Proposed public policies to improve outcomes in vascular surgery: an experts' forum

ABSTRACT Objective To evaluate outcomes of vascular surgeries and identify strategies to improve public vascular care. Methods This was a descriptive, qualitative, and cross-sectional survey involving 30 specialists of the Hospital Israelita Albert Einstein via Zoom. The outcomes of vascular procedures performed in the Public Health System extracted through Big Data analysis were discussed, and 53 potential strategies to improve public vascular care to improve public vascular care. Results There was a consensus on mandatory reporting of some key complications after complex arterial surgeries, such as stroke after carotid revascularization and amputations after lower limb revascularization. Participants agreed on the recommendation of screening for diabetic feet and infrarenal abdominal aortic aneurysms. The use of Telemedicine as a tool for patient follow-up, auditing of centers for major arterial surgeries, and the concentration of complex arterial surgeries in reference centers were also points of consensus, as well as the need to reduce the values of endovascular materials. Regarding venous surgery, it was suggested that there should be incentives for simultaneous treatment of both limbs in cases of varicose veins of the lower limbs, in addition to the promotion of ultrasound-guided foam sclerotherapy in the public system. Conclusion After discussing the data from the Brazilian Public System, proposals were defined for standardizing measures in population health care in the area of vascular surgery.

Application of telesimulation in a medical undergraduate course during the SARS-CoV-2 pandemic: a quantitative and retrospective study

ABSTRACT BACKGROUND: Because of the social isolation and distancing measures that were imposed to stop the spread of coronavirus disease 19 (COVID-19), new ways of teaching were implemented. OBJECTIVES: To describe the implementation of telesimulation and seek to assess students' perceptions regarding telesimulation. DESIGN AND SETTING: Retrospective quantitative study conducted within the hospital simulation at a private medical school in São Paulo, Brazil. METHODS: After telesimulation training, students answered a questionnaire that provided an overall assessment of this activity, self-assessment and assessments of the facilitators and infrastructure provided by the University. RESULTS: Among the students, 50% reported that the activity was below expectations and 45% reported that it was in line with their expectations. The strong points of the activity were the clinical cases, workload and teachers. The main challenge was students' difficulty in reflecting on their learning and the infrastructure. CONCLUSIONS: Since students have less experience and fewer clinical encounters than residents or professionals, they also face more difficulty. Although telesimulation may have provided a valid alternative to replace simulation training during the COVID-19 pandemic, more face-to-face activities should be offered to students, when possible.

Larvas de helmintos no solo de praças públicas de Caxias, Maranhão, Brasil / Helminth larvae in the soil of public squares in Caxias, Maranhão, Brazil / Larvas de helmintos en el suelo de plazas públicas en Caxias, Maranhão, Brasil

Solos de praças públicas são comumente contaminados por helmintos devido ao fácil acesso de cães e gatos infectados. Esses animais ao defecarem podem liberar ovos desses parasitos e, em condições ambientais favoráveis, tornam-se ovos embrionados ou larvas infectantes. O objetivo deste trabalho foi investigar a existência de larvas de helmintos no solo de duas praças públicas do município de Caxias, Maranhão, Brasil, durante a estação chuvosa e seca na região. A pesquisa foi realizada em março de 2018, considerado período chuvoso, e em outubro do mesmo ano, período seco, sendo que foram coletadas trinta amostras de areia, quinze de cada praça, nos dois períodos do ano. O material foi coletado e levado para o Laboratório de Parasitologia do Departamento de Parasitologia e Microbiologia da Universidade Federal do Piauí para análise. Na estação chuvosa, das quinze amostras analisadas na praça A, cinco foram positivas para larvas de ancilostomídeos e das quinze na praça B, três estavam contaminadas com os mesmos helmintos. No período seco, na praça A havia apenas uma amostra com essas larvas e na praça B não foram encontrados parasitos. Os resultados revelaram a presença de larvas de helmintos de caráter zoonótico no solo de praças públicas de Caxias, Maranhão, principalmente no período chuvoso, servindo de alerta à população local.(AU)

