Comparison of the Effects of Full Median Sternotomy vs. Mini-Incision on Postoperative Pain in Cardiac Surgery: A Meta-Analysis.

INTRODUCTION: It is not yet clear whether cardiac surgery by mini-incision (minimally invasive cardiac surgery [MICS]) is overall less painful than the conventional approach by full sternotomy (FS). A meta-analysis is necessary to investigate polled results on this topic. METHODS: PubMed®/MEDLINE, Cochrane CENTRAL, Latin American and Caribbean Health Sciences Literature (or LILACS), and Scientific Electronic Library Online (or SciELO) were searched for all clinical trials, reported until 2022, comparing FS with MICS in coronary artery bypass grafting (CABG), mitral valve surgery (MVS), and aortic valve replacement (AVR), and postoperative pain outcome was analyzed. Main summary measures were the method of standardized mean differences (SMD) with a 95% confidence interval (CI) and P-values (considered statistically significant when < 0.05). RESULTS: In AVR, the general estimate of postoperative pain effect favored MICS (SMD 0.87 [95% CI 0.04 to 1.71], P=0.04). However, in the sensitivity analysis, there was no difference between the groups (SMD 0.70 [95% CI -0.69 to 2.09], P=0.32). For MVS, it was not possible to perform a meta-analysis with the included studies, because they had different methodologies. In CABG, the general estimate of the effect of postoperative pain did not favor any of the approaches (SMD -0.40 [95% CI -1.07 to 0.26], P=0.23), which was confirmed by sensitivity analysis (SMD -0.02 [95% CI -0.71 to 0.67], P=0.95). CONCLUSION: MICS was not globally less painful than the FS approach. It seems that postoperative pain is more related to the degree of tissue retraction than to the size of the incision.

The Effectiveness of a Cell Phone eHealth App in Changing Knowledge, Stigmatizing Attitudes, and Intention to Seek Help Associated With Obsessive-Compulsive Disorder: Pilot Questionnaire Study.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a disabling disorder associated with high interference in people's lives. However, patients with OCD either do not seek help or delay seeking help. Research suggests that this could be explained by poor mental health literacy about the disorder and the associated stigma. OBJECTIVE: This study aims to evaluate the feasibility, acceptability, and preliminary effectiveness of a mental health mobile app, esTOCma, developed to improve knowledge about OCD and its treatment, increase help-seeking intention, and reduce stigmatizing attitudes and social distance associated with OCD. METHODS: We used preintervention, postintervention, and 3-month follow-up assessments in this single-arm pilot intervention. Overall, 90 participants were recruited from the community using the snowball sampling method. We used esTOCma to defeat the "stigma monster" over the course of 10 missions. The participants completed the sociodemographic information and Obsessive-Compulsive Inventory-Revised at preassessment and an acceptability questionnaire at postassessment. All other measures were completed at the preassessment, postassessment, and 3-month follow-up (ie, the Spanish Mental Illness Stigma Attribution Questionnaire-27, the General Help-Seeking Questionnaire, the Social Distance Scale, and the Mental Health Literacy Questionnaire). RESULTS: Of the 90 participants from the community that were assessed for eligibility, 86% (n=78) were allocated to intervention. Of these 78 participants, 79% (n=62) completed the game and answered the postintervention assessment (completer group). Overall, 69% (43/62) of the participants also completed the 3-month follow-up assessment. The participants completing the study were older (P=.003) and had a higher baseline knowledge of OCD (P=.05). The participants took an average of 13.64 (SD 10.50) days to complete the intervention, including the pre- and postassessments. The participants spent an average of 4.56 (SD 3.33) days completing the 10 missions included in the app. Each mission took a mean of between 2 (SD 3.01) and 9.35 (SD 3.06) minutes. The app was rated as useful or very useful by the vast majority of participants 90% (56/62). Moreover, 90% (56/62) of the participants reported that they had learned or learned a lot, and 98% (61/62) of the participants reported that they would recommend the app to a friend. Repeated measures ANOVA (43/62, 69%) showed that after the intervention participants showed an increased knowledge of mental health and intention to seek help as well as fewer stigmatizing attitudes and less social distance. CONCLUSIONS: Preliminary data show that esTOCma is a feasible and acceptable app, and after completing its 10 missions, there is an increase in the understanding of OCD and help-seeking intention along with a decrease in the social stigma and social distance associated with OCD that lasts for at least 3 months. The results support the potential of technology-based interventions to increase the intention to seek help and reduce the stigma associated with OCD. A larger, community-controlled study is also recommended.

