Design thinking como metodologia na elaboração de uma proposta de matriz curricular / Design thinking as a methodology in the elaboration of a curricular structure proposal

Resumo Introdução: A matriz curricular do curso de Medicina pode variar de acordo com o projeto pedagógico de curso (PPC) de cada instituição de ensino superior (IES). Nem sempre a visão da coordenação e do corpo docente do curso de Medicina está alinhada às opiniões dos alunos. Assim, a utilização de uma metodologia para identificar a visão do corpo discente seria fundamental. O design thinking (DT) é um processo que propõe a busca, de forma empática, colaborativa e criativa, de soluções para problemas complexos. Objetivo: Este estudo apresenta o DT como uma metodologia para identificar como os alunos do internato acreditam que deva ser a matriz curricular do primeiro ao quarto ano de um curso de Medicina no estado de São Paulo, e, para tanto, coletaram-se sugestões e pontos que exigiram a reavaliação na matriz original. Método: Realizou-se uma avaliação qualitativa com base no modelo do DT. Os alunos foram divididos em três grupos de cinco alunos, e cada grupo dedicou-se a discutir livremente sobre suas ideias acerca da matriz curricular. Posteriormente, apresentou-se um painel para cada grupo com a separação dos semestres correspondentes - do primeiro ao quarto ano - com post-it representando a matriz curricular vigente do curso de Medicina, e cada grupo teve uma hora para remontar a matriz curricular da maneira que julgasse mais adequado. Resultado: Após a fase de discussão, cada grupo montou sua matriz curricular, e propuseram-se algumas mudanças do ano em que a disciplina era ministrada e a inclusão de algumas matérias. A maioria das sugestões foi julgada procedente e incorporada na matriz curricular. Conclusão: A metodologia do DT contribuiu para a identificação de várias demandas acerca da matriz curricular de uma forma ordenada, empática e colaborativa, levando em consideração a opinião do estudante, sendo, portanto, uma estratégia de planejamento capaz de evidenciar fragilidades e fortalezas do currículo que talvez não fossem percebidas por outras estratégias.

Abstract Introduction: The medical school curricular structure may vary according to the educational planning of each higher education institution (HEI). The viewpoint of the coordination and the medical school faculty is not always aligned with the students' opinions. Thus, using a methodology to identify the students' point of view would be essential. Design thinking (DT) is a process that proposes a search, in an empathetic, collaborative, and creative way, for solutions to complex problems. Objectives: To present DT as a methodology to identify how clinical internship students believe the curricular structure from the 1st to the 4th year of a São Paulo state medical school should be, by collecting suggestions and points that require a re-evaluation process of the current curricular structure. Methods: This is a qualitative assessment, which will use the DT model. Students were divided into three groups of five, and each group was committed to having a free discussion on its ideas concerning the curricular structure. Then, a panel was presented to each group, dividing the semesters from the 1st to the 4th year with post-it notes representing the current curricular structure of the medical school, and each group had one hour to reassemble the curricular structure as they deemed appropriate. Results: After the discussion stage, each group assembled its curricular structure. Some changes concerning the year in which the discipline was provided were proposed, and the inclusion of others. Most of the suggestions were considered valid and were incorporated into the curriculum. Conclusions: The DT methodology contributed to the identification of several demands regarding the curricular structure in an orderly, empathetic, and collaborative way, taking into account the students' opinions. It is, therefore, a planning strategy able to evidence weaknesses and strengths of the curriculum that might not have been noticed by the use of other strategies.

Palliative care in medical education: the students' perception / Cuidados Paliativos na formação médica: percepção dos estudantes

Abstract: Introduction: Population aging, longer life expectancy and the increase in the prevalence of chronic diseases have brought new health demands, among them, palliative care (PC). Although present in the clinical routine, this topic has not yet been included in most medical schools in Brazil. Objective: To know the teaching-learning process in PC according to the perception of medical students from schools that have this subject. Method: Qualitative method through interviews with 35 medical students from 14 medical schools located in the Northeast, Southeast and South regions of the country. Results: The reports were classified into three categories: conception of PC, changes perceived after exposure to PC teaching, challenges and successful strategies identified in PC teaching. Students recognize the value of teaching in PC and have a greater understanding of PC approach and its early indication for people with complex chronic conditions. The inclusion of the topic contributed to the overcoming of fears and taboos related to death, providing greater comfort to deal with human suffering, adding emotional skills. The formal education in PC allowed understanding the person in their biopsychosocial and spiritual dimension. They stressed the importance of communication skills to communicate difficult news, symptom management, teamwork and an individualized approach to the person and their family. Although they identify little theoretical-practical integration in the teaching-learning scenario in PC, they report an interest in the topic, and indicated successive experiences as strategies throughout the training, in a humanist axis. Conclusion: PC teaching brings contributions to medical training that go beyond the learning of the subject and reinforces the development of empathy and compassion, recognized as essential in this profession, as well as the relevance of assertiveness in the management of suffering and the comprehensive care of people with advanced diseases.

Resumo: Introdução: O envelhecimento populacional, a maior expectativa de vida e o aumento da prevalência de doenças crônicas trouxeram novas demandas em saúde, como os cuidados paliativos (CP). Embora presente no cotidiano clínico, essa temática ainda não foi incluída na maioria das escolas médicas no Brasil. Objetivo: Este estudo teve como objetivo conhecer o ensino-aprendizagem em CP na percepção do estudante de Medicina de escolas que dispõem dessa disciplina. Método: Trata-se de estudo qualitativo realizado por meio de entrevistas com 35 estudantes de Medicina de 14 escolas médicas localizadas nas Regiões Nordeste, Sudeste e Sul do país. Resultado: Os relatos foram classificados em três categorias: concepção sobre CP, transformações percebidas após exposição ao ensino de CP, desafios e estratégias exitosas identificados no ensino de CP. Os estudantes reconhecem o valor do ensino de CP e têm maior compreensão sobre a abordagem em CP e sua indicação precoce às pessoas com condições crônicas complexas. A inserção do tema contribuiu para a superação de medos e tabus ligados à morte, conferindo maior conforto para lidar com o sofrimento humano, agregando competências emocionais. A educação formal em CP possibilitou a compreensão da pessoa na dimensão biopsicossocial e espiritual. Os discentes ressaltaram a importância das habilidades de comunicação de notícias difíceis, do manejo de sintomas, do trabalho em equipe e da abordagem individualizada à pessoa e à família dela. Embora tenham identificado pouca integração teórico-prática no cenário de ensino-aprendizagem de CP, os alunos referiram interesse na temática e apontaram como estratégias aproximações sucessivas ao longo da formação, em um eixo humanista. Conclusão: O ensino de CP traz contribuições à formação médica para além da aprendizagem do tema e reforça o desenvolvimento da empatia e compaixão, reconhecidas como essenciais nessa profissão, assim como a relevância da assertividade no manejo do sofrimento e do cuidado integral de pessoas com doenças avançadas.

