A formação de estudantes de Medicina para o cuidado destinado à saúde de pessoas LGBTI+ / The training of Medical students to health care of LGBTI+ people

Resumo: Introdução: A Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais (PNSILGBT) é formada por um agrupamento de diretrizes e planos, sendo um eixo importante para formação dos profissionais de saúde, por meio de ações e estratégias específicas, para minimizar os efeitos da discriminação de gênero e sexualidade de uma população historicamente marginalizada. Na literatura, encontram-se estudos que evidenciam a falta de carga horária específica para gênero e sexualidade, a falta de transversalidade da temática LGBTI+ ou ainda a ausência da abordagem de aspectos socioeconômicos, políticos e raciais da saúde LGBTI+ dentro dos currículos de Medicina no Brasil e no mundo. Objetivo: Este estudo teve como objetivo comparar a percepção entre discentes assumidamente LGBTI+ e discentes heterossexuais no que concerne à formação dos médicos sobre a saúde de minorias sexuais e de gênero. Método: Trata-se de um estudo qualitativo, em profundidade, com análise de discurso de grupos focais, um com alunos LGBTI+ e outro com alunos não LGBTI+, em que se aplicou um questionário semiestruturado com base na análise de práticas discursivas de Spink. Resultado: A análise dos grupos identificou como questões mais pertinentes: pouca carga horária programática; falta de transversalidade; abordagem do tema com olhar pejorativo e preconceituoso; associação da população LGBTI+ com doenças infectocontagiosas ou psiquiátricas; ausência de abordagem dos aspectos socioeconômicos, culturais e raciais da temática; e atenção primária à saúde como espaço de maior abertura para discussões sobre gênero e sexualidade; Conclusão: Há uma percepção, em ambos os grupos, de que o ensino de saúde LGBTI+ é insuficiente e há um despreparo dos alunos para a abordagem da temática de gênero e sexualidade, o que gera impacto direto na assistência em saúde dessa população. Além disso, são necessários mais estudos sobre educação médica em saúde LGBTI+.

Abstract: Introduction: Brazil national public policy for the comprehensive healthcare of the LGBTi+ population consists of several guidelines and plans that include the training of health professionals. Through actions and strategies, it aims to minimize the effects of gender and sexuality discrimination on this historically marginalized population. Studies were found that show a lack of specific hours for gender and sexuality, a lack of transversality of the LGBTI+ topic and a lack of addressing the socioeconomic, political and racial aspects of LGBTI+ health in the curricula of Faculties of Medicine in Brazil and in the world. Objective: To compare the perception between admittedly LGBTI+ students and heterosexual students regarding the training of medical students on the health of sexual and gender minorities. Methodology: An in-depth qualitative study was carried out through two focus groups: one with LGBTI+ students and the other with non-LGBTI+ students. In addition, a semi-structured questionnaire was also applied. The analysis was made through the analysis of Spink's Discursive Practices. Result: Current problems were identified: low number of programmatic hours on the topic; lack of transversality; addressing the topic through a pejorative and prejudiced look; association of LGBTI+ people with infectious or psychiatric diseases; lack of addressing socioeconomic, cultural and racial aspects; Primary Care as a space of greater openness to fight against the cisheteronormative hegemony; Conclusion: LGBTI+ health education is still insufficient, as students feel unprepared to address the issue of gender and sexuality, which directly impacts the healthcare of this population. Additionally, further studies on medical education in LGBTI+ health are needed.

Chlorhexidine gluconate bathing of adult patients in intensive care units in São Paulo, Brazil: Impact on the incidence of healthcare-associated infection

Abstract Background There is an increasing use of daily chlorhexidine gluconate (CHG) bathing to decrease healthcare associated infections (HAI). Daily bathing of patients with CHG has been successfully used to prevent multidrug-resistant organisms (MDROs) HAI in intensive care units (ICU). Methods This was a 12-month, single-center, open, cluster randomized trial, conducted at four ICUs of the University Hospital of Universidade Federal de São Paulo, Unifesp, Brazil. ICUs were randomized to either perform daily bathing of the patients with pH neutral soap and water - control units, or daily bathing with 2% CHG detergent solution - intervention units. We evaluated the incidence density rate of central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), catheter associated urinary tract infection (CAUTI), Klebsiella pneumoniae carbapenemase (KPC)-producing enterobacteria HAI, and death in the intervention and control units. Results A total of 1,640 admissions of 1,487 patients occurred during the study period (41.2% control group, and 58.8% intervention group). Incidence density rates of KPC-producing enterobacteria HAI were 5.01 and 2.25 infections/1000 patient-days in the control units and in the intervention units (p = 0.013) and mortality rates were 28.7% and 18.7% in the control units and in the intervention units (p<0.001), respectively. No difference between groups was observed in CLABSI incidence (p = 0.125), VAP incidence (p = 0.247) and CAUTI incidence (p = 0.435). No serious skin reactions were noted in either study group. Daily 2% CHG detergent solution bathing is a feasible, low cost option for HAI prevention in ICU.

