Relative impact of diagnosis and clinical stage on response to electroconvulsive therapy: a retrospective cohort

Objectives: Electroconvulsive therapy (ECT) is commonly indicated for refractory psychiatric disorders. However, little research has compared response across diagnoses. Here, we aimed to evaluate the relative impact of diagnosis and clinical staging as response predictors in a cross-diagnostic sample. Methods: In a retrospective cohort of adult inpatients (n=287) who underwent at least six sessions of ECT, we investigated predictors of complete response (a clinical global impression of 1) to ECT. We use adjusted regression models to estimate the impact of clinical diagnosis and staging on complete response and dominance analysis to assess the relative importance of these predictors. Results: Those for whom a depressive episode was a primary indication for treatment were the most likely to have complete improvement, while those with psychosis were the least likely; clinical stage had a significant influence on outcome in all diagnoses. A diagnosis of psychosis was the strongest predictor of non-response. Conclusions: A diagnosis of psychosis (mainly schizophrenia) was the strongest predictor of non-response. We also found that clinical staging can aggregate information on ECT response that is independent of clinical diagnosis.

On suicidal ideation: the need for inductive methodologies to advance the field

Abstract Recent scholarly investigation of suicidal ideation has been largely based on identifying associated factors and using ideation-to-action theories to explain its occurrence. However, this approach may not be sufficient, as many aspects of suicidal ideation fall beyond the reach of such conceptualizations. The overemphasis on explaining rather than understanding this phenomenon is a significant factor in this insufficiency. As such, it is argued that qualitative methods that use data to derive theories could offer a more nuanced understanding of suicidal ideation. By adopting bottom-up approaches, researchers can explore how individuals experience and understand suicidal ideation and how it relates to their lives and experiences. Furthermore, use of qualitative research methods could aid in development of more accurate and inclusive definitions that are more firmly grounded in data.

Factores associados à insatisfação dos médicos dos hospitais de nível terciário em Luanda, Angola / Factors Related to the Dissatisfaction of Physicians of Tertiary-level Hospital in Luanda, Angola

Introdução:Na área de saúde, o grau de satisfação dos profissionais determina a qualidade de serviço e a satisfação dos pacientes. Objectivo:Avaliaros factores associados à insatisfação em médicos que trabalham em unidades hospitalares de nível terciário, em Luanda, Angola. Material e Métodos: Estudo transversal, com uma amostra de médicos das principais unidades hospitalares de nível terciário do sector público em Angola. Utilizamos um questionário adaptado de outros instrumentos validados. Usamos o teste Qui-quadrado para analisar a relação entre a insatisfação profissional e as variáveis demográficas e da vida profissional. Resultados: De um total de 164 participantes, a maior parte (83.5%) relatou a insatisfação profissional, principalmente em relação à remuneração (92.7%), horas de trabalho (89.6%), carência de meios de adequados (80.5%) e segurança pessoal (62.8%).Verificou-se uma associação entre a insatisfação e as variáveis local de trabalho, horas de trabalho, diferenciação profissional e área de especialidade (P <0.05).Conclusão:Os resultados indicam uma elevada taxa de insatisfação profissional entre os médicos dos hospitais de nível terciário em Angola, com particular realce para os aspectos da vida profissional e segurança pessoal, o que sugere a necessidade de atenção para as componentes social e profissional com vista à melhoria da qualidade de serviço prestado pelos médicos.Palavras-chave: Insatisfação no trabalho; Médicos;Hospitais, Angola

ABSTRACT Introduction: In the health area, the degree of satisfaction of professionals determines the quality of service and patient satisfaction. Aim: To evaluate the factors associated with dissatisfaction among physicians working in tertiary-level hospitals, in Luanda, Angola. Methods: Cross-sectional study with a sample of physicians from main publics tertiary-level hospitals in Luanda, Angola. A questionnaire adapted from other validated instruments was used. The Chi-square test was used to determine the association between job dissatisfaction and demographic variables and the professional's characteristics. Results: From a total of 164 participants, most (83.5%) stated dissatisfaction, mainly about remuneration (92.7%), working hours (89.8%), correct diagnoses resources (80.5%) and personal security (62.8%). There was association of dissatisfaction with professional characteristics, such as workplace, working hours, professional differentiation and specialty area (P <0.05).Conclusion: The results indicate a high rate of professional dissatisfaction among physicians of tertiary-level hospitals in Angola, suggesting the need to achieve the social and professional satisfaction for improvement of the quality of the services provided.