Soil in public squares is commonly contaminated by helminths due to the easy access of infected dogs and cats. These animals, when defecating, can release helminth eggs and, under favorable environmental conditions, those eggs can become embryonated or infective larvae. The purpose of this work was to investigate the existence of helminth larvae in the soil of two public squares in the city of Caxias, in the state of Maranhão, Brazil, during the rainy and dry seasons in the region. The study was carried out in March 2018, which is considered the rainy season, and in October of the same year, the dry season. A total of thirty sand samples were collected, fifteen from each square, in both periods of the year. The material was collected and taken to the Parasitology Laboratory of the Department of Parasitology and Microbiology of the Federal University of Piauí for analysis. In the rainy season, from the fifteen samples analyzed in square A, five were positive for hookworm larvae; and from the fifteen samples collected from square B, three were contaminated with the same helminths. During the dry period, only one sample from square A presented these larvae while no parasites were found in square B. The results revealed the presence of zoonotic helminth larvae in the soil of public squares in Caxias, Maranhão, mainly in the rainy season, which can be used as a warning sign to the local population.(AU)

Los suelos de las plazas públicas son comúnmente contaminados por helmintos debido al fácil acceso de perros y gatos infectados. Esos animales, al defecar, pueden liberar huevos de esos parásitos y, en condiciones ambientales favorables, convertirse en huevos embrionados o larvas infectantes. El objetivo de este trabajo fue investigar la existencia de larvas de helmintos en el suelo de dos plazas públicas de la ciudad de Caxias, Maranhão, Brasil, durante la estación lluviosa y seca de la región. La investigación se realizó en marzo de 2018, considerada época de lluvias, y en octubre del mismo año, época seca, y se recolectaron treinta muestras de arena, quince de cada plaza, en ambos períodos del año. El material fue recolectado y llevado al Laboratorio de Parasitología del Departamento de Parasitología y Microbiología de la Universidad Federal de Piauí para su análisis. En época de lluvias, de las quince muestras analizadas en la plaza A, cinco resultaron positivas a larvas de anquilostomiasis y de las quince de la plaza B, tres estaban contaminadas con los mismos helmintos. En el período poco lluvioso, en la plaza A solo hubo una muestra con esas larvas y en la plaza B no se encontraron parásitos. Los resultados revelaron la presencia de larvas de helmintos zoonóticos en el suelo de las plazas públicas de Caxias, Maranhão, principalmente en la época de lluvias, sirviendo de alerta a la población local.(AU)

Focal incidental upper abdominal findings on unenhanced chest computed tomography that do not require further imaging: a roadmap for the thoracic radiologist / Achados incidentais focais no abdome superior encontrados na tomografia computadorizada de tórax sem contraste que não requerem investigação adicional: roteiro para o radiologista torácico

Abstract Chest scans usually include the upper abdomen, leading radiologists to evaluate the upper abdominal structures. The aim of this article is to summarize the most common incidental upper abdominal findings that do not require further imaging or management in patients undergoing unenhanced computed tomography of the chest for the investigation of thoracic symptoms or diseases. We review common incidental findings of the liver, gallbladder, spleen, adrenal glands, kidney, and retroperitoneum, as well as findings that mimic other lesions. Thoracic radiologists should be aware of such typical findings and report when no further investigation is needed, thus avoiding unnecessary imaging examinations, protecting patients from additional medical interventions, and allaying patient concerns.

Resumo As tomografias de tórax geralmente incluem o abdome superior, o que implica a avaliação das estruturas abdominais superiores. Nosso objetivo é resumir os achados incidentais mais comuns do abdome superior que não requerem imagem ou tratamento adicional em pacientes submetidos a tomografia computadorizada de tórax sem contraste para investigar sintomas ou doenças torácicas. Achados incidentais comuns do fígado, vesícula biliar, baço, glândulas adrenais, rins, retroperitônio e alterações que podem mimetizar lesões nesses órgãos serão revisados. O radiologista torácico deve estar ciente de tais achados e relatar quando nenhuma investigação adicional for necessária, para evitar excesso de exames, especialmente com radiação ionizante, proteger os pacientes de intervenções médicas e de preocupações.

