Comparative analysis of temporomandibular joint morphology in degenerative joint disease: A cone-beam CT study in patients with and without arthralgia.

This cross-sectional study aimed to compare, by using Cone-Beam Computed Tomography (CBCT), temporomandibular joint (TMJ) morphology among patients with degenerative joint disease (DJD) with or without arthralgia, as well as a control group. METHODS: Thirty-one patients and their respective CBCT TMJ exams were assessed. These individuals were selected from an Orofacial Pain Service and classified into three groups based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD): group 1 (10 patients with TMJ DJD and arthralgia), group 2 (11 patients with TMJ DJD without pain), and group 3 (the control group, consisting of 10 healthy individuals without any signs or symptoms of TMD). A second examiner, who was calibrated and blinded for the patient's diagnosis, evaluated the CBCT images. RESULTS: Group 1 showed a statistically significant association with the variables of erosion (p = 0.003) and osteophyte (p = 0.04) on the condyle surface, as well as concentric condyle position with reduced joint space (p = 0.01). The Kappa concordance index between the clinical diagnosis of DC/TMD and CBCT images was k = 0.134 (p ≤ 0.001). CONCLUSION: The presence of erosion, osteophyte, and concentric condyle position with reduced joint space was statistically associated with DJD and ongoing TMJ joint pain.

Reasons and Expectations for Seeking Spiritual Treatment in Brazilian Spiritist Centers: A Qualitative Study.

The objective of this study is to identify the main motivations and expectations for seeking spiritual treatment (ST) in  spiritist centers. This is a qualitative study developed at two spiritist centers in the state of Mato Grosso, Brazil. ST was considered as the set of activities that use magnetic current as the main treatment method. We observed that most of the participants first sought treatments from health professionals and that, after insufficient results, they went in search of ST. Their treatments take place simultaneously and, for the participants, they complement each other. The motivations that led the participants to ST ranged from physical reasons to mental health complaints and even family conflicts. One possibility for investing in this type of treatment is due to the participants' desire for a more comprehensive approach, and not as a mere solution to the problem that directly afflicts them.

Larvicidal activity of coumarin derivatives on Toxocara canis larvae, cytotoxicity analysis, and in silico bioavailability studies.

Human toxocariasis is a neglected anthropozoonosis with global distribution. Treatment is based on the administration of anthelmintics; however, their effectiveness at the tissue level is low to moderate, necessitating the discovery of new drug candidates. Several groups of synthetic compounds, including coumarin derivatives, have demonstrated bioactivity against fungi, bacteria, and even parasites, such as Dactylogyrus intermedius, Leishmania major, and Plasmodium falciparum. The aim of this study was to evaluate the effect of ten coumarin-derived compounds against Toxocara canis larvae using in vitro, cytotoxicity, and in silico tests for selecting new drug candidates for preclinical tests aimed at evaluating the treatment of visceral toxocariasis. The compounds were tested in vitro in duplicate at a concentration of 1 mg/mL, and compounds with larvicidal activity were serially diluted to obtain concentrations of 0.5 mg/mL; 0.25 mg/mL; 0.125 mg/mL; and 0.05 mg/mL. The tests were performed in a microculture plate containing 100 T. canis larvae in RPMI-1640 medium. One compound (COU 9) was selected for cytotoxicity analysis using J774.A1 murine macrophages and it was found to be non-cytotoxic at any concentration tested. The in silico analysis was performed using computational models; the compound presented adequate results of oral bioavailability. To confirm the non-viability of the larvae, the contents of the microplate wells of COU 9 were inoculated intraperitoneally (IP) into female Swiss mice at 7-8 weeks of age. This confirmed the larvicidal activity of this compound. These results show that COU 9 exhibited larvicidal activity against T. canis larvae, which, after exposure to the compound, were non-viable, and that COU 9 inhibited infection in a murine model. In addition, COU 9 did not exhibit cytotoxicity and presented adequate bioavailability in silico, similar to albendazole, an anthelmintic, which is the first choice for treatment of human toxocariasis, supporting the potential for future investigations and preclinical tests on COU 9.

The larvicidal effect of the supernatant of Lactobacillus acidophilus ATCC 4356 on Toxocara canis.

Human toxocariasis is a parasitic anthropozoonosis that is difficult to treat and control. A previous study carried out with Lactobacillus acidophilus ATCC 4356 revealed that the cell free supernatant (CFS) of this probiotic killed 100% of Toxocara canis larvae in vitro. The present study aimed to investigate the characteristics of the CFS of L. acidophilus ATCC 4356, which may be involved in its larvicidal effects on T. canis. L. acidophilus ATCC 4356 was cultured, and lactic and acetic acids present in the CFS were quantified by high performance liquid chromatography (HPLC). The levels of pH and H2O2 were also analyzed. To assess the larvicidal effect of the CFS, this was tested pure and diluted (1:2 to 1:128) on T. canis larvae. High concentrations of lactic and acetic acids were detected in the CFS. The acidity of the pure CFS was observed at pH 3.8, remaining acidic at dilutions of 1:2 to 1:16. Regarding the in vitro larvicidal effect, 100% death of T. canis larvae was observed using the pure CFS and 1:2 dilution. Based on these results, it can be inferred that the presence of higher concentrations of organic acids and low pH of the medium contributed to the larvicidal activity of the CFS of L. acidophilus ATCC 4356. In addition, the maintenance of the larvicidal effect, even after dilution, suggests a greater chance of the larvicidal effect of this CFS against T. canis in vivo.

Natalizumab extended interval dosing: what about wearing-off effect?

BACKGROUND: Up to two thirds of patients with multiple sclerosis (MS) under natalizumab report a resurgence of symptoms at the end of the natalizumab cycle (wearing-off (WO) effect). At the outbreak of COVID-19, in line with the international recommendations for MS management, our centre switched all clinically stable patients on natalizumab therapy for more than one year from standard interval dosing (SID) to extended interval dosing (EID) with every six weeks infusions. This study aimed to evaluate the impact of EID in WO in MS patients under natalizumab. METHODS: An observational retrospective study in patients with MS under natalizumab on EID was conducted. A questionnaire regarding current (on EID) and past (on SID) experience of WO effect was applied. RESULTS: Seventy-six patients were included. No significant differences were found in the annual relapse rate after the switch to EID (p = 0.083). However, there was a significant increase in the proportion of patients complaining of WO from 38.2% to 56.6% (p = 0.001). Moreover, patients with WO on SID, referred a significant increase in severity (p = 0.019) and duration of WO symptoms (p = 0.029), due to an anticipation of the symptoms relative to the day of natalizumab infusion (p = 0.019), when switching to EID. Symptoms improved with treatment maintenance in 23.3% of patients; instead, a reduction in interval dosing was needed in 54.8% with symptom improvement. CONCLUSION: WO affects a significant proportion of MS patients under natalizumab. Its prevalence, severity, and duration increase on EID, therefore despite clinical effectiveness maintenance of this posology should be individualized.

