The Work of Nurses in Primary Health Care: Crossings of the New Public Management.

The literature in the field of health management mentions a concept called new public management (NPM), introduced in Brazil and France at the end of the 20th century. The objective of the study was to analyze the repercussions of the work of nurses in primary health care in Brazil and France under the influence of NPM. This is an excerpt of a double-titled thesis, which is a research intervention with nurses from two Brazilian states and five French departments. Data were produced between February 2019 and July 2021. The public policy Health on the Hour acted as an institutional transducer, provoking a reduction in access and producing effects on professional practices. In both countries, NPM amplified the predominance of technical and quantifiable acts, the focus on individual care, and the loss of autonomy. Nurses reported insurmountable situations, using the metaphor "Sophie's choice". The results showed that making dilemmatic decisions has been the daily routine of nurses, which has not resulted in debureaucratization and higher quality of care.

Depression and associated factors in medical students in Acapulco during the COVID-19 pandemic: A cross-sectional study.

BACKGROUND: Depression is common in medical students and the Mexican state of Guerrero has the highest rates of depression in the country. Acapulco, the seat of the state medical school, is a tourist destination that experienced early high rates of COVID-19. The COVID-19 pandemic closed all schools in Mexico, obliging a shift from face-to-face to virtual education. In this new context, medical students faced challenges of online teaching including inadequate connectivity and access technologies. Prolonged isolation during the pandemic may have had additional mental health implications. AIM: Assess depression prevalence and its associated factors affecting medical students in Acapulco, Mexico during the COVID-19 pandemic. METHODS: A cross-sectional survey of students of the Faculty of Medicine of the Universidad Autónoma de Guerrero, in November 2020. After informed consent, students completed a self-administered questionnaire collating socio-demographic, academic and clinical variables, major life events and changes in mood. The Beck inventory provided an assessment of depression. Bivariate and multivariate analyses relied on the Mantel-Haenszel procedure to identify factors associated with depression. We estimated the odds ratio (OR) and 95% confidence intervals. RESULTS: 33.8% (435/1288) of student questionnaires showed evidence of depression in the two weeks prior to the study, with 39.9% (326/817) of young women affected. Factors associated with depression included female sex (OR 1.95; 95%CI 1.48-2.60), age 18-20 years (OR 1.36; 95%CI 1.05-1.77), perceived academic performance (OR 2.97; 95%CI 2.16-4.08), perceived economic hardship (OR 2.18; 95%CI 1.57-3.02), and a family history of depression (OR 1.85; 95%CI 10.35-2.54). Covid-19 specific factors included a life event during the pandemic (OR 1.99; 95%CI 1.54-2.59), connectivity problems during virtual classes and difficulties accessing teaching materials (OR 1.75; 95%CI 1.33-2.30). CONCLUSIONS: The high risk of depression in medical students during the COVID-19 pandemic was associated with perceived academic performance and technical barriers to distance learning, in addition to known individual and family factors. This evidence may be useful for the improvement of programs on prevention and control of depression in university students.

Neuraminidase is a host-directed approach to regulate neutrophil responses in sepsis and COVID-19.

