shown in this study. This process should be accompanied by continuous evaluation.

Molecular and serological characterization of pathogenic Leptospira spp. isolated from symptomatic dogs in a highly endemic area, Brazil.

BACKGROUND: Leptospirosis is an endemic zoonosis in Brazil, with a great impact on human and animal health. Although dogs are frequently infected by pathogenic Leptospira, the current epidemiological understanding of canine leptospirosis is mainly based on serological tests that predict the infecting serogroup/serovar. Thus, the present study aimed at identifying the causative agent for severe cases of canine leptospirosis in a highly endemic area through the isolation and characterization of the isolated strains. RESULTS: Urine, serum and blood samples were collected from 31 dogs with suspected acute leptospirosis treated at the Veterinary Hospital Service of Santo Amaro University between 2018 and 2019. Acute infection was confirmed in 17 dogs (54.8%) by the associated use of Polymerase Chain Reaction (PCR), Microscopic Agglutination (MAT) and bacteriological culture. Eleven dogs (35.5%) had titers ≥800, with the most frequent serogroups being Autumnalis and Icterohaemorrhagiae (n = 4 each) and Canicola (n = 2). Leptospires were recovered from four dogs, and Multilocus Sequence Analysis (MLSA) revealed infection caused by L. interrogans, which were further characterized as serogroups Canicola (n = 1) and Icterohaemorrhagiae (n = 3). CONCLUSION: The identity of the isolates and serological pattern of MAT suggest that dogs are highly exposed to the serogroup Icterohaemorrhagiae and Canicola, also indicating possible circulation of serogroups not yet isolated in Brazil, notably serogroup Autumnalis. Our findings also reinforce the usefulness of using multiple diagnostic approaches to confirm acute canine leptospirosis.

Seroepidemiological investigation of animal leptospirosis and molecular characterization of the first Leptospira strain isolated from Fernando de Noronha archipelago, Brazil.

Leptospirosis has been widely reported in insular environments worldwide, characterizing a major public health threat. Although low-genetic biodiversity is expected in these regions, the introduction of domestic and synanthropic mammals may contribute to the wider diversity of leptospiral strains in insular settings. This study proposes a large-scale seroepidemiological investigation of Leptospira infection in animals from Fernando de Noronha archipelago and describes the characterization of the first leptospiral strain ever isolated from an insular setting in Brazil. A total of 1,265 blood samples from domestic (n = 682), synanthropic (n = 133) and wild (n = 450) animals were collected between 2007 and 2014, totalling 12 species. The presence of anti-Leptospira spp. antibodies was investigated by the microscopic agglutination test (MAT), and kidney samples from 20 synanthropic rodents were collected for the isolation of Leptospira spp. The leptospires recovered were further characterized by serogrouping with polyclonal antibodies, whole-genome sequencing and multilocus sequence typing (MLST). The MAT results revealed the presence of agglutinins in 90 samples (7.1%) and the most frequently found serogroup was Icterohaemorrhagiae (n = 57) in practically all species included. Viable leptospires were recovered from one brown rat, and characterization revealed that the isolate belongs to L. interrogans serogroup Pyrogenes. The results suggest that synanthropic rodents might play an important role in leptospiral infection among wildlife and domestic species in the archipelago.

Demografia Médica no Brasil - 2020

A publicação Demografia Médica no Brasil 2020, com resultado da colaboração entre o Conselho Federal de Medicina (CFM) e a Universidade de São Paulo (USP), é uma produção científica que atualiza os conhecimentos acumulados na última década e traz novas informações detalhadas sobre a população de médicos e seu exercício profissional. Em 2020, o Brasil passou a contar com mais de 500 mil médicos. Esse marco vem acompanhado da persistência de desigualdades na distribuição dos profissionais, do aumento desenfreado de cursos e vagas de graduação e da ociosidade de vagas de Residência Médica. Da mesma forma, o crescimento dessa população ocorre com a exposição dos médicos ao aumento do número de vínculos e de jornadas de trabalho. Portanto, o número de médicos no país cresceu, nos últimos anos, na mesma proporção em que se impuseram novos desafios para a profissão médica e o funcionamento do sistema de saúde no país. Assim, a Demografia Médica 2020 do CFM se impõe no debate qualificado, baseado em dados e evidências, com a oferta de subsídios para a atuação das entidades e governantes comprometidos com a valorização da Medicina e as melhorias das condições de saúde da população.