Complejo teniasis/cisticercosis / Teniasis / Cysticercosis complex

RESUMEN La neurocisticercosis, como parte del complejo teniasis/cisticercosis, es la helmintiasis que compromete con mayor frecuencia el sistema nervioso central, particularmente en países en vías de desarrollo, en los cuales su transmisión es endémica. Sus manifestaciones clínicas son variables, de acuerdo con su localización en el sistema nervioso central, y resalta la epilepsia como una de sus principales formas de presentación clínica. Los avances en el uso de métodos diagnósticos inmunológicos, así como las neuroimágenes y la introducción hace dos años de nuevos criterios diagnósticos, han mejorado la certeza diagnóstica. La implementación del tratamiento anticestocida asociado con el uso de corticoides y, en algunos casos particulares, la intervención quirúrgica brindan no solo una opción terapéutica, sino también un mejor pronóstico a los pacientes afectados por esta condición. Hoy el reto se centra en implementar medidas de salud pública sobre en el ciclo biológico del CTC para lograr su erradicación.

SUMMARY Neurocysticercosis, as part of the Teniasis / Cysticercosis complex, is helminthiasis that more frequently involves the central nervous system, particularly in countries undergoing development where its transmission is endemic; its clinical manifestations are variable, according to its location in the central nervous system, highlighting epilepsy as one of its main forms of clinical presentation. Advances in the use of diagnostic methods immunological tests, as well as neuroimaging and the introduction two years ago of new criteria diagnoses have improved the diagnostic certainty, with the implementation of anti-treatment cestocide associated with the use of corticosteroids and, in some particular cases, the intervention surgical treatment provides not only a therapeutic option but also a better prognosis for patients affected by this condition. The challenge today is focused on implementing measures of public health on the biological cycle of the CTC to achieve its eradication.

Inclusion of palliative care teaching in medical schools in Brazil / Cuidados paliativos: inserção do ensino nas escolas médicas do Brasil

Abstract: Introduction: The palliative care (PC) approach is a care modality recommended by the World Health Organization. Suffering and the process of dying are present in everyday clinical practice, affecting people with life-threatening diseases. However, the predominant model of teaching in Brazilian medical schools does not include palliative care. Objectives: The aim of the study was to get to know the Brazilian medical schools that include PC in their curriculum, and how it has been taught. Methods: Descriptive and exploratory study, carried out by searching for medical schools with disciplines in PC, through the analysis of the course syllabi available in the curricular matrices on the official websites of higher education institutions from August to December 2018. They were analyzed considering the offered period of the PC content, workload, scenario, and type of discipline (elective or mandatory). Results: 315 schools registered with the Ministry of Education were found, and only 44 of them (14%) offer courses in PC. These schools are distributed throughout 11 Brazilian states, of which 52% are located in the Southeast region, 25% in the Northeast, 18% in the South, 5% in the Midwest, and none in the North region. The predominant modality of the type of discipline in PC was mandatory in 61% of schools. Most Brazilian medical schools are private entities (57%), a similar percentage to the total number of medical schools identified with the teaching of PC. This course takes place in the 3rd and 4th years of the course; in most schools, the workload was 46,9 hours. The predominant scenario is the classroom, while some institutions provide integration between teaching community service and medical practice. The program contents are diverse, including thanatology, geriatrics and finitude, humanization, bioethics, pain, oncology and chronic diseases. Conclusion: PC education in Brazil is insufficient, which represents a barrier to the training of doctors in line with the recommendations of international entities, the National Curriculum Guidelines and legal frameworks within the scope of SUS. Investments by medical entities and government agencies are necessary to increase teaching in PC and the consequent qualification of medical training.

Resumo: Introdução: Abordagem em cuidados paliativos (CP) é uma modalidade assistencial recomendada pela Organização Mundial da Saúde. O sofrimento e o processo de morrer estão presentes no cotidiano da prática clínica, acometendo pessoas portadoras de doenças ameaçadoras à vida. Entretanto, o currículo predominante das escolas médicas brasileiras não inclui o ensino de CP. Objetivos: Este estudo teve como objetivos conhecer os cursos de Medicina brasileiros que incluem CP em sua grade curricular e verificar de que forma estes vêm sendo ministrados. Métodos: Trata-se de estudo descritivo e exploratório realizado por meio da busca de cursos de Medicina com disciplinas de CP nos sítios virtuais oficiais das instituições de ensino superior, no período de agosto a dezembro de 2018, e da análise das ementas disponíveis nas matrizes curriculares, no que diz respeito ao período oferecido, à carga horária, ao cenário e ao tipo de disciplina, se eletiva ou obrigatória. Resultados: Das 315 escolas de Medicina cadastradas no Ministério da Educação, apenas 44 cursos de Medicina (14%) dispõem de disciplina de CP. Esses cursos estão distribuídos em 11 estados brasileiros, 52% estão na Região Sudeste, 25% na Região Nordeste, 18% na Região Sul, 5% na Região Centro-Oeste, e nenhum na Região Norte. A modalidade predominante do tipo de disciplina foi obrigatória em 61% das escolas. Em relação à natureza, 57% são entidades privadas, percentual semelhante ao total de escolas médicas brasileiras. A disciplina ocorre no terceiro e quarto anos do curso, na maioria das instituições, e a carga horária mediana foi 46,9 horas. O cenário predominantemente é a sala de aula, e algumas instituições proporcionam a integração ensino-serviço-comunidade e prática médica. Os conteúdos programáticos são variados, incluindo tanatologia, geriatria, senescência e finitude, humanização, bioética, dor, oncologia e doenças crônicas. Conclusão: O ensino de CP no Brasil é escasso, o que representa uma barreira à formação de médicos em consonância com as recomendações das entidades internacionais, das Diretrizes Curriculares Nacional e de marcos legais no âmbito do SUS. Fazem-se necessários investimentos das entidades médicas e dos organismos governamentais para a ampliação do ensino de CP e a consequente qualificação da formação médica.