Oral health in individuals with cystic fibrosis: A cross-sectional study.

Cystic Fibrosis (CF) is an autosomal recessive disease characterized by the production of thick and viscous mucus progressively affecting various organs and systems, with recurrent respiratory infections. The aim of this study was to learn about the oral health characteristics in CF patients. METHODOLOGY: Data, such as sociodemographic, general and oral health, were collected from the medical records of CF patients aged 0 to 18 years old. The number of patients with tooth decay, prevalence of developmental defects of enamel (DDE), classification of dental occlusion, sialometry, salivary pH and oral microbial profile and respiratory secretions evaluations were recorded. RESULTS: Most patients had pancreatic insufficiency (84.2%), malnutrition (60%), respiratory problems (75.4%) and genotyping of the F508del (66.7%). Regarding the medications used, 96.5% used vitamins and electrolyte replacement, 84,02% used pancreatic enzymes, 64.9% used dornase alfa and 47% were using antibiotics. The percentage of patients with tooth decay was 19.3%, 47% had DDE, low salivary flow and basic salivary pH. The most prevalent microorganisms found on tongue biofilm and respiratory secretions were SA and PA. There was a positive association between the presence of bacteria and fungi found on both the tongue and respiratory secretions. The presence of fungi on the tongue biofilm was significantly associated with the use of antibiotics. CONCLUSIONS: These findings underscore the importance of dentists focusing on prevention and on the specific needs of the patient as well.

Prevalence, Incidence, and Mortality of Multiple Sclerosis in Coimbra, Portugal.

Multiple sclerosis (MS) is the most common chronic inflammatory, demyelinating, and neurodegenerative disease of the central nervous system in young adults, representing the leading cause of nontraumatic disability in this population. The rising prevalence of MS worldwide makes it critical to recognize the absolute number of patients with MS, demanding the execution of a sustainable healthcare policy. In Portugal, only six studies evaluating MS rates were published, disclosing a prevalence of 64 cases per 100,000 persons and an incidence of 3.1 cases per 100,000 persons/year, but the mortality rates have not been reported. Thus, this observational, cross-sectional study aimed to assess MS prevalence, incidence, and mortality in the city of Coimbra, a region in the center of Portugal. Patients who fulfilled McDonald's Diagnosis Criteria (2017) for MS were recruited. Inclusion criteria were defined according to prevalence, incidence, and mortality studies. The baseline demographic and clinical characterization of the prevalence study population was performed. The MS prevalence rate in Coimbra was 143.45 cases per 100,000 inhabitants. Between 2018 and 2021, the cumulative incidence was 8.52 new cases per 100,000 persons/year. The mortality rate between 2018 and 2021 was 2.84 deaths per 100,000 inhabitants. MS prevalence and incidence in Coimbra are higher than reported in previous similar studies and comparable to Europe's mean prevalence and incidence.

Experimental pain thresholds and psychosocial features across menstrual cycle in myofascial orofacial pain compared to healthy individuals: cross-sectional study / Limiares de dor experimental e características psicossociais ao longo do ciclo menstrual na dor miofascial orofacial em comparação com indivíduos saudáveis: estudo transversal

ABSTRACT BACKGROUND AND OBJECTIVES: The hormonal impact on pain perception during the menstrual cycle is a major focus of study, and further elucidation in temporomandibular disorders (TMD) field is necessary. Thus, this cross-sectional study evaluated experimental pain thresholds, psychosocial features, and clinical pain report on TMD women across menstrual cycle versus healthy controls. METHODS: A total of 220 women's clinical files were screened, with 80 selected and divided into control group (healthy individuals, n=40) and TMD group (myofascial pain, n=40). Regarding the menstrual cycle phases, the files were divided into Pre-Luteal and Luteal. The Perceived Stress Scale (PSS), Pain Catastrophizing Scale (PCS), Mechanical Pain Threshold (MPT), Wind-up (WUR), Pressure Pain Threshold (PPT), Conditioned Pain Modulation (CPM) and Visual Analogue Scale (VAS) were analyzed at a 5% significance level, by Two-Way ANOVA test and post hoc Tukey test. RESULTS: PSS and PCS were significantly different between TMD and control group (p<0.001), regardless of menstrual cycle. Healthy individuals in the Luteal phase presented higher MPT values compared to the other phases (p<0.001). PPT showed significant difference across menstrual phases (p=0.022), but no differences in multiple comparisons. VAS values showed no difference between menstrual cycle phases (p=0.376). CONCLUSION: Finally, healthy individuals in the Luteal phase have higher MPT and PPT values on the orofacial region. Pain report in patients with TMD showed no difference throughout the menstrual cycle, showing that small alterations on experimental pain thresholds may not be clinically relevant. The presence of chronic pain seems to be more related to psychosocial features than hormonal fluctuations.

RESUMO JUSTIFICATIVA E OBJETIVOS: O impacto do ciclo menstrual na percepção da dor é um foco importante de estudo, sendo necessária uma maior elucidação na disfunção temporomandibular (DTM). Assim, este estudo transversal avaliou limiares de dor experimental, características psicossociais e relatos de dor em mulheres com DTM ao longo do ciclo menstrual, comparadas com controles saudáveis. MÉTODOS: 220 prontuários de mulheres foram analisados, sendo 80 selecionados para os grupos de controle (saudáveis, n=40) e DTM (dor miofascial, n=40). Nas fases do ciclo menstrual, as pacientes foram divididas nas categorias Pré-Luteal e Luteal. Os instrumentos Escala de Estresse Percebido (PSS), Escala de Pensamentos Catastróficos (PCS), Limiar de Dor Mecânica (MPT), Wind-up Ratio (WUR), Limiar de Dor à Pressão (PPT), Modulação Condicionada da Dor (CPM) e Escala analógica visual (EAV) foram analisados com nível de significância de 5%, pelos testes ANOVA de dois fatores e Tukey post hoc. RESULTADOS: As escalas PSS e PCS foram significativamente diferentes entre os grupos DTM e controle (p<0,001), independentemente do ciclo menstrual. Indivíduos saudáveis na fase luteal apresentaram MPT maior em comparação com outras fases (p,0,001). O PPT mostrou diferença significativa entre as fases menstruais (p=0,022), sem diferença nas comparações múltiplas. Os valores da EAV não apresentaram diferença entre as fases menstruais (p=376). CONCLUSÃO: Indivíduos saudáveis na fase luteal têm MPT e PPTl maior na região orofacial. Os relatos de dor em pacientes com DTM não mostraram diferença ao longo do ciclo menstrual, indicando que pequenas alterações nos limiares experimentais podem ser clinicamente relevantes. A presença de dor crônica parece estar mais relacionada com características psicossociais do que com flutuações hormonais.

