Exploring men's health in medium and high complexity care in Brazil: A deductive thematic analysis of social determinants.

Background: Men's health is influenced by a complex interplay of social, economic, and cultural determinants. Understanding how these aspects affect the health of adult cisgender men in medium and high-complexity healthcare settings is essential for improving healthcare services and promoting better health outcomes. Objective: This study aimed to analyze the health status of adult cisgender men in medium and high-complexity healthcare settings based on social determinants and conditioners. Methods: This study employed a qualitative design involving 45 adult cisgender men receiving care in medium/high complexity services in Bahia, Brazil. Semi-structured interviews were conducted from July 2019 to February 2020, and data were interpreted based on Dahlgren and Whitehead's Model of Social Determinants of Health using deductive thematic analysis. Results: Proximal determinants included biological aspects, preventive behaviors, lifestyle/social life, and aging processes. Intermediate factors included work conditions, access/utilization of healthcare services/medications, and psychosocial factors. Macro determinants involved income distribution, power dynamics, resource allocation, health inequalities/iniquities, morbidity, culture, political decisions, environmental factors, and structural elements. Conclusion: The health status of men in medium/high complexity care was profoundly influenced by structural social determinants. These determinants impacted healthcare attention, service organization, cultural influences, the reproduction of hegemonic masculinity patterns, lifestyle, social support, and socioeconomic conditions necessary to realize the right to health. Nursing practices should conduct comprehensive assessments that extend beyond physical health indicators.

Biomechanical analysis of total arch maxillary distalization using infrazygomatic crest miniscrews: a finite element analysis study.

AIM: To evaluate the maxillary incisors and canine's immediate movement tendency using three different power arms (PA) height levels during total arch maxillary distalization supported on infrazygomatic crest (IZC) miniscrews according to finite element analysis (FEA). METHODS: Three finite element models of the maxilla were developed based on CBCT imaging of a teenage male patient presenting a Class II Division 1 malocclusion in the early permanent dentition. Maxillary complex, periodontium, orthodontic accessories, IZC miniscrews and an orthodontic wire were digitally created. The PAs were placed between canines and lateral incisors and projected at 4, 7, and 10 mm height distances. After that, distalization forces were simulated between PA and IZC miniscrews. RESULTS: The anterior teeth deformation produced in the FEA models was assessed according to a Von Mises equivalent. The stress was measured, revealing tendencies of initial maxillary teeth movement. No differences were found between the right and left sides. However, there was a significant difference among models in the under-stress areas, especially the apical and cervical root areas of the maxillary anterior teeth. More significant extrusion and lingual tipping of incisors were observed with the 4 mm power arm compared to the 7 mm and 10 mm ones. The 10 mm power arm did not show any tendency for extrusion of maxillary central incisors but a tendency for buccal tipping and intrusion of lateral incisors. CONCLUSION: The maxillary incisors and canines have different immediate movement tendencies according to the height of the anterior point of the en-masse distalization force application. Based on the PA height increase, a change from lingual to buccal tipping and less extrusion tendency was observed for the incisors, while the lingual tipping and extrusion trend for canines increased.

Metabolic syndrome traits exhibit genotype-by-environment interaction in relation to socioeconomic status in the Mexican American family heart study.

Background: Socioeconomic Status (SES) is a potent environmental determinant of health. To our knowledge, no assessment of genotype-environment interaction has been conducted to consider the joint effects of socioeconomic status and genetics on risk for metabolic disease. We analyzed data from the Mexican American Family Studies (MAFS) to evaluate the hypothesis that genotype-by-environment interaction (GxE) is an essential determinant of variation in risk factors for metabolic syndrome (MS). Methods: We employed a maximum likelihood estimation of the decomposition of variance components to detect GxE interaction. After excluding individuals with diabetes and individuals on medication for diabetes, hypertension, or dyslipidemia, we analyzed 12 MS risk factors: fasting glucose (FG), fasting insulin (FI), 2-h glucose (2G), 2-h insulin (2I), body mass index (BMI), waist circumference (WC), leptin (LP), high-density lipoprotein-cholesterol (HDL-C), triglycerides (TG), total serum cholesterol (TSC), systolic blood pressure (SBP), and diastolic blood pressure (DBP). Our SES variable used a combined score of Duncan's socioeconomic index and education years. Heterogeneity in the additive genetic variance across the SES continuum and a departure from unity in the genetic correlation coefficient were taken as evidence of GxE interaction. Hypothesis tests were conducted using standard likelihood ratio tests. Results: We found evidence of GxE for fasting glucose, 2-h glucose, 2-h insulin, BMI, and triglycerides. The genetic effects underlying the insulin/glucose metabolism component of MS are upregulated at the lower end of the SES spectrum. We also determined that the household variance for systolic blood pressure decreased with increasing SES. Conclusion: These results show a significant change in the GxE interaction underlying the major components of MS in response to changes in socioeconomic status. Further mRNA sequencing studies will identify genes and canonical gene pathways to support our molecular-level hypotheses.