Teleconsulta no Contexto da Covid-19: Experiência de uma Equipe em Cuidados Paliativos / Teleconsultation in the Context of the Covid-19: Experience of the Palliative Care Team

Resumo: Introdução: Cuidados paliativos é um direito que deve ser assegurado. Diante da pandemia causada pela Covid-19, a recomendação de isolamento social foi uma das estratégias para o enfrentamento. Relato de experiência: A equipe do Núcleo de Cuidados Paliativos do Hospital Universitário Pedro Ernesto organizou o fluxo de atendimento aos pacientes por meio do acréscimo ao atendimento presencial das modalidades de teleconsulta. Essa ampliação gerou um aumento da comunicação do paciente e da família dele com a equipe de saúde, preservando, dessa forma, um plano terapêutico baseado no cuidado, acolhimento e respeito adequado a esse período de enfretamento do novo coronavírus. Discussão: A comunicação entre os profissionais das diversas áreas de saúde do núcleo se intensificou quanto às discussões dos casos e desfechos apresentados. Apresentam-se as principais estratégias, os processos, as percepções e os desafios desenvolvidos e enfrentados pela equipe interdisciplinar. Destaca-se o papel da equipe de agente facilitador da integração e comunicação entre o paciente, o Hupe e a rede SUS. Conclusão: A equipe do núcleo foi fundamental para que os pacientes e familiares assistidos pudessem atravessar o momento com mais tranquilidade, segurança e cuidado integral.

Abstract: Introduction: Palliative care is a right that must be ensured. Faced with the Covid-19 pandemic, social isolation was one of the recommended strategies for tackling the situation. Experience report: The team from the Palliative Care Unit of Pedro Ernesto University Hospital organized the flow of care for patients by adding teleconsultation to face-to-face care, with the aim of expanding communication between patients and their families and the health team, thus preserving a therapeutic plan based on the care, reception and adequate respect for this period of coping with the new coronavirus. Discussion: Communication between professionals from the different health areas of the unit has intensified due to discussions of the cases and outcomes presented. This article presents the main strategies, processes, perceptions and challenges developed and faced by the interdisciplinary team. The team plays a prominent role in facilitating patient integration and communication with the HUPE and the SUS network. Conclusion: The importance of the team is reflected on, in terms of how the center assists patients and family members to help them through the difficult experience with more peace of mind, security and comprehensive care.

Enzima indolamina-2,3-dioxigenasa 1: implicaciones fisiopatológicas durante la gestación en condiciones de obesidad / Enzyme indoleamine 2,3-dioxygenase 1: physiopathological implications during gestation in obesity conditions

RESUMEN En las gestantes obesas se han observado complicaciones, incluyendo prevalencia de abortos espontáneos y preeclampsia. Se ha propuesto que en parte estas complicaciones podrían explicarse por el ambiente inflamatorio que predomina en la obesidad. La enzima indolami-na-2,3-dioxigenasa 1 (IDO1) es inducida por la citoquina pro-inflamatoria IFN-y, por lo que se ha sugerido un incremento en su expresión en pacientes obesos. IDO1 desempeña funciones claves durante el embarazo, entre las que se encuentra el establecimiento de la tolerancia materno-fetal, la placentación y la regulación del flujo sanguíneo en la placenta. Hasta el momento los estudios que evalúan la expresión de IDO1 en la gestación en condiciones de obesidad son escasos. Por lo tanto, en esta revisión se propuso explorar las implicaciones derivadas de la alteración en la expresión de esta enzima en gestantes obesas. Según la evidencia disponible en la literatura, es posible que en gestantes obesas se presente un aumento en la expresión y la actividad de IDO1. Estas modificaciones podrían tener efectos deletéreos sobre la gestación y estar relacionada con las complicaciones que se observan en gestantes obesas.

ABSTRACT Women who have an obese body mass index are more likely to experience pregnancy complications, including spontaneous abortion and preeclampsia. It has been suggested that these complications are at least in part related to the pro-inflamatory environment that predominates in obesity. Indoleamine-2,3-dioxygenase 1 is an enzyme induced downstream IFN-y signalling, hence it has been suggested that it increases its expression and activity in obese patients. IDO1 exerts multiple functions in pregnancy, including its contribution to materno-fetal tolerance, placentation and regulation of placental blood flow. The evidence about IDO1 in pregnant obese women is scarce. Therefore, herein the implications of an overexpression of IDO1 in pregnant obese patients were explored. The evidence available at the moment suggests that it is possible that IDO1 increases its expression and activity in pregnant obese women contributing to the complications observed on these patients.

Screening mamario en pacientes transgénero bajo tratamiento hormonal cruzado (thc). Situación actual y controversias / Mammary screening in trans patients undergoing hormonal cross-over treatment. Current situation and controversies