Interobserver agreement regarding the Fleischner Society diagnostic criteria for usual interstitial pneumonia patterns on computed tomography / Concordância interobservador nas categorias diagnósticas de pneumonia intersticial usual propostas pela Fleischner Society na tomografia computadorizada

Abstract Objective: To assess interobserver agreement among radiologists regarding the current Fleischner Society diagnostic criteria for usual interstitial pneumonia (UIP) patterns on computed tomography (CT). Materials and Methods: Using the Fleischner Society criteria for UIP CT patterns, five raters, working independently, categorized the high-resolution CT (HRCT) scans of 44 patients with interstitial lung disease who underwent lung biopsy. The raters also evaluated the presence, extent, and distribution of the most relevant imaging findings, as well as indicating their level of confidence in the most likely diagnosis and in up to three diagnostic hypotheses. Results: There was moderate to substantial interobserver agreement regarding the UIP patterns on HRCT—kappa statistic (κ) = 0.59-0.61. Interobserver agreement for the binary scores was substantial (κ = 0.77-0.79), whereas that for the presence of honeycombing was almost perfect (κ = 0.81-0.96). There was agreement regarding at least one of the three diagnostic hypotheses in only 36.4% of the cases. For the level of confidence in the most likely diagnosis, there was only slight to fair agreement (κ = 0.19-0.21). Conclusion: Interobserver agreement regarding the current Fleischner Society CT criteria for UIP was moderate to substantial among raters with varying levels of experience. There was only slight to fair agreement regarding the diagnostic hypotheses and for the level of confidence in the most likely diagnosis.

Resumo Objetivo: Avaliar a concordância interobservador entre radiologistas para os critérios atuais da Fleischner Society para categorias diagnósticas de pneumonia intersticial usual (PIU) em tomografia computadorizada (TC). Materiais e Métodos: Cinco observadores categorizaram independentemente as imagens de TC de 44 pacientes com doença pulmonar intersticial que foram submetidos a biópsia pulmonar empregando as últimas categorias de diagnóstico da Sociedade Fleischner para UIP. Também foram avaliadas presença, extensão e distribuição dos achados de imagem mais relevantes, bem como a confiança no diagnóstico mais provável e em até três hipóteses diagnósticas. Resultados: Houve concordância moderada a alta para as categorias diagnósticas entre os observadores (κ = 0,59-0,61). A concordância interobservador para a pontuação binária foi alta (κ = 0,77-0,79), enquanto para a presença de faveolamento foi considerada de alta a muito alta (κ = 0,81-0,96). Houve concordância em uma das três hipóteses diagnósticas em apenas 36,4% dos casos. Baixa concordância foi encontrada para o diagnóstico mais provável (κ = 0,19-0,21). Conclusão: A concordância entre observadores para os critérios atuais de TC da Fleischner Society para UIP foi moderada a alta entre observadores com diferentes níveis de experiência. Houve baixa concordância nas hipóteses diagnósticas e quanto ao grau de confiança no diagnóstico primário.

Development and content validation of a mobile application for monitoring latent tuberculosis treatment

ABSTRACT Background: Non-compliance with latent tuberculosis infection (LTBI) treatment is a reality. The objective of this study was to develop and validate an mobile device application for monitoring the treatment of LTBI. Methods: We defined the requirements, elaborated on the application's conceptual map, generated implementation and prototyping alternatives, and validated content. Results: Feedback on the validity of content were: "usefulness, consistency, clarity, objectivity, vocabulary, and precision" from professionals, and "clarity" from patients. Conclusions: The application proved to be easy to understand, according to the assessment of both professionals and people undergoing treatment for LTBI.