Profiling recent medical graduates planning to pursue surgery, anesthesia and obstetrics in Brazil.

BACKGROUND: Lack of providers in surgery, anesthesia, and obstetrics (SAO) is a primary driver of limited surgical capacity worldwide. We aimed to identify predictors of entry into Surgery, Anesthesia, and Obstetrics and Gynecology (SAO) fields and preference of working in the public sector in Brazil which may help in profiling medical students for recruitment into these needed areas. METHODS: A questionnaire was applied to all Brazilian medical graduates registered with a Board of Medicine from 2014 to 2015. Twenty-three characteristics were analyzed. Logistic regression was used to determine predictors' influence on outcome. RESULTS: There were 4601 (28.2%) responders to the survey, of which 40.5% (CI 34.7-46.5%) plan to enter SAO careers. Of the 23 characteristics analyzed, eight differed significantly between those who planned to work in SAO and those who did not. Of those eight characteristics, just three were significant predictors in the regression model: preference for working in the hospital setting, having spent more than 70% of their clinical years in practical activities, and valuing the substantial earning potential. These three factors explained only 6.3% of the variance in SAO preference. Within the graduates who preferred SAO careers, there were only two predictors for working in the public sector ("preparatory time before medical school" and valuing "prestige/status"). CONCLUSIONS: Factors affecting specialty and sector choice are multifaceted and difficult to predict. Future programs to fill provider gaps should identify methods other than medical student profiling to assure specialty and sector needs are met.

Complete genome sequence and in silico analysis of L. interrogans Canicola strain DU114: A virulent Brazilian isolate phylogenetically related to serovar Linhai.

Canine leptospirosis is often caused by Leptospira interrogans serovar Canicola. Infected dogs may become asymptomatic carriers of the pathogen, which leads to many public health concerns. In this work, we present the complete genome sequencing and in silico analysis from a virulent Brazilian strain of L. interrogans serovar Canicola, previously isolated from a stray dog in Sao Paulo City. Comparative genomic analysis with a reference genome allowed identification of 1031 INDELs and several arrangement variations. Out of 35,361 SNPs identified, 6780 were missense mutations and 16,114 were synonymous mutations. The Gene Ontology terms more affected by mutations were described. Interestingly, phylogenetic analyses indicated a genetic relatedness of the isolate with serovar Linhai strain 56,609. In addition, we found several virulence-related genes and main outer membrane proteins associated with pathogenesis. This genomic information about canine isolates may help to elucidate the molecular diversity and mechanisms of Leptospira spp. pathogenicity.

Development and validation of a modified TaqMan based real-time PCR assay targeting the lipl32 gene for detection of pathogenic Leptospira in canine urine samples

Abstract A modified TaqMan real-time polymerase chain reaction targeting a 138 bp fragment within the lipl32 gene was developed to identify exclusively pathogenic Leptospira spp. in dog urine samples. Thirty-five samples from dogs with suspected clinical leptospirosis and 116 samples from apparently healthy dogs were tested for presence of leptospiral DNA using the TaqMan-based assay. The results were compared with those from a well-established conventional PCR targeting the 16S RNA encoding gene associated with nucleotide sequencing analysis. The overall agreement between the assays was 94.8% (confidence interval [CI] 95% 88-100%). The newly developed assay presented 91.6% (CI 95% 71.5-98.5%) relative sensitivity (22[+] lipl32 PCR/24[+] 16S RNA and sequencing), 100% (CI 95% 96.3-100%) relative specificity and 98.7% accuracy (CI 95% 94.8-100%). The lipl32 assay was able to detect and quantify at least 10 genome equivalents/reaction. DNA extracted from 17 pathogenic Leptospira spp., 8 intermediate/saprophytic strains and 21 different pathogenic microorganisms were also tested using the lipl32 assay, resulting in amplification exclusively for pathogenic leptospiral strains. The results also demonstrated high intra and inter-assay reproducibility (coefficient of variation 1.50 and 1.12, respectively), thereby qualifying the newly developed assay as a highly sensitive, specific and reliable diagnostic tool for leptospiral infection in dogs using urine specimens.