IgG Isotypes Targeting a Recombinant Chimeric Protein of Trypanosoma cruzi in Different Clinical Presentations of Chronic Chagas Disease.

Chagas disease (CD) is caused by the protozoan Trypanosoma cruzi, which leads to a spectrum of clinical presentations that range from asymptomatic to severe cardiac involvement. The host immune response plays a pivotal role in disease progression. Ig isotypes may contribute to disease pathogenesis. Investigating these components can provide insights into the immunopathogenic mechanisms underlying CD. This cross-sectional study aims to establish a correlation between the Ig profile of individuals infected with T. cruzi with the clinical forms of chronic CD. Serum samples were collected from partner institutions in different states of Brazil. Individuals diagnosed with chronic CD were categorized based on the clinical form of the disease. The indirect ELISA method using the recombinant chimeric Molecular Biology Institute of Paraná membrane protein 8.4 as the antigen was used to determine the Ig profile, including total IgG, IgG1, IgG2, IgG3, and IgG4. Ninety-seven serum samples from patients classified as negative (NEG, n = 38), indeterminate (IND, n = 24), mild cardiac (MC, n = 20), and severe cardiac (SC, n = 15) forms were analyzed. IgG1 exhibited greater levels compared with the other isotypes, showing a significant difference between the MC and IND groups. IgG3 levels were greater in individuals from the MC group compared with the SC group. IgG1 and IgG3 isotypes can serve as biomarkers to evaluate the progression of CD because they exhibit variations across clinical groups. Additional longitudinal studies are necessary to explore the relationship between antibody kinetics and the development of tissue damage.

Current status of the biomechanics of extra-alveolar miniscrews.

Temporary skeletal anchorage devices such as miniscrews are frequently used nowadays. Compared to miniplates, miniscrews are much less expensive and technically easier to place and remove; they are popular and can be easily placed by an orthodontist. Extra-alveolar miniscrews offer benefits compared to inter-radicular miniscrews, such as reduced risk of root damage and the lack of interference with the mesiodistal tooth movement. They are particularly useful for addressing anchorage loss issues and enabling specific tooth movements such as total arch maxillary and mandibular retraction, posterior distalization, molar protraction, molar intrusion, occlusal plane control, and midline correction. The present paper discusses the current biomechanics principles related to the use of extra-alveolar miniscrews placed in the infrazygomatic and mandibular buccal shelf.

Genotype-by-socioeconomic status interaction influences heart disease risk scores and carotid artery thickness in Mexican Americans: the predominant role of education in comparison to household income and socioeconomic index.

Background: Socioeconomic status (SES) is a potent environmental determinant of health. To our knowledge, no assessment of genotype-environment interaction has been conducted to consider the joint effects of socioeconomic status and genetics on risk for cardiovascular disease (CVD). We analyzed Mexican American Family Studies (MAFS) data to evaluate the hypothesis that genotype-by-environment interaction (GxE) is an important determinant of variation in CVD risk factors. Methods: We employed a linear mixed model to investigate GxE in Mexican American extended families. We studied two proxies for CVD [Pooled Cohort Equation Risk Scores/Framingham Risk Scores (FRS/PCRS) and carotid artery intima-media thickness (CA-IMT)] in relation to socioeconomic status as determined by Duncan's Socioeconomic Index (SEI), years of education, and household income. Results: We calculated heritability for FRS/PCRS and carotid artery intima-media thickness. There was evidence of GxE due to additive genetic variance heterogeneity and genetic correlation for FRS, PCRS, and CA-IMT measures for education (environment) but not for household income or SEI. Conclusion: The genetic effects underlying CVD are dynamically modulated at the lower end of the SES spectrum. There is a significant change in the genetic architecture underlying the major components of CVD in response to changes in education.

Neutrophil extracellular traps (NETs), transfusion requirements and clinical outcomes in orthotopic liver transplantation.

Inflammatory phenomena have a direct impact on the prognosis of orthotopic liver transplantation (OLT). Neutrophil extracellular traps (NETs) contribute to OLT inflammation and hemostasis imbalance in OLT. The association between NETosis, clinical outcomes and transfusion requirements is not determined. To evaluate NETs release during OLT and the effect of NETosis ontransfusion requirements and adverse outcomes in a prospective cohort of patients submitted to OLT. We quantified citrullinated histones (cit-H3) and circulating-free-DNA (cf-DNA) in ninety-three patients submitted to OLT in three periods: pre-transplant, after graft reperfusion and before discharge. NETs markers were compared between these periods using ANOVA test. The association of NETosis and adverse outcomes was evaluated using regression models adjusted for age, sex and corrected MELD. We observed a peak of circulating NETs following reperfusion, evidenced by a 2.4-fold increase in cit-H3 levels in the post-graft reperfusion period (median levels of cit-H3 pre transplant: 0.5 ng/mL, after reperfusion: 1.2 ng/mL and at discharge 0.5 ng/mL, p < 0.0001). We observed an association between increased levels of cit-H3 and in-hospital death (OR = 1.168, 95% CI 1.021-1.336, p = 0.024). No association was found between NETs markers and transfusion requirements. There is a prompt release of NETs after reperfusion that is associated with poorer outcomes and death. Intraoperative NETs release seems to be independent of transfusion requirements. These findings highlight the relevance of inflammation promoted by NETS and its impact on OLT adverse clinical outcomes.

