Beneficial Effect of Exogenously Applied Calcium Pyruvate in Alleviating Water Deficit in Sugarcane as Assessed by Chlorophyll a Fluorescence Technique.

The growing demand for food production has led to an increase in agricultural areas, including many with low and irregular rainfall, stressing the importance of studies aimed at mitigating the harmful effects of water stress. From this perspective, the objective of this study was to evaluate calcium pyruvate as an attenuator of water deficit on chlorophyll a fluorescence of five sugarcane genotypes. The experiment was conducted in a plant nursery where three management strategies (E1-full irrigation, E2-water deficit with the application of 30 mM calcium pyruvate, and E3-water deficit without the application of calcium pyruvate) and five sugarcane genotypes (RB863129, RB92579, RB962962, RB021754, and RB041443) were tested, distributed in randomized blocks, in a 3 × 5 factorial design with three replications. There is dissimilarity in the fluorescence parameters and photosynthetic pigments of the RB863129 genotype in relation to those of the RB041443, RB96262, RB021754, and RB92579 genotypes. Foliar application of calcium pyruvate alleviates the effects of water deficit on the fluorescence parameters of chlorophyll a and photosynthetic pigments in sugarcane, without interaction with the genotypes. However, subsequent validation tests will be necessary to test and validate the adoption of this technology under field conditions.

Genomic and epidemiological insight of an outbreak of carbapenemase-producing Enterobacterales in a Portuguese hospital with the emergence of the new KPC-124.

BACKGROUND: Carbapenemase-producing Enterobacterales (CPE) is an increasing problem in healthcare settings. This study aimed to identify the source of a CPE outbreak that occurred in 2022, in a tertiary hospital in the North of Portugal, to identify exposed patients, and to assess the risk of becoming CPE-positive following hospital admission. METHODS: A multi-disciplinary investigation was conducted including descriptive, analytical, and molecular epidemiology, environmental screening, and assessment of infection control measures. Clinical and environmental isolates were analyzed using whole-genome sequencing and phylogenetic analysis. Additionally, a prospective observational cohort study was conducted to further investigate the risk factors associated with the emergence of new cases in cohorts of CPE-negative admitted patients. RESULTS: We observed the presence of multispecies KPC-, IMP-, and/or NDM-producing isolates. Genetically indistinguishable clinical and environmental isolates were found on the same room/ward. The ST45 KPC-3-producing Klebsiella pneumoniae clone was the responsible for the outbreak. During patients' treatment, we detected the emergence of resistance to ceftazidime-avibactam, associated with mutations in the blaKPC-3 gene (blaKPC-46, blaKPC-66 and blaKPC-124, the last variant never previously reported), suggesting a vertical evolutionary trajectory. Patients aged ≥ 75 years, hygiene/feeding-care dependent, and/or subjected to secretion aspiration were risk factors for CPE colonization after hospital admission. Additionally, cases with previous admission to the emergency department suggest that CPE dissemination may occur not only during hospitalization but also in the emergency department. CONCLUSION: Overall, the study highlights that selection pressure with antibiotics, like ceftazidime-avibactam, is a contributing factor to the emergence of new ß-lactamase variants and antibiotic resistance. It also shows that the hospital environment can be a significant source of CPE transmission, and that routine use of infection control measures and real-time molecular epidemiology investigations are essential to ensure the long-term termination of CPE outbreaks and prevent future resurgences.

Promoção ao Aleitamento Materno nos Centros de Educação Infantil do município de São Paulo / Breastfeeding promotion actions at daycare centers in the city of São Paulo

RESUMO Este estudo objetivou descrever as etapas de planejamento, implementação e monitoramento das ações de promoção ao Aleitamento Materno (AM) nos Centros de Educação Infantil (CEI) da Rede Municipal de Ensino de São Paulo. Foram estruturadas quatro frentes de trabalho: elaboração de materiais orientativos; realização de formações; estruturação de campanha de comunicação; e monitoramento. Além de vídeos de publicização, foi produzido informativo para as equipes educacionais com orientações para a manutenção do AM após a matrícula da criança. As formações anuais visaram subsidiar ações pedagógicas e atingiram todos os territórios educacionais do município. A campanha CEI Amigo do Peito definiu critérios para reconhecer os CEI comprometidos com o AM. O número de CEI Amigos do Peito passou de 93 em 2018 para 875 em 2022. Foi enviado formulário eletrônico para todos os CEI do município para avaliação de indicadores: interesse de familiares em manter o AM; ambiente disponível para amamentação; realização de projetos; presença de mães amamentando; e entrega de leite materno. A adesão dos respondentes variou de 40,8% a 50,9%. Os resultados mostraram a urgência da responsabilidade compartilhada entre setores governamentais para promover o AM.