COVID-19 and isolation: Risks and implications in the scenario of new variants

Abstract With the emergence of new variants of SARS-CoV-2, questions about transmissibility, vaccine efficacy, and impact on mortality are important to support decision-making in public health measures. Modifications related to transmissibility combined with the fact that much of the population has already been partially exposed to infection and/or vaccination, have stimulated recommendations to reduce the isolation period for COVID-19. However, these new guidelines have raised questions about their effectiveness in reducing contamination and minimizing impact in work environments. Therefore, a collaborative task force was developed to review the subject in a non-systematic manner, answering questions about SARS-CoV-2 variants, COVID-19 vaccines, isolation/quarantine periods, testing to end the isolation period, and the use of masks as mitigation procedures. Overall, COVID-19 vaccines are effective in preventing severe illness and death but are less effective in preventing infection in the case of the Omicron variant. Any strategy that is adopted to reduce the isolation period should take into consideration the epidemiological situation of the geographical region, individual clinical characteristics, and mask for source control. The use of tests for isolation withdrawal should be evaluated with caution, due to results depending on various conditions and may not be reliable.

COVID-19 in the perioperative period of cardiovascular surgery: the brazilian experience

Abstract Introduction: We investigated the clinical course and outcomes of patients submitted to cardiovascular surgery in Brazil and who had developed symptoms/signs of coronavirus disease 2019 (COVID-19) in the perioperative period. Methods: A retrospective multicenter study including 104 patients who were allocated in three groups according to time of positive real time reverse transcriptase-polymerase chain reaction (RT-PCR) for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2): group 1, patients who underwent cardiac surgery > 10 days after positive RT-PCR; group 2, patients with a positive RT-PCR within 10 days before or after surgery; group 3, patients who presented positive RT-PCR > 10 days after surgery. The primary outcome was mortality and secondary outcomes were postoperative complications, intensive care unit (ICU) length of stay, and postoperative days of hospitalization. Results: The three groups were similar with respect to age, the European System of Cardiac Operative Risk Evaluation score, and comorbidities, except hypertension. Postoperative complications and death were significantly higher in groups 2 and 3 than in group 1, and no significant difference between groups 2 and 3 was seen. Group 2 showed a high prevalence of surgery performed as an urgent procedure. Although no significant differences were observed in ICU length of stay, total postoperative hospitalization time was significantly higher in group 3 than in groups 1 and 2. Conclusion: COVID-19 affecting the postoperative period of patients who underwent cardiovascular surgery is associated with a higher rate of morbidity and mortality. Delaying procedures in RT-PCR-positive patients may help reduce risks of perioperative complications and death.

Regressões em análise: contribuições de Ferenczi e Balint para a técnica psicanalítica / Regressions in psychoanalysis: Ferenczi's and Balint's contributions to the psychoanalytic technique / Regresiones en análisis: contribuciones de Ferenczi y Balint a la técnica psicoanalítica

Na clínica psicanalítica contemporânea temos nos defrontado, cada vez mais, com impasses técnicos que nos exigem repensar a teoria sobre a técnica psicanalítica. Essa revisão teórica se justifica a partir de uma maior incidência de quadros clínicos cujo dinamismo psíquico não se encontra balizado hegemonicamente pela lógica do recalque, mas pela predominância de outros mecanismos defensivos, como a clivagem/splitting do eu, e formas de expressão não verbais como passagens ao ato e acting outs. Diante da necessidade de reconfigurar alguns parâmetros da técnica psicanalítica, delimitamos como objetivo deste artigo a investigação do tema do manejo clínico das regressões em análise a partir das contribuições teórico-clínicas de Sándor Ferenczi e de seus desdobramentos e avanços propostos Michael Balint. Assim, pretendemos extrair das modificações no dispositivo analítico propostas por esses autores, elementos que nos ajudem a pensar o manejo clínico com pacientes cujo sofrimento remete às falhas traumáticas dos primórdios da constituição subjetiva.