Management of acute stroke and urgent neurointerventional procedures during COVID-19 pandemic: recommendations on the Scientific Department on Cerebrovascular Diseases of the Brazilian Academy of Neurology, Brazilian Society of Cerebrovascular Diseases and Brazilian Society of Neuroradiology / Tratamento do acidente vascular cerebral agudo e realização de procedimentos de neurointervenção urgentes durante a pandemia de COVID-19: recomendações do Departamento Científico de Doenças Cerebrovasculares da Academia Brasileira de Neurologia, Sociedade Brasileira de Doenças Cerebrovasculares e Sociedade Brasileira de Neurorradiologia

ABSTRACT Introduction: Although the 2019 severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2, COVID-19) pandemic poses new challenges to the healthcare system to provide support for thousands of patients, there is special concern about common medical emergencies, such as stroke, that will continue to occur and will require adequate treatment. The allocation of both material and human resources to fight the pandemic cannot overshadow the care for acute stroke, a time-sensitive emergency that with an inefficient treatment will further increase mortality and long-term disability. Objective: This paper summarizes the recommendations from the Scientific Department on Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Society of Cerebrovascular Diseases and the Brazilian Society of Neuroradiology for management of acute stroke and urgent neuro-interventional procedures during the COVID-19 pandemic, including proper use of screening tools, personal protective equipment (for patients and health professionals), and patient allocation.

RESUMO Introdução: A pandemia causada pelo novo coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2, COVID-19) apresenta novos e importantes desafios à gestão de saúde no Brasil. Além da difícil missão de prestar atendimento aos milhares de pacientes infectados pelo COVID-19, os sistemas de saúde têm que manter a assistência às emergências médicas comuns em períodos sem pandemia, tais como o acidente vascular cerebral (AVC), que continuam ocorrendo e requerem tratamento com presteza e eficiência. A alocação de recursos materiais e humanos para o enfrentamento à pandemia não pode comprometer o atendimento ao AVC agudo, uma emergência cujo tratamento é tempo-dependente e se não realizado implica em importante impacto na mortalidade e incapacitação a longo prazo. Objetivo: Este trabalho resume as recomendações do Departamento Científico de Doenças Cerebrovasculares da Academia Brasileira de Neurologia, da Sociedade Brasileira de Doenças Cerebrovasculares e da Sociedade Brasileira de Neurorradiologia para o tratamento do AVC agudo e para a realização de procedimentos de neurointervenção urgentes durante a pandemia de COVID-19, incluindo o uso adequado de ferramentas de triagem e equipamentos de proteção pessoal (para pacientes e profissionais de saúde), além da alocação apropriada de pacientes.

Sociodemographic, criminal and forensic characteristics of a sample of female children and adolescents murdered in Brazil. 2010-2016 / Características sociodemográficas, criminales y médico-legales de una muestra de niñas y adolescentes víctimas de homicidio en Brasil. 2010-2016

Abstract Introduction: In Brazil, violence, regardless of the type, is the leading cause of death in adolescents and young adults. Objective: To describe the characteristics of the homicides in which female children and adolescents were the victims based on the autopsy reports recorded in the morgue of the city of Porto Alegre, Brazil. Materials and methods: Cross-sectional study in which 70 autopsy reports of girls and female adolescents who were killed between January 2010 and December 2016 were analyzed. The cases were evaluated according to the homicide motive or the homicide perpetrator, and five categories were established: drug trafficking related death, femicide, homicide perpetrated by a family member, death preceded by sexual violence, and death related to other transgressions. Results: There was a significant increase in the number of girls and female adolescents who were murdered between 2010 (n=7) and 2016 (n=19). Most of the homicides (64.2%) were related to drug, while femicide occurred in 15.7% of the cases. Homicides perpetrated by a family member, or preceded by sexual violence or related with other transgressions were less frequent as they occurred in 10%, 5.7% and 4.2% of the cases, respectively. Conclusion: Greater attention must be paid to the increase in the number of drug trafficking related homicides among female adolescents when creating and implementing relevant public policies.

Resumen Introducción. En Brasil, la violencia, en sus diferentes manifestaciones, es la primera causa de muerte entre adolescentes y adultos jóvenes de ambos sexos. Objetivo. Describir las características de los homicidios de niñas y adolescentes registrados en la morgue de Porto Alegre, Brasil. Materiales y métodos. Estudio transversal que analizó 70 pericias de necropsia de jóvenes víctimas de homicidio entre enero de 2010 y diciembre de 2016. Los casos fueron evaluados según los motivos de los crímenes, identificando 5 categorías: muertes causadas por tráfico de drogas, feminicidios, homicidios familiares, muertes por violencia sexual y homicidios relacionados con otras infracciones legales. Resultados. Hubo un aumento significativo en el número de niñas y mujeres adolescentes víctimas de homicidio entre 2010 (n=7) y 2016 (n=19). La mayoría de casos estuvieron relacionados con el tráfico de estupefacientes (64.2%), mientras que los casos de feminicidio representaron 15.7% da la muestra. Los homicidios cometidos por un familiar, los precedidos de violencia sexual y aquellos relacionados con otras actividades ilegales fueron menos frecuentes con un 10%, 5.7% y 4.2%, respectivamente. Conclusiones. Es necesario prestar más atención al aumento de los homicidios en esta población relacionados con el tráfico de estupefacientes a la hora de crear e implementar políticas públicas al respecto.

The cost of stroke in a public hospital in Brazil: a one-year prospective study / Custo do AVC em um hospital público no Brasil: um estudo prospectivo de um ano

ABSTRACT Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. Objective To measure the costs of stroke care in a public hospital in Joinville, Brazil. Methods We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement. Results We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively. Conclusions Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.