ABSTRACT This study describes the planning, implementation, and monitoring of actions to promote Breastfeeding (BF) in the Municipal Education System of the city of São Paulo. We established a set of four actions: elaboration of instructional material, training of daycare centers employees, development of a communication campaign, and monitoring. Instructional material was elaborated to guide the maintenance of BF after the child's enrollment and videos were produced to disseminate the information. Annual training in all territories of the city was provided to guide pedagogical interventions. The campaign, called CEI Amigo do Peito, established criteria to recognize daycare centers committed to BF promotion. The number of daycare centers committed to BF went from 93 (2018) to 875 (2022). Electronic form was sent to all daycare centers to evaluate the following indicators: interest of family members in maintaining BF, room available for breastfeeding, development of projects, presence of mothers breastfeeding, and delivery of breast milk. Respondents' adherence ranged from 40.8% to 50.9%. The results show the urgency of shared responsibility among government sectors to promote BF.

Pool of items to measure Primary Health Care workers' knowledge on healthy eating.

OBJECTIVE: To develop and validate a self-applicable instrument for measuring primary health care (PHC) workers' knowledge on healthy eating. METHODS: A six-step methodological study to develop and validate a measurement instrument: item development based on the Brazilian Dietary Guidelines' chapters; content validation with a panel of experts; face validation with potential instrument users; online instrument reevaluation by participants of the content and face validation panels; online application of the instrument with PHC workers; confirmatory factor analysis for construct validation. RESULTS: A first version with 25 items underwent content and semantic changes in the content and face validation panels, being reorganized into a second version with 22 items. In the reevaluation, participants considered 21 questions to be clear and representative of the Brazilian Dietary Guidelines, with one being excluded. This third version of the instrument underwent confirmatory factor analysis after being applied online with 209 PHC workers from all Brazilian macroregions. We excluded five items in this analysis: four due to bivariate empty cells and one due to low discrimination capacity. The final model, with 16 items loaded onto one dimension, returned good fit indices [χ2(104) = 119.047, p = 0.1486; RMSEA = 0.026 (90% CI = 0.000 to 0.046), Cfit = 0.979; CFI = 0.924; TLI = 0.913]; its information peak was below average. CONCLUSIONS: The instrument proved to be valid and accurate for assessing PHC workers with below average knowledge of the Brazilian Dietary Guidelines. It might contribute to improving actions to promote healthy eating in Brazilian PHC settings by identifying the need for training health professionals.

Distribution and Clonal Diversity of Staphylococcus aureus and Other Staphylococci in Surface Waters: Detection of ST425-t742 and ST130-t843 mecC-Positive MRSA Strains.

Natural aquatic environments represent one of the most important vehicles of bacterial dissemination. Therefore, we aimed to isolate staphylococci from surface waters and to investigate the presence of antimicrobial resistance genes and virulence factors as well as the genetic lineages of all Staphylococcus aureus isolates. Staphylococci were recovered from water samples collected from 78 surface waters, including rivers, streams, irrigation ditches, dams, lakes, and fountains. The presence of antimicrobial resistance genes and virulence factors was investigated by PCR. Multilocus sequence typing and spa-typing were performed in all S. aureus isolates. From the 78 water samples, 33 S. aureus, one S. pseudintermedius, and 51 coagulase-negative staphylococci (CoNS) were identified. Among the S. aureus isolates, four MRSA were identified, and all harbored the mecC gene. Fourteen S. aureus were susceptible to all antimicrobials tested and the remaining showed resistance to penicillin, erythromycin and/or tetracycline encoded by the blaZ, ermT, msr(A/B), tetL, and vgaA genes. Regarding the clonal lineages, one mecC-MRSA isolate belonged to spa-type t843 and sequence type (ST) 130 and the other three to t742 and ST425. The remaining S. aureus were ascribed 14 spa-types and 17 sequence types. Eleven species of CoNS were isolated: S. sciuri, S. lentus, S. xylosus, S. epidermidis, S. cohnii spp. urealyticus, S. vitulinus, S. caprae, S. carnosus spp. Carnosus, S. equorum, S. simulans, and S. succinus. Thirteen CoNS isolates had a multidrug resistance profile and carried the following genes: mecA, msr(A/B), mph(C), aph(3')-IIIa, aac(6')-Ie-aph(2'')-Ia, dfrA, fusB, catpC221, and tetK. A high diversity of staphylococci was isolated from surface waters including mecCMRSA strains and isolates presenting multidrug-resistance profiles. Studies on the prevalence of antibiotic-resistant staphylococci in surface waters are still very scarce but extremely important to estimate the contribution of the aquatic environment in the spread of these bacteria.

Assessing the Bacterial Community Composition of Bivalve Mollusks Collected in Aquaculture Farms and Respective Susceptibility to Antibiotics.