Common mental disorders in medical students: prevalence and associated factors / Transtornos mentais comuns em estudantes de medicina: prevalência e fatores associados

Abstract Objectives: This study aimed to estimate the prevalence of Common Mental Disorders (CMD) among medical students and identify the factors associated with this disorder. Methods: A cross-sectional study was conducted with all medical students, enrolled from the 1st to the 8th semesters in a public university, in the state of Bahia, Brazil. We used a self-administered questionnaire that included SRQ-20 (Self-Reporting Questionnaire), IPAQ (International Physical Activity Questionnaire - long form) and sociodemographic, school, occupational and health variables. The multivariate analysis was performed using COX Regression for cross-sectional studies. Results: We evaluated 556 students (289 women and 267 men), representing 90.2% of the target population. The overall prevalence of CMD found was 53.3%, 78.8% of students reported feeling nervous, 56.8% experienced poor sleep quality, and 6.5% had suicidal thoughts. After the multivariate analysis, the following factors maintained their association with a higher prevalence of CMD: having no previous undergraduate degree (PR=1.49), having an unfavorable self-perception of health (PR=1.53), not having failed disciplines (PR=1.20), and being a smoker (PR=1.19). Physical activity did not have a protective effect on CMD in this study. Conclusions: The prevalence of CMD among medical students was high and mainly associated with an unfavorable self-perception of health. The results highlight the need for strengthening institutional policies aimed at preventing psychological distress among students.

Resumo Objetivo: Este estudo teve como objetivo estimar a prevalência de transtornos mentais comuns (TMC) entre estudantes de Medicina e os fatores associados a esse agravo. Método: Trata-se de um estudo de corte transversal, do tipo censo, realizado com estudantes de Medicina, do primeiro ao oitavo semestre, de uma universidade pública na Bahia. Utilizou-se um questionário autoaplicável contendo Self-Reporting Questionnaire (SRQ-20), International Physical Activity Questionnaire (IPAQ - forma longa) e variáveis sociodemográficas, escolares, ocupacionais e de saúde. A análise multivariada foi efetuada usando a regressão de Cox para estudos transversais. Resultado: Avaliaram-se 556 estudantes (289 mulheres e 267 homens), o que representa 90,2% da população-alvo. A prevalência geral de TMC encontrada foi de 53,3%, 78,8% dos estudantes afirmaram que se sentem nervosos, 56,8% mencionaram que dormem mal, e 6,5% apontaram que têm ideias de acabar com a própria vida. Após análise multivariada, os seguintes fatores mantiveram associação com maior prevalência de TMC: não possuir graduação prévia (49% a mais de TMC), ter uma autopercepção de saúde desfavorável (53%), não ser dessemestralizado (20%) e fazer uso de tabaco (19%). Neste estudo, atividade física não teve efeito protetor para os TMC. Conclusão: A prevalência de TMC entre os estudantes de Medicina mostrou-se elevada e se associou principalmente à autopercepção de saúde desfavorável. Os resultados obtidos demonstram a necessidade de que as políticas institucionais voltadas à saúde mental e à diminuição do sofrimento psíquico dos estudantes sejam mantidas e ampliadas.

Brazilian Guidelines for Nutrition in Cystic Fibrosis

ABSTRACT Objective To develop a scientific consensus on nutrition in cystic fibrosis. Methods Sixteen coordinators elaborated relevant questions on nutritional therapy in cystic fibrosis, which were divided into six sections: nutritional assessment, nutritional recommendations, nutritional intervention, dietary counseling, special situations and enzyme replacement, and gastrointestinal manifestations. Two to three specialists in the field were responsible for each section and obtaining answers formulated based on standardized bibliographic searches. The available literature was searched in the PubMed®/MEDLINE database, after training and standardization of search strategies, to write the best level of evidence for the questions elaborated. Issues related to disagreement were discussed until a consensus was reached among specialists, based on the current scientific literature. Results Forty-two questions were prepared and objectively answered, resulting in a consensus of nutritional therapy in cystic fibrosis. Conclusion This work enabled establishing a scientific consensus for nutritional treatment of cystic fibrosis patients.

Tabagismo, consumo de bebidas alcoólicas e os fatores associados em estudantes de medicina / Smoking, alcohol consumption and associated factors in medical students

OBJETIVOS: Descrever a prevalência e fatores associados ao uso de bebidas alcoólicas entre estudantes de Medicina. Estimar a prevalência de tabagismo. MÉTODOS: Corte transversal com questionário autoaplicado a todos os estudantes de Medicina de uma universidade pública na Bahia (n = 616), matriculados do primeiro ao oitavo semestre. Análise multivariada por meio de Regressão de Cox identificou os fatores associados ao uso de bebidas alcoólicas, por meio de três desfechos: presença e frequência de uso e o padrão de uso denominado binge drinking. RESULTADOS: Foram estudados 556 estudantes (90,2% de resposta), entre os quais 58,7% bebem, 21% consomem álcool com uma frequência de pelo menos uma vez por semana e 36% fazem binge drinking. O público masculino e os mais ativos fisicamente no lazer apresentaram maiores prevalências de uso de bebidas alcoólicas, seja pela maior frequência de uso ou uso de mais doses em uma ocasião. Variáveis escolares se associaram a uma ou outra modalidade de mensuração do uso de álcool. A prevalência de tabagismo foi de 4,8%. CONCLUSÃO: O uso de bebidas alcoólicas e seu padrão de consumo foram altos na população estudada, consistente com outras populações de estudantes já investigadas. A baixa prevalência de tabagismo é consistente com a literatura, que admite o êxito de políticas públicas destinadas ao controle desse consumo no Brasil.