RESUMO Os países de baixa e media renda enfrentam orçamentos apertados na saúde, não somente devido aos novos recursos terapêuticos, mas relacionado ao custo oneroso do tratamento do acidente vascular cerebral. No entanto, poucos dados prospectivos sobre os custos do AVC, incluindo reperfusão cerebral de países de baixa e média renda estão disponíveis. Objetivo Mensurar os custos do atendimento ao AVC em um hospital público. Métodos Avaliamos prospectivamente todos os custos médicos e não médicos de pacientes internados com diagnóstico de acidente vascular cerebral ou AIT durante 1 ano, analisamos os custos por tipo de AVC e tratamento, tempo de permanência e comparamos os custos hospitalares com o reembolso governamental. Resultados Foram avaliados 274 pacientes. O custo total em um ano foi de US$ 1.307,114; o governo reembolsou o hospital no valor de US$ 1.095.118. Encontramos uma correlação linear significativa entre LOS e custos (r = 0,71). A mediana do custo do AVCI em 134 pacientes que não sofreram reperfusão cerebral (National Institutes of Health Stroke Scale [NIHSS] mediana = 3) foi de US$ 2.803; para pacientes submetidos a alteplase intravenosa (IV) (NIHSS 10), a mediana foi de US$ 5.099 e para os pacientes submetidos a trombectomia intra-arterial (IA) (NIHSS > 10), o custo mediano foi de US$ 10.997. A mediana do custo de uma hemorragia intracerebral primária, hemorragia subaracnóidea e AIT foram de US$ 2.436, US$ 8.031 e US$ 2.677, respectivamente. Conclusões Os tratamentos de reperfusão foram duas a quatro vezes mais caros do que o tratamento conservador. Estudo de custo-efetividade para o tratamento do AVC são necessários.

Barriers and facilitators perceived by people with bipolar disorder for the practice of exercise: a qualitative study / Barreiras e facilitadores percebidos por pessoas com transtorno bipolar para a prática de exercício físico: um estudo qualitativo

Abstract Introduction Exercising regularly has benefits for people with bipolar disorder. Nevertheless, as a group, these patients tend to be less physically active than the general population and little is known from the viewpoint of the patients about the barriers and facilitators to such a practice. Objective To know the barriers and facilitators perceived by people with bipolar disorder for the practice of exercise. Methods This study had a descriptive, qualitative, exploratory nature. The investigation method used for data collection was a semi-structured in-depth interview, using grounded theory as theoretical framework. Results The data analysis generated two main areas of interest: adherence to regular physical exercise (barriers and facilitators) and the participants' exercise history and perception of disease management, as described below. The main findings were: most of our sample did not exercise regularly, nor knew how exercise can positively influence their disorder; with regard to adherence to physical exercise, the presence of symptoms and stigma were the most important barriers to the practice of physical exercise. Social support, especially from family and friends, could be a facilitator to the practice of exercise. Conclusions Even considering the limitations for generalization of qualitative and exploratory studies, understanding perceived barriers and facilitators for the practice of exercise among people who suffer with bipolar disorder may contribute to the promotion of activities in which people with mental illness can participate.

Resumo Introdução A prática regular de exercício físico tem benefícios para pessoas com transtorno bipolar. No entanto, como grupo, esses pacientes tendem a ser mais sedentários do que a população geral, e pouco se sabe do ponto de vista dos pacientes sobre as barreiras e facilitadores para tal prática. Objetivo Conhecer as barreiras e facilitadores percebidos por pessoas com transtorno bipolar para a prática de exercício. Métodos Este foi um estudo descritivo, qualitativo e exploratório. O método de investigação utilizado na coleta de dados foi entrevista semiestruturada em profundidade, segundo a grounded theory. Resultados A análise dos conteúdos que surgiram nas entrevistas gerou duas principais áreas de interesse: adesão ao exercício físico regular (barreiras e facilitadores) e a história de exercícios dos participantes e a percepção do manejo da doença. Os principais achados foram: a maioria da nossa amostra não se exercitava regularmente, nem mesmo sabia como a prática regular podia influenciar positivamente sua doença; em relação à adesão ao exercício físico, a presença dos sintomas e do estigma foram as barreiras mais importantes para praticar o exercício físico. O apoio social, especialmente da família e dos amigos, pode ser um facilitador da adesão ao exercício. Conclusões Apesar das limitações de um estudo qualitativo e exploratório, conhecer as barreiras e os facilitadores percebidos para a prática de exercício entre pessoas que sofrem de transtorno bipolar pode facilitar a promoção de atividades onde essas pessoas possam participar e se beneficiar efetivamente.

Metabolic syndrome and psychiatric disorders: a population-based study

Objective: To identify the association of metabolic syndrome (MetS) and psychiatric disorders in young adults in southern Brazil. Methods: This population based cross-sectional study involved a total of 1,023 young adults between the ages of 21 and 32 years. Current episodes of psychiatric disorders were assessed using the Mini International Neuropsychiatric Interview - Plus version. MetS was evaluated using the National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP III). Results: Of the 1,023 participants, 24.3% were identified with MetS, 13.5% were diagnosed with anxiety disorders, 7.5% with current depression, 3.9% with bipolar disorders and 10.1% were at risk of suicide. MetS was associated with ethnicity (p = 0.022), excess weight (p < 0.001), current anxiety disorders (p < 0.001), current mood disorders (bipolar disorder in mood episode and current depression) (p < 0.001), and suicide risk (p < 0.001). Conclusions: MetS was associated with psychiatric disorders. Awareness of factors associated with MetS can help identify high-risk individuals and stimulate disease prevention and control programs, as well as lifestyle changes.