Diagnosis of acute canine leptospirosis using multiple laboratory tests and characterization of the isolated strains.

BACKGROUND: Dogs presenting with acute leptospirosis may present non-specific clinical and laboratory findings, and the definitive diagnosis may require additional confirmatory tests, including bacterial culture, for the direct or indirect identification of the pathogen. The present study describes the diagnosis of leptospirosis in suspected dogs based on the use of multiple diagnostic tests, including serological, molecular and bacteriological tests, along with the characterization of the recovered leptospiral strains. RESULTS: Urine, serum and blood samples were collected from 33 dogs with suspected clinical leptospirosis treated at the University of São Paulo Veterinary Hospital Service (Hovet FMVZ-USP) between 2013 and 2016. Only dogs with high blood urea nitrogen and creatinine levels in association with multiple clinical manifestations of the disease were included. Leptospiral culture, PCR and serology (Microscopic agglutination test - MAT) were performed in blood and urine samples taken from all suspected dogs at clinical presentation, and an additional prospective MAT titration was performed in seven dogs. Infection could be identified exclusively by PCR in 10 dogs (30.3%), exclusively by MAT in four dogs (12.1%) and by both tests in four dogs, totaling 18 dogs (54.5-95%CI: 37.6-71.5). Six out of eight MAT-confirmed cases presented with the highest titers against the Icterohaemorrhagiae serogroup. Leptospires were recovered from urine samples from two PCR-positive dogs, and both strains could be characterized by Multilocus Sequence Analysis and serogrouping as L. interrogans serogroup Icterohaemorrhagiae. Both isolates were shown to be pathogenic in the hamster model. CONCLUSIONS: The simultaneous use of MAT and PCR was able to increase the diagnosis of leptospirosis in clinically suspected cases. Despite the increasing incidence of new serovars affecting dogs being reported in different locations, our results suggest that leptospiral strains belonging to the Icterohaemorrhagiae serogroup are still a major causative agent of canine leptospirosis in São Paulo, Brazil.

Prospective study of canine leptospirosis in shelter and stray dog populations: Identification of chronic carriers and different Leptospira species infecting dogs.

Dogs are highly susceptible to the leptospiral infection, notably stray and sheltered dogs. Unsanitary conditions often observed in dog shelters may predispose the introduction and spread of leptospires among sheltered populations, potentially increasing the chances for the inadvertent adoption of asymptomatically infected animals. The present work describes a longitudinal study using a multidisciplinary approach for the identification of chronically infected dogs and the characterization of potentially pathogenic strains circulating among stray and sheltered dog populations in São Paulo, Brazil. A total of 123 dogs from three populations were included. The initial evaluation consisted of blood and urine quantitative PCR testing (qPCR), the detection of specific antibodies by microscopic agglutination test (MAT), physical examination and hematological and serum biochemistry analyses. The qPCR-positive dogs were prospectively examined, and reevaluations also included culture from urine samples. Positive qPCR samples were subjected to 16S rRNA and secY gene phylogenetic analysis. The recovered strains were characterized by Multilocus Sequence Typing, polyclonal serogroup identification and virulence determination. Leptospiruria was detected in all populations studied (13/123), and phylogenetic analysis revealed that 10 dogs had L. interrogans infection. Three dogs (3/13) had L. santarosai infection. The secY phylogenetic analysis revealed that the L. santarosai sequences clustered separately from those obtained from other hosts. Ten leptospiruric dogs were reevaluated, and three dogs presented persistent leptospiruria, allowing culturing from two dogs. The strains were characterized as L. interrogans serogroup Canicola (virulent) and L. santarosai serogroup Sejroe (not virulent). Serum samples were retested by MAT using the DU92 and DU114 strains as antigens, and no increased seroreactivity was detected. Asymptomatic L. santarosai infection was observed in all populations studied, suggesting a possible role of dogs in the chain of transmission of this leptospiral species. The results suggest a genetic distinction between lineages of Brazilian L. santarosai maintained by dogs and other animal hosts. Our findings revealed that dogs could act as maintenance hosts for distinct pathogenic Leptospira, highlighting also that asymptomatically infected dogs can be inadvertently admitted and adopted in dog shelters, potentially increasing the risks of zoonotic transmission.