BACKGROUND AND PURPOSE: Neutrophil overstimulation plays a crucial role in tissue damage during severe infections. Because pathogen-derived neuraminidase (NEU) stimulates neutrophils, we investigated whether host NEU can be targeted to regulate the neutrophil dysregulation observed in severe infections. EXPERIMENTAL APPROACH: The effects of NEU inhibitors on lipopolysaccharide (LPS)-stimulated neutrophils from healthy donors or COVID-19 patients were determined by evaluating the shedding of surface sialic acids, cell activation, and reactive oxygen species (ROS) production. Re-analysis of single-cell RNA sequencing of respiratory tract samples from COVID-19 patients also was carried out. The effects of oseltamivir on sepsis and betacoronavirus-induced acute lung injury were evaluated in murine models. KEY RESULTS: Oseltamivir and zanamivir constrained host NEU activity, surface sialic acid release, cell activation, and ROS production by LPS-activated human neutrophils. Mechanistically, LPS increased the interaction of NEU1 with matrix metalloproteinase 9 (MMP-9). Inhibition of MMP-9 prevented LPS-induced NEU activity and neutrophil response. In vivo, treatment with oseltamivir fine-tuned neutrophil migration and improved infection control as well as host survival in peritonitis and pneumonia sepsis. NEU1 also is highly expressed in neutrophils from COVID-19 patients, and treatment of whole-blood samples from these patients with either oseltamivir or zanamivir reduced neutrophil overactivation. Oseltamivir treatment of intranasally infected mice with the mouse hepatitis coronavirus 3 (MHV-3) decreased lung neutrophil infiltration, viral load, and tissue damage. CONCLUSION AND IMPLICATIONS: These findings suggest that interplay of NEU1-MMP-9 induces neutrophil overactivation. In vivo, NEU may serve as a host-directed target to dampen neutrophil dysfunction during severe infections.

Reliability of the five times sit to stand test performed remotely by multiple sclerosis patients.

INTRODUCTION: Multiple Sclerosis, known main cause of non-traumatic neurological disability in adults, leads to changes in muscle strength, especially in the lower limbs. Assessing muscle strength in these patients is thus essential and can be achieved by the Five Times Sit to Stand Test (FTSST), commonly performed in person. Due to the COVID-19 pandemic and social distancing measured adopted, Brazilian physiotherapists turned to remote monitoring and assessment, supported by Resolution n° 516/2020, which required proving the reliability of tests. Given this scenario, this study sought to evaluate the intra- and inter-rater reliability of the Five Times Sit to Stand Test performed remotely and synchronously by multiple sclerosis patients. METHODS: A sample of 33 individuals with relapsing-remitting Multiple Sclerosis (18 women and 15 men, mean age 43.7 ± 13.4 years) were remotely and synchronously by video call. Inter-rater reliability was evaluated by analyzing FTSST execution time, in seconds, timed by two different raters on the same video call. In turn, intra-rater reliability was assessed by analyzing the execution time recorded in two different video calls made by the same rater, within a 24-28-h interval. Descriptive and inferential data analysis were performed using SPSS 20.0 software. Means and standard deviation were calculated for descriptive statistic. Intraclass correlation coefficient (ICC), with a 0.05 significance level, standard error of measurement (SEM) and minimal detectable change (MDC) were calculated for inferential analysis. RESULTS: Data analysis showed excellent ICC values and low SEM and MDC values regarding inter-rater reliability (ICC: 0.993 (0.986-0.996); p-value: <0.001; SEM: 0.6 s; MDC: 1.6 s) and intra-rater reliability (ICC: 0.962 (0.925-0.981); p-value: <0.001; SEM: 1.4 s; MDC: 3.8 s). CONCLUSION: Based on these values, FTSST performed remotely and synchronously by relapsing-remitting Multiple Sclerosis patients is reliable and can be used both by different raters, for assessment, or by the same rater, in pre- and post-test situations.

Mutational profile confers increased stability of SARS-CoV-2 spike protein in Brazilian isolates.

Spike (S) protein has been recognized as a promising molecular target for diagnostic, vaccines and antiviral drugs development for COVID-19. In this study, we analyzed the most predominant mutations in the S protein of Brazilian isolates and predicted the effect of these amino acid alterations to protein conformation. A total of 25,924 sequences were obtained from GISAID for five regions of Brazilian territory (Midwest, North, Northeast, South, and Southeast), according to exclusion criteria. Most of the SARS-CoV-2 isolates belongs to the G clade and showed a large occurrence of D614G, N501Y and L18F substitutions. Prediction effects of these amino acid substitutions on the structure dynamics of the spike protein indicated a positive ΔΔG values and negative ΔΔSVib in most cases which is associated to structural stabilization and flexibility reduction of the S protein. Mutations E484K, N501Y and K417N belong to several SARS-CoV-2 variants of concern such as Alpha, Beta, Gamma and Delta, and showed high incidence among Brazilian isolates. These mutations have been described to increase RBD affinity to ACE-2 host and abolishment of RBD affinity to potent neutralizing ant-RBD. The increase in rates of infection and reinfection requires continuous genomic surveillance studies in order to characterize emerging mutations and monitor vaccine efficacy, and thus consideration structural data and dynamics in the observed phenotypes.Communicated by Ramaswamy H. Sarma.