Aquaculture is a growing sector, providing several products for human consumption, and it is therefore important to guarantee its quality and safety. This study aimed to contribute to the knowledge of bacterial composition of Crassostrea gigas, Mytilus spp. and Ruditapes decussatus, and the antibiotic resistances/resistance genes present in aquaculture environments. Two hundred and twenty-two bacterial strains were recovered from all bivalve mollusks samples belonging to the Aeromonadaceae, Bacillaceae, Comamonadaceae, Enterobacteriaceae, Enterococcaceae, Micrococcaceae, Moraxellaceae, Morganellaceae, Pseudomonadaceae, Shewanellaceae, Staphylococcaceae, Streptococcaceae, Vibrionaceae, and Yersiniaceae families. Decreased susceptibility to oxytetracycline prevails in all bivalve species, aquaculture farms and seasons. Decreased susceptibilities to amoxicillin, amoxicillin/clavulanic acid, cefotaxime, cefoxitin, ceftazidime, chloramphenicol, florfenicol, colistin, ciprofloxacin, flumequine, nalidixic acid and trimethoprim/sulfamethoxazole were also found. This study detected six qnrA genes among Shewanella algae, ten qnrB genes among Citrobacter spp. and Escherichia coli, three oqxAB genes from Raoultella ornithinolytica and blaTEM-1 in eight E. coli strains harboring a qnrB19 gene. Our results suggest that the bacteria and antibiotic resistances/resistance genes present in bivalve mollusks depend on several factors, such as host species and respective life stage, bacterial family, farm's location and season, and that is important to study each aquaculture farm individually to implement the most suitable measures to prevent outbreaks.

Prevalence and Characteristics of Multidrug-Resistant Livestock-Associated Methicillin-Resistant Staphylococcus aureus (LA-MRSA) CC398 Isolated from Quails (Coturnix Coturnix Japonica) Slaughtered for Human Consumption.

Livestock-associated MRSA (LA-MRSA) is a zoonotic pathogen that has been reported in several animals, and it is often associated with clonal complex (CC) 398. We aimed to isolate MRSA from quails and to characterize their antimicrobial resistance and genetic lineages. One hundred swab samples were recovered from quails at the slaughterhouse. The swabs were inoculated onto CHROMagar™ MRSA agar plates for MRSA isolation. The presence of antimicrobial-resistant genes and virulence factors was investigated by PCR. All strains were typed by MLST, SCCmec-, spa- and agr-typing. From the 100 samples, 29 MRSA were isolated. All strains were resistant to penicillin, cefoxitin, ciprofloxacin, erythromycin and clindamycin and carried the blaZ, mecA, ermB and ermC genes. All strains, except one, showed resistance to tetracycline and harbored the tetM, tetK and tetL genes in different combinations. Twenty strains belonged to ST398 and SCCmec type V, and nine strains belonged to the new ST6831. Twenty-eight out of twenty-nine strains were ascribed to t011 and one to t108. As far as we know, this is the first report of MRSA from quails slaughtered for human consumption. Most strains belonged to ST398-t011, which is the most common LA-MRSA clone found in livestock in Europe.

The role of Design Science Research Methodology in developing pharmacy eHealth services.

The increasing focus on efficiency of care has prompted health systems to look for innovative solutions that yield maximum value for care. Integration of care and eHealth are seen as the most promising solutions in the high technological environment of the coming decades. Pharmacy services have been developed to a point where the face of community pharmacy has changed dramatically. Thus, service design and implementation has become an area of increased attention by Pharmacy practice researchers, and the arrival of eHealth concepts to Pharmacy is driving the need to find alternative ways to design new services. Moreover, known barriers and challenges remain when securing integration of pharmacy services with the health systems. In this paper, Design Science Research Methodology (DSRM), a user-centered alternative methodology to the design, development and implementation of health services, especially eHealth services, is presented. This alternative, originally from the Information Sciences field, has been adopted as a service design methodology in diverse settings, including health care. Here, case studies are used to explain how a DSRM process should be conducted in a health care setting, illustrating what methods to choose in each step of the process. Finally, the advantages of DSRM compared to other user-centered methodologies for service design are presented, hopefully prompting the discussion on the use of DSRM for the study of the implementation and sustainability of pharmacy services.

Antimicrobial Resistance and Genetic Lineages of Staphylococcus aureus from Wild Rodents: First Report of mecC-Positive Methicillin-Resistant S. aureus (MRSA) in Portugal.

The frequent carriage of Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA), by wild animals along with its zoonotic potential poses a public health problem. Furthermore, the repeated detection of the mecA gene homologue, mecC, in wildlife raises the question whether these animals may be a reservoir for mecC-MRSA. Thus, we aimed to isolate S. aureus and MRSA from wild rodents living in port areas and to characterize their antimicrobial resistance and genetic lineages. Mouth and rectal swab samples were recovered from 204 wild rodents. The samples were incubated in BHI broth with 6.5% of NaCl and after 24 h at 37 °C the inoculum was seeded onto Baird-Parker agar, Mannitol Salt agar and ORSAB (supplemented with 2 mg/L of oxacillin) plates. Species identification was confirmed by MALDI-TOF MS. The antimicrobial susceptibility testing was performed by the Kirby-Bauer disc diffusion method against 14 antibiotics. The presence of virulence and resistance genes was performed by PCR. The immune evasion cluster (IEC) system was investigated in all S. aureus. All isolates were characterized by MLST, spa- and agr typing. From 204 samples, 38 S. aureus were isolated of which six MRSA were detected. Among the six MRSA isolates, three harbored the mecC gene and the other three, the mecA gene. All mecC-MRSA isolates were ascribed to sequence type (ST) 1945 (which belongs to CC130) and spa-type t1535 whereas the mecA isolates belonged to ST22 and ST36 and spa-types t747 and t018. Twenty-five S. aureus were susceptible to all antibiotics tested. S. aureus isolates were ascribed to 11 MLST and 12 spa-types. S. aureus presents a great diversity of genetic lineages in wild rodents. This is the first report of mecC-MRSA in Portugal.