Physician's sociodemographic profile and distribution across public and private health care: an insight into physicians' dual practice in Brazil.

BACKGROUND: The intertwined relation between public and private care in Brazil is reshaping the medical profession, possibly affecting the distribution and profile of the country's medical workforce. Physicians' simultaneous engagement in public and private services is a common and unregulated practice in Brazil, but the influence played by contextual factors and personal characteristics over dual practice engagement are still poorly understood. This study aimed at exploring the sociodemographic profile of Brazilian physicians to shed light on the links between their personal characteristics and their distribution across public and private services. METHODS: A nation-wide cross-sectional study using primary data was conducted in 2014. A representative sample size of 2400 physicians was calculated based  on the National Council of Medicine database registries; telephone interviews were conducted to explore physicians' sociodemographic characteristics and their engagement with public and private services. RESULTS: From the 2400 physicians included, 51.45% were currently working in both the public and private services, while 26.95% and 21.58% were working exclusively in the private and public sectors, respectively. Public sector physicians were found to be younger (PR 0.84 [0.68-0.89]; PR 0.47 [0.38-0.56]), less experienced (PR 0.78 [0.73-0.94]; PR 0.44 [0.36-0.53]) and predominantly female (PR 0.79 [0.71-0.88]; PR 0.68 [0.6-0.78]) when compared to dual and private practitioners; their income was substantially lower than those working exclusively for the private (PR 0.58 [0.48-0.69]) and mixed sectors (PR 0.31 [0.25-0.37]). Conversely, physicians from the private sector were found to be typically senior (PR 1.96 [1.58-2.43]), specialized (PR 1.29 [1.17-1.42]) and male (PR 1.35 [1.21-1.51]), often working less than 20 h per week (PR 2.04 [1.4-2.96]). Dual practitioners were mostly middle-aged (PR 1.3 [1.16-1.45]), male specialists with 10 to 30 years of medical practice (PR 1.23 [1.11-1.37]). CONCLUSION: The study shows that more than half of Brazilian physicians currently engage with dual practice, while only one fifth dedicate exclusively to public services, highlighting also substantial differences in socio-demographic and work-related characteristics between public, private and dual-practitioners. These results are consistent with the international literature suggesting that physicians' sociodemographic characteristics can help predict dual practice forms and prevalence in a country.

Development and validation of a modified TaqMan based real-time PCR assay targeting the lipl32 gene for detection of pathogenic Leptospira in canine urine samples.