Molecular aspects of COVID-19 and its relationship with obesity and physical activity: a narrative review.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 has several mechanisms of action related to inflammatory responses, especially in individuals diagnosed with obesity. This hyperinflammatory clinical profile resulting from the association between obesity and coronavirus disease 2019 (COVID-19) may be attenuated by regular physical activity. OBJECTIVE: The aim of this study was to review the evidence on the consequences of physical inactivity and physical activity on COVID-19 in patients with obesity. DESIGN AND SETTING: Narrative review at the Bahiana School of Medicine and Public Health in Salvador, Brazil. METHODS: We searched evidence on the association of COVID-19 with physical activity and obesity using the following keywords: "covid-19," "physical activity," and "obesity". The databases used were MEDLINE (PubMed), ScienceDirect, and Virtual Health Library. Studies published from 2019 to 2021 and available in Portuguese, English, and Spanish were included. The final search was conducted on September 26, 2021. RESULTS: We identified 661 studies in the database, among which 71 were considered for inclusion in the narrative review of the molecular aspects of COVID-19 and its relationship with physical activity and obesity. CONCLUSION: This literature review enabled the perception of the relationship between the molecular mechanisms of COVID-19 and obesity. Regular physical activity had various benefits for the inflammatory condition of the studied population, highlighting moderate-intensity.

Molecular Dynamics Analysis of Fast-Spreading Severe Acute Respiratory Syndrome Coronavirus 2 Variants and Their Effects on the Interaction with Human Angiotensin-Converting Enzyme 2.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is evolving with mutations in the spike protein, especially in the receptor-binding domain (RBD). The failure of public health measures in some countries to contain the spread of the disease has given rise to novel viral variants with increased transmissibility. However, key questions about how quickly the variants can spread remain unclear. Herein, we performed a structural investigation using molecular dynamics simulations and determined dissociation constant (K D) values using surface plasmon resonance assays of three fast-spreading SARS-CoV-2 variants, alpha, beta, and gamma, as well as genetic factors in host cells that may be related to the viral infection. Our results suggest that the SARS-CoV-2 variants facilitate their entry into the host cell by moderately increased binding affinities to the human ACE2 receptor, different torsions in hACE2 mediated by RBD variants, and an increased spike exposure time to proteolytic enzymes. We also found that other host cell aspects, such as gene and isoform expression of key genes for the infection (ACE2, FURIN, and TMPRSS2), may have few contributions to the SARS-CoV-2 variant infectivity. In summary, we concluded that a combination of viral and host cell factors allows SARS-CoV-2 variants to increase their abilities to spread faster than the wild type.

[COVID-19 morbidity and mortality associated with chronic disorders, healthcare services, and inequity: evidence for a syndemicMorbimortalidad por COVID-19 asociada a los problemas crónicos de salud, los servicios de salud y las inequidades: evidencia de sindemia]. / Morbimortalidade por COVID-19 associada a condições crônicas, serviços de saúde e iniquidades: evidências de sindemia.