Um instrumento de avaliação do interno de pediatria na Atenção Primária à Saúde / An instrument for evaluation of medical students during the internship of pediatrics Primary Health Care / Un instrumento de evaluación de estudiantes de pediatría en Atención Primaria de Salud

Os estudantes de Medicina têm contato com diferentes áreas e cenários durante o internato e devem ter seu desempenho avaliado em cada um deles. Contudo, muitos estudantes não se sentem devidamente avaliados e, diante disso, nosso objetivo foi desenvolver um instrumento de avaliação do desempenho de estudantes de Medicina, no período do internato em pediatria, para uso durante o estágio realizado na Atenção Primária à Saúde. Realizou-se uma pesquisa metodológica com elaboração de um instrumento e contribuição de especialistas com experiência em ensino, por meio de convites eletrônicos. Ao final do estudo, utilizando-se a técnica Delphi, dos vinte itens constantes no instrumento original, dezessete foram aceitos pelos 11 especialistas que participaram das duas rodadas de análise. Dessa forma, a pesquisa alcançou seu objetivo e, por meio deste artigo, divulgamos a proposta de um "Instrumento de avaliação de internos de Medicina no estágio de pediatria na Atenção Primária à Saúde".

Medical students have contact with different areas and scenarios during their internship and must have their performance evaluated in each of them. However, as many students do not feel properly evaluated, our objective was to develop an instrument to evaluate the performance of Medical students, during their internship in pediatrics, to be used during their practice in Primary Health Care. A methodological research was carried out with the elaboration of an instrument and the contribution of specialists with experience in teaching, using electronic invitations. At the end of the study, through the Delphi technique, seventeen of the twenty items contained in the original instrument were accepted by the 11 specialists who participated in the two rounds of analysis. Thus, the research reached its objective and, through this article, we disseminate the proposal of an "Instrument for the evaluation of Medical interns in the pediatric internship in Primary Health Care".

Los estudiantes de Medicina tienen contacto con diferentes áreas y escenarios durante su pasantía y deben evaluar su desempeño en cada uno de ellos. Sin embargo, muchos estudiantes no se sienten debidamente evaluados y, ante eso, nuestro objetivo fue desarrollar un instrumento para evaluar la actuación de los estudiantes de Medicina, durante su pasantía en pediatría, para ser utilizado mientras ejecutan la Atención Primaria de Salud. Se realizó una investigación metodológica con la elaboración de un instrumento y el aporte de especialistas con experiencia en la docencia, a través de invitaciones electrónicas. Al final del estudio, utilizando la técnica Delphi, de los veinte ítems contenidos en el instrumento original, se aceptaron diecisiete por los 11 especialistas que participaron en las dos rondas de análisis. De esta forma, la investigación alcanzó su objetivo y, por medio de este artículo, divulgamos la propuesta de un "Instrumento para la evaluación de Médicos internos en el internado de pediatría en Atención Primaria de Salud".

Anterior Open-Bite Treatment with Lingual Spurs and Chincup: a Prospective, Randomized Digital Model Study / Tratamento da Mordida Aberta Anterior com Esporão Lingual e Mentoneira: Estudo Prospectivo Randomizado em Modelos de Estudo Digitais

Esse estudo propectivo teve como objetivo realizar a avaliação das alterações dentoalveolares em modelos digitais de pacientes cuja mordida aberta anterior foi tratada seguindo dois protocolos distintos: esporão lingual e mentoneira. A amostra foi composta por 41 pacientes (27 do sexo feminino e 14 do sexo masculino) com idades entre 7-10 anos (média de idade de 8.37 anos), dentição mista com diagnóstico de mordida aberta anterior (média de -3.43mm) e tratados ao longo de um ano. Os pacientes foram aleatoriamente dividiso em dois grupos de acordo com a terapia realizada: Grupo 1 (n=23) tratados com esporão lingual, e Grupo 2 (n=18) tratados com mentoneira pré-fabricada. Os modelos de gesso foram escaneados, gerando uma imagem tridimensionao em qual as medidas foram realizadas em 2 tempos distintos: T1 (imediatamente antes do tratamento) e T2 (um ano após o início do tratamento). Alteraçnoes transversais, comprimento e perímetro dos arcos dentários superior e inferior, trespasse horizontal e vertical, assim como inclinação dos incisivos centrais foram avaliadas. O Coeficiente de Correlação Interclasse (CCI) e o método Bland-Altman foram aplicados para verificar o erro intra examinador. Os resultados foram analisados através do Teste T pareado e independente adotando uma significância de 5%. Após um ano de tratamento, observou-se alerações estatisticamente significantes em todas as variáveis, exceto perímetro e comprimento dos arcos superio e inferior, inclinação do incisivo central superior e trespasse horizontal. As alterações enre os grupos (T2-T1) apresentaram resultados similares. Concluiu-se que ambos os protocolos apresentaram mudanças semelhantes na mordiada aberta anterior após um ano de tratamento.(AU)

Immediate skeletal effects of rapid maxillary expansion at midpalatal suture opening with Differential, Hyrax and Haas expanders.