OBJECTIVES: To describe the prevalence and factors associated with the use of alcoholic beverages among medical students. Estimate the prevalence of smoking. METHODS: Cross-sectional study (census) with a self-administered questionnaire in medical students at a public university in Bahia (n = 616) enrolled from the first to the eighth semester. Multivariate analysis using Cox Regression identified the factors associated with the use of alcoholic beverages, through three outcomes: presence and frequency of use and the pattern of use called binge drinking. RESULTS: 556 students were studied (90.2% response), among which, 58.7% drink, 21% consume alcohol at least once a week and 36% do binge drinking. The male population and those more physically active at leisure time showed a higher prevalence of alcohol use, either due to the higher frequency of use or the use of more doses on one occasion. School variables were associated with one or another method of measuring alcohol use. The prevalence of smoking was 4.8%. CONCLUSION: The use of alcoholic beverages and their consumption pattern were high in the studied population, consistent with other student populations already investigated. The low prevalence of smoking is consistent with the literature that admits the success of public policies aimed at controlling this consumption in Brazil.

Holofotes acesos durante a pandemia da covid-19: paradoxos do processo de trabalho da enfermagem / Reflectores encendidos durante la pandemia del covid-19: contradicciones del proceso de trabajo de enfermería / Spotlights on during covid-19 pandemic: paradoxes in the nursing work process

RESUMO Objetivo: abordar de forma crítica e reflexiva os paradoxos relacionados às condições de trabalho da Enfermagem, de (des) valorização da profissão diante da pandemia da Covid-19 e da necessidade de se pensar em promoção de ambientes de trabalho saudáveis. A doença Covid-19 é uma pandemia que está influenciando os hábitos de vida e o trabalho contemporâneo. Os profissionais da Enfermagem são o maior número de trabalhadores atuantes na linha de frente no combate a essa doença. A rotina desses profissionais já era exaustiva, mas em tempos de pandemia a carga de trabalho torna-se maior e os turnos mais estressantes, devido a vários fatores como: medo de contaminação, informações deficientes, escassez de recursos humanos e materiais. Assim, torna-se urgente promover ambientes saudáveis, conforme recomenda a Organização Mundial de Saúde, visando a segurança, saúde e bem-estar dos trabalhadores. Método: estudo reflexivo realizado a partir da literatura científica e da análise crítica das autoras, abordando condições de trabalho e valorização da Enfermagem, indicando os paradoxos relacionados ao processo de trabalho. Resultados: essa reflexão abordou importantes desafios para a Enfermagem. Ao mesmo tempo em que os profissionais lutam em defesa da vida, combatendo a Covid-19 pautados em conhecimentos científicos, atitudes humanizadas e nos preceitos éticos, a profissão ainda é desvalorizada e vivencia condições de trabalho precárias. Conclusão: a expectativa é de os holofotes permanecerem acesos para a Enfermagem, mesmo após a pandemia, "iluminando" melhores condições de trabalho e reconhecimento profissional, além de ambientes laborais saudáveis com medidas concretas para o presente e o futuro.

RESUMEN Objetivo: enfocar de manera crítica y reflexiva las contradicciones de las condiciones de trabajo de enfermería, de (des) valorización de la profesión ante la pandemia del Covid-19 y la necesidad de pensar en la promoción de ambientes de trabajo saludables. El Covid-19 es una pandemia que afecta costumbres y trabajo. La cantidad de profesionales de enfermería que actúan en la línea de frente de combate a la enfermedad es superior a la de los demás profesionales. La rutina de dicho personal ya solía seragotadora y, ahora, en tiempos de pandemia, la carga laboral es aún mayor y los turnos más desgastantes a causa de factores tales como el temor al contagio, información deficiente, escasez de recursos humanos y material. Por ello, es urgente promover ambientes saludables, tal como lo recomienda la Organización Mundial de la Salud, con miras a la seguridad, salud y bienestar de los trabajadores. Método: estudio reflexivo realizado a partir de la literatura científica y del análisis crítico de las autoras, quienes enfocan las condiciones laborales y valorización de Enfermería y muestran las contradicciones del proceso laboral. Resultados: esta reflexión enfocó desafíos importantes para Enfermería. Mientras los profesionales luchan por la viday combaten el Covid-19 en base a conocimiento científico, actitudes humanizadas y principios éticos, la profesión está desvalorizada socialmente y los trabajadores conviven con condiciones laborales precarias. Conclusión: hay expectativas de que los reflectores permanezcan encendidos enfocandoEnfermería, aún después de la pandemia, "iluminando" mejores condiciones de trabajoy reconocimiento profesional, además de ambientes laborales saludables, con medidas concretas para el presente y el futuro.

ABSTRACT Objective: to approach critically and reflexively the paradoxes related to the working conditions of Nursing, the (de)valuation of the profession in the face of the Covid-19 pandemic and the need to think about promoting healthy work environments. Covid-19 disease is a pandemic that is influencing contemporary lifestyle and work habits. Nursing professionals are the largest number of workers working on the front lines in the fight against this disease. The routine of these professionals was already exhausting, but in times of pandemic the workload becomes greater and the shifts more stressful, due to several factors such as: fear of contamination, deficient information, scarcity of human and material resources. Thus, it is urgent to promote healthy environments, as recommended by the World Health Organization, aiming at the safety, health, and well-being of workers. Method: reflective study carried out from the scientific literature and the critical analysis of the authors, addressing working conditions and valuing Nursing, indicating the paradoxes related to the work process. Results: this reflection addressed important challenges for Nursing. At the same time that the professionals fight in defense of life, fighting Covid-19 based on scientific knowledge, humanized attitudes and ethical precepts, the profession is still undervalued and experiences precarious working conditions. Conclusion: the expectation is that the spotlight will remain on for Nursing, even after the pandemic, "illuminating" better working conditions and professional recognition, in addition to healthy working environments with concrete measures for the present and the future.