Can an app increase health literacy and reduce the stigma associated with obsessive-compulsive disorder? A crossover randomized controlled trial.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a disabling condition with a high delay in seeking treatment. esTOCma is an app developed to increase mental health literacy (MHL) about OCD, reduce stigma, and increase the intention to seek professional treatment. It is a serious game and participants are asked to fight against the "OCD stigma monster" by accomplishing 10 missions. The aim of this study is to evaluate the effectiveness of this app in a community sample. METHODS: A randomized controlled trial with a crossover design was carried out. Participants were randomized to two groups: immediate use (iApp, n = 102) and delayed use (dApp, n = 106) of esTOCma. The iApp group started using the app at baseline until the game was over. The dApp group initiated at 10-days until the game finished. Participants were requested to complete a set of questionnaires at baseline and 10-day, 20-day and 3-month follow-ups. RESULTS: The Time×Group interaction effect was significant for the primary outcome measures: there was an increase in MHL and intention to seek help, and a decrease in stigma and OC symptoms, with large effect sizes, only after using the app. Changes were maintained (or increased) at follow-up. LIMITATIONS: The study did not include an active control group and some of the scales showed low internal consistency or a ceiling effect. CONCLUSIONS: This study provides first evidence for the effectiveness of esTOCma as a promising intervention to fight stigma and reduce the treatment gap in OCD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04777292. Registered February 23, 2021, https://clinicaltrials.gov/ct2/show/NCT04777292.

Studies in the Mentality of Literates: 3. Conceptual Structure and Nonsense of Personality Testing.

In this study, third in a series of studies of the relationships between the dominant type of the Word Meaning Structure (WMS) and various psychic processes, response patterns on personality questionnaires with Likert-type response format of individuals with different levels of education (including adult illiterates) in Brazil (N = 102) and in Estonia (N = 520) were assessed with person oriented methods of data analysis. We found that responses to two personality questionnaires (International Personality Item Pool Questionnaire, IPIP-Q60 and Estonian Collectivism Scale, ESTCOL) are inconsistent and do not correspond to theories that underlie construction and interpretation of such assessment tools. Two novel ways to assess inconsistent response patterns were developed. The Consistency Index (CI) characterizes between-item inconsistency and the Determinacy Index (DI) characterizes within-item inconsistency. The dominant type of the WMS and the level of education were related to both CI and DI. Higher level of between-item inconsistency characterizes everyday conceptual thinkers with lower levels of education and higher level of within-item inconsistency was observed among logical conceptual thinkers with higher levels of education. Systematic relationships between WMS and inconsistent patterns of responses indicate that responses on personality questionnaires cannot be interpreted in terms of personality characteristics. The results of our study also provide further support to the idea that dominant type of the WMS is a pervasive characteristic of the psyche and determines qualitatively possibilities and limits of the psychic processes. The results of this study are in agreement with the idea that WMS defines the "Great Divide."

Estigma asociado a los problemas de salud mental en población universitaria española / Stigma associated with mental health problems in the Spanish university population

El conocimiento sobre los problemas de salud mental y el contacto previo son variables clave en la lucha contra el estigma. Los objetivos del estudio fueron: (1) explorar el nivel de estigma asociado a los trastornos mentales en estudiantes de diferentes Grados universitarios y (2) analizar la evolución del estigma en estudiantes de Psicología. Dos grupos completaron el “Cuestionario de atribución” (AQ-27). El grupo 1 compuesto por 392 estudiantes de primer curso de los diferentes grados evaluados (Medad= 18,59 años; DT= 1,29; 60% mujeres), y el grupo 2 por 152 estudiantes de tercer curso de Psicología (Medad= 24,35 años; DT= 8,97; 73,4% mujeres). Los estudiantes del grupo 1 con contacto previo con trastornos mentales mostraron actitudes menos estigmatizantes. Se observaron diferencias en función del Grado cursado. El grupo 2 mostró menores niveles de estigma a lo largo del curso académico. Los resultados apoyan la eficacia que la formación en salud mental y las intervenciones de sensibilización mediante el contacto con personas con problemas de salud mental, pueden tener en la reducción del estigma. (AU)

Knowledge about mental health problems and previous contact are key variables in the fight against stigma. The aims of the study were: (1) to explore the level of stigma associated with mental disorders in students of different university degrees, and (2) to analyse the evolution of stigma in psychology students. Two groups completed the Attribution Questionnaire (AQ-27). Group 1 consisted of 392 first-year students of the different degrees evaluated (Mage= 18.59 years, SD=1.29, 60% female), and group 2 consisted of 152 third-year Psychology undergraduates (Mage= 24.35 years, SD= 8.97, 73.4% female). Group 1 students with previous contact with mental disorders showed less stigmatising attitudes. Differences were observed according to grade level. Group 2 showed lower levels of stigma throughout the academic year. The results support the effectiveness that mental health education and awareness-raising interventions through contact with people with mental health problems can have in reducing stigma. (AU)

Enhancing mental health literacy in obsessive-compulsive disorder and reducing stigma via smartphone: A randomized controlled trial protocol.

