Left ventricular hypertrophy: hypertensive or hypertrophic cardiomyopathy? What a dilemma! A case report / Hipertrofia ventricular izquierda: ¿cardiopatía hipertensiva o miocardiopatía hipertrófica? ¡Vaya dilema! Reporte de caso

Abstract In the presence of the left ventricle hypertrophy (LVH), the differential diagnosis with hypertrophic cardiomyopathy (HCM) or some phenocopy must be always considered, which can be easily suspected when the hypertrophy is markedly asymmetric. However, when the hypertrophy is homogeneous, especially if the patient has concomitant hypertension, it may be a challenge to distinguish between hypertensive and HCM, although some clinical features may help us to suspect it. In addition, patients with HCM may present with exertional angina due to microcirculation involvement in the setting of the hypertrophy itself or dynamic obstruction in the left ventricular outflow tract, but in some cases, the presence of concomitant coronary artery disease must be suspected as the cause of angina, especially if the patient has an intermediate or high-risk probability of having ischemic heart disease. We present the case of a 46-year-old Afro-American man with poorly controlled hypertension who was found to have severe LVH, and who presented with symptoms of exertional angina during follow-up. We will review the clinical features that can help us in the differential diagnosis in this context.

Resumen Ante la presencia de hipertrofia del ventrículo izquierdo (HVI), siempre se debe considerar el diagnóstico diferencial con la miocardiopatía hipertrófica (MCH) o alguna fenocopia, que puede sospecharse fácilmente cuando la hipertrofia es marcadamente asimétrica. Además, los pacientes con MCH pueden presentar angina de esfuerzo debido a la afectación de la microcirculación en el contexto de la propia hipertrofia o si ésta condiciona obstrucción dinámica al tracto de salida del ventrículo izquierdo, pero en algunos casos debe sospecharse la presencia de enfermedad coronaria concomitante como causa de la angina, especialmente si el paciente tiene una probabilidad de riesgo intermedio o alto de padecer cardiopatía isquémica. Presentamos el caso de un varón de 46 años de afroamericana con hipertensión arterial mal controlada a quien se le detectó una HVI severa, y que durante el seguimiento presentó síntomas de angina de esfuerzo. Revisaremos las características clínicas que nos pueden ayudar en el diagnóstico diferencial en este contexto.

Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders guidelines for the treatment of adult obsessive-compulsive disorder. Part II: cognitive-behavioral therapy

Objectives: To summarize evidence-based cognitive-behavioral therapy (CBT) treatment and propose clinical interventions for adult patients with obsessive-compulsive disorder (OCD). Methods: The literature on CBT interventions for adult OCD, including BT and exposure and response prevention, was systematically reviewed to develop updated clinical guidelines for clinicians, providing comprehensive details about the necessary procedures for the CBT protocol. We searched the literature from 2013-2020 in five databases (PubMed, Cochrane, Embase, PsycINFO, and Lilacs) regarding study design, primary outcome measures, publication type, and language. Selected articles were assessed for quality with validated tools. Treatment recommendations were classified according to levels of evidence developed by the American College of Cardiology and the American Heart Association. Results: We examined 44 new studies used to update the 2013 American Psychiatric Association guidelines. High-quality evidence supports CBT with exposure and response prevention techniques as a first-line treatment for OCD. Protocols for Internet-delivered CBT have also proven efficacious for adults with OCD. Conclusion: High-quality scientific evidence supports the use of CBT with exposure and response prevention to treat adults with OCD.

Variaciones anatómicas en la vascularización del colon derecho y su implicancia en la escisión completa del mesocolon con linfadenectomía D3. Estudio de corte transversal / Anatomical variations in right colon vascularization: its implication in complete mesocolic excision with D3 lymphadenectomy. A cross-sectional study

Introducción: La escisión completa del mesocolon con linfadenectomía D3 (CME-D3) mejora los resultados de los pacientes operados por cáncer del colon. Reconocer adecuadamente la anatomía vascular es fundamental para evitar complicaciones. Objetivo: El objetivo primario fue determinar la prevalencia de las variaciones anatómicas de la arteria mesentérica superior (AMS) y sus ramas en relación a la vena mesentérica superior (VMS). El objetivo secundario fue evaluar la asociación entre las distintas variantes anatómicas y el sexo y la etnia de lo pacientes. Diseño: Estudio de corte transversal. Material y métodos: Se incluyeron 225 pacientes con cáncer del colon derecho diagnosticados entre enero 2017 y diciembre de 2020. Dos radiólogos independientes describieron la anatomía vascular observada en las tomografías computadas. Según la relación de las ramas de la AMS con la VMS, la población fue dividida en 2 grupos y subdividida en 6 (1a-c, 2a-c). Resultados: La arteria ileocólica fue constante, transcurriendo en el 58,7% de los casos por la cara posterior de la VMS. La arteria cólica derecha, presente en el 39,6% de los pacientes, cruzó la VMS por su cara anterior en el 95,5% de los casos. La variante de subgrupo más frecuente fue la 2a seguida por la 1a (36,4 y 24%, respectivamente). No se encontró asociación entre las variantes anatómicas y el sexo u origen étnico. Conclusión: Las variaciones anatómicas de la AMS y sus ramas son frecuentes y no presentan un patrón predominante. No hubo asociación entre las mismas y el sexo u origen étnico en nuestra cohorte. El reconocimiento preoperatorio de estas variantes mediante angiotomografía resulta útil para evitar lesiones vasculares durante la CME-D3. (AU)

Background: Complete mesocolic excision with D3 lymphadenectomy (CME-D3) improves the outcomes of patients operated on for colon cancer. Proper recognition of vascular anatomy is essential to avoid complications. Aim: Primary outcome was to determine the prevalence of anatomical variations of the superior mesenteric artery (SMA) and its branches in relation to the superior mesenteric vein (SMV). Secondary outcome was to evaluate the association between these anatomical variations and sex and ethnicity of the patients. Design: Cross-sectional study. Material and methods: Two hundred twenty-fivepatients with right colon cancer diagnosed between January 2017 and December 2020 were included. Two independent radiologists described the vascular anatomy of computed tomography scans. The population was divided into 2 groups and subdivided into 6 groups (1a-c, 2a-c), according to the relationship of the SMA and its branches with the SMV. Results: The ileocolic artery was constant, crossing the SMV posteriorly in 58.7% of the cases. The right colic artery, present in 39.6% of the patients, crossed the SMV on its anterior aspect in 95.5% of the cases. The most frequent subgroup variant was 2a followed by 1a (36.4 and 24%, respectively). No association was found between anatomical variants and gender or ethnic origin. Conclusions: The anatomical variations of the SMA and its branches are common, with no predominant pattern. There was no association between anatomical variations and gender or ethnic origin in our cohort. Preoperative evaluation of these variations by computed tomography angi-ography is useful to avoid vascular injuries during CME-D3. (AU)

Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders guidelines for the treatment of adult obsessive-compulsive disorder. Part I: pharmacological treatment

Objectives: To summarize evidence-based pharmacological treatments and provide guidance on clinical interventions for adult patients with obsessive-compulsive disorder (OCD). Methods: The American Psychiatric Association (APA) guidelines for the treatment of OCD (2013) were updated with a systematic review assessing the efficacy of pharmacological treatments for adult OCD, comprising monotherapy with selective serotonin reuptake inhibitors (SSRIs), clomipramine, serotonin and norepinephrine reuptake inhibitors (SNRIs), and augmentation strategies with clomipramine, antipsychotics, and glutamate-modulating agents. We searched for the literature published from 2013-2020 in five databases, considering the design of the study, primary outcome measures, types of publication, and language. Selected articles had their quality assessed with validated tools. Treatment recommendations were classified according to levels of evidence developed by the American College of Cardiology and the American Heart Association (ACC/AHA). Results: We examined 57 new studies to update the 2013 APA guidelines. High-quality evidence supports SSRIs for first-line pharmacological treatment of OCD. Moreover, augmentation of SSRIs with antipsychotics (risperidone, aripiprazole) is the most evidence-based pharmacological intervention for SSRI-resistant OCD. Conclusion: SSRIs, in the highest recommended or tolerable doses for 8-12 weeks, remain the first-line treatment for adult OCD. Optimal augmentation strategies for SSRI-resistant OCD include low doses of risperidone or aripiprazole. Pharmacological treatments considered ineffective or potentially harmful, such as monotherapy with antipsychotics or augmentation with ketamine, lamotrigine, or N-acetylcysteine, have also been detailed.

Análise dos casos de violência interpessoal contra mulheres / Análisis de casos de violencia interpersonal contra mujeres / Analysis of cases of interpersonal violence against women

Resumo Objetivo Analisar os casos notificados de violência interpessoal contra as mulheres no estado do Espírito Santo. Métodos Estudo analítico, do tipo transversal, em que foram analisados os casos notificados de violência contra a mulher no período de 2011 a 2018 no Espírito Santo. Os dados que foram analisados neste estudo são resultantes das Fichas de Notificação/Investigação de Violência Interpessoal e Autoprovocada provenientes do Sistema de Informação de Agravos de Notificação (SINAN). As análises estatísticas foram realizadas por meio do teste de Qui-quadrado e regressão de Poisson, utilizando o software Stata 14.1, sendo considerados significativos valores de p menores que 0,05. Resultados A notificação de violência interpessoal no sexo feminino representou frequência de 74,9% (n=20.449; IC95%: 74,4-75,4). Foi observado que crianças e idosas apresentaram 35% mais prevalência desse agravo comparada aos adolescentes. Há maior frequência desse fenômeno entre pessoas de cor preta / parda (RP: 1,07; IC95%:1,05-1,08) comparada àquelas de cor branca. Quanto às características do agressor verifica-se maior prevalência na faixa etária de 25 anos e mais (RP: 1,09; IC95%: 1,06-1,11), do sexo masculino (RP: 3,02; IC95%: 2,88-3,17) e sob suspeita de uso de álcool no momento da agressão (IC95%: 1,05-1,08). Em relação ao evento, nota-se uma frequência 1,28 vezes maior em via pública. Conclusão Fatores sociodemográficos, comportamentais e experiências pessoais de violência influenciam a ocorrência do fenômeno.

Resumen Objetivo Analizar los casos notificados de violencia interpersonal contra mujeres en el estado de Espírito Santo. Métodos Estudio analítico, tipo transversal, en el que se analizaron los casos notificados de violencia contra la mujer en el período de 2011 a 2018 en Espírito Santo. Los datos que fueron analizados en este estudio son resultantes de las Fichas de Notificación/Investigación de Violencia Interpersonal y Autoprovocada provenientes del Sistema de Información de Agravios de Notificación (SINAN). Los análisis estadísticos se realizaron mediante la prueba χ2 de Pearson y regresión de Poisson, con el uso del software Stata 14.1, donde se consideraron significativos valores de p menores que 0,05. Resultados La notificación de violencia interpersonal en el sexo femenino representó una frecuencia de 74,9 % (n=20.449; IC95 %: 74,4-75,4). Se observó que niñas y adultas mayores presentan un 35 % más de prevalencia de este agravio, comparadas con adolescentes. Existe una mayor frecuencia de este fenómeno en personas de color negro / pardo (RP: 1,07; IC95 %:1,05-1,08), comparadas con las de color blanco. Respecto a las características del agresor, se verificó mayor prevalencia en el grupo de edad de 25 años o más (RP: 1,09; IC95 %: 1,06-1,11), de sexo masculino (RP: 3,02; IC95 %: 2,88-3,17) y con sospecha de uso de alcohol en el momento de la agresión (IC95 %: 1,05-1,08). Con relación al evento, se observa una frecuencia 1,28 veces mayor en la vía pública. Conclusión Factores sociodemográficos, de comportamiento y experiencias personales de violencia influyen para que suceda este fenómeno

Abstract Objective To analyze the reported cases of interpersonal violence against women in the state of Espírito Santo. Methods This is an analytical, cross-sectional study, which analyzed the reported cases of violence against women from 2011 to 2018 in Espírito Santo. The data that were analyzed in this study are the result of the Reporting Forms/Investigation of Interpersonal and Self-inflicted Violence from the Reporting Diseases Information System (SINAN). Statistical analyzes were performed using the chi-square test and Poisson regression, using Stata 14.1, with p-values lower than 0.05 being considered significant. Results Interpersonal violence reporting in females represented a frequency of 74.9% (n=20,449; 95%CI: 74.4-75.4). It was observed that children and older adults had a 35% higher prevalence of this condition compared to adolescents. There is a higher frequency of this phenomenon among black/brown people (PR: 1.07; 95%CI: 1.05-1.08) compared to white people. As for aggressor characteristics, there is a higher prevalence in the age group of 25 years and older (PR: 1.09; 95%CI: 1.06-1.11), male (PR: 3.02; 95%CI: 2.88-3.17) and under suspicion of alcohol consumption at the time of aggression (95%CI: 1.05-1.08). Regarding the event, there is a frequency 1.28 times higher on public thoroughfare. Conclusion Sociodemographic, behavioral factors and personal experiences of violence influence its occurrence.