Constructing Japanese MeSH term dictionaries related to the COVID-19 literature

The coronavirus disease 2019 (COVID-19) pandemic has led to a flood of research papers and the information has been updated with considerable frequency. For society to derive benefits from this research, it is necessary to promote sharing up-to-date knowledge from these papers. However, because most research papers are written in English, it is difficult for people who are not familiar with English medical terms to obtain knowledge from them. To facilitate sharing knowledge from COVID-19 papers written in English for Japanese speakers, we tried to construct a dictionary with an open license by assigning Japanese terms to MeSH unique identifiers (UIDs) annotated to words in the texts of COVID-19 papers. Using this dictionary, 98.99% of all occurrences of MeSH terms in COVID-19 papers were covered. We also created a curated version of the dictionary and uploaded it to PubDictionary for wider use in the PubAnnotation system.

O-JMeSH: creating a bilingual English-Japanese controlled vocabulary of MeSH UIDs through machine translation and mutual information

Previous approaches to create a controlled vocabulary for Japanese have resorted to existing bilingual dictionary and transformation rules to allow such mappings. However, given the possible new terms introduced due to coronavirus disease 2019 (COVID-19) and the emphasis on respiratory and infection-related terms, coverage might not be guaranteed. We propose creating a Japanese bilingual controlled vocabulary based on MeSH terms assigned to COVID-19 related publications in this work. For such, we resorted to manual curation of several bilingual dictionaries and a computational approach based on machine translation of sentences containing such terms and the ranking of possible translations for the individual terms by mutual information. Our results show that we achieved nearly 99% occurrence coverage in LitCovid, while our computational approach presented average accuracy of 63.33% for all terms, and 84.51% for drugs and chemicals.

Training in healthcare during and after COVID-19: proposal for simulation training

SUMMARY INTRODUCTION: The challenge of facing COVID-19 falls under all health care structures, and without specific training to health care professionals they are probably the professionals with the highest level of exposure. Regardless of the level of health care, the training of professionals aims to optimize resources and attend patients while assuring quality and security. POINT OF VIEW: This report proposes simulation training for health care professionals to update professionals for attending patients during the pandemic. This training was built with five simulated stations, considering different stages of a patient with COVID-19. This report takes advantage of different simulation techniques, such as skills training, standardized patient, medium- and high-fidelity simulator, rapid cycle of deliberate practice, and in situ simulation. DISCUSSION: Medical procedures for COVID-19 patients offer additional risk for health care professionals, especially considering exposure to procedures that generate aerosols, such as compression, mask ventilation, and orotracheal intubation. Thus, finding educational strategies that allow training is essential to simulate the evolution of COVID-19 patients in a safe manner. CONCLUSION: Simulation has proven to be a useful and effective form of training around the world for training health teams on the front lines for patient care in COVID-19.

Embolization of renal tumor bone metastasis: case report / Embolização de metástase óssea de tumor renal: relato de caso

Abstract Primary or secondary bone tumors can manifest in different ways, from simple bone pain to possible pathological fractures. Hypervascularized tumors are of greatest concern, with increased incidence of complications. Preoperative embolization of the bone tumor is an effective measure for reducing blood loss during open surgery to excise the tumor. With appropriate experience, the risks of the procedure are minimal and final outcomes are highly satisfactory. The purpose of this paper is to describe the case of a 43-year-old male patient with a metastatic renal cell tumor in the left proximal femur (seen on lower limb computed tomography) who underwent selective preoperative embolization. The procedure resulted in a remarkable absence of bleeding and successful response to subsequent onco-orthopedic surgery.

Resumo Os tumores ósseos, primários ou secundários, podem se manifestar de várias formas, desde dor óssea até fraturas patológicas. A preocupação maior repousa sobre tumores hipervascularizados, com maior incidência de complicações. A embolização pré-operatória do tumor ósseo é uma medida eficaz para reduzir a perda sanguínea durante a exérese tumoral em cirurgia aberta. Com uma experiência apropriada, os riscos do procedimento são mínimos, com resultados finais bastante satisfatórios. O presente artigo tem por finalidade descrever o caso de um paciente do sexo masculino, de 43 anos, com tumor metastático de células renais em fêmur proximal esquerdo (visualizado por angiotomografia de membro inferior), submetido à embolização arterial seletiva pré-operatória. O procedimento resultou em ausência de sangramento e ótima resposta à cirurgia onco-ortopédica realizada.