In contemporary psychoanalytic clinic we have faced increasingly technical deadlocks that require to rethink the psychoanalytic technique theory. This situation requires a revision of psychoanalysis technical theory. This theoretical revision is justified by a higher incidence of clinical conditions whose psychic dynamic is not hegemonic marked by the logic of repression, but the predominance of other defensive mechanisms, e.g. splitting, and non-verbal forms of expression such as acting out. Given the need to reconfigure some parameters of the psychoanalytic technique, we set as the objective of this article the investigation of clinical management of regressions under analysis from the theoretical and clinical contributions of Sándor Ferenczi and from developments and advances by Michael Balint. Therefore, from the changes proposed by these authors, we will attempt to extract elements that will help us think different clinical management of patients whose suffering refers to traumatic failures in the early stages of development, in an analytical setting.

En la clínica psicoanalítica contemporánea nos hemos enfrentado, cada vez más, con impases técnicos que nos obligan a repensar la teoría sobre la técnica psicoanalítica. Esta revisión teórica se justifica por una mayor incidencia de cuadros clínicos cuyo dinamismo psíquico no responde a la lógica de la represión, sino por el predominio de otros mecanismos defensivos, como el clivaje / escisión del yo, y formas de expresión no verbal como pasajes al acto y "acting outs". Ante la necesidad de reconfigurar algunos parámetros de la técnica psicoanalítica, el objetivo de este artículo es delinear la investigación del tema del manejo clínico de las regresiones en análisis, a partir de las contribuciones teórico-clínicas de Sándor Ferenczi y sus desdoblamientos y avances en la teoría de Michael Balint. Así, pretendemos extraer, de las modificaciones en el dispositivo analítico propuestas por esos autores, elementos que nos ayuden a pensar sobre el manejo clínico con pacientes cuyo sufrimiento remite a los fracasos traumáticas de los primordios de la constitución subjetiva.

Baseline factors associated with death in a COVID-19 hospital cohort, Sao Paulo, 2020

ABSTRACT This study aimed to verify socio-demographic and baseline clinical factors associated with death in a hospital cohort of patients with COVID-19. A retrospective cohort study was conducted between February and December 2020 in a university hospital in the city of São Paulo, using Hospital Epidemiology Center data. RT-PCR-positive patients were selected to compose the sample (n = 1,034). At the end of the study, 362 (32%) patients died. In this cohort, age equal to or greater than sixty years (HR = 1.49) and liver disease (HR = 1.81) were independent risk factors for death from COVID-19 associated with higher in-hospital mortality.

O trauma em Ferenczi e seus desdobramentos nas obras de Balint e Winnicott: regressões em análise e seu manejo clínico / Trauma in Ferenczi and its unfoldings in the works of Balint and Winnicott: regressions under analysis and their clinical handling / El trauma en Ferenczi y sus desdoblamientos en las obras de Balint y Winnicott: regresiones en análisis y su manejo clínico

O objetivo deste artigo é investigar a problemática do trauma a partir das contribuições teórico-clínicas de Sándor Ferenczi e dos seus desdobramentos e avanços nas teorias de Michael Balint e Donald Winnicott. Assim, pretendemos explorar as proximidades e diferenças conceituais entre estes autores, principalmente em relação ao papel do ambiente na experiência traumática, das defesas primitivas que são acionadas neste caso e do aspecto terapêutico das regressões em análise. Além dessa diferenciação, buscaremos extrair das modificações no dispositivo analítico propostas por esses autores elementos que nos ajudem a pensar o manejo clínico com pacientes cujo sofrimento remete às falhas traumáticas dos primórdios da constituição subjetiva.

This article aims to investigate the discussion of trauma theory from the theoretical-clinical contributions of Sándor Ferenczi and the developments and advances held by the theories of Michael Balint and Donald Winnicott. Thus, we intend to explore the proximities and the conceptual differences of these authors, especially in relation to the role of the environment in the traumatic experience, the primitive defenses that are put into action and the therapeutic aspect of the regressions under analysis. Besides this differentiation, we will try to extract from the modifications in the analytical setting proposed by these authors, elements that will help us to think about the clinical handling of patients whose suffering refers to traumatic failures in the early stages of development.

El objetivo de este artículo es investigar la problemática del trauma a partir de las contribuciones teórico-clínicas de Sándor Ferenczi y sus desdoblamientos y avances en las teorías de Michael Balint y Donald Winnicott. Así, pretendemos explorar la proximidad y las diferencias conceptuales de estos autores, principalmente, en relación al papel del ambiente en la experiencia traumática, de las defensas primitivas que se accionan y del aspecto terapéutico de las regresiones en análisis. Además de esta diferenciación, buscaremos extraer, de las modificaciones en el dispositivo analítico propuestas por esos autores, elementos que nos ayuden a pensar el manejo clínico con pacientes cuyo sufrimiento remite a los fracasos traumáticas de los primordios de la constitución subjetiva.