Background: Obsessive-compulsive disorder (OCD) is a disabling disorder that can be successfully treated. However, individuals with OCD do not seek or delay seeking treatment. This delay may be explained by poor mental health literacy and stigmatizing attitudes toward OCD in community. In order to work on these variables, a gamified mental health mobile application (app) called esTOCma has been developed. The purpose of this study is to describe the protocol for a study to test the efficacy of esTOCma, increasing mental health literacy and help-seeking intention, reducing the stigmatizing attitudes and social distance suffered by people with OCD, as well as the distress associated with obsessive-compulsive symptoms. Methods: A randomized controlled trial with a crossover design with two conditions (immediate-use App group versus delayed-use App group) will be conducted on a non-clinical adult sample of the community of a minimum size of 200 participants. Participants in the immediate-use App group will start using the app at baseline until completion (10 days); whereas participants in the delayed-use App group will wait 10 days, and then start using the app until completion (10 days). The outcomes will be measured at four assessment points (baseline; 10 days from baseline; and 20 days from baseline; and after 3 months). The following instruments will be administered: Attribution Questionnaire, General Help-Seeking Questionnaire, Social Distance Scale, Mental Health Literacy, Psychoeducation Questionnaire, Social Desirability Scale, Single-Item Self-esteem Scale, and Obsessive-Compulsive Inventory-Revised. Discussion: This protocol presents the first study to describe a randomized control trial of a mental health app focused on changing mental health literacy, stigmatizing attitudes, social distance and help-seeking intention associated with OCD. An app intervention of these characteristics is especially relevant nowadays as the COVID-19 pandemic has increased obsessive-compulsive symptoms and severity. An improvement in general knowledge about OCD and a reduction in stigma could be associated with earlier OCD detection and an increase in help-seeking intention, which could result in greater wellbeing. Moreover, normalizing intrusions and knowledge about the cognitive OCD model could serve as a protective variable in vulnerable individuals. Trial registration: ClinicalTrials.gov identifier: NCT04777292. Registered February 23, 2021, https://clinicaltrials.gov/ct2/show/NCT04777292.

ASIA syndrome: Adverse reaction or autoimmunity?

Introduction: Adjuvant-Induced Autoimmune / Auto-inflammatory Syndrome (ASIA) is an immune-mediated condition by the exposure of material previously considered inert, such as silicone, aluminum salts, mineral oils, hyaluronic acid and metallic implants. In addition to a genetic component, there is a risk of development of an undifferentiated connective tissue disease, which varies clinically and laboratorially depending on the adjuvant material used. Patients and methods: This paper addresses two cases reported, in caucasian subjects, born and residents in Madeira Island, Portugal. In this article are described two different histological patterns occurring in ASIA patients, due to mammoplasty with silicone. Conclusion: Although ASIA does not meet the diagnostic requirements for connective tissue disease, there is a close relationship with the development of autoimmune conditions. These cases aim to alert the medical community to the existence of this entity, encourage the notification of situations arising from exposure to adjuvants and investigate the presence of a genetic predisposition and a suggestive histological pattern in excisional biopsies of satellite adenomegalies.

The use of deliberate reflection to reduce confirmation bias among orthopedic surgery residents / O uso da reflexão deliberada para reduzir o viés de confirmação em residentes de ortopedia

Introduction: cognitive biases might affect decision-making processes such as clinical reasoning and confirmation bias is among the most important ones. The use of strategies that stimulate deliberate reflection during the diagnostic process seems to reduce availability bias, but its effect in reducing confirmation bias needs to be evaluated. Aims: to examine whether deliberate reflection reduces confirmation bias and increases the diagnostic accuracy of orthopedic residents solving written clinical cases. Methods: experimental study comparing the diagnostic accuracy of orthopedic residents in the resolution of eight written clinical cases containing a referral diagnosis. Half of the written cases had a wrong referral diagnosis. One group of residents used deliberate reflection (RG), which stimulates comparison and contrast of clinical hypotheses in a systematic manner, and a control group (CG), was asked to provide differential diagnoses with no further instruction. The study included 55 third-year orthopedic residents, 27 allocated to the RG and 28 to the CG. Results: residents on the RG had higher diagnostic scores than the CG for clinical cases with a correct referral diagnosis (62.0±20.1 vs. 49.1±21.0 respectively; p = 0.021). For clinical cases with incorrect referral diagnosis, diagnostic accuracy was similar between residents on the RG and those on the CG (39.8±24.3 vs. 44.6±26.7 respectively; p = 0.662). We observed an overall confirmation bias in 26.3% of initial diagnoses (non-analytic phase) and 19.5% of final diagnoses (analytic phase) when solving clinical cases with incorrect referral diagnosis. Residents from RG showed a reduction in confirmation of incorrect referral diagnosis when comparing the initial diagnosis given in the non-analytic phase with the one provided as the final diagnosis (25.9±17.7 vs. 17.6±18.1, respectively; Cohen d: 0.46; p = 0.003). In the CG, the reduction in the confirmation of incorrect diagnosis was not statistically significant. Conclusions:confirmation bias was present when residents solved written clinical cases with incorrect referral diagnoses, and deliberate reflection reduced such bias. Despite the reduction in confirmation bias, diagnostic accuracy of residents from the RG was similar to those from the CG when solving the set of clinical cases with a wrong referral diagnosis.