Clinical simulation strategies for knowledge integration relating to initial critical recognition and management of COVID-19 for use within continuing education and health-related academia in Brazil: a descriptive study

ABSTRACT BACKGROUND: The COVID-19 pandemic has led to an immense need to develop training on case recognition and management, with a focus on patients' and health professionals' safety at several levels of healthcare settings in Brazil. Different simulation strategies can be included in the diverse clinical care phases for these patients. OBJECTIVE: To suggest a complete simulation-based training program for Brazilian hospitals and/or academic institutions at this moment of the pandemic. DESIGN AND SETTING: Descriptive analysis on possible simulated clinical cases using different methodologies, thereby supporting suspected or confirmed COVID-19 patients. METHODS: This was a reflective theoretical descriptive study on an educational program based on clinical simulation, with four practical phases at different performance and complexity levels. Wearing, handling and adequately disposing of personal protective equipment, along with specific respiratory procedures in different healthcare settings up to intensive care for seriously infected patients were addressed. RESULTS: This program was designed for application at different Brazilian healthcare levels through different clinical simulation strategies. Summaries of expected performance were suggested in order to standardize technical capacity within these simulation settings, so as to serve these levels. CONCLUSIONS: Developing training programs for situations such as the current COVID-19 pandemic promotes safety not only for patients but also for healthcare workers. In the present context, clear definition of which patients need hospital outpatient or inpatient care will avoid collapse of the Brazilian healthcare system. Institutions that do not have simulated environments can, through the examples described, adopt procedures to promote didactic information in order to help healthcare professionals during this time.

SciBabel: a system for crowd-sourced validation of automatic translations of scientific texts

Scientific research is mostly published in English, regardless of the researcher's nationality. However, this growing practice impairs or hinders the comprehension of professionals who depend on the results of these studies to provide adequate care for their patients. We suggest that machine translation (MT) can be used as a way of providing useful translation for biomedical articles, even though the translation itself may not be fluent. To tackle possible mistranslation that can harm a patient, we resort to crowd-sourced validation of translations. We developed a prototype of MT validation and edition, where users can vote for that translation as valid, or suggest modifications (i.e., post-editing the MT). A glossary match system is also included, aiming at terminology consistency.

SciBabel: a system for crowd-sourced validation of automatic translations of scientific texts

Scientific research is mostly published in English, regardless of the researcher's nationality. However, this growing practice impairs or hinders the comprehension of professionals who depend on the results of these studies to provide adequate care for their patients. We suggest that machine translation (MT) can be used as a way of providing useful translation for biomedical articles, even though the translation itself may not be fluent. To tackle possible mistranslation that can harm a patient, we resort to crowd-sourced validation of translations. We developed a prototype of MT validation and edition, where users can vote for that translation as valid, or suggest modifications (i.e., post-editing the MT). A glossary match system is also included, aiming at terminology consistency.

PharmacoNER Tagger: a deep learning-based tool for automatically finding chemicals and drugs in Spanish medical texts

Automatically detecting mentions of pharmaceutical drugs and chemical substances is key for the subsequent extraction of relations of chemicals with other biomedical entities such as genes, proteins, diseases, adverse reactions or symptoms. The identification of drug mentions is also a prior step for complex event types such as drug dosage recognition, duration of medical treatments or drug repurposing. Formally, this task is known as named entity recognition (NER), meaning automatically identifying mentions of predefined entities of interest in running text. In the domain of medical texts, for chemical entity recognition (CER), techniques based on hand-crafted rules and graph-based models can provide adequate performance. In the recent years, the field of natural language processing has mainly pivoted to deep learning and state-of-the-art results for most tasks involving natural language are usually obtained with artificial neural networks. Competitive resources for drug name recognition in English medical texts are already available and heavily used, while for other languages such as Spanish these tools, although clearly needed were missing. In this work, we adapt an existing neural NER system, NeuroNER, to the particular domain of Spanish clinical case texts, and extend the neural network to be able to take into account additional features apart from the plain text. NeuroNER can be considered a competitive baseline system for Spanish drug and CER promoted by the Spanish national plan for the advancement of language technologies (Plan TL).