Violência física contra o sexo feminino no espírito santo / Violencia física contra la mujer en espírito santo-brasil / Physical violence against women in espírito santo

RESUMO Objetivo: identificar a frequência da notificação de violência física contra o sexo feminino no estado do Espírito Santo, no período de 2011 a 2018, e sua associação com as características da vítima, do agressor e da ocorrência. Método: estudo transversal, com análise dos casos de violência física contra mulheres notificadas no Sistema de Informação de Agravos de Notificação em 2011-2018. As associações foram testadas pelo teste qui-quadrado de Pearson e regressão de Poisson. Resultados: a notificação de violência física contra meninas e mulheres representou uma frequência de 54,1%. O grupo feminino de 20 a 59 anos tem cerca de 4,3 vezes mais prevalência de ser vítima de violência física quando comparado ao grupo de 0-9 anos. As mulheres pretas/pardas têm 1,06 vezes mais frequência de notificação de violência física. A maior parte das ocorrências do evento foi observado entre as sem deficiência/transtorno e residentes na zona urbana/periurbana. A violência física contra mulheres foi 1,71 vezes mais praticada por um conhecido, e com suspeita de uso de álcool (RP:1,07). Conclusão: a violência física contra o sexo feminino foi elevada e apresenta associação com determinadas características da vítima do agressor e da ocorrência, tais achados podem nortear as tomadas de decisões no enfrentamento a violência.

RESUMEN Objetivo: identificar la frecuencia de notificación de violencia física contra el sexo femenino en el estado del Espírito Santo-Brasil, en el período de 2011 a 2018, y su asociación con las características de la víctima, del agresor y de la ocurrencia. Método: estudio transversal, con análisis de los casos de violencia física contra mujeres notificados en el Sistema de Información de Agravios de Notificación en 2011-2018. Las asociaciones fueron comprobadas por la prueba Chi-cuadrado de Pearson y regresión de Poisson. Resultados: la notificación de violencia física contra niñas y mujeres representó una frecuencia de 54,1%. El grupo femenino de 20 a 59 años tiene cerca de 4,3 veces más prevalencia de ser víctima de violencia física cuando comparado al grupo de 0-9 años. Las mujeres negras/pardas tienen 1,06 veces más frecuencia de notificación de violencia física. La mayor parte de las ocurrencias del evento fue observada entre las sin discapacidad/trastorno y residentes en la zona urbana/periurbana. La violencia física contra mujeres fue 1,71 veces más practicada por un conocido, y con sospecha de uso de alcohol (RP:1,07). Conclusión: la violencia física contra el sexo femenino fue elevada y presenta asociación con determinadas características de la víctima del agresor y de la ocurrencia, tales hallazgos pueden guiar las tomas de decisiones en el enfrentamiento a la violencia.

ABSTRACT Objective: to identify the frequency of notification of physical violence against women in the state of Espírito Santo, from 2011 to 2018, and its association with the characteristics of the victim, the aggressor and the occurrence. Method: cross-sectional study with analysis of cases of physical violence against women reported in the Notifiable Diseases Information System in 2011-2018. The associations were tested by Pearson's chi-square test and Poisson regression. Results: the notification of physical violence against girls and women represented a frequency of 54.1%. The female group aged 20 to 59 years has about 4.3 times more prevalence of being a victim of physical violence when compared to the group aged 0-9 years. Black/brown women have 1.06 times more frequency of notification of physical violence. Most of the occurrences of the event were observed among those without disability/disorder and residents in the urban/periurban area. Physical violence against women was 1.71 times more practiced by an acquaintance, and with suspected alcohol use (PR:1.07). Conclusion: physical violence against women was high and presents association with certain characteristics of the victim of the aggressor and the occurrence, such findings can guide decision-making in coping with violence.

Enfermería de práctica avanzada en atención primaria de la salud / Advanced practice nursing in primary health care

Introducción: La enfermería de práctica avanzada está constituida por los cuidados de calidad que brinda una enfermera experta en conocimientos y competencias clínicas, que le permite tomar decisiones complejas en beneficio de poblaciones vulnerables, por lo que es una actividad clave en la atención primaria de salud. Objetivo: Analizar la evidencia científica relacionada a las experiencias de la implementación de enfermería de práctica avanzada en la atención primaria de salud. Métodos: Revisión sistemática de artículos publicados entre el año 2010 al 2020 en bases de datos SciELO, LILACS, Science Direct, REDALYC, PubMed y Elsevier en idioma castellano, inglés y portugués, para lo cual se utilizó la metodología de Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Se aplicó el uso de los Descriptores en Ciencias de la Salud (DeCS), Descriptores MeSH y la combinación de los operadores booleanos OR y AND. Se revisaron 405 artículos y luego de aplicar los criterios de inclusión y exclusión se seleccionaron 15. Conclusiones: La mayoría de los estudios revisados respaldan la necesidad de potenciar el progresivo desarrollo de la Enfermería de Práctica Avanzada y su incorporación en el sistema de salud para responder a las necesidades de salud de la población, pese a que existen dificultades en su implementación en especial en la regulación y la formación(AU)

Introduction: Advanced practice nursing is made up of quality care provided by a nurse expert in clinical knowledge and skills, allowing her to make complex decisions for the benefit of vulnerable populations, which is why it is a key activity in primary health care. Objective: To analyze the scientific evidence related to the experiences of the implementation of advanced practice nursing in primary health care. Methods: Systematic review of articles published between 2010 and 2020 in SciELO, LILACS, Science Direct, REDALYC, PubMed and Elsevier databases in Spanish, English and Portuguese, for which the Preferred Reporting Items for Systematic methodology was used. Reviews and Meta-Analyses (PRISMA); Likewise, the use of Descriptors in Health Sciences (DeCS), MeSH Descriptors and the combination of the Boolean operators OR and AND were applied. 405 articles were reviewed and after applying the inclusion and exclusion criteria, 15 were selected. Conclusions: Most of the reviewed studies support the need to promote the progressive development of Advanced Practice Nursing and its incorporation into the health system to respond to the health needs of the population, despite the fact that there are difficulties in its implementation in especially in regulation and training(AU)