Pharmacy Electronic Records and Patient Clustering: Exploring New Ways to Increase the Provision of Tailored Pharmaceutical Services.

Patients' electronic records in community pharmacy are an untapped resource to uncover new ways of providing healthcare services. In this paper, we present a preliminary work, where we explore this resource, aiming to identify patients' clusters that will help to define a future algorithm. This algorithm will then enable community pharmacists to provide tailored pharmaceutical interventions according to patient's risk assessment and needs. In this way, this work will provide a way to overcome known barriers for community pharmacists' provision of services and integration in the health system, while also contributing to support a better care for chronic patients.

Efficacy of a glucose meter connected to a mobile app on glycemic control and adherence to self-care tasks in patients with T1DM and LADA: a parallel-group, open-label, clinical treatment trial.

OBJECTIVE: The main aim of the study was to evaluate the patients' glycemic control and adherence to self-care tasks. METHODS: Patients with type 1 diabetes mellitus (T1DM) or latent autoimmune diabetes of the adult (LADA) using a multiple daily injection (MDI) regimen with carbohydrate counting (n = 25, Subgroup B) or fixed insulin dose (n = 25, Subgroup C) were allocated to use the application (app) for 12 weeks. Both subgroups were compared with each other and against a control group (n = 25, Group A) comprising patients with T1DM or LADA treated with continuous subcutaneous insulin infusion (CSII) in a parallel-group, open-label, clinical treatment trial. All patients had glycated hemoglobin (A1C) levels measured and were asked to fill out the Diabetes Self-Management Profile (DSMP) questionnaire at study start and end. The patients were instructed to measure capillary glucose six times daily in study weeks 4, 8, and 12. RESULTS: Mean A1C levels decreased 0.725% in Subgroup C in intragroup analysis (p = 0.0063), and had a mean variation of 0.834% compared with Group A (p = 0.003). Mean DSMP scores increased 5.77 points in Subgroup B in intragroup analysis (p = 0.0004) and increased by a mean of 6.815 points in relation to Group A (p = 0.002). CONCLUSION: OneTouch Reveal improved both A1C levels and DSMP scores in patients with T1DM or LADA compared with standard treatment (CSII).

Efficacy of a glucose meter connected to a mobile app on glycemic control and adherence to self-care tasks in patients with T1DM and LADA: a parallel-group, open-label, clinical treatment trial

ABSTRACT Objective: The main aim of the study was to evaluate the patients' glycemic control and adherence to self-care tasks. Materials and methods: Patients with type 1 diabetes mellitus (T1DM) or latent autoimmune diabetes of the adult (LADA) using a multiple daily injection (MDI) regimen with carbohydrate counting (n = 25, Subgroup B) or fixed insulin dose (n = 25, Subgroup C) were allocated to use the application (app) for 12 weeks. Both subgroups were compared with each other and against a control group (n = 25, Group A) comprising patients with T1DM or LADA treated with continuous subcutaneous insulin infusion (CSII) in a parallel-group, open-label, clinical treatment trial. All patients had glycated hemoglobin (A1C) levels measured and were asked to fill out the Diabetes Self-Management Profile (DSMP) questionnaire at study start and end. The patients were instructed to measure capillary glucose six times daily in study weeks 4, 8, and 12. Results: Mean A1C levels decreased 0.725% in Subgroup C in intragroup analysis (p = 0.0063), and had a mean variation of 0.834% compared with Group A (p = 0.003). Mean DSMP scores increased 5.77 points in Subgroup B in intragroup analysis (p = 0.0004) and increased by a mean of 6.815 points in relation to Group A (p = 0.002). Conclusion: OneTouch Reveal improved both A1C levels and DSMP scores in patients with T1DM or LADA compared with standard treatment (CSII).

Pool of items to measure Primary Health Care workers' knowledge on healthy eating

ABSTRACT OBJECTIVE To develop and validate a self-applicable instrument for measuring primary health care (PHC) workers' knowledge on healthy eating. METHODS A six-step methodological study to develop and validate a measurement instrument: item development based on the Brazilian Dietary Guidelines' chapters; content validation with a panel of experts; face validation with potential instrument users; online instrument reevaluation by participants of the content and face validation panels; online application of the instrument with PHC workers; confirmatory factor analysis for construct validation. RESULTS A first version with 25 items underwent content and semantic changes in the content and face validation panels, being reorganized into a second version with 22 items. In the reevaluation, participants considered 21 questions to be clear and representative of the Brazilian Dietary Guidelines, with one being excluded. This third version of the instrument underwent confirmatory factor analysis after being applied online with 209 PHC workers from all Brazilian macroregions. We excluded five items in this analysis: four due to bivariate empty cells and one due to low discrimination capacity. The final model, with 16 items loaded onto one dimension, returned good fit indices [χ2(104) = 119.047, p = 0.1486; RMSEA = 0.026 (90% CI = 0.000 to 0.046), Cfit = 0.979; CFI = 0.924; TLI = 0.913]; its information peak was below average. CONCLUSIONS The instrument proved to be valid and accurate for assessing PHC workers with below average knowledge of the Brazilian Dietary Guidelines. It might contribute to improving actions to promote healthy eating in Brazilian PHC settings by identifying the need for training health professionals.