Simulation centers and pedagogical planning: two sides of the same coin / Centros de simulação e projeto pedagógico: dois lados da mesma moeda

AIMS: This article discusses the main issues related to the use and structuring of a simulation center, namely, logistics, use of resources and alignment between the pedagogical project and simulated activities. METHODS: A narrative literature review, with search in Web of Science, PubMed, SciELO and Google Scholar databases, included articles published up to June 2017. RESULTS: Medical simulation has been implemented in the health courses for training and assessment. Because of this implantation, many simulation centers have been created, involving a high cost for the construction as well as the maintenance. Many of the simulation centers have a low acceptance from teachers and students, letting them underused, especially when the methodology is not correctly implemented. The simulation centers will become important when they are aligned with the pedagogical planning. Planning a simulation center is a timeconsuming task, which requires visiting another simulation center to avoid major adjustments afterwards. It is important to identify the target group and the usage of the simulation center on the pedagogical planning to define the number of users and the type of structure. Also, it is necessary to identify the type of simulators the simulation center will use. Faculty development and multiple disciplinary teams are required. The lack of faculty development is one of the reasons of the underuse of the simulation center. Besides faculty development, other ways of optimize the simulation center is research and partnership between medical school and hospital. Medical school will have funding opportunities and interaction with society. The hospital will qualify their employees and increase the safety of their patients. While conducting the budget, there is a need to consider all those points, since only the physical space and the simulators are not sufficient for a good simulation center. CONCLUSIONS: The integration between education, research and assistance, and the alignment with the pedagogical project are of utmost importance for the use of simulation in healthcare, and essential for the development of new training and knowledge.

OBJETIVOS: Discutir as principais questões relacionadas ao uso e estruturação de um centro de simulação: logística, aproveitamento dos recursos e alinhamento entre o projeto pedagógico e as atividades simuladas. MÉTODOS: Revisão narrativa da literatura, com busca nas bases de dados Web of Science, PubMed, SciELO e Google Scholar, incluiu artigos publicados até junho de 2017. RESULTADOS: A simulação médica tem sido inserida nos cursos da área de saúde tanto para treinamento quanto para avaliação. Com isso, houve um grande aumento de centros de simulação, os quais envolvem um alto custo tanto para sua infraestrutura geral e especificidades como para manutenção. Muitas vezes os centros de simulação têm uma baixa aceitação docente e discente, tornando-os subutilizados, principalmente quando a metodologia não é implementada adequadamente. O método será mais valorizado quando houver um alinhamento entre o projeto pedagógico e as atividades simuladas. O planejamento de um centro de simulação é uma tarefa árdua que exige estudo prévio, conhecimento sobre o currículo institucional, orçamento e visitas a outros centros já existentes para evitar grandes ajustes posteriores que potencialmente são difíceis e onerosos. Para um melhor aproveitamento logístico, é necessário inicialmente identificar o público alvo e a inserção curricular do método, para definir a quantidade de participantes, tipos de salas e tipos de simuladores. A capacitação docente e o envolvimento multiprofissional são necessários para o bom funcionamento do centro de simulação, sendo que um dos principais motivos para a sua subutilização é a falta de capacitação docente. Além de capacitar os docentes, outras formas para utilizar os centros de simulação estão relacionadas à pesquisa e à parceria entre escolas de medicina e serviços hospitalares. Nessa parceria, as instituições de ensino ganham oportunidades de financiamento e interação com a sociedade, enquanto os hospitais ganham qualificação e aumentam a segurança de seus pacientes. Todas essas questões devem ser consideradas quando o estudo orçamentário é realizado, pois apenas o ambiente físico e os simuladores não são suficientes para o aproveitamento do ambiente simulado. CONCLUSÕES: A integração entre educação, pesquisa e assistência, e o alinhamento com o projeto pedagógico, são de extrema importância para a utilização da simulação na área da saúde, e essenciais para o desenvolvimento de novos treinamentos e conhecimentos.