Free three-dimensional image software in local extension assessment of oral squamous cell carcinoma: a pilot study

Abstract Objective: Oral Squamous Cell Carcinoma (OSCC) is conventionally treated by surgical resection, and positive surgical margins strongly increase local recurrence and decrease survival. This study aimed to evaluate whether a Three-Dimensional Segmentation (3DS) image of OSCC confers advantage over Multiplanar Reconstruction (MPR) of OSCC using images of computed tomography scan in surgical planning of tumor resection. Methods: Twenty-six patients with locally advanced OSCC had tumor morphology and dimensions evaluated by MPR images, 3DS images, and Surgical Pathology Specimen (SPS) analyses (gold standard). OSCC resection was performed with curative intent using only MPR images. Results: OSCC morphology was more accurately assessed by 3DS than by MPR images. Similar OSCC volumes and dimensions were obtained when MPR images, 3DS images and SPS measurements were considered. Nevertheless, there was a strong correlation between the OSCC longest axis measured by 3DS and SPS analyses (ICC = 0.82; 95% CI 0.59-0.92), whereas only a moderate correlation was observed between the longest axis of OSCC measured by MPR images and SPS analyses (ICC = 0.51; 95% CI 0.09-0.78). Taking only SPS with positive margins into account, MPR images and 3DS images underestimated the tumor's longest axis in eight out of 11 (72.7%) and 5 out of the 11 (45.5%) cases, respectively. Conclusion: Our data present preliminary evidence that 3DS model represents a useful tool for surgical planning of OSCC resection, but confirmation in a larger cohort of patients is required. Level of evidence: Laboratory study.

Efectividad de intervención educativa sobre conocimientos y aplicación del Proceso de Atención de Enfermería / Effectiveness of an Educational Intervention about Knowledge and Application of the Nursing Care Process

Introducción: Se observan dificultades en el manejo del Proceso de Atención de Enfermería en los internos de enfermería, que limitan su aplicación y pone en riesgo la calidad del cuidado. Objetivo: Evaluar la efectividad de una capacitación para internos, sobre conocimientos y aplicación del Proceso de Atención de Enfermería. Métodos: Estudio pre experimental, con un grupo, antes y después, en el instituto Nacional Materno Perinatal, 2018. Población = 78, Muestra = 60 internos de enfermería. Después del pre test se planificó y realizó la capacitación a 12 grupos de cinco internos cada uno, cada cuatro semanas y se aplicó post test. La prueba de Smirnov- Kolmogorov determinó la distribución de normalidad de los datos y según las variables y tiempo de observación se aplicó estadísticos descriptivos. Trasformando las puntuaciones vigesimales a categorías: desaprobado, regular, bueno, muy bueno y excelente se obtuvo el valor final de las variables. La prueba de hipótesis, se realizó mediante Prueba t de Student para medias de dos muestras emparejadas. Resultados: La edad media fue 24 años, 86 por ciento (52) sexo femenino. Las calificaciones antes de la intervención, fueron de 10,6 ± 1,45 para los conocimientos y 13,7 ± 1,21 para la aplicación, del proceso de atención de enfermería después 16,4 ± 1,57 y 17,2 ± 1,64 respectivamente. Conclusión: Demostró la efectividad del programa la variación positiva en el nivel de conocimientos del Proceso de Atención de Enfermería de "regular "a "muy bueno" y en el de aplicación de un nivel "regular" a "bueno y excelente"(AU)

Introduction: Difficulties are perceived with respect to management of the nursing care process by nursing interns, which limits its application and puts quality of care at risk. Objective: To assess the effectiveness of a training received by interns concerning knowledge and application of the nursing care process. Methods: One-group pretest-posttest pre-experimental study carried out in 2018 at the National Maternal and Perinatal Institute. The population and the sample were 78 and 60 nursing interns, respectively. After the pretest, training was planned and carried out, every four weeks, with twelve groups of five interns each. Then posttest was applied. The Smirnov-Kolmogorov test determined the normality distribution of the data and, according to the variables and observation time, descriptive statistics was applied. Transforming the vigesimal scores into the categories disapproved, fair, good, very good and excellent, the final value of the variables was obtained. The hypothesis test was performed using Student's t test for means of two paired samples. Results: The mean age was 24 years. 86 percent (52) were female. The scores before the intervention were 10.6 ± 1.45 for knowledge and 13.7 ± 1.21 for application. For the posttest application of the nursing care process, such scores were 16.4 ± 1.57 and 17.2 ± 1.64, respectively. Conclusion: The effectiveness of the program was demonstrated by the positive level variation in knowledge about the nursing care process, being from regular to very good. In the application level, it moved from the level regular to good and excellent(AU)

Conocimiento, actitudes y prácticas sobre la Malaria en comunidades de Maniapure, Estado Bolívar

Introducción: La Malaria es una enfermedad de importancia epidemiológica, la cual ha tenido un repunte en los últimos años en el Estado Bolívar. Al ser potencialmente mortal, es vital la elaboración de estrategias preventivas basadas en los conocimientos y prácticas comunitarias. Objetivos: Identificar los conocimientos, actitudes y prácticas relacionados con la malaria y comparar con hallazgos de otras áreas endémicas. Métodos: Se realizó un estudio observacional, descriptivo y de corte transversal en la región de Maniapure del 28 al 31 de agosto del 2018. Se aplicó un cuestionario de 30 preguntas de respuestas cerradas. Los resultados fueron presentados según su frecuencia absoluta y relativa. Resultados: Se entrevistaron a 77 jefes de familia, de los cuales 63,64 % (n=49) refirió tener antecedente de malaria y 38,96 % (n=30) conoció a alguien que haya fallecido en su comunidad por esta. En cuanto a conocimientos, 79,22 % (n=61) sabe que la enfermedad se adquiere por la picadura de un mosquito, 51,95 % (n=40) cree que se transmite por el agua y 97,4 % (n=75) asocia la fiebre como síntoma principal. A nivel de actitudes y prácticas, el 92,21 % (n=71) acudiría al médico para tratar la enfermedad, 62,34 % (n=29) mantiene los canales y zanjas limpias y 70,13 % (n=54) usa mosquitero y/o repelente. Conclusión: El área de Maniapure se ubica en una región endémica, y al tratarse de poblaciones susceptibles con diferente trasfondo cultural, se deben elaborar planes educativos individualizados orientados a la prevención, y evaluar su impacto en la práctica.