OBJECTIVE: The aim of this study was to test the null hypothesis that there is no difference at the midpalatal suture opening after rapid maxillary expansion (RME) using Expander with Differential Opening (EDO), Hyrax-type and Haas-type expanders. METHODS: Occlusal radiographs of 52 patients (19 males and 33 females; average age= 9.46?1.20 years) treated with RME were divided into three groups, according to the expander used: EDO (n=17), Hyrax-type (n=21) and Haas-type (n=14). The evaluated variables were: A) Distance between the maxillary central incisors at the incisal edge; B) Distance between the alveolar ridges at the midpalatal suture; C) Suture opening at 10-mm distance from the crest to posterior, at the midpalatal suture; D) Suture opening at 20-mm distance from the crest to posterior, at the midpalatal suture; and E) Suture opening at 30-mm distance from the crest to posterior, at the midpalatal suture. To assess the normality of variables, the Shapiro-Wilk test was performed. For intergroup comparison, ANOVA with a significance level of 5% was used. RESULTS: At the region A, Hyrax-type (4.66 mm) and EDO (4.87 mm) groups presented larger openings than the Haas-type group (3.43 mm). In regions B and C, EDO showed a statistically significant greater opening than the Haas-type group. In region D, a smaller opening of the midpalatal suture was observed in the Haas-type group, compared to the Hyrax-type and EDO groups. CONCLUSIONS: EDO and Hyrax-type produced greater immediate skeletal effects, compared with Haas-type, but these differences were about 1 mm and might not be clinically significant.

Influence of anxiety and catastrophizing on pain perception in orthodontic treatment and its association with inflammatory cytokines.

Pain is common in orthodontic treatment, is subject to individual variation, and is associated with anxiety and stress, which can potentially become catastrophizing. The aim of the present study was to determine the variability of pain response after the insertion of orthodontic separators and to assess the association of pain levels with dental anxiety, catastrophizing, tooth sensitivity, and genetic expression of cytokines. To this end, 70 patients of both genders were divided into two equal groups according to the elastomeric separator used: G1 (Dentaurum) and G2 (Orthometric). Two separators were inserted in the mesial and distal sides of the lower right first molar. Participants were instructed to rate the level of pain at T0 (before insertion), T1 (just after insertion), and T2 (24 hours after insertion) on a visual analog scale. The gingival crevicular fluid was collected at T0 and T2. The levels of anxiety, catastrophizing, tooth sensitivity, and cytokine expression were also assessed. Statistical analysis was performed with the Fisher-Freeman-Halton, chi-squared, Spearman's correlation, and dependent and independent t tests (α=5%). Pain intensity was higher at T2 than at T1, in both groups (P<.05). An association was established (P<.05) between pain intensity at T1 and catastrophizing, and at T2 with anxiety and catastrophizing. Within-group differences in cytokine expression were found between T0 and T2. There was no correlation between cytokine expression and pain levels, anxiety, catastrophizing, and sensitivity at T2. Tooth separation produced variable pain levels, which were influenced by anxiety and catastrophizing, however, pain level was not correlated with increased cytokine expression.

Total arch maxillary distalization using infrazygomatic crest miniscrews in the treatment of Class II malocclusion: a prospective study.

OBJECTIVES: To evaluate treatment effects in Class II patients using infrazygomatic crest (IZC) miniscrews (MS). MATERIALS AND METHODS: A prospective sample of 25 adolescents (14 females and 11 males; mean age: 13.6 ± 1.5 years) who underwent maxillary dentition distalization treatment with IZC MSs were recruited. Lateral cephalograms and digital models at the beginning of treatment (T1) and after Class II molar correction (T2) were obtained. To compare cephalometric and digital model changes, paired t-test and Wilcoxon test were used. A significance level of 5% was used. RESULTS: All patients achieved Class II molar correction over a mean period of 7.7 ± 2.5 months. The IZC MS therapy provided 4 mm of distalization; there was 1.2 mm of intrusion of the first molar with 11.2° distal tipping. The maxillary incisors were retracted 4.7 mm and tipped lingually 13.4°. Overjet and overbite showed a reduction of 3.6 mm and 2.4 mm, respectively. The occlusal plane rotated clockwise 2.8°. The upper lip was retracted by 1 mm and the nasolabial angle increased 5.1°. There was an increase in the interpremolar and intermolar distances. CONCLUSIONS: Total arch distalization of the maxillary dentition using IZC MS was effective in the treatment of Class II malocclusions.

Dental arch changes comparison between Expander with Differential Opening, Hyrax-type and Haas-type expanders: A prospective clinical study.