Immunopathological mechanisms involved in SARS-CoV-2 infection / Mecanismos imunopatológicos envolvidos na infecção por SARS-CoV-2

ABSTRACT Introduction: Coronavirus disease 2019 (Covid-19) has become a global health emergency. Although many scientific advances have been achieved over the last few months, the knowledge about how the etiologic agent SARS-CoV-2 interacts with the host's immune system, regulating the pathogenesis and the outcome of the disease, is not yet fully understood. Objective: This is a narrative literature review to discuss the available evidence on modes of transmission and the main immunopathological mechanisms involved in SARS-CoV-2 infection. Material and method: A search in the indexed journals was carried out in the PubMed/MEDLINE database, during the period from January to May 2020. The following descriptors were used in the research: Covid-19, SARS-CoV-2, transmission, immunity, immunopathogenesis, and pathogenesis. Results and discussion: Transmission of SARS-CoV-2 occurs through contact with airway secretions from a symptomatic patient. However, scientific evidence encourages transmission by asymptomatic and/or oligosymptomatic patients. Immunopathological studies suggest that the hypercytokinaemia promotes lung tissue damage and, subsequently, organ and system involvement, leading to decompensation, organ dysfunction and death. Regarding the humoral response, the high titers of B lymphocytes and antibodies, traditionally, correlated with the protection of the host, may be associated with the severity of the disease by SARS-CoV-2. Conclusion: The host's immune response is determinant in the pathogenesis of Covid-19. However, further in vivo and/or in vitro studies are needed to elucidate the pathogenic mechanisms of SARS-CoV-2 and, thus, assist in the development of a vaccine and/or therapeutic target.

RESUMEN Introducción: La enfermedad por coronavirus 2019 (Covid-2019) se ha convertido en una emergencia sanitaria mundial. A pesar de los muchos avances científicos recientes, el conocimiento acerca de cómo el agente etiológico SARS-CoV-2 interactúa con el sistema inmunitario del huésped, regulando la patogénesis y el resultado de la enfermedad, todavía no está totalmente claro. Objetivo: Revisión de la literatura a fin de discutir la evidencia disponible sobre las formas de transmisión y los principales mecanismos inmunopatológicos involucrados en la infección por SARS-CoV-2. Material y métodos: Se realizó una búsqueda por periódicos indexados en la base de datos PubMed/MEDLINE, desde enero hasta mayo de 2020. Se han utilizado las siguientes palabras clave en la investigación: Covid-19, SARS-CoV-2, transmission, immunity, immunopathogenesis y pathogenesis. Resultados y discusión: La transmisión del SARS-CoV-2 ocurre por el contacto con secreciones de las vías respiratorias de un paciente sintomático. Sin embargo, evidencias científicas indican la transmisión por pacientes asintomáticos y/o oligosintomáticos. Estudios inmunopatológicos sugieren que la tormenta de citocinas causa lesión en pulmones y, posteriormente, daño en órganos y sistemas, que conduce a la descompensación, disfunción orgánica y muerte. Sobre la inmunidad humoral, los títulos elevados de linfocitos B y anticuerpos, tradicionalmente relacionados con la protección del huésped, pueden estar asociados a la gravedad de la enfermedad por SARS-CoV-2. Conclusión: La respuesta inmunológica del huésped es determinante para la patogénesis de la Covid-19. No obstante, se necesitan más estudios in vivo y/o in vitro para aclarar los mecanismos de patogenicidad del SARS-CoV-2 y, así, ayudar en el desarrollo de una vacuna y/u objetivo terapéutico.

RESUMO Introdução: A doença do coronavírus 2019 (Covid-19) tornou-se uma emergência de saúde mundial. Embora muitos avanços científicos tenham sido alcançados nos últimos meses, o conhecimento sobre como o agente etiológico SARS-CoV-2 interage com o sistema imunológico do hospedeiro, regulando a patogênese e o resultado da doença, ainda não está totalmente esclarecido. Objetivo: Revisão da literatura com o objetivo de discutir as evidências disponíveis sobre as formas de transmissão e os principais mecanismos imunopatológicos envolvidos na infecção pelo SARS-CoV-2. Material e método: Realizou-se uma busca de periódicos indexados na base de dados PubMed/MEDLINE, durante o período de janeiro a maio de 2020. Os seguintes descritores foram utilizados na pesquisa: Covid-19, SARS-CoV-2, transmission, immunity, immunnopathogenesis e pathogenesis. Resultados e discussão: A transmissão do SARS-CoV-2 ocorre pelo contato com secreções das vias aéreas de um paciente sintomático. No entanto, evidências científicas fomentam a transmissão por pacientes assintomáticos e/ou oligossintomáticos. Os estudos imunopatológicos sugerem que a hipercitocinemia promove lesão do tecido pulmonar e, posteriormente, comprometimento de órgãos e sistemas, levando a descompensação, disfunção orgânica e óbito. Sobre a resposta humoral, os altos títulos de linfócitos B e anticorpos, tradicionalmente correlacionados com a proteção do hospedeiro, podem estar associados à gravidade da doença pelo SARS-CoV-2. Conclusão: A resposta imunológica do hospedeiro é determinante na patogênese da Covid-19. No entanto, mais estudos in vivo e/ou in vitro são necessários para elucidar os mecanismos de patogenicidade do SARS-CoV-2 e, assim, auxiliar no desenvolvimento de uma vacina e/ou alvo terapêutico.

Knowledge, attitude and practice of brazilian obstetricians regarding episiotomy / Conhecimento, atitude e prática dos obstetras brasileiros em relação à episiotomia

Abstract Objective To determine the prevalence of episiotomy and the factors associated with the knowledge, attitude and practice (KAP) of Brazilian obstetricians in relation to this procedure. Methods A KAP survey was conducted with obstetricians working in Brazil. An electronic form containing structured questions previously evaluated using the Delphi method was created in Google Docs and sent by e-mail. A multivariate logistic regression was performed to determine the principal factors associated with adequate KAP. For each dependent variable (knowledge, attitude and practice) coded as adequate (1 = yes; 0 = no), a multiple logistic regression model was developed. Binary codes (1 = yes and 0 = no) were assigned to every independent or predictor variables. Prevalence ratios (PRs) and their respective 95% confidence intervals (95%CIs) were calculated as measures of relative risk, at a significance level of 5%. Results Out of the 13 thousand physicians contacted, 1,163 replied, and 50 respondents were excluded. The mean episiotomy rate reported was of 42%. Knowledge was determined as adequate in 44.5% of the cases, attitude, in 10.9%, and practice, in 26.8% of the cases. Conclusion Most respondents had inadequate knowledge, attitudes and practices regarding episiotomy. Although some factors such as age, teaching, working in the public sector and attending congresses improved knowledge, attitude and practice, we must recognize that episiotomy rates remain well above what would be considered ideal. Adequate knowledge is more prevalent than adequate attitude or practice, indicating that improving knowledge is crucial but insufficient to change the outlook of episiotomies in Brazil.