Introduction: Malaria is a disease with public health significance, with an increase in the last years in Bolivar State. As a potentially life-threatening infection, the development of preventive strategies based on community knowledge and practices is necessary. Objectives: To identify the knowledge, attitudes, and practices related to malaria and compare it with findings from other endemic areas. Methods: An observational, descriptive, and cross-sectional study was conducted in the Maniapure region from August 28 to 31, 2018. A questionnaire of 30 questions with closed answers was applied. The results were presented according to their absolute and relative frequency. Results: 77 family leaders were interviewed, of which 63.64 % (n=49) reported having a history of malaria and 38.96 % (n=30) knew someone who had died in their community from it. About knowledge, 79.22 % (n=61) knew that the disease is acquired by a mosquito bite, 51.95 % (n=40) believed that it's transmitted through water, and 97.4 % (n=75) associate fever as the main symptom. In relation to attitudes and practices, 92.21 % (n=71) would go to the doctor to treat the disease, 62.34 % (n=29) kept the channels and ditches clean and 70.13 % (n= 54) used a mosquito net and/or repellent. Conclusion: Maniapure is located in an endemic region, and since they have susceptible population with different cultural backgrounds, individualized educational plans (focused on prevention) should be elaborated, as well as test the impact in practices.

Niveles de Burnout y estrategias de afrontamiento en docentes de educación superior / Burnout Levels and Coping Strategies in Higher Education Professors

Introducción: Los educadores y trabajadores de la salud se hallan entre las personas susceptibles a estrés y Burnout Objetivo: Discutir, en base a la literatura científica, los niveles de Burnout y las estrategias de afrontamiento en docentes de educación superior. Métodos: Revisión sistemática de artículos publicados entre 2010 y 2018 en las bases de datos EBSCO host, SCIELO, ERIC, SCIENCE DIRECT, SCOPUS, REDALYC, DOAJ y LILACS. En la estrategia de búsqueda se utilizó el diagrama de flujo Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). Se revisaron 18 artículos (en idiomas español, portugués e inglés) tras aplicar los criterios de inclusión y exclusión. Conclusiones: No queda claro si existe Burnout en los docentes de educación superior. Se asocia levemente niveles altos de agotamiento y despersonalización con alto compromiso laboral; estrés laboral y nivel de agotamiento alto con menor satisfacción laboral; relación entre alto nivel de agotamiento con profesores jóvenes con menos experiencia; agotamiento con factores académicos como horas de enseñanza; Burnout con actividades de investigación; mayor estrés con condición laboral contratado. No se halló relación significativa entre Burnout y sentimientos de autoeficacia o desempeño docente; cansancio emocional y satisfacción ocupacional. Las estrategias para afrontar el estrés que utilizan los docentes son las enfocadas en la solución del problema, la búsqueda de ayuda o apoyo social y la revaluación positiva(AU)

Introduction: Health educators and general workers in the sector are among the people vulnerable to stress and burnout Objective: To discuss, based on the scientific literature, burnout levels and coping strategies in higher education professors. Methods: Systematic review of articles published between 2010 and 2018 in the databases EBSCO host, SCIELO, ERIC, SCIENCE DIRECT, SCOPUS, REDALYC, DOAJ, and LILACS. In the search strategy, the Preferred Reporting Items for Systematic Review and Meta-Analyzes (PRISMA) flowchart was used. Eighteen articles (in Spanish, Portuguese, and English) were reviewed after applying the inclusion and exclusion criteria. Conclusions: It is not clear if burnout exists in higher education professors. High levels of exhaustion and depersonalization are slightly associated with high work commitment. Job stress and high level of exhaustion are associated with less job satisfaction. Relationship between high level of exhaustion is associated with younger professors with less experience. Exhaustion is associated with academic factors such as teaching hours. Burnout is associated with research activities. Increased stress is associated with an employment condition as contracted. No significant relationship was found between burnout and feelings of self-efficacy or teaching performance, or between emotional fatigue and occupational satisfaction. The strategies for dealing with stress that teachers use are those focused on solving the problem, seeking help or social support, and positive revaluation(AU)

Factores asociados al ausentismo laboral de enfermeras / Factors Associated to Work Absenteeism in Nurses

Introducción: El ausentismo en enfermería es un problema frecuente, de gran impacto socioeconómico que pone en riesgo la calidad de atención. Objetivo: Describir el ausentismo laboral y los factores asociados en enfermeros de un hospital nivel III. Métodos: Investigación descriptiva transversal, en el Hospital Nacional Dos de Mayo de Lima-Perú durante 2018. La población estuvo constituida por 471 enfermeras y la muestra aleatoria por 72. Se revisaron los registros de ausencias de los años 2016 y 2017, se aplicó un cuestionario previo consentimiento informado. Los datos fueron procesados y analizados utilizando estadísticas descriptivas. Resultados: El 97,22 por ciento (70) pertenecía al sexo femenino; 47,22 por ciento (34) tenía entre 31 y 44 años; 50 por ciento (36) eran casadas y 23,61 por ciento (17) separadas. La tasa de ausentismo fue de 4 por ciento; la de severidad de 40 horas pérdidas por cada 1000 horas/enfermeras trabajadas; se perdieron 6 turnos por enfermero al año. Conclusiones: La magnitud del ausentismo total por faltas es alta. Predominó el ausentismo parcial, no programado: tardanzas y permisos. Los factores personales asociados al ausentismo fueron: tener niños pequeños; vínculo laboral con otra institución; tener niños, pero además tener bajo su cuidado a padres ancianos; tener una enfermedad crónica además de cuidar a sus padres y tener niños; ser padre y madre en el hogar, además de tener niños, doble trabajo y cuidar de uno de sus padres. Los factores laborales y extralaborales fueron: dificultades en el área de trabajo, no poder cambiar el turno; y las capacitaciones externas(AU)