Lipid disorders among Black Africans non-users of lipid-lowering medication

ABSTRACT Objective: Angola is a sub-Saharan African country where the population has scarce access to lipidlowering medication. We sought to determine the frequency of lipid disorders among Angolan nonusers of lipid-lowering medication. Material and methods: A cross-sectional descriptive study was carried out in a sample of 604 workers from the public sector. Blood pressure and anthropometric data were measured along with biochemical parameters including total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). LDL-C to HDL-C ratio (LDL-C/HDL-C) was obtained from LDL-C and HDL-C levels. Results: High frequencies of elevated blood pressure (44.8%), metabolic syndrome (20.2%), increased TC (39.2%) and increased LDL-C (19.3%) were found. Low HDL-C was more frequent in women (62.4% vs. 36.1%, p < 0.001). Isolated hypercholesterolemia was more frequent in men (9.6% vs. 2.5%, p < 0.001). Among men TC, TG, LDL-C and LDL-C/HDL-C ratio were higher and HDL-C was lower in obese than in low-weight and normal-weight participants. Among women TC, TG, LDL-C and LDL-C/HDL-C ratio were higher in obese than in normal-weight participants. Significant linear trend of increasing TC and LDL-C levels as age increased was detected for both genders (p for trend < 0.05). Conclusion: The results of our study showed a high frequency of lipid disorders in Angolan non-users of lipid-lowering medication.

Diagnóstico tardio de sífilis congênita: uma realidade na atenção à saúde da mulher e da criança no brasil / Late diagnosis of congenital syphilis: a recurring reality in women and children health care in brazil

RESUMO Objetivo: Descrever um caso de sífilis congênita com diagnóstico tardio e identificar as oportunidades perdidas nas diversas fases/níveis da atenção à saúde, que retardaram a realização do diagnóstico. Descrição do caso: Menino, 34 dias de vida, encaminhado da Unidade Básica de Saúde a um hospital terciário por apresentar aumento do volume abdominal e icterícia progressiva há 2 semanas, hipocolia fecal, hepatoesplenomegalia, anemia, plaquetopenia e elevação de enzimas hepáticas. Ao exame físico, apresentava lesões eritemato-descamativas nas mãos e nos pés e exantema macular em região inguinal, presença de ascite, fígado palpável a 5 cm do rebordo costal direito e baço palpável a 3 cm do rebordo costal esquerdo. Sorologia do lactente: CMIA (quimioluminescência de micropartículas) reagente, VDRL (Venereal Diseases Research Laboratory) 1:1024 e TPHA (Treponema pallidum Hemaglutination) reagente. Sorologia materna: CMIA e TPHA reagentes, VDRL 1:256. Radiografia de ossos longos mostrava periostite simétrica; levantamento periosteal; e bandas metafisárias lucentes em fêmures, úmeros, ulnas e tíbias. Após tratamento com penicilina cristalina, apresentou melhora clínica e laboratorial, recebendo alta no 18º dia de internação. Comentários: Este caso mostra que ainda ocorre diagnóstico tardio de sífilis congênita por falhas nas estratégias de prevenção dessa doença, tanto na atenção básica quanto nos níveis secundário e terciário. A aplicação das intervenções preconizadas pelo Ministério da Saúde e a identificação das situações em que ocorrem falhas na sua execução são importantes para a avaliação da assistência de rotina em todos os níveis de atenção e nas diversas unidades responsáveis pelo cuidado do recém-nascido e do lactente jovem.

ABSTRACT Objective: To describe a case of congenital syphilis with a late diagnosis and identify missed opportunities at diverse phases/levels of healthcare, which led to late diagnosis. Case description: Boy, 34 days of life, referred from a basic healthcare unit to a tertiary hospital due to enlarged abdominal volume and progressive jaundice for 2 weeks, fecal hypocholia, hepatosplenomegaly, anemia, low platelet count and elevated liver enzymes. At physical examination, the infant presented with erythematous-exfoliative lesions on the palms and soles, macular rash in the inguinal region, ascitis, palpable liver 5 cm below the right costal margin and a palpable spleen 3 cm from the left costal margin. Infant serology: reactive CMIA (chemiluminescent microparticle immunoassay), VDRL (Venereal Diseases Research Laboratory) 1:1024 and reactive TPHA (Treponema pallidum Hemagglutination). Maternal serology: reactive CMIA and TPHA, VDRL 1:256. Radiography of the long bones showed symmetric periostitis, periosteal thickening, and lucent bands in the femur, humerus, ulna and tibia. After treatment with crystalline penicillin, the infant showed clinical and laboratory improvement, receiving hospital discharge at the 18th hospitalization day. Comments: This case shows that congenital syphilis is occasionally diagnosed late as a result of failed strategies to prevent this disease, both in the basic and secondary/tertiary levels of care. The application of interventions recommended by the Ministry of Health and identification of the situation in which there is ineffective implementation of these measures are important to assess routine care in all levels of healthcare and diverse units responsible for newborn and infant health care.