Introducción Las personas transgénero (varones y mujeres trans, género neutro, etc.) realizan tratamientos médicos y/o quirúrgicos a fin de adecuarse a su identidad de género. Dentro de los procedimientos disponibles, se encuentran incluidos aquellos que pueden modificar la glándula mamaria (tratamiento hormonal cruzado, mastectomía/masculinización del tórax/colocación de prótesis mamarias). Se desconoce actualmente el riesgo de desarrollar cáncer de mama en la población trans. Sin embargo, están establecidas pautas de screening mamario que permitirían un adecuado seguimiento de la salud mamaria, tanto en varones trans como en mujeres trans. Objetivo El objetivo principal es estudiar la situación actual respecto del screening mamario realizado a pacientes trans por parte de sus médicos de cabecera en un hospital de la Ciudad de Buenos Aires. Material y método Se evaluaron las historias clínicas de un total de 489 personas trans atendidas en el Hospital Durand entre los años 2006 y 2017. 1. Se relevó la realización de estudios mamarios de screening previos a la instauración del tratamiento hormonal cruzado (thc) en pacientes trans. 2. Se analizó la valoración de riesgo de cáncer de mama previo al inicio del thc. 3. Finalmente, se propone un algoritmo de evaluación previo y posterior al comienzo del tratamiento hormonal en estos pacientes, según hormonoterapia recibida, y la realización de cirugía mamaria, acorde a normas internacionales y la revisión de la bibliografía. Resultados Se observó que un 37,7% de varones trans y un 18,1% de mujeres trans tenían estudios mamarios realizados. Respecto de la valoración de riesgo, en un 11,5 y un 11,1% (varones y mujeres trans) no estaban recolectados los antecedentes familiares, y, en los casos en que figuraban, estaban incompletos. Conclusiones Se postula mantener las pautas de screening mamario aplicadas para mujeres cis tanto en varones trans hasta la realización de la mastectomía/masculinización del tórax (luego mantener el examen físico) como en mujeres trans que reciben thc

Introduction Transgender patients perform both medical and surgical treatments in order to adapt to their gender identity. Within the procedures, those that can modify the mammary gland are included (cross-hormonal treatment, mastectomy / placement of breast prostheses). The risk of developing breast cancer in the trans population is currently unknown. However, screening guidelines are established and would allow adequate monitoring of mammary health, both in trans men and trans women. Objective The main objective is to study the current situation regarding breast screening performed on trans patients by their family doctors in a hospital in the City of Buenos Aires. Materials and method The clinical histories of a total of 489 transgender people attended at the Durand Hospital between 2006 and 2017 were evaluated. We studied: 1. breast screening studies prior to the initiation of cross-hormone treatment (thc) in trans patients; 2. the risk assessment of breast cancer prior to the start of thc; 3. finally, an algorithm of evaluation before and after the start of hormonal treatment is proposed in these patients, according to hormone therapy received and the performance of breast surgery, according to international standards and bibliographic review. Results It was observed that 37.7% of trans men and 18.1% of trans women had breast studies performed. Regarding the risk assessment, 11.5 and 11.1% (men and trans women) there was no family history collected, and most cases they were incomplete. Conclusions It is postulated to maintain the mammary screening guidelines for cis women both in trans men until the completion of the mastectomy (then maintain the physical examination) and in trans women who receive thc

Factores de riesgo para intento de suicidio en personas con trastorno depresivo en atención secundaria / Risk factors for suicide attempts in people with depressive disorders treated in secondary health care

Background: Depression is the most common psychiatric disorder in people with suicidal behavior. The knowledge of its risk factors should help to design preventive strategies. Aim: To describe suicidal behavior and risk factors for attempted suicide in people with major depressive disorders (MDD). Material and Methods: A 12-month follow-up study was conducted in 112 outpatients at three psychiatric care centers of Ñuble, Chile, with baseline and quarterly assessments. Demographic, psychosocial and clinical factors as potential risk factors of suicide attempts, were assessed. A clinical interview with DSM-IV diagnostic criteria checklist, Hamilton Depression Scale and the List of Threatening Experiences and Multidimensional Scale of Perceived Social Support were applied. Results: Sixty seven percent of participants had suicidal ideation and 43.8% had attempted suicide. Suicide risk was significantly higher in participants with a single major depressive episode (odds ratio [OR] = 3.98; 95% confidence intervals [CI] = 1,29-12,32 p = 0.02) and those with previous suicide attempts (OR = 13.15; 95% CI = 3,87-44.7 p < 0.01). Young age, not having a partner, being unemployed, having a severe major depressive episode, having psychotic symptoms, having a personality disorder and being devoid of medical illness increased the risk of suicide attempts, but they did not reach statistical significance. Conclusions: Significant risk factors should be specially considered when designing suicide preventive strategies in patients with MDD.

First - line, non - cryopreserved autologous stem cell transplant for poor - risk germ - cell tumors: Experience in a developing country

ABSTRACT Purpose: The current first - line treatment for non - seminomatous germ cell tumor (NSGCT) consists of four cycles of cisplatin, etoposide, and bleomycin (BEP), which results in 5 - year overall survival < 60% in patients with poor - risk features. Autologous hematopoietic stem cell transplantation (auto - HSCT) as a method for overcoming high toxicity after high dose chemotherapy (HDC) has been explored in different solid tumors, but has remained standard practice only for NSGCT. Our objective was to describe outcomes of patients with poor - risk NSGCT who underwent first - line autologous HSCT in a tertiary center in Mexico. Patients and Methods: Twenty nine consecutive patients with NSGCT who received first - line, non - cryopreserved autologous HSCT at the National Institute of Medical Sciences and Nutrition Salvador Zubiran in Mexico City, Mexico, from November 1998 to June 2016, were retrospectively analyzed. Results: The median age at transplantation was 23 (15 - 39) years. Most patients (n = 18, 62%) had testicular primary tumor, and 23 had metastases (79%). Complete response after auto - HSCT was observed in 45%. Non - relapse mortality was 0. Five - year relapse / progression free and overall survival were 67% and 69%, respectively. Conclusions: This small single limited - resource institution study demonstrated that patients with poor - risk NSGCT are curable by first - line HDC plus autologous HSCT and that this procedure is feasible and affordable to perform using non - cryopreserved hematopoietic stem cells.

Predictores de remisión del trastorno depresivo mayor en tratamiento en el nivel secundario de atención / Predictors of remission from major depressive disorder in secondary care

Background The knowledge of predictive factors in depression should help to deal with the disease. Aim To assess potential predictors of remission of major depressive disorders (MDD) in secondary care and to propose a predictive model. Material and Methods A 12 month follow-up study was conducted in a sample of 112 outpatients at three psychiatric care centers of Chile, with baseline and quarterly assessments. Demographic, psychosocial, clinical and treatment factors as potential predictors, were assessed. A clinical interview with the checklist of DSM-IV diagnostic criteria, the Hamilton Depression Scale and the List of Threatening Experiences and Multidimensional Scale of Perceived Social Support were applied. Results The number of stressful events, perceived social support, baseline depression scores, melancholic features, time prior to beginning treatment at the secondary level and psychotherapeutic sessions were included in the model as predictors of remission. Sex, age, number of previous depressive episodes, psychiatric comorbidity and medical comorbidity were not significantly related with remission. Conclusions This model allows to predict depression score at six months with 70% of accuracy and the score at 12 months with 72% of accuracy.