Bacterial Diversity and Antibiotic Susceptibility of Sparus aurata from Aquaculture.

In a world where the population continues to increase and the volume of fishing catches stagnates or even falls, the aquaculture sector has great growth potential. This study aimed to contribute to the depth of knowledge of the diversity of bacterial species found in Sparus aurata collected from a fish farm and to understand which profiles of diminished susceptibility to antibiotics would be found in these bacteria that might be disseminated in the environment. One hundred thirty-six bacterial strains were recovered from the S. aurata samples. These strains belonged to Bacillaceae, Bacillales Family XII. Incertae Sedis, Comamonadaceae, Enterobacteriaceae, Enterococcaceae, Erwiniaceae, Micrococcaceae, Pseudomonadaceae and Staphylococcaceae families. Enterobacter sp. was more frequently found in gills, intestine and skin groups than in muscle groups (p ≤ 0.01). Antibiotic susceptibility tests found that non-susceptibility to phenicols was significantly higher in gills, intestine and skin samples (45%) than in muscle samples (24%) (p ≤ 0.01) and was the most frequently found non-susceptibility in both groups of samples. The group of Enterobacteriaceae from muscles presented less decreased susceptibility to florfenicol (44%) than in the group of gills, intestine and skin samples (76%). We found decreased susceptibilities to ß-lactams and glycopeptides in the Bacillaceae family, to quinolones and mupirocin in the Staphylococcaceae family, and mostly to ß-lactams, phenicols and quinolones in the Enterobacteriaceae and Pseudomonadaceae families. Seven Enterobacter spp. and five Pseudomonas spp. strains showed non-susceptibility to ertapenem and meropenem, respectively, which is of concern because they are antibiotics used as a last resort in serious clinical infections. To our knowledge, this is the first description of species Exiguobacterium acetylicum, Klebsiella michiganensis, Lelliottia sp. and Pantoea vagans associated with S. aurata (excluding cases where these bacteria are used as probiotics) and of plasmid-mediated quinolone resistance qnrB19-producing Leclercia adecarboxylata strain. The non-synonymous G385T and C402A mutations at parC gene (within quinolone resistance-determining regions) were also identified in a Klebsiella pneumoniae, revealing decreased susceptibility to ciprofloxacin. In this study, we found not only bacteria from the natural microbiota of fish but also pathogenic bacteria associated with fish and humans. Several antibiotics for which decreased susceptibility was found here are integrated into the World Health Organization list of "critically important antimicrobials" and "highly important antimicrobials" for human medicine.

Scale for evaluating food and nutrition education practices in Primary Health Care / Escala de avaliação de práticas de educação alimentar e nutricional na Atenção Primária em Saúde

ABSTRACT Objective To develop, validate and analyse intra- and inter-raters' agreement and reliability of a scale for the evaluation of food and nutrition education practices in primary health care. Methods Three theoretical references were used for the development of items with answers on a 4-point scale (not observed, partially/satisfactorily/fully observed): the Brazilian Dietary Guidelines, the Interprofessional Collaborative Practice and the Family Health Strategy as models for organizing primary health care. The scale was submitted for content and face panel validation and it was further reevaluated online. Thirty specialists used the scale for the rating of 4 videos produced for the study showing food and nutrition education practices in primary health care settings. Intra- and inter-raters agreement and reliability were analyzed by test at one time point and retest 30 days later. Results The scale initially included 72 items but was reduced to 17 items after content and face validation, together with a fill-out manual that was reviewed by experts. In the re-evaluation, all 17 items were maintained, and content adjustments were made in the manual. Thirty raters applied the scale to the videos in the test, and 28 in the retest. All videos obtained combined kappa values of >0.4. In the test-retest, 19 raters showed >80% agreement; in the inter-rater evaluation, 14 raters generated kappa values >0.75. Conclusion The scale underwent content and face validation and showed to be useful to diagnose the absence and the full addressing of the Brazilian Dietary Guidelines content with good intra- and inter-rater agreement and reliability in different settings of Primary Health Care.

RESUMO Objetivo Desenvolver e avaliar a validade e a confiabilidade de uma escala de avaliação das práticas de educação alimentar e nutricional na Atenção Primária em Saúde. Métodos Para o desenvolvimento dos itens, com quatro opções de resposta cada (não observado, parcialmente/satisfatoriamente/plenamente observado), foram utilizadas as recomendações de três referenciais teóricos - o Guia Alimentar para a População Brasileira, Prática Colaborativa Interprofissional e Estratégia Saúde da Família - como modelos de organização do cuidado na Atenção Primária. A escala passou por validação de conteúdo e aparente com painéis presenciais, sendo posteriormente reavaliada em plataforma online. Trinta especialistas aplicaram a escala na avaliação de quatro vídeos com encenações de práticas de educação alimentar e nutricional na Atenção Primária. Foram analisadas a concordância e a confiabilidade intra e interobservadores com teste e reteste após 30 dias. Resultados A escala foi desenvolvida com 72 itens, sendo reduzida a 17 itens após validação de conteúdo e aparente, acompanhados de manual de preenchimento revisado por especialistas. Na reavaliação, os 17 itens foram mantidos e o conteúdo do manual foi reajustado. Na avaliação dos vídeos, a escala foi aplicada por 30 avaliadores no teste e por 28 no reteste Todos os vídeos obtiveram kappas combinados >0,4. No teste-reteste, 19 avaliadores apresentaram concordâncias >80%; na avaliação interobservadores, 14 avaliadores apresentaram kappas >0,75. Conclusão A escala passou por validação de conteúdo e aparente e mostrou-se adequada para diagnosticar a ausência e a abordagem plena dos conteúdos do Guia Alimentar, com boa concordância e confiabilidade intra e interobservadores em diversas situações de cuidado na Atenção Primária.