Tempo de Graduação em Medicina: uma Estimativa em 15 Coortes de Graduados na Universidade Agostinho Neto, Angola / Undergraduate Course Duration in Medicine: an Estimation in the 15 Graduate Cohorts at the Agostinho Neto University, Angola

RESUMO O tempo de conclusão do curso de graduação em Medicina está bem estabelecido nos programas de formação das escolas médicas em todo o mundo. Entretanto, nem todos os estudantes concluem o curso no tempo esperado, o que pode resultar numa baixa taxa de graduação. Contudo, uma análise isolada da taxa de graduação não permite prever com precisão a magnitude de custos de formação se não levar em conta o tempo médio de conclusão da formação, particularmente para a Medicina, que exige avultados recursos e cujo tempo de formação é o mais longo. O objetivo do estudo foi determinar o tempo médio de permanência no curso, assim como a proporção de estudantes que se gradua no tempo esperado de conclusão do curso. Foi feita uma análise retrospectiva dos dados de 15 coortes de estudantes graduados pela Faculdade de Medicina da Universidade Agostinho Neto (FMUAN), em Angola, no período de 2001 a 2015. Os dados foram recolhidos do arquivo acadêmico da FMUAN. Do total de 1.259 graduados, 59,7% eram mulheres, e a média de idade na conclusão do curso foi de 35 ± 7 anos. A taxa média de admissão ao curso foi de 6,8%, e foram graduados, em média, 88 médicos por ano, sendo 36 homens e 52 mulheres. A taxa de graduação foi de 82,2%, sendo que os estudantes demoraram, em média,dez anos para concluir o curso, e apenas 24,2% concluíram o curso no tempo esperado de seis anos. Os resultados sugerem que, apesar de ter havido uma elevada taxa de graduação, poucos concluem o curso no tempo regulamentar, realçando a importância de identificar as causas da estadia prolongada de estudantes no curso, o que pode ter implicação na gestão acadêmica e na planificação de recursos humanos de saúde. A taxa de graduados no tempo ideal, combinada com a taxa de graduação, pode ser um indicador de eficiência e um instrumento de apoio na gestão do sistema de educação médica.

ABSTRACT The time required to complete undergraduate medical courses is well established in medical school training programs worldwide. However, not all students complete the degree in the expected timeframe, which can lead to a low graduation rate. Nevertheless, an isolated analysis of the graduation rate does not accurately predict the magnitude of training costs if it does not take into account the average completion time, particularly for undergraduate medical course for which the training time is longer and requires substantial resources. The aim of this study was to determine the length of time to complete the degree, as well as the proportion of students who graduated within the regular timeframe. In this retrospective study, we analysed data from 15 cohorts of medical students who finished the undergraduate program at the Faculty of Medicine of the Agostinho Neto University (FMUAN) in Angola, from 2001 to 2015. Data were collected from the academic records registered at the FMUAN. From the total number of graduates (n = 1259), 59.7% were women and the average age at course completion was 35 ± 7 years. The average admission rate was 6.8%, and it was found that 88 students (36 men and 52 women) had graduated per year. On average, students took 10 years to complete the degree. The graduation rate was 82.2%, and only 24.2% of the total graduates concluded the program in the regular period of six years. The results suggest that despite a high graduation rate, less than one third of the students finished the training program within the expected timeframe, highlighting the need to identify the causes of prolonged course duration which may have implications for both academic management and for human resource planning in health. Thus, a combined analysis of graduation rate and the time to complete the undergraduate course may be a good indicator of the efficiency of the medical education system.

Frequency of brain tissue donation for research after suicide

Objectives: To describe the frequency of brain tissue donation for research purposes by families of individuals that committed suicide. Methods: All requests for brain tissue donation to a brain biorepository made to the families of individuals aged 18-60 years who had committed suicide between March 2014 and February 2016 were included. Cases presenting with brain damage due to acute trauma were excluded. Results: Fifty-six cases of suicide were reported. Of these, 24 fulfilled the exclusion criteria, and 11 others were excluded because no next of kin was found to provide informed consent. Of the 21 remaining cases, brain tissue donation was authorized in nine (tissue fragments in seven and the entire organ in two). Conclusions: Donation of brain tissue from suicide cases for research purposes is feasible. The acceptance rate of 42.8% in our sample is in accordance with international data on such donations, and similar to rates reported for neurodegenerative diseases.