OBJECTIVE: Compare changes in arch form after RME achieved by Expander with Differential Opening (EDO), Hyrax-type and Haas-type expanders. MATERIALS AND METHODS: Dental models were obtained from 61 patients aged 7-11 years before expansion (T1) and 6 months after the active phase when the appliances were removed (T2). The groups were formed according to the expander used: EDO (n = 18, mean age: 9.46 ± 0.82 years), Hyrax-type (n = 22, mean age: 9.62 ± 1.57 years) and Haas-type (n = 21, mean age: 9.29 ± 1.05 years). The expander`s activation protocol consisted of 7 mm, except for EDO`s anterior screw, which was 9 mm. The measurements of upper and lower intercanine distance, inter-first permanent molar, arch perimeter and length, maxillary canine and first-permanent molar inclination, and palatal depth were performed using the OrthoAnalyzer 3D software. Intergroup comparisons of T1 and between changes (T2-T1) were performed using ANOVA followed by Tukey. RESULTS: In the upper intercanine distance EDO provided a greater increase than Haas-type. In the distance between upper fist permanent molars EDO showed higher values than Haas-type and Hyrax-type. In the lower intercanine distance and maxillary arch length, Haas-type promoted higher increase than EDO. CONCLUSIONS: The EDO promoted greater transverse changes in anterior region than Haas-type and greater transverse changes in posterior region of the maxilla than both conventional expanders. The appliance used for RME influences dental arch changes after treatment; therefore, it is recommended to individualize the choice of expander depending on the clinical necessity of each case.

Diretivas antecipadas de vontade na percepção de estudantes de Medicina / Advance directives in the perception of Medical students

Resumo: Introdução: A autonomia do paciente na tomada de decisões a respeito da sua vida e das condutas diagnósticas e terapêuticas na sua saúde tem sido objeto de valorização social crescente. As diretivas antecipadas de vontade surgem, então, como um meio de o paciente expressar sua última vontade, salvaguardando o princípio da autonomia. No processo de aprendizagem acadêmica, na maioria das escolas médicas, o acadêmico se compromete com a vida, e toda a sua capacitação é fundamentada em aspectos técnicos, e apenas uma pequena parte do currículo, quando presente, abrange conteúdo específico voltado para a terminalidade da vida. A medicina evoluiu com importantes avanços tecnológicos que resultaram em melhorias na qualidade de vida, porém também trouxeram um prolongamento questionável da vida, com tratamentos muitas vezes injustificáveis e com a obstinação terapêutica de manter a vida a qualquer custo. Objetivo: Este estudo teve como objetivo analisar a percepção de estudantes de Medicina sobre as diretivas antecipadas de vontade. Método: O instrumento de pesquisa foi elaborado com uma entrevista individual e semiestruturada, aplicada pela plataforma de pesquisa Google Forms. Por causa do período de pandemia pelo Sars-CoV-2, a pesquisa foi realizada de forma não presencial em conformidade com a legislação vigente nacional. Após fechamento da amostra por exaustão, analisaram-se as respostas de 13 estudantes. Resultado: Em conformidade aos elementos, passos e critérios metodológicos, as informações obtidas foram classificadas e dispostas em duas categorias: dignidade da pessoa humana e autonomia do paciente; e conhecimento sobre diretivas antecipadas de vontade. Conclusão: Essa análise qualitativa trouxe à tona importantes temas, como a regulamentação que norteia as diretivas antecipadas de vontade e os princípios que envolvem a bioética, a fim de consolidar o respeito, a autonomia e a dignidade do paciente que está, ou estará, passando pela terminalidade da vida.

Abstract: Introduction: The patient's autonomy in making decisions about their life and about diagnostic and therapeutic approaches related to their health has been the object of growing social value. Then advanced directives appear to express the patient's last will, safeguarding the Principle of Autonomy. During the undergraduate learning process, students are committed to life, and all of their training is based on technical aspects. Only a small part of the curriculum covers specific contents focused on terminal illness, when present. Medicine has evolved with important technological advances that resulted in quality-of-life improvement, but also brought a questionable extension of life, with often unjustifiable treatments and a therapeutic obstinacy to maintain life at any cost. Objective: The aim of this study is to analyze the perception of medical students about end-of-life directives. Method: A descriptive qualitative research was carried out through an individual and semi-structured interview, applied through Google forms. Due to the period of pandemic caused by the SARS-CoV-2, the survey was carried out remotely, in accordance with current national legislation. After the target was attained through sample exhaustion, the responses of 13 students were analyzed. Results: In accordance with the elements, steps and methodological criteria, the obtained information was classified and arranged into two categories: Human Dignity and Patient Autonomy; Knowledge of Advance Will Directives. Conclusion: This qualitative analysis brought to light important topics such as the regulation that guides advance will directives and principles that involve bioethics, to consolidate the respect, autonomy and dignity of the patient who is, or will be, undergoing the terminality of life.