Prevalence and Determinants of Painful and Painless Neuropathy in Type 1 Diabetes Mellitus.

Aims: To evaluate (1) the prevalence of diabetic distal symmetrical sensory-motor polyneuropathy (DSPN) and painful DSPN among patients with type 1 diabetes mellitus (DM1) aged over 18 years and (2) the determinant factors of neuropathy and pain in those patients. Materials and Methods: An epidemiological, cross-sectional, observational study was performed; 330,386 people were included, and a total of 444 people were diagnosed with DM1. After exclusion of possible confounders, 360 patients were assessed for painless and painful DSPNs using neurological examination and questionnaires for neuropathy and pain. Odds ratio (OR) and confidence intervals (95% CI) were estimated using multinomial logistic regression models. The analysis was based on a framework with four conceptual levels that consider feasible pathways between several risk factors: (1) socio-demographic factors and diabetes duration, (2) patient habits, (3) co-morbidities, and (4) metabolic factors and disease complications. Results: The prevalence of DSPN and painful DSPN were 42.8 and 18.9%, respectively. Diabetes duration was positively associated with painful (OR = 1.107, 95% CI: 1.107-1.139) and painless DSPN (OR = 1.069, 95% CI: 1.043-1.096). Education level was negatively associated with painful DSPN (OR = 0.889, 95% CI: 0.826-0.957). Sex (female) was positively associated only with painless DSPN (OR = 1.769, 95% CI: 1.007-3.107). Being a current or former smoker was positively associated only with painless DSPN (OR = 1.940, 95% CI: 1.069-3.518). Hypertension was positively associated with painful DSPN (OR = 2.474, 95% CI: 1.110-5.512) and painless DSPN (OR = 2.565, 95% CI: 1.252-5.256). Glycated hemoglobin (HbA1c) was positively associated only with painless DSPN (OR = 1.193, 95% CI: 1.018-1.399). Conclusions: Diabetes duration and hypertension have a direct impact on the development of painful and painless DSPN. However, female sex and HbA1c have a direct effect only on the development of painless DSPN, and education level has an indirect effect on the development of painful DSPN. Therefore, it can be concluded that different etiological factors have different contributions to the development of neuropathy and pain.

Tecnologias de apoio à implementação do guia alimentar para a população brasileira na atenção básica / Technologies to support the implementation of the dietary guidelines for the Brazilian population in primary health care

Introdução: A disseminação das recomendações de guias alimentares é vista globalmente como primordial na agenda de promoção da alimentação adequada e saudável, destacando-se a capacitação dos seus facilitadores. Objetivo: Desenvolver e validar tecnologias de apoio à implementação do Guia Alimentar para a População Brasileira na Atenção Básica em Saúde (ABS). Metodologia: Foram produzidos três manuscritos sobre desenvolvimento e validação de instrumentos de aferição. Artigo 1 - GAB1 (escala de mensuração do conhecimento de profissionais de saúde da ABS sobre o Guia Alimentar) foi desenvolvida e validada em seis etapas: desenvolvimento dos itens, validação de conteúdo com painel de juízes, validação aparente com potenciais usuários da escala, reavaliação online, aplicação online com profissionais de saúde da ABS de todas as macrorregiões brasileiras e análise fatorial confirmatória para validação de constructo. Artigo 2 - GAB2 (escala de mensuração da autoeficácia e eficácia coletiva de profissionais de saúde da ABS para aplicar o Guia Alimentar) passou pelas mesmas etapas metodológicas do artigo 1. Artigo 3 - GAB3 (escala de avaliação da abordagem do Guia Alimentar por profissionais de saúde da ABS em intervenções educativas) foi desenvolvida, validada e testada em cinco etapas: desenvolvimento dos itens; validação de conteúdo com painel de juízes; validação aparente com potenciais usuários da escala; reavaliação online; teste e reteste para análise da concordância e confiabilidade intra e interobservadores com especialistas aplicando GAB3 na avaliação de 4 vídeos produzidos para o estudo. Resultados: Artigo 1 - GAB1 foi desenvolvida com 25 itens, passando para 22 itens após validação de conteúdo e aparente. Na reavaliação, 21 itens foram considerados claros e representativos do Guia Alimentar e 1 foi excluído. Essa versão da escala foi aplicada pela internet com 209 profissionais de saúde da ABS. Foram excluídos 5 itens na análise fatorial confirmatória, sendo 4 por células bivariadas vazias e 1 por baixa discriminação. O modelo final com 16 itens compondo 1 dimensão retornou bons índices de ajuste. O pico de informação da escala esteve abaixo da média. Artigo 2 - GAB2 foi desenvolvida inicialmente com 22 itens, chegando a 24 itens divididos igualmente em 2 seções (autoeficácia e eficácia coletiva) após validação de conteúdo e aparente. Todos os itens foram considerados claros e representativos do Guia Alimentar na reavaliação. O modelo multidimensional da GAB3 apresentou excelentes índices de adequação na análise fatorial confirmatória e a versão final obteve pico de informação na média. Artigo 3 - GAB3 teve seus itens reduzidos de 72 para 25 na validação de conteúdo. Na validação aparente passou para 17 itens, acompanhando manual de preenchimento revisado posteriormente por especialistas. Todos os itens foram considerados claros e representativos do Guia Alimentar na reavaliação e ajustes de conteúdo no manual foram realizados nessa etapa. Trinta especialistas no Guia Alimentar empregaram GAB3 assistindo aos vídeos no teste e 28 no reteste. Todos os vídeos obtiveram kappas combinados >0,4. No teste-reteste, 1 avaliador teve concordância consigo mesmo <0,4 e para confiabilidade, 2 avaliadores apresentaram kappa <0,4. Conclusões: Foram produzidas escalas e vídeos como tecnologias de apoio à implementação do Guia Alimentar na ABS.