Incidence and functional outcome of atrial fibrillation and non-atrial fibrillation- related cardioembolic stroke in Joinville, Brazil: a population-based study / Incidência e desfecho funcional de AVC cardioembólico com e sem fibrilação atrial em Joinville, Brazil: estudo de base populacional

ABSTRACT Among ischemic strokes, cardioembolic (CE) stroke has the worst outcome. We measured the incidence of atrial fibrillation (AF) and non-AF related CE strokes, previous anticoagulant use, and the 90-day functional outcome. Using multiple overlapping sources, we included all CE strokes that occurred in 2015 in Joinville, Brazil. Of the 374 ischemic strokes, 23% (84) were CE. The CE age-adjusted incidence, per 1,000 person-years, was 0.14 (0.11–0.17). Of the 26 patients with known prior AF, 73% (19) were not anticoagulated, 77% (20) had a CHA2DS2VASc score ≥ 3 and 81% (21) had a HAS-BLED score < 3. After three months, approximately one third of those 26 patients died or became disabled. The incidence of CE stroke in our sample was lower than in other population-based studies. The opportunity for anticoagulation was missed in one third of cases.

RESUMO Entre todos os subtipos de AVC isquêmico, os eventos cardioembólicos (CE) apresentam os piores prognósticos. Determinamos a incidência de AVC isquêmico CE, associada ou não à fibrilação atrial (FA), o uso prévio de anticoagulantes e os desfechos funcionais em Joinville, Brasil. Utilizando múltiplas e sobrepostas fontes de informação, registramos todos os primeiros eventos CE ocorridos em 2015. Entre 374 eventos isquêmicos, 23% (84) foram CE. A incidência ajustada, para qualquer fonte cardioembólica, foi 0.14 (0.11–0.17) por 1000 pessoas-ano. Entre 26 pacientes com FA previamente conhecida, 73% (19) não estavam anticoagulados, 77% (20) tinham ≥ 3 pontos na escala CHA2DS2VASc e 81 % (21) < 3 pontos na escala HAS-BLED. Após 3 meses, um terço destes 26 pacientes morreram ou ficaram dependentes. A incidência de AVC I CE em Joinville é menor do que em outros estudos de base populacional. Um terço dos casos de AVC I CE com FA previamente conhecida perderam a oportunidade de anticoagulação.

Brazilian guidelines for endovascular treatment of patients with acute ischemic stroke / Diretrizes brasileiras para o tratamento endovascular de pacientes com acidente vascular cerebral isquêmico agudo

ABSTRACT These guidelines are the result of a joint effort from writing groups of the Brazilian Stroke Society, the Scientific Department of Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Stroke Network and the Brazilian Society of Diagnostic and Therapeutic Neuroradiology. Members from these groups participated in web-based discussion forums with predefined themes, followed by videoconference meetings in which controversies and position statements were discussed, leading to a consensus. This guidelines focuses on the implications of the recent clinical trials on endovascular therapy for acute ischemic stroke due to proximal arterial occlusions, and the final text aims to guide health care providers, health care managers and public health authorities in managing patients with this condition in Brazil.

RESUMO Estas diretrizes são o resultado de um esforço conjunto de membros da Sociedade Brasileira de Doenças Cerebrovasculares (SBDCV), Departamento científico de Doenças Cerebrovasculares da Academia Brasileira de Neurologia (ABN), Rede Brasil AVC (RBAVC) e da Sociedade Brasileira de Neurorradiologia Diagnóstica e Terapêutica (SBNR). Membros destas 4 entidades participaram de fórum de discussões por internet de temas pré-definidos, seguidos de encontros de videoconferência para discussão de pontos controversos e das recomendações, em busca de um consenso final. Estas diretrizes tem seu foco sobre as implicações dos recentes ensaios clínicos de tratamento endovascular do acidente vascular cerebral (AVC) isquêmico agudo relacionado a oclusão de artérias proximais. O texto final foi elaborado para servir de orientação no manejo destes pacientes AVC isquêmico pelos diferentes profissionais de saúde, gestores de saúde pública e de saúde complementar no Brasil.

Cognition and functioning in bipolar depression

Objectives: Depressive symptoms are associated with worse outcomes in patients with bipolar disorder (BD). However, scarce data are available regarding neurocognitive profiles across different areas of functioning among BD patients with moderate and severe depression. Our objective was to assess cognition and global functioning in a group of patients with bipolar depression. Methods: Data were available for 100 patients with bipolar depression (78% female) and 70 controls (64% female) paired by age and education level. Cognitive function was assessed with a neuropsychological test battery. Functioning was assessed with the Functioning Assessment Short Test. Results: In patients, severe depression was associated with poorer cognitive performance on measures of executive function. Patients with severe depression showed worse global functioning than those with moderate depression (z = 2.54, p = 0.011). In patients with severe depression, lower global functioning was associated with lower scores in working memory (r = -0.200, p = 0.010), and executive function (r = -0.210, p = 0.007; and r = 0.293, p < 0.001). Conclusion: Our findings suggest cognitive impairment and global functioning impairment are associated with the severity of depressive symptoms in bipolar depression. Intensive treatment of depressive symptoms in patients with BD is crucial to improve cognitive functioning and, consequently, functional outcomes.

Cerebrum-cervical arterial dissection in adults during sports and recreation / Dissecção arterial cérebro-cervical em adultos durante prática de esportes e recreação

Dissection of cervical arteries constitutes a medical emergency. Although relatively rarely, activities classified as sports and recreation may be a cause of arterial dissection independently of neck or head trauma. The purpose of the present paper was to present a series of cases of cerebrum-cervical arterial dissection in individuals during or soon after the practice of these sports activities. Methods Retrospective data on patients with arterial dissection related to sports and recreation. Results Forty-one cases were identified. The most frequently affected vessel was the vertebral artery. A large variety of activities had a temporal relationship to arterial dissection, and jogging was the most frequent of these. This is the largest case series in the literature. Conclusion Arterial dissection may be a complication from practicing sports.