Incidence of surgical site infection after craniotomy: comparison between three months and twelve months of epidemiological surveillance

ABSTRACT Objective: To determine the incidence of surgical site infection in patients undergoing craniotomy and to compare 12-month and 3-month post-discharge surveillance periods in terms of their impact on the incidence of surgical site infection in those patients. Methods: This was a retrospective cohort study involving 173 adult patients submitted to "clean" craniotomy, with or without implants, during the six-month period, at a university hospital in the city of São Paulo, Brazil. All the patients were evaluated in the pre-, trans- and postoperative periods and were followed for 12 months to analyze the development of surgical site infections. Results: Of the 173 patients undergoing craniotomy during the study period, 20 developed an surgical site infection during the first, and 12 months after discharge, the overall incidence of surgical site infection therefore being 11.56%, compared with a 1-month incidence of 8.67% and a 3-month incidence of 10.98%. Among the 106 patients who received implants, the 1-, 3-, and 12-month incidence of surgical site infection was 7.54% (n= 8), 8.49% (n= 9), and 9.43% (n= 10), respectively. Among the 67 patients who did not receive implants, the 1-, 3-, and 12-month incidence of surgical site infection was 10.44% (n= 7), 14.92% (n= 10), and 14.92% (n= 10), respectively. Conclusion: The incidence of surgical site infection after craniotomy is high. Reducing the duration of the post-discharge surveillance period from 12 months to 3 months did not cause significant losses in the numbers of surgical site infection identified or a substantial decrease in their incidence.

O Manejo Clínico de "Casos Difíceis": Herança e Atualidade de Sándor Ferenczi nas Abordagens de Winnicott e Balint / The Clinical Handling of "Difficult Cases": Heritage and Relevance of Sándor Ferenczi in the Approaches of Winnicott and Balint / El Manejo Clínico de los "Casos Difíciles": El Patrimonio y la Relevancia de Sandor Ferenczi en los Enfoques de Winnicott y Balint / La Prise en Charge Clinique des Cas «Difficiles¼: Le Patrimoine et la Pertinence de Sándor Ferenczi dans les Approches de Winnicott et Balint

O presente trabalho tem como objetivo central explicitar como os remanejamentos teóricos e reformulações técnicas de Ferenczi, que foram, posteriormente, ampliados por Michael Balint e Donald Winnicott, podem ser tomados como norteadores para pensarmos os impasses da clínica contemporânea. Nesse sentido, buscaremos destacar como a ênfase que esses autores conferem à regressão em análise e a uma postura mais empática e acolhedora do analista constituem importantes balizas para o manejo clínico com os pacientes cujo sofrimento psíquico não está referido ao modelo da neurose.

The aim of this article is to discuss how Ferenczi's theoretical changes and technique reformulations, which were amplified by Michael Balint and Donald Winnicott, can be taken as a possible guide to think the difficulties in contemporary clinic. In this sense, we will seek to highlight the emphasis that these authors give to regression in analysis and in a more empathetic and welcoming attitude of the analyst as an important boundary for handling with patients whose psychic suffering is not referred to the neurosis model.

Este trabajo está dirigido principalmente a explicar cómo las reformulaciones técnicas y teóricas de Ferenczi, que posteriormente fueron ampliados por Michael Balint y Donald Winnicott, pueden tomarse como una guía para pensar los impasses de la clínica contemporánea. En este sentido, vamos a tratar de poner énfasis en la importancia que estos autores dan a la regresión en análisis y a una actitud más empática y acogedor del analista pensándolas como coordenadas importantes para el manejo clínico de los pacientes cuyo sufrimiento psíquico no hace referencia al modelo de la neurosis.

Ce travail vise essentiellement à expliquer comment les reformulations théoriques et de la techinique de Ferenczi, qui ont été plus tard étendu par Michael Balint et Donald Winnicott, peuvent être considérées comme un guide pour penser les impasses de la clinique contemporaine. En ce sens, nous chercherons à mettre en évidence la façon dont l'accent que ces auteurs donnent à la regression dans l'espace analytique, à une attitude plus sympathique et accueillant de l'analyste, sont des directions très importants pour la prise en charge clinique des patients dont la souffrance psychique se distingue du modèle de la nevrose.