Objective: To identify factors correlated with the incidence and mortality from COVID-19 and investigate syndemic situations at the global level. Method: An ecologic study of confirmed COVID-19 cases and deaths was performed using information collected from the European Center for Disease Prevention and Control in 2019 and 2020. World Bank indicators and information obtained from Worldometer Coronavirus were used to characterize the countries. Descriptive analyses and correlations between independent variables were performed, followed by multiple linear regression analysis to identify factors correlated with COVID-19 incidence and mortality. Results: Data were obtained for 185 countries. Mean case incidence was 16 482/1,000 population, whereas mean COVID-19 mortality was 291/1,000 population, with the highest and lowest rates recorded in North America and East Asia and Pacific respectively. A positive correlation was identified between incidence rate and percent population aged 15 to 64 years, urban population, inequality measured by the Gini coefficient, and six out of the seven regions analyzed (except East Asia and Pacific). Mortality rate was negatively correlated with population aged 0 to 14 years and positively correlated with urban population, inequality measured by the Gini coefficient, and all regions analyzed except East Asia and Pacific. Conclusions: COVID-19 morbidity and mortality were correlated with the burden of chronic diseases, aging population, and low capacity of healthcare services for testing and providing hospital beds, a scenario complicated by social inequality in countries and regions, indicating a syndemic effect.

Objetivo: Identificar los factores correlacionados con la incidencia de COVID-19 y la mortalidad por esa causa y verificar las situaciones de sindemia a escala mundial. Métodos: Se realizó un estudio ecológico de casos de COVID-19 y de defunciones confirmadas por esa causa a partir de la información obtenida del Centro Europeo para la Prevención y el Control de las Enfermedades en el 2019 y el 2020. Para caracterizar a los países, se utilizaron indicadores del Banco Mundial y del sitio web de referencia Worldometer Coronavirus. Se hicieron análisis descriptivos y de correlación entre las variables independientes para crear posteriormente un modelo de regresión lineal múltiple con el fin de identificar los factores correlacionados con la incidencia de COVID-19 y la mortalidad por esa causa. Resultados: Se obtuvieron datos de 185 países. La tasa media de incidencia de casos de COVID-19 fue de 16 482 por mil habitantes y la tasa media de mortalidad por esa causa fue de 291 por mil habitantes. Las regiones de América del Norte y de Asia oriental y el Pacífico presentaron los mayores y menores índices, respectivamente. Se observó una correlación positiva de la tasa de incidencia con la proporción del grupo de 15 a 64 años de edad, la población urbana, la desigualdad medida por el coeficiente de Gini y seis de las siete regiones analizadas (excepto Asia oriental y el Pacífico). La tasa de mortalidad presentó una correlación negativa con el grupo de 0 a 14 años de edad y positiva con la población urbana, la desigualdad medida por el coeficiente de Gini y todas las regiones analizadas, excepto Asia oriental y el Pacífico. Conclusiones: La morbimortalidad por COVID-19 guardó una correlación con la carga de problemas crónicos de salud, el envejecimiento de la población y la poca capacidad de realizar pruebas en los servicios de salud y de ofrecer camas de hospital, cuadro agravado en los países o regiones con una elevada tasa de desigualdad social y característico de una situación de sindemia.

Direct SARS-CoV-2 infection of the human inner ear may underlie COVID-19-associated audiovestibular dysfunction.

BACKGROUND: COVID-19 is a pandemic respiratory and vascular disease caused by SARS-CoV-2 virus. There is a growing number of sensory deficits associated with COVID-19 and molecular mechanisms underlying these deficits are incompletely understood. METHODS: We report a series of ten COVID-19 patients with audiovestibular symptoms such as hearing loss, vestibular dysfunction and tinnitus. To investigate the causal relationship between SARS-CoV-2 and audiovestibular dysfunction, we examine human inner ear tissue, human inner ear in vitro cellular models, and mouse inner ear tissue. RESULTS: We demonstrate that adult human inner ear tissue co-expresses the angiotensin-converting enzyme 2 (ACE2) receptor for SARS-CoV-2 virus, and the transmembrane protease serine 2 (TMPRSS2) and FURIN cofactors required for virus entry. Furthermore, hair cells and Schwann cells in explanted human vestibular tissue can be infected by SARS-CoV-2, as demonstrated by confocal microscopy. We establish three human induced pluripotent stem cell (hiPSC)-derived in vitro models of the inner ear for infection: two-dimensional otic prosensory cells (OPCs) and Schwann cell precursors (SCPs), and three-dimensional inner ear organoids. Both OPCs and SCPs express ACE2, TMPRSS2, and FURIN, with lower ACE2 and FURIN expression in SCPs. OPCs are permissive to SARS-CoV-2 infection; lower infection rates exist in isogenic SCPs. The inner ear organoids show that hair cells express ACE2 and are targets for SARS-CoV-2. CONCLUSIONS: Our results provide mechanistic explanations of audiovestibular dysfunction in COVID-19 patients and introduce hiPSC-derived systems for studying infectious human otologic disease.