Importância e desafios do treinamento simulado em saúde / Importance and challenges of simulation training in healthcare

O uso da simulação no ensino em saúde amplia as oportunidades de aprendizagem, contribuindo de forma relevante para a prevenção de erros durante a atividade profissional. Entretanto, são vários os desafios para alcançar um treinamento simulado eficiente, incluindo a necessidade de adaptar o conhecimento produzido em diferentes contextos. Como deve ser organizado um centro de simulação? Como levar em conta as peculiaridades dos estudantes na aplicação do conceito de debriefing? Os instrumentos de avaliação foram validados para a população na qual estão sendo aplicados? Quais elementos devem ser incluídos no ensino baseado em simulação para melhorar a aquisição e/ou a retenção de habilidades, conhecimentos e atitudes? Em que momento do currículo introduzir cada possibilidade de treinamento simulado, de modo a tornar o investimento válido? Neste editorial, os autores assinalam a importância do treinamento simulado em saúde e a necessidade de pesquisas que objetivem entender as diferentes situações e fornecer respostas a estas questões.

The use of simulation in health education expands learning opportunities, contributing in a relevant way to the prevention of errors during professional activity. However, there are several challenges to achieving efficient simulated training, including the need to adapt the knowledge produced in different contexts. How should a simulation center be organized? How to take into account the peculiarities of the students in applying the concept of debriefing? Have the evaluation tools been validated for the population in which they are being applied? What elements should be included in simulation-based teaching to improve acquisition and/or retention of skills, knowledge, and attitudes? At what point, in the curriculum, should every possibility of simulated training be introduced in order to make the investment valid? In this editorial, the authors point out the importance of simulation training in healthcare and the need for research aimed at understanding the different situations and providing answers to these questions.

Parâmetros e efeitos do laser não ablativo no tratamento de melasma facial / Parameters and effects of non-ablative laser in facial melasma

O uso do laser não ablativo no tratamento do melasma tem sido abordado em diversos estudos, porém, não há consenso na literatura quanto aos parâmetros e feitos de intervenções baseadas neste recurso. O objetivo deste estudo foi identificar e descrever parâmetros e efeitos do laser não ablativo no tratamento de hiperpigmentação de pele (melasma). Trata-se de uma revisão sistemática da literatura baseada no Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A busca eletrônica compreendeu as seguintes bases de dados: PubMed, Physiotherapy Evidence Database (PEDro), Science Direct e SciELO. Foram identificados inicialmente 641 documentos nas bases de dados eletrônicas, enquanto na busca manual 26 artigos foram encontrados, após leitura e análise 7 artigos foram selecionados. Foram analisados 7 artigos correspondentes as bases de dados PubMed e Science Direct, todos na língua inglesa e publicados a partir do ano de 2010. Apenas um estudo utilizou uma amostra maior que 30 indivíduos, os demais utilizaram em média 16 participantes, com predomínio do sexo feminino e classificação segundo Fitzpatrick entre III-V. O comprimento de onda variou entre 1064 nm a 1550 nm e a energia máxima não ultrapassou 4 J/cm². De acordo com as variáveis avaliadas, os protocolos testados demonstraram que o laser não ablativo foi ineficaz no tratamento de melasma facial, sobretudo após a interrupção da terapia. (AU)