Resumo Objetivo Determinar o nível e os fatores associados a conhecimento, atitude e prática (CAP) dos obstetras brasileiros em relação à episiotomia. Métodos Foi realizado um estudo de corte transversal do tipo inquérito CAP com obstetras atuantes no território brasileiro. Foi criado um formulário eletrônico com perguntas estruturadas e previamente avaliadas pelo método Delphi, que foi enviado por e-mail pelo sistema Google Docs. Foi realizada uma análise multivariada de regressão logística múltipla para determinação dos principais fatores associados ao conhecimento, à atitude e à prática adequados. Para cada variável dependente (conhecimento, atitude e prática) codificada como adequada (1 = sim; 0 = não) foi construído um modelo de regressão logística múltipla. Todas as variáveis independentes ou preditivas foram codificadas binariamente (1 = sim; 0 = não). As razões de prevalência (RPs) e seus respectivos intervalos de confiança de 95% (ICs95%) foram calculados como medidas do risco relativo, com um nível de significância de 5%. Resultados Dos 13 mil obstetras contatados, foram obtidas 1.163 respostas, sendo 50 participantes excluídos. A média da taxa de episiotomia relatada foi de 42%. Verificou-se que 44,5% dos médicos tinham conhecimentos adequados, 10,9% tinham atitudes adequadas e 26,8% tinham práticas adequadas. Conclusão A maioria dos participantes tinha conhecimento, atitudes e práticas inadequadas em relação à episiotomia. Embora alguns fatores como idade, ensino, trabalho no setor público e participação em congressos melhorem o conhecimento, a atitude e a prática, é preciso reconhecer que as taxas de episiotomia permanecem bem acima do que se considera ideal. O conhecimento adequado é mais prevalente do que a atitude ou a prática adequadas, indicando que a melhora do conhecimento é crucial, mas insuficiente para mudar o panorama das episiotomias neste país.

Utilização da Aprendizagem Baseada em Equipes como Método de Avaliação no Curso de Medicina / The Use Of Team-Based Learning As An Evaluation Method On The Medicine Course

RESUMO A educação de adultos pressupõe a utilização de metodologias ativas de ensino-aprendizagem, que proponham concretamente desafios a serem superados pelos estudantes, tendo o professor como facilitador e orientador do processo. O objetivo deste estudo foi relatar o uso da Aprendizagem Baseada em Equipes (ABE) como estratégia de avaliação dos alunos na disciplina Interação Ensino-Serviço na Comunidade (Iesc) no curso de Medicina. A aplicação da ABE ocorreu em duas turmas da Iesc, respeitando as três etapas previstas na metodologia. A experiência obtida com a aplicação da ABE em substituição à prova tradicional demonstrou aspectos relevantes, como: na preparação, é fundamental que o acadêmico se comprometa a estudar os temas propostos; a utilização de aplicativo foi uma estratégia inovadora; o desempenho da equipe superou o individual. A aplicação dos conceitos ocorreu nas aulas de campo da Iesc, pois esta propõe a observação de casos clínicos reais nas unidades de saúde e comunidade, utilizando os conhecimentos teóricos adquiridos para direcionar intervenções. A aplicação da ABE se mostrou um método eficiente para avaliação na Iesc, que se pauta na perspectiva da interação e processos colaborativos. O uso do recurso tecnológico como ferramenta despertou interesse entre os estudantes, minimizando a tensão que geralmente ocorre durante o processo da avaliação tradicional. É importante que os cursos de formação em saúde façam uma análise constante para que práticas do ensino tradicional não sejam supervalorizadas em detrimento das práticas ativas de aprendizagem.

ABSTRACT Adult education presupposes the use of active teaching and learning methodologies that propose challenges to be overcome by students, with the teacher acting as facilitator and guiding the process. The objective of this study was to report the use of Team-Based Learning (TBL) as one of the methods used to evaluate students in the subject Teaching-Service interaction in the Community (IESC), of the Medicine Course. TBL was applied with two classes IESC classes. The experience gained through the application of TBL, instead of the traditional test, demonstrated some relevant aspects, for example: in the preparation, it is fundamental that the student is committed to studying the proposed topics; the use of application was an innovative strategy that motivated the academics to participate actively in the process; the performance of the team took precedence over individual performance. The concepts learned were put into practice in the IESC field classes, since they involve observation of real clinical cases in the Health Units and in the community, using the theoretical knowledge acquired, in the interventions. The application of TBL proved to be an efficient evaluation method in the IESC, which is based on the perspective of interaction and collaborative processes. The use of the technological resource as a tool sparked the students' interest, minimizing the stress that usually occurs during the traditional assessment. It is important that health training courses provide a review, to ensure that traditional teaching practices are not given too much weight, at the expense of active learning practices.

Avaliação da investigação de óbitos por causas mal definidas no estado da Bahia, Brasil, em 2010 / Assessment of the investigation of deaths from ill-defined causes in the state of Bahia in 2010

Resumo A investigação de óbitos por causas mal definidas (CMD) tem sido uma estratégia utilizada pelos serviços de saúde para redução do percentual destes óbitos. Este estudo teve como objetivo avaliar a adesão dos municípios na utilização de formulários preconizados na investigação de óbitos por CMD e o impacto destas investigações na redução percentual desses óbitos no Sistema de Informações sobre Mortalidade. Analisou-se a utilização dos formulários Investigação do Óbito com Causa Mal Definida (IOCMD) e autópsia verbal (AV), e o percentual de reclassificação da causa básica (CB) de morte após as investigações, em uma amostra probabilística de 27 municípios no Estado da Bahia e a capital Salvador, no ano de 2010. Dos 27 municípios da amostra, aproximadamente 50% investigaram os óbitos por CMD utilizando-se os formulários preconizados. Foram identificados 1092 óbitos por CMD, dos quais 53,1% foram investigados: em 40,5% dos casos utilizou-se apenas o formulário IOCMD, apenas o formulário AV em 15,3%, e ambos os formulários em 14,3% dos casos. A investigação dos óbitos por CMD possibilitou a redução do percentual desses óbitos de 16,5% para 9,9%, e mostrou-se mais efetiva quando realizada utilizando-se os formulários preconizados.