Pharmacokinetic/pharmacodynamic target attainment of intravenous β-lactam regimens against Gram-negative bacteria isolated in a Brazilian teaching hospital

ABSTRACTINTRODUCTION: Monte Carlo simulations have been used for selecting optimal antibiotic regimens for treatment of bacterial infections. The aim of this study was to assess the pharmacokinetic and pharmacodynamic target attainment of intravenous β-lactam regimens commonly used to treat bloodstream infections (BSIs) caused by Gram-negative rod-shaped organisms in a Brazilian teaching hospital.METHODS: In total, 5,000 patients were included in the Monte Carlo simulations of distinct antimicrobial regimens to estimate the likelihood of achieving free drug concentrations above the minimum inhibitory concentration (MIC; fT > MIC) for the requisite periods to clear distinct target organisms. Microbiological data were obtained from blood culture isolates harvested in our hospital from 2008 to 2010.RESULTS: In total, 614 bacterial isolates, including Escherichia coli, Enterobacterspp., Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa, were analyzed Piperacillin/tazobactam failed to achieve a cumulative fraction of response (CFR) > 90% for any of the isolates. While standard dosing (short infusion) of β-lactams achieved target attainment for BSIs caused by E. coliand Enterobacterspp., pharmacodynamic target attainment against K. pneumoniaeisolates was only achieved with ceftazidime and meropenem (prolonged infusion). Lastly, only prolonged infusion of high-dose meropenem approached an ideal CFR against P. aeruginosa; however, no antimicrobial regimen achieved an ideal CFR against A. baumannii.CONCLUSIONS:These data reinforce the use of prolonged infusions of high-dose β-lactam antimicrobials as a reasonable strategy for the treatment of BSIs caused by multidrug resistant Gram-negative bacteria in Brazil.

Does the change on gastrointestinal tract microbiome affects host?

During the past decade, studies on the composition of human microbiota and its relation to the host became one of the most explored subjects of the medical literature. The development of high-throughput molecular technologies allowed a deeper characterization of human microbiota and a better understanding of its relationship with health and disease. Changes in human habits including wide use of antimicrobials can result in dysregulation of host–microbiome homeostasis, with multiple consequences. The purpose of this review is to highlight the most important evidence in the literature of host–microbiome interactions and illustrate how these intriguing relations may lead to new treatment and prevention strategies.

Pheochromocytomas

Introduction: Pheochromocytomas are rare neuroendocrine tumors, producing catecholamines, which usually affect the adrenal medulla region of the adrenal gland. These tumors may clinically manifest in several ways, presenting themselves in most patients with persistent hypertension or paroxysmal. Ten percent of cases are considered malignant, confirmed by the presence of metastases and approximately 24% of cases are associated with inherited syndromes. Diagnostic confirmation of these syndromes implies preparatory workup, treatment and stringent follow-up, preferably with a multidisciplinary team. Objective: This study is a survey of recent studies to clarify issues related to clinical, diagnosis, genetic and treatment aspects of these patients. Conclusion: It is widely accepted that a significant percentage of patients with sporadic pheochromocytoma may have germline mutations leading to more widespread disease development and/or malignancy, and that surgical treatment in these cases must be complemented by careful clinical surveillance for early diagnosis of recurrences. This study prioritized the importance of conducting a proper pretreatment workup in cases of pheochromocytoma, which provides the additional information required for a rational course of treatment for patients.

Preventing catheter-associated infections in the Pediatric Intensive Care Unit: impact of an educational program surveying policies for insertion and care of central venous catheters in a Brazilian teaching hospital

Objectives: To determine the impact of an educational program on the prevention of central venous catheter-related infections in a Brazilian Pediatric Intensive Care Unit. Patients and Methods: All patients admitted to the unit between February 2004 and May 2005 were included in the cohort study in a longitudinal assessment. An educational program was developed based on the Centers for Disease Control and Prevention recommendations for prevention of catheter-associated infections and was adapted to local conditions and resources after an initial observational phase. Incidence of catheter-associated infections was measured by means of on-site surveillance. Results: One hundred eighteen nosocomial infections occurred in 253 patients (46.6 infections per 100 admissions) and in 2,954 patient-days (39.9 infections per 1,000 patient-days). The incidence-density of catheter infections was 31.1 episodes per 1.000 venous central catheter-days before interventions, and 16.5 episodes per 1,000 venous central catheter-days afterwards (relative risk 0.53 [95 percent CI 0.28-1.01]). Corresponding rates for exit-site catheter infections were 8.0 and 2.5 episodes per 1,000 venous central catheter-days [0.32 (0.07-1.49)], and the rates for bloodstream infections were 23.1 and 13.9 episodes per 1,000 venous central catheter-days, before and after interventions [0.61 (0.32-1.14)]. Conclusion: A prevention strategy targeted at the insertion and maintenance of vascular access can decrease rates of vascular-access infections in pediatric intensive care unit.