Introdução: os vieses cognitivos podem afetar tanto os processos de tomada de decisão como o raciocínio clínico e o viés de confirmação está entre os mais importantes. O uso de estratégias que estimulem a reflexão deliberada durante o processo diagnóstico parece reduzir o viés de disponibilidade, mas seu efeito na redução do viés de confirmação precisa ser avaliado. Objetivos: examinar se a reflexão deliberada reduz o viés de confirmação e aumenta a acurácia do diagnóstico de residentes de ortopedia ao resolverem casos clínicos escritos. Métodos: estudo experimental comparando a acurácia diagnóstica de residentes de ortopedia na resolução de oito casos clínicos escritos contendo um diagnóstico de encaminhamento. Metade dos casos escritos tinha um diagnóstico de encaminhamento errado. Um grupo de residentes utilizou a reflexão deliberada (GR), que estimula a comparação e o contraste de hipóteses clínicas de maneira sistemática, e um grupo controle (GC) foi solicitado a fornecer diagnósticos diferenciais sem maiores instruções. O estudo incluiu 55 residentes de ortopedia do terceiro ano, 27 alocados no GR e 28 no GC. Resultados: residentes no GR tiveram escores diagnósticos mais altos do que o GC para casos clínicos com um diagnóstico de encaminhamento correto (62,0±20,1 vs. 49,1±21,0 respectivamente; p = 0,021). Para os casos clínicos com diagnóstico de encaminhamento incorreto, a acurácia diagnóstica foi semelhante entre os residentes do GR e os do GC (39,8±24,3 vs. 44,6±26,7 respectivamente; p = 0,662). Observamos viés geral de confirmação em 26,3% dos diagnósticos iniciais (fase não analítica) e 19,5% dos diagnósticos finais (fase analítica) na resolução de casos clínicos com diagnóstico de encaminhamento incorreto. Os residentes do GR mostraram uma redução na confirmação do diagnóstico de encaminhamento incorreto ao comparar o diagnóstico inicial dado na fase não analítica com aquele fornecido como diagnóstico final (25,9±17,7 vs. 17,6±18,1, respectivamente; Cohen d: 0,46; p = 0,003). No GC, a redução na confirmação do diagnóstico incorreto não foi estatisticamente significativa. Conclusões: o viés de confirmação esteve presente quando os residentes resolveram casos clínicos escritos com diagnósticos de encaminhamento incorretos e a reflexão deliberada reduziu esse viés. Apesar da redução do viés de confirmação, a acurácia diagnóstica dos residentes do GR foi semelhante à do GC na solução do conjunto de casos clínicos com diagnóstico de encaminhamento incorreto.

Benign metastasizing leiomyoma - a case of benign metastasis.

Leiomyomas are benign tumours of smooth muscle cells that most often affect the female genital tract, but their metastasis to extra-uterine locations represent rare, yet misunderstood phenomena. The authors present a clinical case of a 42-year-old woman, who underwent a hysterectomy 15 years ago due to myomas, admitted with multiple pulmonary nodules and abdominal mass, diagnosed by imaging tests, in the context of haemoptysis. The anatomopathological exams of the pulmonary and abdominal lesions were compatible with the diagnosis of benign metastatic leiomyoma. Benign metastatic leiomyoma is a rare condition that particularly affects women of childbearing age, with a history of hysterectomy for uterine fibroids. Hence, this entity must be considered in the differential diagnosis of women with pulmonary nodules of uncertain aetiology.

Nano-structured myelin: new nanovesicles for targeted delivery to white matter and microglia, from brain-to-brain.