Impact of alcohol consumption among patients in hepatitis C virus treatment / Impacto do consumo alcoólico entre pacientes em tratamento da hepatite C

ABSTRACT BACKGROUND: Recent studies have questioned the recommendation of abstinence from alcohol for at least 6 months for alcoholic patients to be treated for hepatitis C. OBJECTIVE: The present study aimed to assess the impact of alcohol consumption among patients undergoing hepatitis C treatment. METHODS: In this cross-sectional study, 121 patients [78 (64.5%) men; 28-70 years] were evaluated. They were divided as follows: patients who consumed <12 g of ethanol/day throughout life (Group 1), 12-59 g/day (Group 2) and ≥60 g/day (Group 3). Patients were treated with pegyla­ted-interferon plus ribavirin. RESULTS: These three groups could not be distinguished in terms of the severity of liver fibrosis and frequency of HCV genotype-1 infection. In Group 3, treatment discontinuation (32.4%) was higher than in the Group 1 (9.4%) or Group 2 (0%), it was higher among patients who drank during treatment (66.7% vs 21.4%) and among those who had not been abstinent for at least 6 months (72.7% vs 15.4%). Moderate alcohol drinkers showed good adherence and did not discontinue the treatment. The frequencies of sustained viral response among patients in Group 3 (44.4%) were similar to those in Group 1 (61%) and Group 2 (68.4%). CONCLUSION: Heavy drinkers more often discontinued treatment for hepatitis C, but those that received this treatment had acceptable sustained viral response rates. These results suggest that heavy drinkers should not be systematically excluded from the treatment, but they should be monitored to avoid drinking and abandoning treatment, mainly those who have not been abstinent for at least 6 months.

RESUMO CONTEXTO: Estudos recentes têm questionado a recomendação de abstinência do álcool por pelo menos 6 meses para pacientes alcoolistas serem tratados para hepatite C. OBJETIVO: Este estudo objetivou avaliar o impacto do consumo de álcool entre pacientes submetidos ao tratamento para a hepatite C. MÉTODOS: Neste estudo transversal, avaliou-se 121 pacientes [78 (64,5%) homens; 28-70 anos). Eles foram divididos em três grupos: pacientes que consumiam <12 g de etanol/dia na vida (Grupo 1); 12-59 g/dia (Grupo 2) e ≥60 g/dia (Grupo 3). Pacientes foram tratados com interfe­ron-peguilado mais ribavirina. RESULTADOS: Os três grupos não puderam ser distinguidos em relação à gravidade da fibrose hepática e das frequências de infecção pelo genótipo-1 do HCV. No Grupo 3, descontinuação do tratamento (32,4%) foi maior do que no Grupo 1 (9,4%) ou Grupo 2 (0%), foi maior entre pacientes que beberam durante o tratamento (66,7% vs 21,4%) e entre aqueles que não estavam em abstinência por pelo menos 6 meses (72,7% vs 15,4%). Pacientes do Grupo 2 tiveram boa aderência e não descontinuaram o tratamento. As frequências de resposta virológica sustentada entre pacientes do Grupo-3 (44,4%) foi semelhante àquelas do Grupo 1 (61%) e do Grupo 2 (68,4%). CONCLUSÃO: Bebedores pesados mais frequentemente descontinuaram o tratamento da hepatite C, mas aqueles que foram tratados tiveram aceitáveis taxas de resposta virológica sustentada. Esses resultados sugerem que bebedores pesados não deveriam ser sistematicamente excluídos do tratamento, mas sim serem monitorados para evitar beber e abandonar o tratamento, principalmente aqueles que não estão abstinentes por pelo menos 6 meses.

Maternidad después de 35 años: cuidado orientado a proteger la mujer y su hijo / Maternidade depois de 35 anos: o cuidado de proteger as mulheres que enfrentam e seu filho / Motherhood after 35 years: care oriented to protect women andtheir child

Objetivo: Describir las creencias y prácticas de las gestantes mayores de 35 años que afrontan una gestación de alto riesgo, hospitalizadas en una institución de tercer nivel en el municipio de Cali, durante el año 2015. Materiales y Métodos: Se empleó la etnoenfermería (Leininger) para explorar la perspectiva émica de las gestantes. Para el análisis de los datos se utilizó el método de James P. Spradley. Participaron dieciocho mujeres, mayores de 35 años hospitalizadas en una institución nivel III. El tamaño de muestra se definió por saturación de datos. La información se obtuvo a través de entrevistas en profundidad Resultados: Las participantes admiten sentimientos de frustración y ansiedad cuando se enteraron que estaban embarazadas, lo que las llevó a realizar prácticas de auto cuidado que favorecían tanto a ellas como a su hijo por nacer y a establecer relaciones con su red de apoyo familiar para afrontar de una manera menos compleja la situación que estaban viviendo. Conclusiones: Las gestantes mayores de 35 años realizan prácticas de cuidado influenciadas por sus creencias, las cuales han sido transmitidas a través de la tradición oral por sus familiares, amigos o pares que estaban viviendo su misma situación.

Objective: Describe the beliefs and practices of pregnant women older than 35 years who face a pregnancy, hospitalized in a third level institution in Santiago de Cali, Colombia, during the year 2015. Materials and Methods: Ethno nursing (Leininger) was used to explore the emic perspective of pregnant women. The method of James P. Spradley was used for data analysis. Eighteen women, over the age of 35 who were hospitalized in a third level institution, participated. The sample size was defined by data saturation. The information was obtained through in-depth interviews. Results: The participants admitted feelings of frustration and anxiety at the time they realized they were pregnant, which led them to perform selfcare practices favoring both the pregnant women and their unborn child. Those practices helped them to establish relationships with their family support network and in a way less complex overcome the situation they were living. Conclusions: Pregnant women older than 35 years performed care practices influenced by their beliefs, which have been transmitted through oral tradition by their family, friends or peers whom were living the same situation.