Os cuidados paliativos na visão de internos de um curso de medicina: estudo transversal / Palliative care from the perspective of internal medicine students: a cross-cross study / Cuidados paliativos desde la perspectiva de estudiantes de medicina: un estudio transversal

Este estudo teve por objetivo verificar o conhecimento de estudantes de medicina sobre cuidados paliativos em saúde durante a sua formação. Método: Estudo transversal com 58 participantes dentre um universo de 200 internos de medicina dos quatro últimos períodos da graduação (internato médico) de uma instituição de ensino superior brasileira privada sem fins lucrativos, que tem um currículo integrado com o uso intensivo de metodologias ativas de ensino-aprendizagem. Foi utilizado um questionário, enviado por meio eletrônico e que foi baseado no instrumento americano "Physician's End-of-Life Care Attitude Scale". A coleta de dados ocorreu no terceiro trimestre de 2020 e os dados foram analisados por meio da estatística descritiva simples. Resultados: Participaram 58 estudantes, entre 20 e 34 anos, sendo 72% mulheres. Apenas 15,5% se consideraram competentes em dar notícias ruins. Quanto ao manejo clínico, 65,5% necessitaram maior supervisão ou instrução básica na dispneia terminal. Na decisão de retirada do suporte ventilatório de um paciente incapaz de decidir por si, 74,1% se preocuparam com questões legais e profissionais e 77,6% com questões éticas. Em relação ao pensamento sobre a morte do paciente, 67,2% se manifestaram ansiosos ou desconfortáveis. 80% dos estudantes classificaram como importante ou muito importante abordar a temática dos cuidados paliativos durante o internato. Conclusão: Os estudantes expressaram graus variados de conhecimento acerca do tema. Manifestaram maior segurança no manejo dos principais sintomas clínicos. Observou-se que o tema morte provoca certo grau de angústia e desconforto nos estudantes, que consideram necessário o conhecimento sobre cuidados paliativos.

This study aimed to verify the knowledge of medical students about palliative health care during their training. Method: Cross-sectional study with 200 medical students from the last four periods of graduation (medical internship) at a private, non-profit Brazilian higher education institution, which has an integrated curriculum with the intensive use of active teaching-learning methodologies. A questionnaire was used, sent electronically and based on the American instrument "Physician's End-of-Life Care Attitude Scale". Data collection took place in the third quarter of 2020 and the data were analyzed using simple descriptive statistics. Results: 58 students, aged between 20 and 34 years old, 72% of whom were women. in terminal dyspnea. In the decision to withdraw ventilatory support from a patient unable to decide for himself, 74.1% were concerned with legal and professional issues and 77.6% with ethical issues. Regarding the thought about the patient's death, 67.2% expressed anxiety or discomfort. 80% of the students classified it as important or very important to address the topic of palliative care during the internship. Conclusion: The students expressed varying degrees of knowledge about the topic. They showed greater confidence in the management of the main clinical symptoms. It was observed that the theme of death causes a certain degree of anguish and discomfort in students.

Este estudio tuvo como objetivo verificar el conocimiento de los estudiantes de medicina sobre los cuidados paliativos en salud durante su formación. Método: Estudio transversal con 200 estudiantes de medicina de los últimos cuatro períodos de graduación (internado médico) en una institución de educación superior brasileña privada, sin fines de lucro, que tiene un plan de estudios integrado con el uso intensivo de metodologías activas de enseñanza-aprendizaje. Se utilizó un cuestionario, enviado electrónicamente y basado en el instrumento estadounidense "Physician's End-of-Life Care Attitude Scale". La recolección de datos se realizó en el tercer trimestre de 2020 y los datos se analizaron mediante estadística descriptiva simple. Resultados: 58 estudiantes, con edades entre 20 y 34 años, de los cuales el 72% eran mujeres. En la decisión de retirar el soporte ventilatorio a un paciente incapaz de decidir por sí mismo, el 74,1% se preocupó por cuestiones legales y profesionales y El 77,6% con problemas éticos. En cuanto al pensamiento sobre la muerte del paciente, el 67,2% manifestó ansiedad o malestar. El 80% de los estudiantes calificaron como importante o muy importante abordar el tema de cuidados paliativos durante la pasantía. Conclusión: Los estudiantes expresaron diversos grados de conocimiento sobre el tema. Mostraron mayor confianza en el manejo de los principales síntomas clínicos. Se observó que el tema de la muerte provoca cierto grado de angustia y malestar en los estudiantes.