Neurodegenerative diseases affect millions of people worldwide and the presence of various physiological barriers limits the accessibility to the brain and reduces the efficacy of various therapies. Moreover, new carriers having targeting properties to specific brain regions and cells are needed in order to improve therapies for the brain disorder treatment. In this study, for the first time, Myelin nanoVesicles (hereafter defined MyVes) from brain-extracted myelin were produced. The MyVes have an average diameter of 100-150 â€‹nm, negative zeta potential, spheroidal morphology, and contain lipids and the key proteins of the myelin sheath. Furthermore, they exhibit good cytocompatibility. The MyVes were able to target the white matter and interact mainly with the microglia cells. The preliminary results here presented allow us to suppose the employment of MyVes as potential carrier to target the white matter and microglia in order to counteract white matter microglia-related diseases.

Heart Dissemination: A Clinical Case of Melanoma.

Introduction. Primitive malignant heart tumours are rare, specific cases. The presence of cardiac metastases, often in the pericardium, besides indicating disseminated oncological disease, represents a diagnostic challenge since they tend to be asymptomatic. Malignant cutaneous melanoma (MCM) is the neoplasm that most often affects the heart. Patients and Methods. The authors describe a case report of a 59-year-old female patient with a history of non-insulin-treated diabetes mellitus, arterial hypertension, dyslipidemia, and remitting cutaneous malignant melanoma who underwent skin excision, lymphadenectomy, and adjuvant chemotherapy in 1996. In April 2014, she resorted to emergency service due to epigastric pain and progressive tiredness. Due to the persistence of the complaints, abdominal ultrasound was performed, which showed a large pericardial effusion, corroborated later by teleradiography and echocardiography. The patient underwent pericardiocentesis, which isolated neoplastic cells. A computed tomography study of the chest, abdomen, and pelvis revealed bilateral and pericardial pleural effusion, as well as alterations suggestive of pericardial and pulmonary metastasis. Later, fine-needle aspiration puncture of the left posterior cervical nodule confirmed histologically malignant melanoma metastasis. Discussion. Given the natural history of melanoma that when metastasized has an overall survival of 15-20% for 5 years, its metastatic spread may occur several years after its surgical excision. Thus, patients with a history of melanoma and heart failure who develop new cardiac symptoms of unknown aetiology should undergo imaging studies such as echocardiography, computed tomography, and magnetic resonance imaging.

Teachers' Knowledge and Stigmatizing Attitudes Associated With Obsessive-Compulsive Disorder: Effectiveness of a Brief Educational Intervention.

Because children and adolescents are vulnerable to developing obsessive-compulsive disorder (OCD), classroom teachers play an important role in the early identification and intervention in students with OCD. The present study aims to explore the recognition of OCD, general knowledge about this disorder, implications in the classroom, and stigmatizing attitudes among teachers, as well as the effectiveness of a brief educational intervention about OCD. Participants (n = 95; mean age = 43. 29 years old; 64.3% female) were primary and secondary school teachers who were randomly assigned to an experimental group or a control group. All of them completed a set of self-report questionnaires, read an educational fact sheet (either about OCD in the experimental group or about a healthy diet in the control group), and again completed the questionnaires. Results show that prior to the intervention, most of the teachers identified the contamination and order OCD symptoms described in a vignette as specific to OCD (82.1%) and would recommend talking about the problem (98.9%) and seeking help (94.7%). However, only a few (36.8%) knew about the most effective OCD treatments or identified compulsions as a main OCD symptom (33%). Moreover, only about half of the teachers correctly identified OCD's possible interference in classroom routines, such as delays to achieve perfection or concentration problems, and strategies for dealing with OCD, such as continuing with the class rhythm. Stigma levels were from low to moderate. After the brief educational intervention, participants in the experimental group increased their knowledge about OCD, improved their strategies for managing a student with OCD symptoms, and had fewer stigmatizing attitudes associated with pity (p < 0.05). These changes were not observed in the control group. We can conclude that this brief and easy-to-administer intervention is an effective educational intervention to significantly improve teachers' knowledge and attitudes, at least in the short-term. These results are especially relevant because OCD is associated with high interference and long delays in seeking treatment, and teachers have a unique opportunity to help with prevention, early identification, and recommending an adequate intervention for OCD.

Acute Iatrogenic Agranulocytosis: A Rare and Dire Case of an Adverse Drug Reaction to Be Aware.

BACKGROUND: Iatrogenic agranulocytosis (IA), by nonchemotherapeutic drugs, is a rare adverse event, resulting in a neutrophil count under 0.5 × 109 cells/L with fever or other suggestive signs of infection. METHODS: This paper discusses the possible mechanisms responsible for agranulocytosis induced by nonchemotherapeutic drugs. It also describes three cases as well as potential ways to handle such iatrogenic situations. CONCLUSION: Neutropenia under 0.1 × 109 cells/L predispose patients to potentially fatal infections. Empiric broad-spectrum antibiotic and hematopoietic growth factors may be helpful in shortening hospitalization and prevent further infectious complications. Not all drugs associated with IA require frequent hematological monitoring, except medications such as clozapine, ticlopidine, and antithyroids.