The use of non-ablative laser in the treatment of melasma has been used in several studies, however, there is no consensus in the literature regarding the parameters and interventions based on this resource. The objective of this study was to identify and describe parameters and effects of nonablative laser in the treatment of skin hyperpigmentation (melasma). This is a systematic review of the literature based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA). The study included the following databases: PubMed, Physiotherapy Evidence Database (PEDro), Science Direct and SciELO. We initially identified 641 documents in the electronic databases, while in the manual search 26 articles were found, and after reading and analyzing 7 articles were selected. We analyzed these 7 articles corresponding to the PubMed and Science Direct databases, all in the English language and published after the year 2010. Only one study used a sample > 30 individuals, the others used on average 16 participants, with a predominance of female gender and Fitzpatrick classification according to III-V. The wavelength ranged from 1064 nm to 1550 nm and the maximum energy did not exceed 4 J/cm². According to the variables evaluated, the protocols tested demonstrated that the non-ablative laser was ineffective in the treatment of facial melasma, especially after the end of the therapy. (AU)

Novas perspectivas de fisioterapia respiratória em lesão medular - uma revisão sistemática / New perspectives for chest physical therapy in spinal cord injury - a systematic review

Resumo Objetivo: Descrever e analisar parâmetros e efeitos da estimulação elétrica de superfície na função muscular respiratória de pessoas com lesão medular, sobretudo durante a tosse. Métodos: Foi realizada uma revisão sistemática da literatura, com base no Preferred Reporting items for Systematic Reviews and Meta-Analyses. A busca foi realizada nas bases de dados PubMed, PEDro e LILACS, por meio dos seguintes descritores: "estimulação elétrica funcional", "eletroestimulação, estimulação elétrica", "tosse", "higiene brônquica", "quadriplegia", "lesão medular espinhal", "tetraplegia" e "sujeito com tetraplegia" - em espanhol, inglês e português, sem restrição quanto ao ano de publicação. Foram incluídos artigos com amostra de indivíduos com lesão medular assistidos por estimulação elétrica com desfecho relacionado ao sistema respiratório, e foram excluídos artigos com ensaios invasivos de estímulo a tosse. Resultados: Os 12 artigos incluídos revelam heterogeneidade nos protocolos de eletroestimulação da função expiratória, que podem incluir frequências de 30 a 50 Hz, com pulsos de 25 a 400 μs, aplicada por até oito eletrodos distribuídos pelos músculos expiratórios e acessórios. O tempo de aplicação também foi variável e a amplitude de corrente frequentemente estimada pela percepção do paciente, podendo chegar a valores superiores a 100mA. Conclusão: Apesar de não ser possível estabelecer parâmetros rigorosos de fisioterapia por meio da estimulação elétrica, pela escassez e qualidade de estudos que comparem sistematicamente parâmetros de estimulação em subgrupos, foram observadas alterações positivas nas variáveis de função muscular respiratória avaliadas, como o pico de fluxo expiratório e de tosse, em pessoas com lesão medular cervical e torácica.

Abstract Objective: To describe and analyze parameters and effects of surface electrical stimulation on the respiratory muscular function among individuals with spinal cord injuries, especially while coughing. Methods: A systematic literature review was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The search was conducted in the PubMed, PEDro, and LILACS databases, using the following descriptors: "functional electrical stimulation," "electrostimulation, electrical stimulation," "coughing," "bronchial hygiene," "quadriplegia," "spinal cord injury", "tetraplegia", and "individual with tetraplegia" - in Spanish, English and Portuguese, with no restrictions on year of publication. Inclusion criteria were: articles describing studies with samples of individuals with spinal cord injuries treated with electrical stimulation and outcomes related to the respiratory system. Articles containing studies with invasive cough stimulation trials were excluded. Results: The 12 selected articles revealed the heterogeneity of electrostimulation protocols for expiratory function, which can include frequencies ranging from 30 to 50 Hz; pulse from 25 to 400 μs; applied in up to eight electrodes distributed across the expiratory and accessory muscles. Time of administration also varied, and the current amplitude was usually estimated by the patient's perception, reaching values higher than 100mA. Conclusion: Even though the review did not find rigorous parameters for physical therapy using electrical stimulation, because of the shortage and low-quality of the studies that systematically compare stimulation parameters among subgroups, positive changes were observed in the assessed respiratory muscle function variables, such as peak expiratory and cough flow in individuals with cervical and thoracic spinal cord injury.