Introduction: The dissemination of dietary guidelines is globally seen as crucial for the healthy eating promotion policies, especially those targeting the training of facilitators. Objective: To develop and validate technologies to support the implementation of the Brazilian Dietary Guidelines (BDG) in Primary Health Care (PHC). Methodology: Three manuscripts about development and validation of measurement tools were written. Manuscript 1 - GAB1 (scale for measuring the knowledge of PHC professionals about the BDG) was developed and validated in six steps: items' development, content validation with panel of experts, face validation with potential users, online reevaluation by health professionals and experts, online application with PHC professionals working all over Brazil's macro-regions, confirmatory factor analysis to investigate construct validity. Manuscript 2 - GAB2 (scale for measuring the self-efficacy and collective efficacy of PHC professionals to apply the BDG) were submitted to the same procedures described in manuscript 1. Manuscript 3 - GAB3 (scale for evaluating the implementation of the BDG in PHC educational interventions) was developed, validated and tested in five steps: items' development; content validation with panel of experts; face validation with potential users; online reevaluation; test-retest to analyze intra and interobserver agreement and reliability with experts applying GAB3 while watching 4 videos produced for this study. Results: Manuscript 1 - GAB1 was initially developed with 25 items and it was reduced to 22 items after content and face validation. GAB1's items were considered clear and representative of the BDG, with exception of 1 item that was excluded when the scale was reevaluated. This version of the scale was applied to 209 PHC professionals through a website. In the confirmatory factor analysis, GAB1's initial model constituted by 21 items had 5 items excluded: 4 returned bivariate empty cells and 1 with lowest discrimination value. All the fit indices returned a well-fitted model constituted by 16 items loaded onto 1 dimension, with peak of information centered below the mean. Manuscript 2 - GAB2 was initially developed with 22 items and it reached 24 items equally divided in part A (self-efficacy) and B (collective efficacy) after content and face validation. All GAB2's items were considered clear and representative of the BDG when reevaluated. GAB2 showed to have excellent fit indices, with peak of information centered around the mean. Manuscript 3 - GAB3's items were reduced from 72 to 25 after content validation. The scale reached 17 items in the face validation accompanied by a completion manual, reviewed by specialists. All the 17 items were considered clear and representative of the BDG when reevaluated and adjustments in the manual's content were made. Thirty raters applied GAB3 to watch the videos for test and 28 for the retest. All videos obtained combined kappa values>0.4. In the test-retest, only one rater had an agreement <0.4 and for reliability, only two raters had kappa values <0.4. Conclusions: Scales and videos were produced as technologies to support the implementation of the BDG in PHC.

Content validity of an educational workshop based on the Dietary Guidelines for the Brazilian Population / Validade de conteúdo de uma ofi cina educativa baseada no Guia Alimentar para a População Brasileira

ABSTRACT Objective To describe the development and validation of a workshop protocol for the implementation of the Dietary Guidelines for the Brazilian Population in primary healthcare units. Methods This descriptive study was developed in the state of São Paulo, Brazil, and it involved 20-25 professionals in the experimentation phase and 12 experts in the content validity phase. The workshop protocol was developed according to three theoretical references: Dietary Guidelines, Interprofessional Collaborative Practice and Critical Reflexive Methodology. The protocol consisted of four 4-hour modules, 16 activities in 16 hours. The activities matrix was composed of three axes: (a) organizational strategies, (b) dietary guideline comprehension and (c) dietary guideline implementation. For the validity analysis, the expert panel assessed clarity, relevance and theoretical representativeness. Content validity index was calculated, and adequate activities scored >0.80. The proportion of experts who recognized the presence of the theoretical framework in the activities was calculated. Results All 16 proposed activities obtained a score greater than the established cut-off point, both for clarity and relevance. For theoretical representativeness analysis, the dietary guidelines reached higher scores on the (b) and (c) axes of the protocol and was less recognized on the (a) axis, whose highest score was for the Critical Reflexive Methodology. Interprofessional Collaborative Practice presented a higher score on the (c) axis and a lower one on the (b) axis. Conclusion The protocol was considered appropriate for its purpose and with potential application in the different scenarios of primary health care in Brazil.