Objetivo: Descrever as crenças e práticas das gestantes maiores de 35 anos que afrontam uma gestação de alto risco, hospitalizadas em uma instituição de terceiro nível no município de Cali, durante o ano 2015. Materiais e Métodos: Se empregou a etno-enfermagem (Leininger) para explorar a perspectiva êmica das gestantes. Para a análise dos dados se utilizou o método de James P. Spradley. Participaram dezoito mulheres, maiores de 35 anos hospitalizadas em uma instituição nível III. O tamanho da amostra se definiu por saturação de dados. A informação se obteve a través de entrevistas em profundidade Resultados: As participantes admitem sentimentos de frustração e ansiedade quando souberam que estavam grávidas, o que as levou a realizar práticas de auto cuidado que favoreceram tanto a elas como o seu filho por nascer e a estabelecer relações com sua rede de apoio familiar para afrontar de uma maneira menos complexa a situação que estavam vivendo. Conclusões: As gestantes maiores de 35 anos realizam práticas de cuidado influenciadas por suas crenças, as quais têm sido transmitidas a través da tradição oral por suas familiares, amigos os pares que estavam vivendo sua mesma situação.

Características clínicas del trastorno depresivo mayor en tratamiento en el nivel secundario de atención / Clinical features of major depressive disorders treated in secondary health care facilities in Chile

Background: Depression is considered the second leading cause of disability worldwide. Aim: To describe the clinical characteristics and the evolution of major depressive disorder (MDD) in secondary care. To evaluate the association between socio-demographic and clinic variables with the first or recurrent major depressive events (MDE). Material and Methods: Clinical features, treatment, remission and duration of MDE were evaluated during a follow up lasting 12 months in 112 participants aged 44 ± 15 years (79% women). Patients were assessed as outpatients every three months at three psychiatric care centers of Chile. Clinical interviews were carried out using DSM-IV diagnostic criteria checklists and the Hamilton Depression Scale was applied. Results: Most patients were referred from primary care. The mean time lapse for referral to the secondary level was 10.8 months. Most patients had episodes that were recurrent, severe, with a high rate of psychosis, with suicide attempts and melancholic features and with psychiatric and medical comorbidities. Remission rate was 27.5%. In only 16 % of patients, the episode lasted six months or less. The group with recurrent episodes had different age, sex and clinical features. Conclusions: MDD treated at the secondary care level is severe and its symptoms are intense. The time lapse prior to referral was prolonged. Primary care management and referral of these patients should be studied more closely.

Efecto terapéutico del alprostadil en pacientes con isquemia crítica terminal de los miembros inferiores / Therapeutic effect of alprostadil in patients with critical lower limb ischemia

Resumen Objetivo: El manejo de la isquemia crítica de los miembros inferiores representa un reto para el cirujano vascular debido a la alta tasa de amputaciones y mortalidad. Las opciones de manejo actuales: puente femorodistal, angioplastia con o sin la colocación de Stents y la resección de la placa con láser o de manera mecánica, presentan a largo plazo una tasa de éxito muy baja y un número de amputaciones supracondíleas que continúa siendo elevado. Métodos: Para este estudio prospectivo se reclutaron 173 pacientes con diagnóstico de estadio avanzado, con isquemia crítica de miembro inferior quienes fueron tratados con alprostadil (60- 120 mcgr/día) por vía intravenosa sistémica por 28 días. La respuesta se midió clínicamente por mejoría del llenado capilar y con el uso de la escala análoga visual del dolor. Resultados: Al momento del alta hospitalaria el 94.3% de los pacientes mejoró el puntaje en la escala análoga visual del dolor (p < 0.0001). El seguimiento a más de un año del tratamiento con alprostadil mostró que el 97% de los pacientes mejoró significativamente su estadio de isquemia, evitándose así una amputación mayor. No se observó respuesta al tratamiento en pacientes previamente intervenidos por vía endovascular (5 pacientes). Conclusiones: El tratamiento de pacientes con isquemia crítica de miembro inferior con alpostadil por infusión intravenosa, con bolos diarios de entre 60 y 120 mcg durante 28 días, este medicamento es seguro y presenta mínimos efectos secundarios. Esta terapia mejora sustancialmente el estadio funcional de Rutherford en estos pacientes y evita amputaciones mayores.

Abstract Objetive: Management of critical lower limb ischemia represents a challenge for the vascular surgeon due to the high rate of amputations and mortality. Current management options include femorodistal bypass, angioplasty with or without stent and laser or mechanical resection of the plaque. They present a low success rate in the long run and a number of supracondylar amputations that still remains high. Methods: This prospective study included 173 patients diagnosed with advanced stage critical lower limb ischemia who were treated with systemic intravenous alprostadil (60 - 120 mcg/day) during 8 days. Response was measured clinically with improvement of capillary refill and using the visual analog scale for pain. Results: Upon discharge 94.3% of patients improved their visual analogue scale score for pain (p < 0.0001). Follow-up for more than a year of alprostadil treatment revealed that 97% of patients significantly improved their ischemia status, thus avoiding further amputation. No response to treatment was observed in patients who had previously undergone endovascular surgery (5 patients). Conclusions: Treating patients with critical lower limb ischemia with intravenous alprostadil, administering daily doses of between 60 and 120 mcg during 28 days shows that this drug is safe and causes minimal secondary effects. This therapy significantly improves Rutherford's function state in these patients and avoids further amputations.