Causes of multidrug-resistant tuberculosis from the perspectives of health providers: challenges and strategies for adherence to treatment during the COVID-19 pandemic in Brazil.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) is a serious phenomenon on a global scale that can worsen with the COVID-19 pandemic. The study aimed to understand the perceptions of health professionals about MDR-TB, their strategies to ensure adherence to treatment and their challenges in the context of the COVID-19 pandemic in a priority municipality for disease control. METHODS: We conducted a qualitative study and recruited 14 health providers (four doctors, three nurses, three nursing technicians, three nursing assistants and a social worker) working in a city in the state of São Paulo, Brazil. Remote semi-structured interviews were conducted with the participants. For data analysis, the thematic content analysis technique was applied according to the study's theoretical framework. RESULTS: The study revealed the causes of MDR-TB are associated with poverty, vulnerability, and social risk. A pre-judgement from the providers was observed, namely, all patients do not adhere due their resistance and association with drug abuse or alcoholism. The study also observed difficulty among health providers in helping patients reconstruct and reframe their life projects under a care perspective, which would strengthen adherence. Other issues that weakened adherence were the cuts in social protection and the benefits really necessary to the patients and a challenge for the providers manage that. The participants revealed that their actions were impacted by the pandemic and insecurity and fear manifested by patients after acquiring COVID-19. For alleviating this, medical appointments by telephone, delivery of medicine in the homes of patients and visits by health professionals once per week were provided. CONCLUSION: The study advances knowledge by highlighting the challenges faced by the health system with the adherence of patients with MDR-TB in a context aggravated by the pandemic. An improvement in DOT is really necessary to help the patients reframe their lives without prejudices, face their fears and insecurity, recover their self-esteem and motivate in concluding their treatment.

International Survey of Operative Practices for Otologists and Neurotologists During the COVID-19 Crisis.

OBJECTIVE: To investigate the influence of the COVID-19 pandemic on operative practices of otology and neurotology providers internationally. STUDY DESIGN: Cross-sectional survey. METHODS: A 78-question survey was distributed to otologists and neurotologists between May 12, 2020 and June 8, 2020 to assess the impact of the pandemic on surgical practices. Sections within the survey delineated time periods: prior to the crisis, onset of the crisis, during the crisis, postcrisis transition. RESULTS: Of 396 survey respondents, 284 participants from 38 countries met inclusion criteria.Respondents were 16.9% female and 82.4% male, with a most common age range of 40 to 49 years (36.3%). 69.8% of participants had been in practice for over 10 years and most respondents worked in an academic medical center (79.2%). The average operative weekly caseload was 5.3 (SD 3.9) per surgeon prior to the crisis, 0.7 (SD 1.2) during the COVID-19 crisis, and 3.5 (SD 3.3) for those who had begun a postcrisis transition at the time of survey administration (p < 0.001). 71.5% of providers did not perform an elective otologic or neurotologic operative procedure during the initial crisis period. 49.8% reported modifying their surgical technique due to the COVID-19 pandemic. Use of powered air-purifying respirators and filtering facepiece 2 or 3 (FFP2/FFP3) respirators were in minimal supply for 66.9% and 62.3% of respondents, respectively. CONCLUSION: The COVID-19 pandemic impacted the otology and neurotology community globally, resulting in significant changes in operative volume and case selection. Modification of surgical technique and shortages of personal protective equipment were frequently reported.

Patients' perceptions regarding multidrug-resistant tuberculosis and barriers to seeking care in a priority city in Brazil during COVID-19 pandemic: A qualitative study.