Uso da reflexão deliberada como estratégia para reduzir o viés de confirmação diagnóstica em residentes de ortopedia / Use of deliberate deep thinking as a strategy to reduce diagnostic validation bias in orthopedic residents

Introdução: O raciocínio clínico, assim como outros processos de tomada de decisão, parece estar sujeito a vieses cognitivos, dentre os quais se destaca o viés de confirmação. Estratégias que estimulam a reflexão sobre a tomada de decisão de maneira estruturada podem auxiliar na redução desses vieses e sua utilização na resolução de casos de trauma em ortopedia precisa ser avaliada. Objetivos: Verificar se a reflexão deliberada reduz o viés de confirmação e aumenta a acurácia diagnóstica entre residentes de ortopedia na resolução de casos clínicos escritos. Métodos: Estudo experimental comparando a acurácia diagnóstica na resolução de oito casos clínicos entre um grupo que utilizou a reflexão deliberada (GR) e um grupo controle, que refletiu de maneira livre (GC). Para induzir viés de confirmação, em todos os casos, foi mencionado um diagnóstico de encaminhamento, sendo que, para a metade dos casos, esse diagnóstico estava correto e para a outra metade, incorreto. Resultados: Participaram do estudo 55 residentes do terceiro ano de ortopedia, sendo 27 alocados no GR e 28 no GC. Em relação à acurácia diagnóstica, o GR apresentou escores maiores que os encontrados no GC, nos casos clínicos em que o encaminhamento apresentava o diagnóstico correto (62,0 ± 20,1 vs. 49,1 ± 21,0 respectivamente; p=0,021). Nos casos com diagnóstico de encaminhamento incorreto, a acurácia diagnóstica foi semelhante entre os residentes do GR e aqueles do GC (39,8 ± 24,3 vs. 44,6 ± 26,7 respectivamente; p=0,662). Analisando a resposta de ambos os grupos em relação aos casos que continham diagnóstico de encaminhamento incorreto, observou-se a ocorrência de viés de confirmação em 26% dos diagnósticos fornecidos inicialmente e em 19,5% dos diagnósticos finais. Os residentes do GR apresentaram uma redução de confirmação do diagnóstico incorreto de encaminhamento, comparando o diagnóstico dado de maneira não analítica com o diagnóstico final, fornecido após a reflexão deliberada (25,9 ± 17,7 vs. 17,6 ±18,1, respectivamente; Cohen d: 0,46; p=0,003). No GC, a redução na confirmação do diagnóstico incorreto, comparando o diagnóstico não analítico com o fornecido após a reflexão livre, não foi estatisticamente significativo. Conclusão: O GR apresentou maior acurácia diagnóstica do que o GC, na resolução de casos com encaminhamento correto. Verificou-se a presença do viés de confirmação nos casos clínicos com encaminhamentos incorretos e a reflexão deliberada contribuiu para reduzir esse viés. Apesar da redução do viés de confirmação, a acurácia diagnóstica dos residentes do GR foi semelhante à do GC, na resolução desse conjunto de casos.

Introduction: Clinical reason as well as other decision-making processes seems to be subject to cognitive bias, among which validation bias stands out. Strategies, which stimulate deep thinking on decision-making in a structured manner, can help to reduce these biases and their use in orthopaedic trauma resolution cases need deeper evaluation. Objectives: To verify whether deliberate deep thinking reduces validation bias and increases diagnostic accuracy among orthopaedic residents in resolution of written clinical cases. Methods: An experimental study comparing diagnostic accuracy in resolution of eight clinical cases among a group that used deliberate deep thinking (GR) and a control group that reflected freely (GC). To induce validation bias, in all cases a referral diagnosis was mentioned, and for half of the cases this diagnosis was correct and for the other half, incorrect. Results: 55 third year orthopaedic residents participated in the study, 27 of whom were assigned to GR and 28 to GC. Regarding diagnostic accuracy, GR has shown higher scores than those encountered in GC, in clinical cases where the referral presented the correct diagnosis (62.0 ± 20.1 vs. 49.1 ± 21.0 respectively; p=0.021). In cases with incorrect referral diagnosis, the diagnostic accuracy was similar amongst residents of GR and those of GC (39.8 ± 24.3 vs. 44.6 ± 26.7 respectively; p=0.662). By the response analysis in both groups concerning cases containing incorrect referral diagnosis, a validation bias was observed in 26% of the initially provided diagnoses and 19.5% on final diagnoses. GR residents showed a reduction of validation of incorrect referral diagnosis, comparing the diagnosis given in a non-analytical manner with the final diagnosis, provided after deliberate deep thinking (25.9 ± 17.7 vs. 17.6 ±18.1, respectively; Cohen d: 0.46; p=0.003). In GC, the diagnosis incorrect validation reduction compared with the non-analytical diagnosis provided after free deep thinking was not statistically significant. Conclusion: GR showed greater diagnostic accuracy than GC in correct referral cases resolution. Validation bias presence was verified in clinical cases with incorrect referrals, and deliberate deep thinking contributed to reducing this bias. Despite the reduction of validation bias, the diagnostic accuracy of the GR residents was similar to that of the GC in resolution of this set of cases