Introduction: Absenteeism in nursing is a frequent problem, of great socioeconomic impact and representing a risk for the quality of care. Objective: To describe work absenteeism and its associated factors in nurses of a third-level hospital institution. Methods: Cross-sectional and descriptive research carried out at Dos de Mayo National Hospital in Lima-Peru, during 2018. The study group consisted of 471 nurses and the random sample was made up of 72. The absence records of the years 2016 and 2017 were reviewed, and a questionnaire with prior informed consent was applied. The data were processed and analyzed using descriptive statistics. Results: 97.22 percent (70) belonged to the female sex, 47.22 percent (34) were at aged 31-44, 50 percent (36) were married, and 23.61 percent (17) were separated. The rate of absenteeism was 4 percent, severity was 40 hours lost per 1000 worked hours per nurses, and 6 shifts were lost per nurse yearly. Conclusions: The magnitude of total absenteeism due to nonattendances is high. Partial and unanticipated absenteeism predominated: late arrivals and leaves. The personal factors associated with absenteeism were having young children, employment relationship with another institution; having children at the same time of having elderly parents under the nurse's care, having a chronic illness in addition to caring for their parents and having children, being a father and mother at home, besides having children, two jobs and taking care of one of their parents. The labor and extra-labor factors were difficulties in the work area, not being able to change the shift, and external training(AU)

Impact of One-Catheter Strategy with TIG I Catheter on Coronary Catheterization Performance and Economic Costs / Impacto da Estratégia de um Cateter com Cateter TIG I no Desempenho da Coronariografia por Cateterismo e Custos Econômicos

Abstract Background: Coronary angiography with two catheters is the traditional strategy for diagnostic coronary procedures. TIG I catheter permits to cannulate both coronary arteries, avoiding exchanging catheters during coronary angiography by transradial access. Objective: The aim of this study is to evaluate the impact of one-catheter strategy, by avoiding catheter exchange, on coronary catheterization performance and economic costs. Methods: Transradial coronary diagnostic procedures conducted from January 2013 to June 2017 were collected. One-catheter strategy (TIG I catheter) and two-catheter strategy (left and right Judkins catheters) were compared. The volume of iodinated contrast administered was the primary endpoint. Secondary endpoints included radial spasm, procedural duration (fluoroscopy time) and exposure to ionizing radiation (dose-area product and air kerma). Direct economic costs were also evaluated. For statistical analyses, two-tailed p-values < 0.05 were considered statistically significant. Results: From a total of 1,953 procedures in 1,829 patients, 252 procedures were assigned to one-catheter strategy and 1,701 procedures to two-catheter strategy. There were no differences in baseline characteristics between the groups. One-catheter strategy required less iodinated contrast [primary endpoint; (60-105)-mL vs. 92 (64-120)-mL; p < 0.001] than the two-catheter strategy. Also, the one-catheter group presented less radial spasm (5.2% vs. 9.3%, p = 0.022) and shorter fluoroscopy time [3.9 (2.2-8.0)-min vs. 4.8 (2.9-8.3)-min, p = 0.001] and saved costs [149 (140-160)-€/procedure vs. 171 (160-183)-€/procedure; p < 0.001]. No differences in dose-area product and air kerma were detected between the groups. Conclusions: One-catheter strategy, with TIG I catheter, improves coronary catheterization performance and reduces economic costs compared to traditional two-catheter strategy in patients referred for coronary angiography.

Resumo Fundamento: A cineangiocoronariografia com dois cateteres é a estratégia tradicional para procedimentos coronarianos de diagnóstico. O cateter TIG I permite canular ambas as artérias coronárias, evitando a troca de cateteres durante a cineangiocoronariografia por acesso transradial. Objetivo: O objetivo deste estudo é avaliar o impacto da estratégia de um cateter, evitando a troca de cateter, no desempenho da coronariografia por cateterismo e nos seus custos econômicos. Métodos: Foram coletados os procedimentos diagnósticos coronarianos transradiais realizados entre janeiro de 2013 e junho de 2017. A estratégia de um cateter (cateter TIG I) e a estratégia de dois cateteres (cateteres coronários direito e esquerdo de Judkins) foram comparadas. O volume de contraste iodado administrado foi o endpoint primário. Os endpoints secundários eram espasmo radial, duração do procedimento (tempo de fluoroscopia) e exposição a radiações ionizantes (produto dose-área e kerma no ar). Os custos econômicos diretos também foram avaliados. Para as análises estatísticas, valores de p < 0,05 bicaudais foram considerados estatisticamente significativos. Resultados: De um total de 1.953 procedimentos em 1.829 pacientes, 252 procedimentos foram atribuídos à estratégia de um cateter e 1.701 procedimentos à estratégia de dois cateteres. Não houve diferenças nas características basais entre os grupos. A estratégia de um cateter exigiu menos contraste iodado [endpoint primário; (60-105) -mL vs. 92 (64-120) -mL; p < 0,001] em comparação com a estratégia de dois cateteres. Além disso, o grupo da estratégia de um cateter apresentou menos espasmo radial (5,2% vs. 9,3%, p = 0,022) e menor tempo de fluoroscopia [3,9 (2,2-8,0) -min vs. 4,8 (2,9-8,3) -min, p = 0,001] e economia de custos [149 (140-160)-€/procedimento vs. 171 (160-183) -€/procedimento; p < 0,001]. Não foram detectadas diferenças no produto dose-área e kerma no ar entre os grupos. Conclusões: A estratégia de um cateter, com cateter TIG I, melhora o desempenho da coronariografia por cateterismo e reduz os custos econômicos em comparação com a estratégia tradicional de dois cateteres em pacientes encaminhados para cineangiocoronariografia.

Personality Inventory for DSM-5 (PID-5): cross-cultural adaptation and content validity in the Brazilian context / Inventário de Personalidade para o DSM-5 (PID-5): adaptação transcultural e validade de conteúdo para o contexto brasileiro

Abstract Objective To describe the process of cross-cultural adaptation of the Personality Inventory for DSM-5 (PID-5) to the Brazilian context. Methods Cross-cultural adaptation involved the steps of independent translation of the instrument, synthesis version, and back-translation. Analysis of content validity was conducted by a multidisciplinary expert committee and consisted of quantitative assessment of agreement indicators. The test was then applied to a target population. Results All the steps required for a cross-cultural adaptation were followed and satisfactory agreement values (≥ 4.75) were reached for most of the structures assessed. Most of the changes suggested by the experts were followed; these changes consisted primarily of adjustments to verb tense and agreement and the inclusion of letters and words to allow gender inflection. In the pre-test, no suggestions were made and the instrument was considered comprehensible. Conclusion The Brazilian version of the PID-5 was found to be adequate to the Brazilian context from semantic, idiomatic, cultural, and conceptual perspectives. The Brazilian version assessed here can be freely used, was approved by the publishers who hold the copyright on the instrument, and is considered the official version of the instrument. New studies are underway to determine the validity and reliability of the PID-5.