Adherencia terapéutica: conceptos, determinantes y nuevas estrategias / Therapeutic adherence: concepts, determinants and new strategies

Antecedentes : La no adhesión al tratamiento medicamentoso es considerada un fenómeno complejo y multifactorial desde los años 70. De acuerdo a esto y con el objetivo principal mejorar las tasas mundiales de adherencia a los tratamientos común - mente usados, la Organización Mundial de la Salud (OMS) lanzó en el 2001 el Proyecto sobre Adherencia Terapéutica. A partir de este, se han realizado multiples estudios en este tema con una alta variabilidad de resultados. Se realizó la revisión de recomendaciones para el estudio de la adherencia terapéutica, implicaciones y consecuencias de la no adherencia, escalas que evalúan adherencia, factores predictores, factores que inluyen y estrategias de intervención. Fuentes: se reviso la base de datos de Google académico que identiico lo estudios sobre adherencia publicados entre los años 2014- 2016. Desarrollo: La OMS deinió la adherencia como el grado en que el comportamiento de una persona se corresponde con las recomendaciones acordadas de un prestador de asistencia sanitaria, en relación con la toma de medicación, el seguimiento de una dieta o la modiicación de hábitos de vida. La magnitud del grado de no adhesión mundial a los tratamientos de Enfermedades Crónicas (EC) varía de 25% a 50% (incluso 30-60% en otros es - tudios), pero esta adhesión a tratamientos, es mucho menor en los países en vía de desarrollo por la escasez de recursos sanitarios y las inequidades en el acceso a la atención de salud. Conclusión : Las intervenciones para mejorar la adherencia deben ser discutidas con el paciente, considerando sus problemas y necesidades individuales...(AU)

Comparación por sexo en imagen corporal, síntomas psicopatológicos y conductas alimentarias en jóvenes entre 14 y 25 años / Body image, psychological symptoms and eating disorders among Chilean adolescents and young adults

The construction of body image is crucial during adolescent development. Several studies show that body dissatisfaction is common, especially among women. This is a risk factor for eating behavior disorders. Aim: To describe psychological variables and dimensions about body image among adolescents and young adults. Material and Methods: Three self-administered questionnaires, MBSRQ (Multidimensional Body Self Relations Questionnaire) that measures body image, Symptom Checklist (SCL-90) that measures the presence of psychological and psychiatric symptoms and the Eating Disorder Inventory (EDI-2), which measures eating problems, were applied to 1,438 students aged 19 ± 2.7 years (53% women) from three Chilean regions. Results: Sixty five percent of respondents would like to weigh less. Compared with men, women have greater psychological distress, concerns about their appearance and their weight, are more obsessed with thinness, and have fewer behaviors aimed at solving these problems. Conclusions: A high percentage of respondents want to lose weight. In addition, women have serious desires and search for thinness.

A violência familiar sob a ótica da promoção da saúde: a trajetória do município do Rio de Janeiro / Family violence from the health promotion perspective: the path taken by the municipality of Rio de Janeiro

Objetivos: Analisar a percepção dos gestores da saúde do Município do Rio de Janeiro em relação à abordagem da violência familiar, com foco na promoção da saúde e as ações desenvolvidas nos últimos dez anos para a efetivação das políticas públicas sobre o tema. Métodos: Um estudo de caso realizado no nível central e regional da gestão municipal, com a aplicação de entrevistas individuais semiestruturadas aos gestores e o levantamento de documentos oficiais. Foi utilizada a análise de conteúdo com a identificação das seguintes categorias analíticas no relato dos gestores: percepção do gestor, possibilidades de atuação integrando as ações de promoção da saúde e transformações na produção de saúde. Resultados: Os relatos demonstram que as ferramentas da promoção podem ampliar as possibilidades de intervenção na atenção primária para a abordagem da violência familiar, em especial no modelo organizacional proposto na Estratégia Saúde na Família (ESF), em que esta atuação se mostra particularmente desafiadora. Foram apontadas algumas ações facilitadoras, como a proximidade com o território e o protagonismo social. Conclusões: As políticas desenvolvidas na gestão municipal têm exercido importante papel indutor na construção de novas práticas de saúde, a partir de uma perspectiva intersetorial. O olhar diferenciado dos gestores sobre a violência familiar parece fundamental para a ampliação de ações de prevenção da violência e de promoção à saúde.

Objective: Evaluate the perception of healthcare sector managers in Municipal Rio de Janeiro, concerning their approach to family violence, from the perspective of health promotion and the actions developed in the last ten years, towards the implementation of public health policies on this issue. Method: This is a case study conducted at the central and regional levels of municipal health management, through the application of semistructured interviews with individual managers and the survey of official data. Report content was analyzed and stratified into the following categories: manager's perceptions and options for linking health promotion actions to transformations in health production. Results: Promotion tools can expand the range of possible interventions within primary care, especially under the organizational model proposed in the Family Health Strategy, where the options for addressing family violence are particularly challenging. Some facilitating factors were indicated, such as closer contact with the territory, and social advocacy. Conclusion: The policies developed at the city management level have boosted the construction of innovative healthcare practices, based on an intersectoral perspective. Healthcare management's unique approach to family violence represents an essential element for expanded actions towards violence prevention and health promotion.

Uso de alcohol en los estudiantes de tercero a quinto semestre del programa de psicología de una universidad privada de la ciudad de barranquilla / Alcohol use among students in third to fifth semester of psychology program at a private university in the city of barranquilla

El presente artículo da a conocer los resultados de una investigación que tuvo como objetivo describir la presencia del uso de alcohol en estudiantes de tercero a quinto semestre del programa de Psicología de una universidad privada en la ciudad de Barranquilla. La muestra estuvo conformada por 147 estudiantes de III, IV y V semestres y el instrumento utilizado fue la escala AUDIT, para identificar aquellos sujetos que tenían consumos nocivos de alcohol en un estado inicial. Se identificó la presencia de hábitos de consumo de alcohol en los estudiantes. Igualmente se identificaron individuos en los 10 reactivos de la escala. Se hallaron diferencias clínica y estadísticamente significativas en las puntuaciones del AUDIT, también se mostraron tamaños del efecto de grandes a enormes.

This article reveals the results of an investigation that aimed to describe the presence of alcohol use among students in third to fifth semester of Psychology program at a private university in the city of Barranquilla. The sample was comprised of 147 students of III, IV and V semesters and the instrument used was the scale AUDIT, to identify those subjects which had harmful consumption alcohol at an early stage. We identified the presence of student alcohol consumption habits. Also individuals were identified in the reactive 10 scale. Clinically and statistically significant differences AUDIT scores were found, large effect sizes were also huge.