Influence of anxiety and catastrophizing on pain perception in orthodontic treatment and its association with inflammatory cytokines

Abstract Pain is common in orthodontic treatment, is subject to individual variation, and is associated with anxiety and stress, which can potentially become catastrophizing. The aim of the present study was to determine the variability of pain response after the insertion of orthodontic separators and to assess the association of pain levels with dental anxiety, catastrophizing, tooth sensitivity, and genetic expression of cytokines. To this end, 70 patients of both genders were divided into two equal groups according to the elastomeric separator used: G1 (Dentaurum) and G2 (Orthometric). Two separators were inserted in the mesial and distal sides of the lower right first molar. Participants were instructed to rate the level of pain at T0 (before insertion), T1 (just after insertion), and T2 (24 hours after insertion) on a visual analog scale. The gingival crevicular fluid was collected at T0 and T2. The levels of anxiety, catastrophizing, tooth sensitivity, and cytokine expression were also assessed. Statistical analysis was performed with the Fisher-Freeman-Halton, chi-squared, Spearman's correlation, and dependent and independent t tests (α=5%). Pain intensity was higher at T2 than at T1, in both groups (P<.05). An association was established (P<.05) between pain intensity at T1 and catastrophizing, and at T2 with anxiety and catastrophizing. Within-group differences in cytokine expression were found between T0 and T2. There was no correlation between cytokine expression and pain levels, anxiety, catastrophizing, and sensitivity at T2. Tooth separation produced variable pain levels, which were influenced by anxiety and catastrophizing, however, pain level was not correlated with increased cytokine expression.

Por que e como reformar um currículo inovador? Um relato de experiência de Londrina / Why and how to reform an innovative curriculum? An experience report from Londrina

Resumo: Introdução: O curso de graduação em Medicina da Universidade Estadual de Londrina foi o segundo do Brasil a adotar currículo integrado e Aprendizagem Baseada em Problemas (PBL). Apesar de seu currículo inovador ter servido de referência a outras escolas, avaliações recentes mostraram a necessidade de reforma. Relato de experiência: As avaliações sistemáticas do curso indicaram os seguintes problemas: dificuldade de adaptação dos ingressantes à primeira série; desorganização da sequência de conteúdos ao longo do curso; falta de motivação docente para as atividades da primeira à quarta série; necessidade de incluir tópicos obrigatórios e novas tendências; e desgaste da metodologia (PBL) a partir da terceira série. Um amplo trabalho de reforma curricular foi iniciado, baseado na construção coletiva, culminando em mudanças, como: o desenho de uma primeira série mais acolhedora por meio da inclusão de nivelamento de ciências básicas e mentoria; a reorganização cronológica dos conteúdos; o redesenho dos módulos, agora organizados ao redor de grandes áreas ou especialidades afins; a adoção de metodologias ativas mais motivadoras; e a inclusão de novos conteúdos. Discussão: A adoção de novas metodologias ativas em substituição à PBL em alguns momentos apresenta vantagens estratégicas. A Aprendizagem Baseada em Equipes (TBL), mais estruturada que a PBL, pode ajudar na adaptação dos ingressantes à primeira série e facilitar a realização de metodologias ativas num contexto de escassez de docentes. A Aprendizagem Baseada em Casos (CBL) é mais motivadora e pode ser mais efetiva para desenvolver habilidades de raciocínio clínico nas séries pré-internato. Conclusão: O novo currículo, que incorpora as mudanças mencionadas, foi implantado em 2022. Novas avaliações mostrarão se as mudanças trarão melhorias ao curso em termos de adaptação, motivação e resultados de aprendizagem.

Abstract: Introduction: The undergraduate medical course of the State University of Londrina was the second in Brazil to adopt an integrated curriculum and Problem-Based Learning (PBL). Despite its innovative curriculum, which became a reference for other schools, new assessments showed the need to reform it. Experience Report: Systematic course evaluations showed some issues: difficulties in adaptation of new students attending the first year; disorganized sequence of contents throughout the course; teachers' lack of motivation for activities from first to the fourth years; need to include new contents; and deterioration of the methodology (PBL) in third and fourth years. A wide collective effort for curricular reform was initiated, which led to important changes, such as: a more welcoming first year, by including mentoring and activities for the leveling of basic knowledge; chronological reorganization of contents; redesign of modules around great areas of knowledge or related specialties; adoption of new and more motivating active learning and teaching methodologies, and the inclusion of new topics/trends. Discussion: The adoption of other active learning and teaching methodologies present strategic advantages in replacement for PBL. Team-Based Learning (TBL) is a more structured method than PBL, so it can help newcomers to adapt to the first year and make it easier to implement active methodologies in a context of teacher shortage. Case-Based Learning (CBL) generates higher motivation and can be more effective to foster the development of clinical reasoning skills in the preclinical years. Conclusion: The new curriculum, incorporating the changes described above, started in 2022. Further evaluations will show whether the changes will improve the course in terms of adaptability, motivation and learning outcomes.

Technological advances in the serological diagnosis of Chagas disease in dogs and cats: a systematic review.