Forecast UTI: application for predicting intensive care unit beds in the context of the COVID-19 pandemic. / Forecast UTI: aplicativo para previsão de leitos de unidades de terapia intensiva no contexto da pandemia de COVID-19.

In view of the need to manage and forecast the number of Intensive Care Unit (ICU) beds for critically ill COVID-19 patients, the Forecast UTI open access application was developed to enable hospital indicator monitoring based on past health data and the temporal dynamics of the Coronavirus epidemic. Forecast UTI also enables short-term forecasts of the number of beds occupied daily by COVID-19 patients and possible care scenarios to be established. This article presents the functions, mode of access and examples of uses of Forecast UTI, a computational tool intended to assist managers of public and private hospitals within the Brazilian National Health System by supporting quick, strategic and efficient decision-making.

Frente à necessidade de gerenciamento e previsão do número de leitos de unidades de terapia intensiva (UTIs) para pacientes graves de COVID-19, foi desenvolvido o Forecast UTI, um aplicativo de livre acesso, que permite o monitoramento de indicadores hospitalares com base em dados históricos do serviço de saúde e na dinâmica temporal da epidemia por coronavírus. O Forecast UTI também possibilita realizar previsões de curto prazo do número de leitos ocupados pela doença diariamente, e estabelecer possíveis cenários de atendimento. Este artigo apresenta as funções, modo de acesso e exemplos de uso do Forecast UTI, uma ferramenta computacional destinada a auxiliar gestores de hospitais da rede pública e privada do Sistema Único de Saúde (SUS) no subsídio à tomada de decisão, de forma rápida, estratégica e eficiente.

En vista de la necesidad de administrar y prever el número de camas en la Unidad de Cuidados Intensivos para pacientes graves de COVID-19, se desarrolló Forecast UTI: una aplicación de acceso abierto que permite el monitoreo de indicadores hospitalarios basados en datos históricos del servicio salud y la dinámica temporal de esta epidemia por coronavirus También es posible hacer pronósticos a corto plazo del número de camas ocupadas diariamente por la enfermedad y establecer posibles escenarios de atención. Este artículo presenta las funciones, el modo de acceso y ejemplos de uso de Forecast UTI, una herramienta computacional capaz de ayudar a los gestores de hospitales públicos y privados en el Sistema Único de Salud, ya que apoyan la toma de decisiones de manera rápida, estratégica y eficiente.

A mathematical model for the coverage location problem with overlap control.

The Coverage Location Problem (CLP) seeks the best locations for service to minimize the total number of facilities required to meet all demands. This paper studies a new variation of this problem, called the Coverage Location Problem with Overlap Control (CLPOC). This problem models real contexts related to overloaded attendance systems, which require coverage zones with overlaps. Thus, each demand must be covered by a certain number of additional facilities to ensure that demands will be met even when the designated facility is unable to due to some facility issue. This feature is important in public and emergency services. We observe that this number of additional facilities is excessive in some demand points because overlaps among coverage zones occur naturally in CLP. The goal of the CLPOC is to control overlaps to prioritize regions with a high density population or to minimize the number of coverage zones for each demand point. In this paper, we propose a new mathematical model for the CLPOC that controls the overlap between coverage zones. We used a commercial solver to find the optimal solutions for available instances in the literature. The computational tests show that the proposed mathematical model found appropriate solutions in terms of number of demand points with minimum coverage zones and sufficient coverage zones for high demand points.

Forecast UTI: application for predicting Intensive Care Units beds in the context of the covid-19 pandemic / Forecast UTI: aplicación para pronosticar lechos de Unidades de Cuidados Intensivos en el contexto de la pandemia de covid-19 / Forecast UTI: aplicativo para previsão de leitos de unidades de terapia intensiva no contexto da pandemia de covid-19

In view of the need to manage and forecast the number of beds in the Intensive Care Units for critically ill patients in Covid-19, the Forecast UTI was developed: an open access application that allows the monitoring of hospital indicators based on historical data from the service health and the temporal dynamics of the epidemic. It is also possible to make short-term forecasts of the number of beds occupied daily by the disease and to establish possible care scenarios. This article presents the functions, mode of access and examples of use of Forecast UTI, a computational tool capable of assisting managers of public and private hospitals in the Unified Health System, since they support decision-making quickly, strategically and efficiently.