Resumo Objetivo Apresentar o processo de adaptação transcultural do Personality Inventory for DSM-5 (PID-5) para o contexto brasileiro. Métodos A adaptação transcultural envolveu as etapas de tradução independente, versão síntese e retrotradução. A validade de conteúdo foi realizada por um comitê multidisciplinar de especialistas, com avaliação quantitativa dos índices de concordância. Por fim, o pré-teste foi conduzido com a população-alvo. Resultados Todos os estágios da adaptação transcultural foram seguidos, e na maioria das estruturas avaliadas, os valores de concordância foram satisfatórios (≥ 4.75). Grande parte das sugestões de modificações feitas pelos especialistas foram acatadas, sendo as principais relacionadas a ajustes no tempo e concordância verbal e a inclusão de letras e palavras para permitir a flexão de gênero. No pré-teste nenhuma sugestão foi apresentada e o instrumento foi considerado compreensível. Conclusão A versão brasileira do PID-5 mostrou-se adequada ao contexto brasileiro sob as perspectivas semântica, idiomática, cultural e conceitual. A versão brasileira avaliada é de uso livre, foi aprovada pelas editoras responsáveis pelos direitos autorais do instrumento e é considerada oficial. Novos estudos estão sendo conduzidos para aprimorar a busca por evidencias de validade e confiabilidade.

Ensinando a Anamnese Psiquiátrica para Estudantes de Medicina através da Inversão de Papéis: Relato de Experiência / Teaching Psychiatric Anamnesis to Medical Students through Role Reversal: Experience Report

RESUMO Introdução Tem havido um renovado interesse pela temática da relação médico-paciente e dos valores humanitários na formação dos estudantes de Medicina, pois a capacidade de sentir empatia pelos pacientes é considerada um dos pilares da boa prática médica. A inversão de papéis é uma técnica derivada do psicodrama que pode favorecer o desenvolvimento da capacidade empática na relação médico-paciente. Objetivo Relatar a experiência de ensino-aprendizagem da anamnese psiquiátrica no curso de Semiologia em Psiquiatria com alunos da terceira série do curso médico da Faculdade de Medicina de Botucatu (Unesp), utilizando a inversão de papéis como principal método pedagógico. Método Relato de experiência. A atividade é desenvolvida em cinco etapas distintas, mas inter-relacionadas: (1) leitura e estudo autônomos da apostila de propedêutica psiquiátrica; (2) realização da anamnese em três grupos de 15 alunos, em que estes alternam o papel de médico (entrevistador) e paciente (entrevistado); (3) realização de uma anamnese completa com um colega de turma, alternando-se também o papel de paciente e de médico; (4) realização, pela mesma dupla, da anamnese psiquiátrica com um paciente internado no hospital geral universitário; (5) discussão das anamneses realizadas, atividade em que os alunos assumem o papel do paciente entrevistado para relatar, em primeira pessoa, os dados obtidos na entrevista. Resultados Os alunos mostram-se colaborativos, participando com interesse de todas as etapas da atividade, que parece favorecer não apenas o aprendizado específico da anamnese psiquiátrica, mas também a capacidade empática pelos colegas e pacientes. Nas discussões, atenção especial é dada às descobertas e dificuldades vivenciadas pelos estudantes nessas atividades práticas, assim como aos sentimentos experimentados em cada uma das etapas do processo. A atitude do preceptor de ouvir e acolher com respeito todos os relatos, dúvidas e manifestações afetivas dos alunos procura ser um modelo de postura de acolhimento sem julgamento dos problemas e sentimentos dos pacientes, postura fundamental para o estabelecimento da aliança terapêutica. Conclusão A inversão de papéis pode auxiliar os estudantes de Medicina no aprendizado da anamnese psiquiátrica, assim como no desenvolvimento da empatia, habilidade essencial à prática médica de boa qualidade.

ABSTRACT Introduction There has been renewed interest in the doctor-patient relationship and humanitarian values in the training of medical students, given that the ability to feel empathy for patients is considered one of the pillars of good medical practice. Role reversal is a technique derived from Psychodrama that can promote the development of empathic capacity in the doctor-patient relationship. Objective to report a teaching-learning experience of psychiatric anamnesis in the course of Semiology in Psychiatry with 3rd year students of Botucatu Medical School (UNESP), using the technique of role reversal as the main pedagogical approach. Method experience report. The activity has been developed in five distinct but interrelated stages: 1) autonomous reading and studying the psychiatric propaedeutic courseware; 2) performing the anamnesis in three groups of 15 students, in which they alternate between the roles of physician (interviewer) and patient (interviewed); 3) performing a complete anamnesis with a classmate, also alternating the roles of patient and physician; 4) the same pair of students performs the psychiatric anamnesis with an inpatient of the general university hospital; 5) discussion of the anamneses performed, an activity in which the students assume the role of the patient, reporting, in the first person, the data obtained in the interview. Results the students have been collaborative, participating with interest in all stages of the activity, which seems to favour not only the specific learning of psychiatric anamnesis, but also their empathic capacity towards colleagues and patients. In the discussions, special attention has been given to the discoveries and difficulties experienced by the students in these practical activities, and the feelings experienced in each stage of the process. The preceptors' attitude of respectfully listening to and accepting all the reports, doubts and affective manifestations of the students provides a model for an accepting and non-judgemental attitude toward patients' problems and feelings, which is fundamental for the development of the therapeutic alliance. Conclusion Role reversal can be used to help medical students develop their skills in psychiatric anamnesis, and their empathy, an essential skill for good quality medical practice.