BACKGROUND: Chagas disease (CD) is caused by Trypanosoma cruzi, which is transmitted mainly through the feces/urine of infected triatomine bugs. The acute phase lasts 2-3 months and is characterized by high parasitemia and nonspecific symptoms, whereas the lifelong chronic phase features symptoms affecting the heart and/or digestive tract occurring in 30-40% of infected individuals. As in humans, cardiac abnormalities are observed in T. cruzi-infected dogs and cats. We reviewed the technological advances in the serological diagnosis of CD in dogs and cats. METHODS: A review of the published literature during the last 54 years (1968-2022) on the epidemiology, clinical features, diagnosis, treatment and prevention of CD in dogs and cats was conducted. RESULTS: Using predefined eligibility criteria for a search of the published literature, we retrieved and screened 436 publications. Of these, 84 original studies were considered for inclusion in this review. Dogs and cats are considered as sentinels, potentially indicating an active T. cruzi transmission and thus the risk for human infection. Although dogs and cats are reputed to be important for maintaining the T. cruzi domestic transmission cycle, there are no commercial tests to detect past or active infections in these animals. Most published research on CD in dogs and cats have used in-house serological tests prepared with native and/or full-length recombinant antigens, resulting in variable diagnostic performance. In recent years, chimeric antigens have been used to improve the diagnosis of chronic CD in humans with encouraging results. Some of them have high performance values (> 95%) and extremely low cross-reactivity rates for Leishmania spp., especially the antigens IBMP-8.1 to IBMP-8.4. The diagnostic performance of IBMP antigens was also investigated in dogs, showing high diagnostic performance with negligible cross-reactivity with anti-Leishmania infantum antibodies. CONCLUSIONS: The development of a commercial immunodiagnostic tool to identify past or active T. cruzi infections in dogs and cats is urgently needed. The use of chimeric recombinant T. cruzi antigens may help to fill this gap and is discussed in this review.

Modelling kidney outcomes based on MELD eras - impact of MELD score in renal endpoints after liver transplantation.

BACKGROUND: Acute kidney injury is a common complication in solid organ transplants, notably liver transplantation. The MELD is a score validated to predict mortality of cirrhotic patients, which is also used for organ allocation, however the influence of this allocation criteria on AKI incidence and mortality after liver transplantation is still uncertain. METHODS: This is a retrospective single center study of a cohort of patients submitted to liver transplant in a tertiary Brazilian hospital: Jan/2002 to Dec/2013, divided in two groups, before and after MELD implementation (pre-MELD and post MELD). We evaluate the differences in AKI based on KDIGO stages and mortality rates between the two groups. RESULTS: Eight hundred seventy-four patients were included, 408 in pre-MELD and 466 in the post MELD era. The proportion of patients that developed AKI was lower in the post MELD era (p 0.04), although renal replacement therapy requirement was more frequent in this group (p < 0.01). Overall mortality rate at 28, 90 and 365 days was respectively 7%, 11% and 15%. The 1-year mortality rate was lower in the post MELD era (20% vs. 11%, p < 0.01). AKI incidence was 50% lower in the post MELD era even when adjusted for clinically relevant covariates (p < 0.01). CONCLUSION: Liver transplants performed in the post MELD era had a lower incidence of AKI, although there were more cases requiring dialysis. 1-year mortality was lower in the post MELD era, suggesting that patient care was improved during this period.

The repositioned drugs disulfiram/diethyldithiocarbamate combined to benznidazole: Searching for Chagas disease selective therapy, preventing toxicity and drug resistance.

Chagas disease (CD) affects at least 6 million people in 21 South American countries besides several thousand in other nations all over the world. It is estimated that at least 14,000 people die every year of CD. Since vaccines are not available, chemotherapy remains of pivotal relevance. About 30% of the treated patients cannot complete the therapy because of severe adverse reactions. Thus, the search for novel drugs is required. Here we tested the benznidazole (BZ) combination with the repositioned drug disulfiram (DSF) and its derivative diethyldithiocarbamate (DETC) upon Trypanosoma cruzi in vitro and in vivo. DETC-BZ combination was synergistic diminishing epimastigote proliferation and enhancing selective indexes up to over 10-fold. DETC was effective upon amastigotes of the BZ- partially resistant Y and the BZ-resistant Colombiana strains. The combination reduced proliferation even using low concentrations (e.g., 2.5 µM). Scanning electron microscopy revealed membrane discontinuities and cell body volume reduction. Transmission electron microscopy revealed remarkable enlargement of endoplasmic reticulum cisternae besides, dilated mitochondria with decreased electron density and disorganized kinetoplast DNA. At advanced stages, the cytoplasm vacuolation apparently impaired compartmentation. The fluorescent probe H2-DCFDA indicates the increased production of reactive oxygen species associated with enhanced lipid peroxidation in parasites incubated with DETC. The biochemical measurement indicates the downmodulation of thiol expression. DETC inhibited superoxide dismutase activity on parasites was more pronounced than in infected mice. In order to approach the DETC effects on intracellular infection, peritoneal macrophages were infected with Colombiana trypomastigotes. DETC addition diminished parasite numbers and the DETC-BZ combination was effective, despite the low concentrations used. In the murine infection, the combination significantly enhanced animal survival, decreasing parasitemia over BZ. Histopathology revealed that low doses of BZ-treated animals presented myocardial amastigote, not observed in combination-treated animals. The picrosirius collagen staining showed reduced myocardial fibrosis. Aminotransferase de aspartate, Aminotransferase de alanine, Creatine kinase, and urea plasma levels demonstrated that the combination was non-toxic. As DSF and DETC can reduce the toxicity of other drugs and resistance phenotypes, such a combination may be safe and effective.