Establishing th reference range for t lymphocyes subpopulations in adults andd children from Brazil / Estabelecimento de valores de referencias para subpopulacoes de linfocitos T em adultos e criancas no Brasil

SUMMARY In Brazil, the existing reference values for T-lymphocytes subsets are based on data originated in other countries. There is no local information on normal variation for these parameters in Brazilian adults and children. We evaluated the normal variation found in blood donors from five large Brazilian cities, in different regions, and in children living in Salvador, and Rio de Janeiro. All samples were processed by flow cytometry. The results were analyzed according to region, gender, and lifestyle of blood donors. A total of 641 adults (63% males), and 280 children (58% males) were involved in the study. The absolute CD3+, and CD4+ cells count were significantly higher for females (adults and children). Higher CD4+ cell count in adults was associated with smoking, while higher CD8+ count was found among female children. Higher counts, for all T-cells subsets, were detected in blood donors from southeast / south regions while those living in the northern region had the lowest values. Individuals from midwestern and northeastern regions had an intermediate count for all these cells subsets. However, these differences did not reach statistical significance. In Brazil, gender and smoking, were the main determinants of differences in T-lymphocytes reference values. .

RESUMO Os valores de referências de linfócitos T existentes no Brasil são baseados em dados originados de outros países. Não existem dados locais da variação normal para estes parâmetros em adultos e crianças brasileiras. Avaliamos a variação normal encontrada em doadores de sangue de cinco grandes cidades brasileiras em diferentes regiões e em crianças residentes em Salvador e Rio de Janeiro. Todas as amostras foram processadas por citometria de fluxo. Os resultados foram analisados de acordo com região, gênero e estilo de vida dos doadores. Um total de 641 adultos (63% homens) e 280 crianças (58% meninos) participaram do estudo. Valores absolutos de CD3+ e CD4+ foram significantemente maiores no gênero feminino (adultos e crianças). Maiores valores de CD4+ em adultos foram associados com tabagismo, enquanto que maiores valores de CD8+ foram encontrados entre crianças do sexo feminino. Adultos das regiões sul e sudeste apresentaram maiores valores absolutos para todas as células T enquanto que adultos da região norte, apresentaram menores valores. Indivíduos residentes no nordeste e centro-oeste obtiveram contagens intermediárias para todas as populações de células T. Entretanto, estas diferenças entre as regiões, não demonstraram diferença estatística. No Brasil, gênero e tabagismo foram os principais determinantes para diferenças em valores de referências de linfócitos T. .

Azoospermia y fertilización asistida: rol de la histología testicular en el éxito de icsi / Azoospermia and assisted reproduction: role of testicular histology in the success of ICSI

Introducción: La infertilidad masculina afecta aproximadamente al 7por ciento de los hombres, presentándose hasta el 15 por ciento de ellos con azoospermia. El conocimiento del tipo de azoospermia (obstructiva o no obstructiva) y la localización de la falla (pre-testicular, testicular o post-testicular) es vital para conocer el pronóstico de fertilidad de la pareja y plantear un plan terapéutico adecuado. Actualmente, la extracción de espermatozoides desde epidídimo o testículo de pacientes azoospérmicos, y la posterior inyección intracitoplásmática de éstos (ICSI, por sus siglas en inglés) ha permitido obtener embriones viables para su posterior transferencia. Materiales y métodos: Estudio descriptivo retrospectivo de 42 parejas infértiles con diagnóstico de azoospermia; que se sometieron a biopsia testicular, ICSI y posterior transferencia de embriones, entre los años 2004 y 2012. Se lleva a cabo un análisis de la edad de los pacientes, resultados de la histopatología testicular y su asociación con los resultados de la fertilización asistida. Resultados: 42 pacientes azoospérmicos se sometieron a biopsia testicular y extracción de espermatozoides en el mismo acto quirúrgico. La edad promedio de los pacientes fue de 36 años para los hombres y 32 años para las mujeres. En el análisis histológico de los tejidos testiculares, el 31por ciento de los pacientes presentaban espermatogénesis conservada (EC), el 35.7 por ciento atrofia mixta (AM), el 14.3 por ciento hipoespermatogénesis (HE), el 14.3 por ciento detención de la maduración (DM) y un 4.8 por ciento presentaba otras histologías. Lograron embarazo clínico 14 de 42 parejas (33,3 por ciento), siendo la tasa de embarazo específica por patología de 38,5 por ciento para EC, 26.7 por ciento para AM, 50 por ciento para HE, 16,7 por ciento para DM y 50 por ciento para las otras histologías. 12 de las 42 parejas realizaron más de un ciclo de transferencias...

Introduction: Male infertility affects approximately 7percent of men, presenting up to 15 percent with azoospermia. Knowing the type of azoospermia (obstructive or non-obstructive) and the location of the problem (pre-testicular, testicular and post-testicular) is vital to recognize the fertility prognosis of the couple and present a proper treatment plan. Currently, the extraction of sperm from epididymis or testis of azoospermic patients, and subsequent intracytoplasmic sperm injection (ICSI) has yielded viable embryos for transfer. Materials and Methods: Retrospective study of 42 infertile couples diagnosed with azoospermia, who underwent testicular biopsy, ICSI and subsequent embryo transfer, between 2004 and 2012. We performed an analysis of the patients’ age, testicular histopathology results and their association with assisted fertilization outcome. Results: 42 azoospermic patients underwent testicular biopsy and sperm extraction in the same surgery. The average age of patients was 36 years for men and 32 years for women. Histologic analysis of testicular tissue showed that 31 percent of patients had normal spermatogenesis (NS), 35.7 percent mixed atrophy (MA), 14.3 percent hypospermatogenesis (HS), 14.3 percent maturation arrest (MTA) and 4.8 percent had other histologies. 14 of 42 couples achieved clinical pregnancy (33.3 percent), with a specific pregnancy rate of 38.5 percent for NS, 26.7 percent for MA, 50 percent for HS, 16.7 percent for MTA and 50 percent for other histologies. 12 of 42 couples underwent more than one transfer cycle. Conclusions: The use of ICSI is a suitable alternative for infertile couples with severe male factor. The results of this technique are favorable for most histologies. Patients with MA exhibit sertoli solo syndrome and / or tubular sclerosis foci associated to regions with normal spermatogenesis, enabling the sperm extraction for ICSI.