A modified TaqMan real-time polymerase chain reaction targeting a 138bp fragment within the lipl32 gene was developed to identify exclusively pathogenic Leptospira spp. in dog urine samples. Thirty-five samples from dogs with suspected clinical leptospirosis and 116 samples from apparently healthy dogs were tested for presence of leptospiral DNA using the TaqMan-based assay. The results were compared with those from a well-established conventional PCR targeting the 16S RNA encoding gene associated with nucleotide sequencing analysis. The overall agreement between the assays was 94.8% (confidence interval [CI] 95% 88-100%). The newly developed assay presented 91.6% (CI 95% 71.5-98.5%) relative sensitivity (22[+] lipl32 PCR/24[+] 16S RNA and sequencing), 100% (CI 95% 96.3-100%) relative specificity and 98.7% accuracy (CI 95% 94.8-100%). The lipl32 assay was able to detect and quantify at least 10 genome equivalents/reaction. DNA extracted from 17 pathogenic Leptospira spp., 8 intermediate/saprophytic strains and 21 different pathogenic microorganisms were also tested using the lipl32 assay, resulting in amplification exclusively for pathogenic leptospiral strains. The results also demonstrated high intra and inter-assay reproducibility (coefficient of variation 1.50 and 1.12, respectively), thereby qualifying the newly developed assay as a highly sensitive, specific and reliable diagnostic tool for leptospiral infection in dogs using urine specimens.

Demografia médica no Brasil - 2018 / Medical Demographics in Brazil - 2018

A avaliação da disponibilidade, da distribuição e da capacidade da força de trabalho médico é essencial para o futuro de um sistema de saúde que precisa oferecer serviços qualificados à população. A quarta edição da Demografia Médica traz informações atualizadas e oferece novos dados que permitem melhor compreensão da realidade da prática médica no País. Desenvolvida com metodologia consistente, oferece condições para o dimensionamento do impacto das decisões de gestores (públicos e privados) nas esferas política, administrativa e no campo da assistência em saúde. No momento em que o Sistema Único de Saúde (SUS) completa 30 anos, em um cenário de crise causada por subfinanciamento e falta de infraestrutura, a Demografia Médica torna mais evidente a necessidade de estratégias que facilitem a distribuição de médicos qualificados no território nacional. Assim, estimula uma visão crítica sobre a autorização indiscriminada de abertura de escolas médicas no Brasil. Este trabalho contou com as participações da Universidade de São Paulo (USP) e do Conselho Regional de Medicina do Estado de São Paulo (Cremesp). Foram recebidos ainda subsídios da Associação Médica Brasileira (AMB) e da Comissão Nacional de Residência Médica (CNRM). Em síntese, esta publicação sinaliza o compromisso do CFM com a pesquisa científica de excelência e destinada à contribuição para um projeto de Nação mais justo, ético e solidário.

Molecular and serological characterization of the first Leptospira santarosai strain isolated from a dog.

Leptospirosis is a zoonotic disease of global importance caused by pathogenic Leptospira species. Dogs can become asymptomatically infected, acting like reservoir hosts for pathogenic Leptospira, notably Leptospira interrogans serovar Canicola. Identification of such individuals and characterization of leptospires involved in chronic infections may unravel the role of dogs in the epidemiology of particular leptospiral strains. The aim of the present work was to describe the first Leptospira santarosai strain isolated from a dog. The dog was kept in a public shelter in São Paulo city, Brazil, and presented asymptomatic urinary shedding detected by PCR. Prospective evaluation was performed to fully characterize its chronic carrier state. The dog did not present anti-Leptospira titles or clinical/laboratorial abnormalities during the evaluations; nevertheless long-term urinary shedding was confirmed by PCR and leptospires were recovered from two occasions. The isolated strain was molecularly characterized by partial 16S rRNA and secY gene sequencing and MLST analysis. Serogroup identification was performed using polyclonal antibodies. The strain was identified as Leptospira santarosai, serogroup Sejroe. This is the first evidence in the literature of the isolation of L. santarosai in dogs. Our findings show that dogs can persistently harbor leptospires other than L. interrogans.

Natural Infection of the Wild Canid Lycalopex gymnocercus by the Protozoan Rangelia vitalii, the Agent of Canine Rangeliosis.

Rangelia vitalii is a piroplasmid that causes canine rangeliosis, a severe hemorrhagic disease of domestic dogs in South America. We report about R. vitalii infecting a pampas fox (Lycalopex gymnocercus). The fox, which developed a fatal illness, was also infected by Hepatozoon canis and Capillaria hepatica.