A dissecção das artérias cervicais é uma emergência médica. Embora de forma relativamente rara, certas atividades descritas como esportes e recreação podem ser a causa de dissecção arterial independentemente de trauma de crânio ou cervical. O propósito do presente estudo é apresentar uma série de casos de dissecção de artérias cérebro-cervicais em indivíduos durante ou logo após a prática destas atividades desportivas. Métodos Dados retrospectivos de pacientes com dissecção arterial relacionada à prática de esportes e recreação. Resultados Quarenta e um casos foram identificados. A artéria mais frequentemente afetada foi a vertebral. Uma grande variedade de atividades teve relação temporal com a dissecção arterial, sendo a corrida a mais frequente delas. Esta é a maior série de casos da literatura. Conclusão Dissecção arterial pode ser uma complicação da prática de esportes.

Association of interleukin-10 levels with age of onset and duration of illness in patients with major depressive disorder

Objective: To investigate peripheral levels of interleukin-10 (IL-10) in patients with major depressive disorder (MDD) and bipolar disorder (BD) and evaluate the relationship between IL-10, age of disease onset, and duration of illness. Methods: Case-control study nested in a population-based cohort of 231 individuals (age 18-24 years) living in Pelotas, state of Rio Grande do Sul, Brazil. Participants were screened for psychopathology using the Mini-International Neuropsychiatric Interview (MINI) and the Structured Clinical Interview for DSM-IV (SCID-I). Serum IL-10 was measured using commercially available immunoassay kits. Results: Peripheral levels of IL-10 were not significantly different in individuals with MDD or BD as compared to controls. However, higher IL-10 levels were found in MDD patients with a later disease onset as compared with controls or early-onset patients. In addition, IL-10 levels correlated negatively with illness duration in the MDD group. In the BD group, age of onset and duration of illness did not correlate with IL-10 levels. Conclusion: Higher levels of IL-10 are correlated with late onset of MDD symptoms. Moreover, levels of this cytokine might decrease with disease progression, suggesting that an anti-inflammatory balance may be involved in the onset of depressive symptoms and disease progression in susceptible individuals.

Quality of life, social functioning, family structure, and treatment history associated with crack cocaine use in youth from the general population

Objective:To assess the relationship between crack cocaine use and dimensions of quality of life and social functioning in young adults.Methods:This was a cross-sectional, population-based study involving 1,560 participants in Pelotas, Brazil. Crack cocaine use and abuse were investigated using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) inventory. Outcomes of interest were quality of life, religiosity, and social functioning in terms of education, occupational status, family structure, and medical treatment history.Results:Lifetime crack cocaine use was associated with poor quality of life, worse functioning, impaired academic performance, and lower religious involvement. A greater maternal presence and higher paternal absence were more also more pronounced in crack cocaine users, who were also more likely to seek psychological and psychiatric treatment than the general population.Conclusion:Quality of life was severely impacted by crack cocaine use, especially in terms of general and physical health. Social functioning also differed between the general population and crack users, who had lower educational attainment and religious involvement. Maternal presence, paternal absence, and mental health-seeking behaviors were also more frequent among crack cocaine users, although these individuals reported lower rates of treatment satisfaction. Crack cocaine users also had significant social impairment, so that interventions involving family management and a greater focus on general health, quality of life, and functioning may make crucial contributions to the recovery of this group.

Countertransference and therapeutic alliance in the early stage of adult psychodynamic psychotherapy / Contratransferência e aliança terapêutica no início da psicoterapia psicodinâmica de adultos

Objectives:The primary objective of this study was to assess the relationship between countertransference (CT) and therapeutic alliance (TA) during the early stages of psychodynamic psychotherapy. A secondary objective is to assess associations between CT and variables related to therapist and patient and between CT and other patient variables investigated, which were defense mechanisms, symptomology and functionality.Methodology: This was a cross-sectional study that enrolled 30 patients treated by 17 different therapists at the psychotherapy clinics of two psychiatry centers. Assessments of each patient-therapist pair were conducted between their fourth and 10th sessions.Results: The CT distance domain exhibited a moderate negative correlation with TA, particularly its sub-dimension representing the patient's capacity for work in therapy. Moderate positive correlations were observed between CT distance and the splitting defense mechanism and between CT closeness and suppression defenses, in addition to moderate negative correlation between CT indifference and the fantasy defense mechanism. Another finding was higher scores for CT indifference in association with socioeconomic classes D and E.Conclusions: The quality of CT may provide a source of information about TA. A high degree of CT distance represents a low level of TA, particularly with relation to the patient's working capacity, although presence of the splitting defense mechanism can affect CT, to the extent that it constitutes a confounding variable. The concept of CT is useful to psychotherapists, providing a source of information about the patient's internal world and about certain elements of therapy, such as the quality of TA, which is important for good treatment results.