RESUMO Objetivo Descrever o desenvolvimento e validação de um protocolo de oficina de educação permanente para implementação do Guia Alimentar para a População Brasileira no âmbito da atenção primária à saúde. Métodos Este estudo descritivo foi desenvolvido no estado de São Paulo. Participaram do estudo 20-25 profissionais de saúde na fase de experimentação e 12 doze especialistas na fase de validação de conteúdo. O protocolo da oficina foi desenvolvido de acordo com três referenciais teóricos: o Guia Alimentar, a Prática Colaborativa Interprofissional e a Metodologia Crítico Reflexiva. O protocolo da oficina foi definido em 4 módulos com 16 atividades, em 16 horas. A matriz de atividades compreendeu três eixos: (a) estratégias organizacionais, (b) compreensão do Guia Alimentar e (c) implementação do Guia Alimentar. Para validação de conteúdo o painel de especialistas avaliou a clareza, relevância e representatividade teórica do protocolo. Índice de validade de conteúdo foi calculado e atividades adequadas pontuaram >0,80. A proporção de especialistas que reconheceu a presença do referencial teórico nas atividades foi calculada. Resultados Todas as 16 atividades propostas obtiveram escores maiores do que o ponto de corte estabelecido, tanto para clareza como para relevância. Na análise da representatividade teórica, o Guia Alimentar alcançou escores mais altos nos eixos (b) e (c), e foi menos reconhecido no eixo (a), cuja maior pontuação ocorreu para a Metodologia Crítico Reflexiva. A Prática Colaborativa Interprofissional apresentou maior pontuação no eixo (c) e menor no eixo (b). Conclusão O protocolo foi considerado adequado à sua finalidade e com potencial de aplicação nos diversos cenários da atenção primária à saúde no Brasil.

Students' Perceptions of Team-based Learning in an Undergraduate Nutrition School.

This article was migrated. The article was marked as recommended. Introduction: Current challenges in the food and nutrition fields have required training nutritionists to develop teamwork skills, demanding the use of active methodologies. Methods: This qualitative descriptive study aimed at knowing Nutrition students' perceptions about the use of Team Based Learning (TBL) in a course. Focus groups were conducted and submitted to content analysis. Results: Categories were grouped into three axes: (1) principles of the method ( teamwork, individual preparation and teacher's role), (2) results of the experience ( knowledge acquisition, critical judgment and communication/argumentation) and (3) meanings of the experience ( engagement/motivation and preference for the method). Teamwork was the most frequent category (51 occurrences), followed by knowledge acquisition (44) and engagement/motivation (35). Axis 1 categories came out linked to each other and to at least one Axis 2 category, revealing the course's coherence with TBL principles, thus allowing better knowledge acquisition, communication skills, and development of critical judgment. Axis 3 was connected to the others, pointing out that both principles of the method and results of the experience contributed to students' engagement and preference for the method. Conclusion: According tostudents' perceptions, TBL can contribute to provide nutritionists with better technical training, critical judgment, and communication skills.

Anthropometry and body composition of vertically HIV-infected children and adolescents under therapy with and without protease inhibitors.

OBJECTIVE: Although the benefits of highly active antiretroviral therapy (HAART) have been documented, it is thought to be associated to disturbances in nutritional status. These disturbances may occur early in life and are poorly understood. The present study aimed to investigate the relationship between anthropometric parameters and body composition of perinatally HIV-infected children and adolescents under HAART, according to use and non-use of protease inhibitors. DESIGN: Cross-sectional study undertaken between August and December 2007. Demographic, socio-economic, clinical and anthropometric data were collected from the patients. The χ 2 test, Wilcoxon rank sum test (Mann-Whitney) and t test were used to compare the following variables between users and non-users of protease inhibitors: age, gender, per capita income, HAART exposure, antiretroviral therapy adopted in the last three years, CD4 count, viral load, pubertal stage, nutritional status (BMI-for-age, height-for-age, waist and neck circumferences, triceps skinfold thickness, body fat percentage, upper-arm fat area and upper-arm muscle area). SETTING: An HIV/AIDS out-patient clinic, São Paulo, Brazil. SUBJECTS: One hundred and fifteen patients (children and adolescents aged 6-19 years). RESULTS: Protease inhibitors users had a higher prevalence of stunting (P=0.03), lower BMI (P=0.03) and lower percentage of body fat (P=0.05) compared with non-users. There was no statistically significant difference between the HAART regimens and measurements of fat adiposity. CONCLUSIONS: The findings of the study suggest that children and adolescents under protease inhibitors are at higher risk of growth and development deviations, but not at risk of body fat redistribution.