Frente à necessidade de gerenciamento e previsão do número de leitos de unidades de terapia intensiva (UTI) para pacientes graves de covid-19, foi desenvolvido o Forecast UTI, um aplicativo de livre acesso e que permite o monitoramento de indicadores hospitalares com base em dados históricos do serviço de saúde e na dinâmica temporal dessa epidemia por coronavírus. O Forecast UTI também possibilita realizar previsões de curto prazo sobre número de leitos ocupados pela doença diariamente, e estabelecer possíveis cenários de atendimento. Este artigo apresenta as funções, modo de acesso e exemplos de uso do Forecast UTI, uma ferramenta computacional destinada a auxiliar gestores de hospitais da rede pública e privada do Sistema Único de Saúde no subsídio à tomada de decisão, de forma rápida, estratégica e eficiente. 

Kikuchi-Fujimoto Syndrome: A Rare Entity to Consider.

INTRODUCTION: Kikuchi-Fujimoto disease (KFD) is a rare, benign, necrotizing lymphadenitis of unknown aetiology with good prognosis. It is characterized by cervical lymphadenopathy, nocturnal diaphoresis and fever. Surgical excision of the adenopathy, histopathological study and immunophenotyping are crucial for diagnosis. PATIENTS AND METHODS: This paper describes five patients with three different histological subtypes of KFD, including an atypical presentation masquerading as pyelonephritis and two other cases where physicians mistakenly started chemotherapy. In one other case cytomegalovirus was identified as the responsible aetiological agent, while in the remaining patient, KFD evolved into an autoimmune condition. DISCUSSION: KFD, although rare, may mimic infectious, autoimmune and neoplastic diseases. It also poses a risk for the subsequent development of an autoimmune disorder. LEARNING POINTS: Kikuchi-Fujimoto disease (KFD), although rare, should be included in the differential diagnosis of patients with cervical lymphadenopathy and fever of unknown origin.Early recognition of KFD may minimize the use of unnecessary aggressive examinations and therapies.The course of KFD in most patients is self-limiting, but there is a risk of progression to an autoimmune syndrome.

Studies in the mentality of literates: 2. Conceptual structure, cognitive inhibition and verbal regulation of behavior.

We studied cognitive inhibitory processes and verbal regulation of behavior of individuals with different levels of education (including adult illiterates) in Brazil (N = 136) and in Estonia (N = 560) with person-oriented methods of data analysis. Our aim was to discover whether dominant type of word meaning structure (WMS) can define the "Great Divide", the single breaking point that universally defines certain direction of subsequent to it cultural evolution. We found that both cognitive inhibition of irrelevant for the task at hand information or actions as well as correct activation of relevant information or actions is significantly more common in individuals who rely predominantly on logical concepts in their thinking. The higher level of education was also associated with more efficient cognitive inhibition and activation. The patterns of test performance also suggest that there can be a qualitative difference in the efficiency of cognitive inhibition-activation processes between everyday conceptual and logical conceptual thinkers. The former group of individuals may achieve much higher performance levels than any individual in the former group. We also discuss cognitive similarities and differences between adults with low or no formal education on the one hand and children and educated adults with brain damage on the other. The results are in agreement with the theory of unilineal hierarchic cultural evolution. Individual psychic development and cultural evolution can be both understood in terms of the WMS development.

Studies in the Mentality of Literates: 1. Conceptual Structure and Aspects of Visual Perception.

We studied visual-perceptual abilities of individuals with different levels of education (including adult illiterates) in Brazil (N = 136) and in Estonia (N = 560) with person-oriented methods of data analysis. Our aim was to discover whether dominant type of word meaning structure (WMS) can define the "Great Divide", the single breaking point that universally defines certain direction of subsequent to it cultural evolution. We particularly focused on the everyday concept-logical concept shift that takes place in the formal education system. We found that logical concepts were rarely available for illiterates; availability of logical conceptual thought increases together with the level of education. Most illiterates were able to find figures of concrete objects from complex overlapping and embedded contour figures but none of them could find all abstract figures from the same complex figures. Also none of the illiterates could perform beyond chance level in both mental rotation tasks together. Ability to perform correctly on all visual-spatial tasks increased with the increase in logical concepts and with the increasing level of education. The distribution of respondents according to the WMS level, level of education, and performance on the visual-spatial tasks indicated that individuals are developmentally heterogeneous: achievement of the tertiary level of education and logical conceptual thinking mechanisms does not guarantee high level performance on the visual-spatial tasks. The results are in agreement with the theory of unilineal hierarchic cultural evolution. Individual psychic development and cultural evolution can be both understood in terms of the WMS development.