This study aimed to analyze the discourses of patients who were diagnosed with multidrug-resistant tuberculosis, the perception of why they acquired this health condition and barriers to seeking care in a priority city in Brazil during the COVID-19 pandemic. This was an exploratory qualitative study, which used the theoretical-methodological framework of the Discourse Analysis of French matrix, guided by the Consolidated Criteria for Reporting Qualitative Research. The study was conducted in Ribeirão Preto, São Paulo, Brazil. Seven participants were interviewed who were undergoing treatment at the time of the interview. The analysis of the participants' discourses allowed the emergence of four discursive blocks: (1) impact of the social determinants in the development of multidrug-resistant tuberculosis, (2) barriers to seeking care and difficulties accessing health services, (3) perceptions of the side effects and their impact on multidrug-resistant tuberculosis treatment, and (4) tuberculosis and COVID-19: a necessary dialogue. Through discursive formations, these revealed the determinants of multidrug-resistant tuberculosis. Considering the complexity involved in the dynamics of multidrug-resistant tuberculosis, advancing in terms of equity in health, that is, in reducing unjust differences, is a challenge for public policies, especially at the current moment in Brazil, which is of accentuated economic, political and social crisis. The importance of psychosocial stressors and the lack of social support should also be highlighted as intermediary determinants of health. The study has also shown the situation of COVID-19, which consists of an important barrier for patients seeking care. Many patients reported fear, insecurity and worry with regard to returning to medical appointments, which might contribute to the worsening of tuberculosis in the scenario under study.

Impact and trend of COVID-19 in the Brazilian prison system: an ecological study. / Impacto e tendência da COVID-19 no sistema penitenciário do Brasil: um estudo ecológico.

Given the rapid spread of new coronavirus within the prison system, this study's objective was to identify spatial clusters for the occurrence of COVID-19 in the incarcerated population and analyze temporal trends of confirmed cases in the Brazilian prison system. This ecological study considered the five Brazilian macro-regions to be units of analysis, with its 26 states and the Federal District. The population was composed of all COVID-19 cases confirmed from April 14th to August 31st, 2020. The source used to collect data was the COVID-19 Monitoring Panel from the National Prison Department. Descriptive analysis, scan statistics, and time series were performed. A total of 18,767 COVID-19 cases were reported among the incarcerated population, 4,724 in São Paulo. The scan statistic analysis resulted in 14 spatial risk clusters for COVID-19 among persons deprived of liberty; the highest-risk cluster was in the Federal District. Although the country ends the series with a decreasing behavior, a growing trend was verified in most of the study period. The conclusion is that there is a need to implement mass testing among the incarcerated population while continually monitoring and recording COVID-19 cases.

Tendo em vista a rápida disseminação do novo coronavírus no sistema prisional, o presente trabalho teve como objetivos identificar aglomerados espaciais para ocorrência da COVID-19 na população privada de liberdade (PPL) e analisar a tendência temporal dos casos confirmados no sistema penitenciário do Brasil. Estudo ecológico que considerou como unidades de análise as cinco macrorregiões do Brasil, seus 26 estados e o Distrito Federal. A população foi composta por todos os casos de COVID-19 confirmados, no período de 14 de abril a 31 de agosto de 2020. A fonte de dados utilizada foi o Painel de Monitoramento dos casos de COVID-19 nos sistemas prisionais do Departamento Penitenciário Nacional. Realizou-se análise descritiva, estatística de varredura e análise da tendência temporal. Foram notificados 18.767 casos de COVID-19 na PPL, dos quais 4.724 ocorreram no estado de São Paulo. A estatística de varredura possibilitou a identificação de 14 clusters espaciais de risco para COVID-19 na PPL, sendo o aglomerado de maior risco formado pelo Distrito Federal. Embora o país finalize a série com um comportamento decrescente, observa-se que no período de investigação a tendência apresentou um comportamento maioritariamente crescente. Evidencia-se a necessidade de testagem em massa, monitoramento e registro contínuo dos casos de COVID-19 na PPL do país.