Abstract The investigation of deaths from ill-defined causes (DIDC) has been a strategy of health services to reduce the proportion of these events. This study aimed to estimate the adherence of municipalities to the use of recommended forms in the investigation of DIDC and the impact of these investigations on the reduction of these deaths in the Mortality Information System. The use of the Investigation of Death from Ill-defined Cause (IOCMD) and Verbal Autopsy (VA)forms and the proportion of reclassified underlying cause of death following investigations were analyzed in a probabilistic sample of 27 municipalities of Bahia state, and its capital Salvador, in 2010. Of the 27 municipalities, approximately 50% used the recommended forms to investigate DIDCs. Of the 1,092DIDCs in the sample, 53.1% were investigated: in 40.5% of the cases, only the IOCMD form was used; in 15.3%, only the VA form was used; and both forms were used in 14.3% of the cases. The investigation of DIDCs reduced the percentages of these deaths from 16.5% to 9.9% and proved to be more effective when performed using the recommended forms.

Avaliação de um aplicativo para smartphone para aprimoramento da certificação médica da causa da morte / Evaluation of a smartphone application to improve medical certification of the cause of death

RESUMO Introdução: O aplicativo para smartphone AtestaDO foi desenvolvido para auxiliar o médico na certificação da causa de morte. Neste estudo se propõe avaliar a aceitabilidade desse aplicativo. Métodos: Médicos foram convidados para participar de reuniões sobre certificação correta da causa da morte e avaliar o aplicativo em três etapas dessas reuniões, realizadas em Natal e em dois grandes hospitais de Belo Horizonte. Resultados: Em Natal, 82% dos 38 médicos participantes tinham mais de 20 anos de graduação, e em Belo Horizonte, mais de 67% dos 58 médicos tinham menos de 5 anos de graduação. As seções "Interface do aplicativo", "Como atestar as causas de morte", "Prática com exercícios" e "Outras informações para o médico" foram bem avaliadas por mais de 50% dos médicos de Belo Horizonte. Em Natal, todas as seções foram bem avaliadas por pelo menos 80% dos médicos. Mais de 70% dos participantes de Natal e da segunda etapa de Belo Horizonte usariam o aplicativo para preencher a causa de morte. A probabilidade de usar o AtestaDO para dar aulas sobre preenchimento da Declaração de Óbito foi de 83% para médicos de Natal, mas inferior a 60% em Belo Horizonte. Nas três etapas, a maioria dos médicos recomendaria o uso do aplicativo para outros colegas. Conclusão: A avaliação do aplicativo AtestaDO mostrou boa aceitabilidade. Espera-se que o uso dessa ferramenta permita alcançar melhorias na certificação médica da causa do óbito.

ABSTRACT Introduction: A smartphone application named AtestaDO was developed to support physicians with medical certification of the cause of death. The objective of this study is to evaluate the acceptability of the app. Methods: Physicians were invited to attend meetings on the proper certification of cause of death, and to evaluate the application in a national workshop in Natal (first stage) and in two large hospitals in Belo Horizonte (second and third stages). Results: In Natal, 82% of 38 physicians had more than 20 years of experience and in Belo Horizonte, more than 67% of 58 physicians had less than 5 years of experience. The sections "Application interface", "How to certify the causes of death", "Practice with exercises" and "Other information for physicians" were positively evaluated by more than 50% of physicians in Belo Horizonte. In Natal, all sections were positively evaluated by at least 80% of participants. More than 70% of the participants in both Natal and the second stage of Belo Horizonte indicated they would possibly use AtestaDO to guide filling of a death certificate. The probability of using AtestaDO to teach classes on filling death certificates was 83.3% for Natal's physicians but less than 60% in Belo Horizonte. In the three stages, most physicians would recommend using the application to other colleagues. Conclusion: The evaluation of AtestaDO showed good acceptability. We expect that the use of this tool enables improvements in medical certification of causes of death.

Avaliação do impacto da investigação dos óbitos com códigos garbage na qualidade da informação sobre causas de morte no nordeste do Brasil / The impact of the investigation on deaths classified as garbage codes on the quality of the cause-of-death information in the Northeast region, Brazil

RESUMO Objetivo: avaliar o impacto da investigação dos óbitos classificados como causas garbage (CG) na qualidade da informação sobre causas de morte em municípios da região Nordeste do Brasil em 2017. Método: estudo avaliativo sobre a investigação dos óbitos com CG em 18 municípios do Nordeste, a partir do seguinte fluxo: identificação de óbitos com CG prioritárias; investigação em prontuários e nos laudos dos institutos de medicina legal; e avaliação da requalificação e especificação das causas de morte de acordo com a Código Internacional de Doenças e segundo grupos de causas do estudo Global Burden of Disease 2015 (GBD 2015). Resultados: dentre 18.681 óbitos classificados como CG prioritárias, 7.352 (39%) foram investigados e, destes, 5.160 (70%) tiveram causas reclassificadas, das quais 4.087 (79%) para causas especificadas. As causas mal definidas (n = 4.392) foram as mais frequentes dentre as CG e as que apresentaram maior proporção de mudança de causa (80%), e 57% alteraram para causas especificadas. A redução das CG contribuiu para detecção de grande variedade de causas específicas segundo grupos do nível 3 do GBD 2015, sendo a violência interpessoal a que obteve maior mudança percentual (11,8%). Conclusão: a investigação dos óbitos com CG prioritárias revelou-se importante estratégia para especificação das causas básicas de morte, podendo influenciar diretamente na formulação, execução e avaliação das políticas de saúde.

ABSTRACT Objective: to evaluate the impact of investigation of deaths classified as garbage codes (GC) on the quality of the causes-of-death information in municipalities in the Northeast region of Brazil in 2017. Method: an investigation was conducted on the deaths classified as GC in 18 municipalities in the Northeast region as follows: identification of deaths with priority GC; review of medical records from health services and forensic institutes; and evaluation of the reclassification of causes of death according to the International Classification of Diseases (ICD-10) and groupings of the Global Burden of Disease 2015 (GBD 2015). Results: among 18,681 deaths classified as priority GC, 7,352 (39%) were investigated and, of these, 5,160 (70%) had reclassified causes, of which 4,087 (79%) were changed to specified causes. Ill-defined causes (n = 4,392) were the most frequent among GC and those with a higher proportion of cause change (80%), and 57% were changed to specified causes. The reduction of GC contributed to the detection of a wide variety of specific causes according to groups of level 3 of the GBD 2015, being the interpersonal violence the cause that obtained the highest percentage change (11.8%). Conclusion: The investigation of deaths with priority GC proved to be an important strategy to specify causes of death, and it may influence the formulation, execution and evaluation of health policies.