Objetivos: O objetivo principal desta pesquisa foi avaliar a relação entre a contratransferência (CT) e a aliança terapêutica (AT) no início da psicoterapia psicodinâmica. O objetivo secundário é avaliar a associação da CT com as variáveis da dupla e da CT com as demais variáveis do paciente avaliadas, que foram os mecanismos de defesa, sintomatologia e funcionalidade.Metodologia:Trata-se de um estudo transversal com 30 pacientes do ambulatório de psicoterapia de dois serviços de psiquiatria, atendidos por 17 terapeutas. As avaliações ocorreram entre quarto e décimo encontros da dupla.Resultados:A dimensão da CT distância apresentou correlação negativa moderada com a AT, especialmente sua dimensão que representa a capacidade de trabalho em terapia do paciente. Foram verificadas correlações moderadas positivas entre CT distância e cisão e entre CT proximidade e supressão, além da correlação moderada negativa da CT indiferença com fantasia. Outro dado encontrado foi a presença de maiores níveis da CT indiferença diante de pacientes da classe socioeconômica D e E.Conclusões:A qualidade da CT pode servir de fonte de informações sobre a AT. A presença de alta CT que indica distância está relacionada a baixa AT, sobretudo em relação a capacidade de trabalho do paciente, ainda que a presença de cisão pode influenciar a CT, de forma que representa uma variável de confusão. A CT é um conceito útil ao psicoterapeuta, servindo como fonte de informações sobre o mundo interno do paciente e sobre elementos da psicoterapia, como a qualidade da AT, importante para os bons resultados dos tratamentos.

Screening for Fabry Disease in Left Ventricular Hypertrophy: Documentation of a Novel Mutation / Rastreio de Doença de Fabry na Hipertrofia Ventricular Esquerda: Documentação de uma Nova Mutação

AbstractBackground:Fabry disease is a lysosomal storage disease caused by enzyme α-galactosidase A deficiency as a result of mutations in the GLA gene. Cardiac involvement is characterized by progressive left ventricular hypertrophy.Objective:To estimate the prevalence of Fabry disease in a population with left ventricular hypertrophy.Methods:The patients were assessed for the presence of left ventricular hypertrophy defined as a left ventricular mass index ≥ 96 g/m2 for women or ≥ 116 g/m2 for men. Severe aortic stenosis and arterial hypertension with mild left ventricular hypertrophy were exclusion criteria. All patients included were assessed for enzyme α-galactosidase A activity using dry spot testing. Genetic study was performed whenever the enzyme activity was decreased.Results:A total of 47 patients with a mean left ventricular mass index of 141.1 g/m2 (± 28.5; 99.2 to 228.5 g/m2] were included. Most of the patients were females (51.1%). Nine (19.1%) showed decreased α-galactosidase A activity, but only one positive genetic test − [GLA] c.785G>T; p.W262L (exon 5), a mutation not previously described in the literature. This clinical investigation was able to establish the association between the mutation and the clinical presentation.Conclusion:In a population of patients with left ventricular hypertrophy, we documented a Fabry disease prevalence of 2.1%. This novel case was defined in the sequence of a mutation of unknown meaning in the GLA gene with further pathogenicity study. Thus, this study permitted the definition of a novel causal mutation for Fabry disease - [GLA] c.785G>T; p.W262L (exon 5).

ResumoFundamento:A doença de Fabry é uma doença lisossomal de sobrecarga provocada pela deficiência da enzima α-galactosidase A como resultado de mutações no gene GLA. O envolvimento cardíaco carateriza-se por hipertrofia ventricular esquerda progressiva.Objetivo:Estimar a prevalência da doença de Fabry numa população com hipertrofia ventricular esquerda.Métodos:Os doentes foram avaliados para a presença de hipertrofia ventricular esquerda definida por massa do ventrículo esquerdo indexada como ≥ 96 g/m2 para mulheres ou ≥ 116 g/m2 para homens. Estenose aórtica severa e hipertensão arterial, com hipertrofia ventricular esquerda discreta, foram critério de exclusão. Todos os doentes incluídos foram avaliados para a atividade da enzima α-galactosidase A com testes de gota seca. No caso de atividade enzimática diminuída, realizava-se estudo genético.Resultados:Foram incluídos 47 doentes com uma média de massa indexada de 141,1 g/m2 (± 28,5; 99,2 a 228,5 g/m2]. A maioria (51,1%) dos doentes era do sexo feminino. Nove deles (19,1%) tinham diminuição da atividade da α-galactosidase A, mas apenas um teste genético foi positivo − [GLA] c.785G>T; p.W262L (éxon 5), uma mutação não descrita na literatura. O trabalho de investigação clínica permitiu estabelecer uma associação entre a mutação e a apresentação clínica.Conclusão:Em uma população de doentes com hipertrofia ventricular esquerda, documentamos uma prevalência de doença de Fabry de 2,1%. O novo caso foi definido na sequência de uma mutação de significado indeterminado no gene GLA com posterior estudo de patogenicidade. Este estudo permitiu, assim, definir uma nova mutação causal para doença de Fabry - [GLA] c.785G>T; p.W262L (éxon 5).