Immunological and Morphological substantiation of the use of dental stick with biopharmaceuticals in the complex therapy of inflammatory periodontal diseases

Aim of the study: clinical, immunological and morphological substantiation of the use of a dental stick with biopharmaceuticals in the complex therapy of inflammatory periodontal diseases. Research methods: leukocyte migration test, cytograms, the study of quantitative and qualitative content of spontaneously released mixed saliva, measurement of the total content of protein, the content of secretory immunoglobulin A (sIgA) and lysozyme in it. Clinical improvement of the periodontal tissues condition after treatment by 77% was registered. OHI-S (hygienic index), PI (periodontal disease index), PMA (papillary-marginal-alveolar index) were 7.5, 3.4, and 8.7 times lower, respectively, compared to the pre-treatment group. The depth of periodontal pockets decreased 2.6-3.4 times, the number of sessions per treatment course was reduced to 3-8 visits to the doctor. The amount of mixed saliva (in comparison with the initial data) increased 2.7 times, normal levels were restored and were 1.2 ml higher than control indicators. Protein levels, lysozyme and sIgA concentrations increased and exceeded the pre-treatment level 1.8 times and by 44.5%, respectively. Cytograms data revealed that the number of red blood cells (in one field of view) in the gingiva specimens in inflammatory periodontal diseases (IPD) patients was 2.3 times lower, count of leukocytes with signs of destruction was 13.4 lower and intact leukocyte count was 3.8 times lower. Lymphocyte count was 2 times lower, indicating that the inflammatory process in periodontal tissues was reduced as a re sult of the reduction of the microbial burden: staphylococci and actinomycetes were detected 3 times less often, diplococci ­ 3.5 times less often, filamentous bacteria and streptococci ­ 4 times less often, protists ­ 5 times less often, respectively. The number of cocci microcolonies was 2.7 times higher. The number of fibroblasts (in one field of view) increased threefold, the content of collagen filaments of the normally oriented structure increased 1.4 times, compared to the original data, which indicated the formation of favorable conditions for healing and reparative regeneration processes. The results of the study showed that the use of a dental stick during local IPD therapy is an effective way of correcting changes in clinical and laboratory indicators of local immunity and that dental stick is a promising new dosage form in practical periodontology.

The Effect of Fibroblast Growth Factors in Grafted Fascia into the Vocal Fold of Rabbits

Abstract Introduction The human larynx is a very important organ for communication. Many conditions lead to scarring of the vocal folds, decreasing voice quality. Objective We aimed to determine whether fibroblast growth factors (FGFs) may influence tissue integration of grafted fascia into the vocal folds of an animal model. Methods This is an experimental animal study with 12 adult rabbits that were submitted to a grafting fragment obtained from superficial cervical fascia into the vocal fold lamina propria, bilaterally. The right vocal fold was injected with FGFs. The animals were sacrificed after 1 month or 12 months, depending on the group they were assigned to, and a histological analysis of their vocal folds was performed.We analyzed the histological changes (such as the presence of fibrosis and neovascularization) induced by the acute or chronic inflammatory reactions. Results The FGFs induced acute inflammatory changes in all animals after 1 month of the initial experiment. The presence of FGFs triggered more fibrosis than the expected due to the surgical procedure itself when compared with the control side of all animals after 12 months of the initial experiment. Conclusions Fibroblast growth factors alone do not represent a good therapeutic option in phonosurgery, since we observed higher levels of fibrosis in the vocal fold lamina propria. Further studies combining more substances may be necessary to elucidate the best option to be used in this kind of surgery. (AU)

Assessment of safety culture in a public hospital in the Federal District, Brazil / Evaluación de la cultura de seguridad en un hospital público en el Distrito Federal, Brasil / Avaliação da cultura de segurança em um hospital público no Distrito Federal, Brasil

ABSTRACT Objective: to assess the perception of health professionals regarding safety culture of a high complexity public hospital of the Federal District, Brazil. Method: cross-sectional and descriptive study. The Safety Attitudes Questionnaire was used in electronic format. Descriptive and inferential analyses were carried out. Results: 358 professionals participated, with 242 (67.6%) being female. Of these, 224 (62.6%) worked directly or indirectly with patients in assistance activities; 79 (22.1%) in administrative activities; 14 (3.9%) in management; and 41 (11.5%) in others. The total score was 57.1. Job satisfaction factors and stress perception had the most expressive results, 76.2 and 68.8, respectively. The category "working conditions" presented the lowest result, 40.7. Conclusion: the results are below the score of 75, value recommended as indicative of a positive safety atmosphere. We suggest the implementation of actions for the promotion of safety culture and new studies with representative samples of all segments of workers.

RESUMEN Objetivo: evaluar la percepción de los profesionales de salud sobre la cultura de seguridad de un hospital público de alta complejidad del Distrito Federal, Brasil. Método: estudio transversal y descriptivo. Se utilizó el Cuestionario Actitudes de Seguridad en el formato electrónico. Se realizaron análisis descriptivos e inferenciales. Resultados: participaron 358 profesionales, siendo 242 (67,6%) mujeres. De estos, 224 (62,6%) trabajaban directa o indirectamente con el paciente en actividades asistenciales; 79 (22,1%) en administrativas; 14 (3,9%) en gerenciales; y 41 (11,5%) en otras. La puntuación total fue de 57,1; los factores de satisfacción en el trabajo y percepción del estrés tuvieron los resultados más expresivos, 76,2 y 68,8, respectivamente. La categoría de las condiciones de trabajo tuvo el resultado más bajo, 40,7. Conclusión: los resultados están por debajo de la puntuación 75, valor recomendado como indicativo de un clima de seguridad positivo. Se sugiere la implementación de acciones para la promoción de la cultura de seguridad y nuevos estudios con muestra representativa de todos los segmentos de trabajadores.

RESUMO Objetivo: avaliar a percepção dos profissionais de saúde sobre a cultura de segurança de um hospital público de alta complexidade do Distrito Federal, Brasil. Método: estudo transversal e descritivo. Utilizou-se o Questionário Atitudes de Segurança no formato eletrônico. Foram realizadas análises descritivas e inferenciais. Resultados: participaram 358 profissionais, sendo 242 (67,6%) do sexo feminino. Destes, 224 (62,6%) trabalhavam direta ou indiretamente com o paciente em atividades assistenciais; 79 (22,1%) em administrativas; 14 (3,9%) em gerenciais; e 41 (11,5%) em outras. O escore total foi de 57,1; os fatores satisfação no trabalho e percepção do estresse tiveram os resultados mais expressivos, 76,2 e 68,8, respectivamente. O quesito condições de trabalho teve o resultado mais baixo, 40,7. Conclusão: os resultados estão abaixo do escore 75, valor recomendado como indicativo de um clima de segurança positivo. Sugere-se a implementação de ações para a promoção da cultura de segurança e novos estudos com amostra representativa de todos os segmentos de trabalhadores.