Investigation of garbage code deaths to improve the quality of cause-of-death in Brazil: results from a pilot study / Investigação de óbitos por códigos garbage para melhoria da qualidade de causas de morte no Brasil: resultados de um estudo piloto

ABSTRACT Introduction: Reliable cause-of-death statistics are an important source of information on trends and differentials in population health. In Brazil, the Mortality Information System is responsible for compiling cause of death (CoD) data. Despite the success in reducing R-codes ill-defined causes of death, other garbage codes (GC), classified as causes that cannot be the underlying CoD, according to the Global Burden of Disease study, remain a challenge. The Ministry of Health (MoH) aims to decrease the proportion of all GCs, and a pilot study tested a comprehensive strategy to investigate GC deaths that occurred in 2015. Methods: The research was conducted in seven Brazilian cities during five months in 2016: two rural cities, one metropolitan area, and four capitals. For all GCs selected, municipal healthcare workers collected information about the terminal disease from hospital records, autopsies, family health teams, and home investigation. The fieldwork was coordinated at Federal level in partnership with State and municipal teams. Results: Out of 1,242 deaths selected, physicians analyzed the information collected and certified the CoD in 1,055 deaths, resulting in 92.6% of cases having their underlying cause changed to a usable ICD-10 code. Discussion: It is noteworthy the capacity the health teams in the seven cities showed during the implementation of the pilot. Conclusion: After results analysis, the GC investigation protocol was modified, and the implementation scaled up to 60 cities in 2017.

RESUMO Introdução: Estatísticas confiáveis em mortalidade são importante fonte de evidências de tendências e diferenciais na saúde da população. No Brasil, o Sistema de Informação sobre Mortalidade é responsável por compilar dados da causa de morte (CM). Embora tenha havido sucesso na redução de causas mal definidas de morte, ainda há um problema com outros códigos garbage (GC), classificados como causas de morte que não devem ser registradas como básicas, segundo o estudo de Carga Global de Doença. O Ministério da Saúde estabeleceu uma meta para diminuir a proporção de todos os GC e testou em estudo piloto uma estratégia abrangente para investigar as mortes. Métodos: A pesquisa foi realizada em 7 cidades do Brasil durante 4 meses: 2 em áreas rurais, 1 em área metropolitana e 4 em capitais. Os agentes municipais de saúde coletaram informações sobre a doença terminal obtida nos registros hospitalares, autópsias, equipes de saúde da família e investigação domiciliar. O trabalho de campo foi coordenado pelo nível federal, juntamente com as equipes estaduais e municipais. Resultados: Dos 1.242 óbitos selecionados, médicos analisaram as informações coletadas e certificaram a CM em 1.055 óbitos, resultando em 92,6% dos casos tendo sua causa subjacente alterada para código específico da CID-10. Discussão: Destaca-se a capacidade de articulação que as equipes de saúde apresentaram no cumprimento das etapas propostas para o trabalho. Conclusão: Após o estudo piloto, o protocolo de investigação foi modificado e sua implementação foi ampliada para 60 cidades em 2017.

Improving the usefulness of mortality data: reclassification of ill-defined causes based on medical records and home interviews in Brazil / Aprimorando dados de mortalidade: reclassificação de causas mal definidas baseada em registros clínicos/entrevistas domiciliares no Brasil

ABSTRACT Introduction: Brazil presented a high proportion of ill-defined causes of death (IDCD) in 2000, compromising accurate cause-of-death analysis. Objective: To analyze specific underlying causes for deaths originally assigned as IDCD in the Mortality Information System (SIM - Sistema de Informação sobre Mortalidade), after investigation activities implemented in country between 2006 and 2017. Method: For all IDCD identified in the SIM, municipal health professionals collected information about the final disease obtained from hospital records, autopsies, forms of family health teams, and home investigation. Specific causes among reclassified IDCD after investigation were evaluated according to age groups and four calendar periods. Results: Proportions of IDCD reassigned to other causes after review increased over time, reaching 30.1% in 2017. From a total of 257,367 IDCD reclassified in 2006-2017, neonatal-related conditions, injury, ischemic heart disease and stroke were the leading causes detected in the age groups 0-9 years, 10-29 years, 30-69 years, 70 years and over, respectively. Discussion: The similarity and plausibility of cause-specific proportions derived from the reclassification of IDCD by age group over time indicate the accuracy of the investigation data. Conclusion: High proportions of IDCD reassigned to more informative causes after review indicate the success of this approach to correct misclassification in the SIM, an initiative that should be maintained. Training physicians on death certification along with better quality of medical care and access to health services would lead to further improvement.

RESUMO Introdução: As proporções de causas de morte mal definidas (CMD) foram elevadas no Brasil em 2000. Objetivo: Analisar causas específicas para óbitos originalmente como CMD no Sistema de Informação sobre Mortalidade (SIM), após investigação implementada no país entre 2006 e 2017. Metodologia: Para as CMD identificadas no SIM, profissionais das secretarias de saúde coletaram informações sobre a doença final obtida nos registros hospitalares, autópsias, formulários de equipes de saúde da família e investigação domiciliar. Causas específicas entre as CMD reclassificadas após investigação foram avaliadas segundo idade em quatro períodos. Resultados: Proporções de CMD reclassificadas para outras causas após revisão aumentaram ao longo do tempo, atingindo 30,1% em 2017. De um total de 257.367 CMD reclassificadas entre 2006 e 2017, causas perinatais, causas externas, cardiopatia isquêmica e doença cerebrovascular foram os principais grupamentos de causas nos grupos etários de 0-9 anos, 10-29 anos, 30-69 anos, 70 anos ou mais, respectivamente. Discussão: A similaridade e a plausibilidade das proporções de causas específicas detectadas entre as CMD nos grupos etários ao longo do tempo indicam acurácia dos dados da investigação. Conclusão: Causas mais informativas detectadas após a revisão das CMD indicam o sucesso dessa abordagem para corrigir erros de classificação no SIM, que deve ser mantida. Maior capacitação dos médicos no preenchimento do atestado de óbito e melhor acesso e qualificação dos serviços de saúde são importantes para melhoria futura.