Histoplasmosis in HIV/AIDS patients in Amazonas, Northern Brazil.

Histoplasmosis is commonly observed in AIDS patients as a neglected opportunistic disease that has an important relationship with environmental factors. The present study described the clinical characteristics of HIV/AIDS patients diagnosed with disseminated histoplasmosis in a tertiary healthcare facility in Manaus, Amazonas, Brazil, and evaluated the patients' homes and urban environmental samples as a source of exposure to Histoplasma capsulatum. A review of medical records from 2017 to 2019 of patients with HIV/AIDS associated with histoplasmosis was carried out, as well as the collection of environmental samples in the homes of these patients. These samples were subjected to DNA extraction and then subjected to qPCR. A total of 62 patients diagnosed with HIV/AIDS and histoplasmosis were identified, which corresponds to 4.5% (n = 62/1372) of the HIV/AIDS cases detected in the period. Of these, 68% (n = 42/62) were male, with a mean age of 36 years and low education. In 47% (n = 29/62) of the cases, the diagnosis of HIV/AIDS and histoplasmosis occurred simultaneously. Mortality was 45% (n = 28/62), and 68% (n = 42/62) of these patients did not regularly use highly active antiretroviral therapy. The main symptoms found were respiratory, gastrointestinal, and weight loss, and in 81% (n = 50/62), the place of residence was in an urban area. A total of 57 environmental samples were analyzed, and the presence of Histoplasma capsulatum was not detected in any of the analyzed samples. There was a high mortality rate in the studied group of patients with AIDS and histoplasmosis. Most patients reported residing in urban areas of Manaus, with no history of travel to other areas previously known as being high risk for histoplasmosis.

Disfonia: retrato de um grupo populacional na cidade de Guarulhos / Dysphonia: portrait of a population group in the city of Guarulhos / Disfonía: retrato de un grupo de población en la ciudad de Guarulhos

Introdução: A disfonia causa impacto na qualidade de vida e no mercado de trabalho, sendo sinto-ma importante para triagem de neoplasia laríngea. Objetivo: Realizar avaliação estatística de um grupo populacional da cidade de Guarulhos com queixa de disfonia. Método: Trata-se de um estudo transversal com utilização de amostra correspondente a 2.564 exames, videolaringoscópicos ou nasofibrolaringoscó-picos, de pacientes acima de 5 anos de idade, no município de Guarulhos da região metropolitana de São Paulo, pelo mesmo médico otorrinolaringologista e pelo mesmo fonoaudiólogo, entre os meses de abril de 2011 e abril de 2012. Avaliaram-se as alterações no diagnóstico da voz, levando em consideração idade e sexo dos pacientes. Foram descritos os sexos das pessoas segundo diagnósticos com uso de frequências absolutas e relativas e verificou-se a existência de associação entre sexo e diagnóstico através do uso de teste da razão de verossimilhanças (Kirkwood e Sterne, 2006). As idades foram descritas, segundo diagnósticos, com uso de medidas resumo (média, desvio-padrão (DP), mediana, mínimo e máximo), e foram comparadas as idades entre os diagnósticos, com uso de teste análise de variâncias (ANOVA) seguido de comparações múltiplas de Tukey (Neter et al., 1996). Os testes foram realizados com nível de significância de 5%. Resultados: Há maior frequência de homens com diagnóstico de neoplasias ou câncer que nos demais diagnósticos. Dos 2.564 exames, 477 apresentaram laringite crônica, sendo 69% do gênero feminino; 279 disfonia funcional, 63,4% do gênero feminino; 137 alterações estruturais míni-mas (AEM), 69,3% do gênero feminino; 36 disfunções neurológicas, sendo igualmente divididos entre os gêneros; e 12 apresentaram neoplasias, sendo 83,3% do masculino. Conclusão: Verificou-se maior número de alterações benignas no gênero feminino. Neoplasias e disfunções neurológicas predominaram no gênero masculino. A disfonia funcional e as AEM ocorrem em pacientes abaixo dos 40 anos, enquanto as demais ocorrem até em idades avançadas, acima dos 50 anos.

Introduction: Dysphonia impacts in quality of life and in the labor market, being an important symptom for screening laryngeal neoplasia. Objective: Perform a statistical evaluation of a population group in the city of Guarulhos complaining of dysphonia. Method: This is a cross-sectional study using a sample corresponding to 2,564 examinations, videolaryngoscopic or nasofibrolaryngoscopic, of pa-tients over 5 years of age, in the municipality of Guarulhos of the metropolitan region of São Paulo, by the same ENT physician and the same speech therapist, between April 2011 and April 2012. Changes in voice diagnosis were evaluated taking into account the age and gender of the patient. The sex of subjects was described according to diagnoses using absolute and relative frequencies, and the existence of an association between sex and diagnosis was verified through the use of likelihood ratio testing (Kirkwood and Sterne, 2006). Ages were described according to diagnoses using summary measurements (mean, standard deviation, median, minimum and maximum), and compared the ages between diagnoses, using variance analysis (ANOVA) followed by multiple comparisons by Tukey (Neter et al., 1996). The tests were performed with a significance level of 5%. Results: There is a higher frequency of men diagnosed with neoplasms or cancer than in other diagnoses. Of the 2,564 tests, 477 had chronic laryngitis, 69% in females; 279 functional dysphonia, 63.4% female; 137 minimal structural alterations (AEM), 69.3% female; 36 neurological dysfunctions, being equally divided between genders; and 12 presented neoplasms, 83.3% in males. Conclusion: There were a higher number of benign alterations in the female gender. Neoplasms and neurological dysfunctions predominated in males. Functional dysphonia and AEM occur in patients under 40 years of age, while the others occur even at advanced ages, above 50 years of age.

Introducción: La disfonía impacta en la calidad de vida y en el mercado laboral, siendo un sínto-ma importante para el cribado de la neoplasia laríngea. Objetivo: Realizar una evaluación estadística de un grupo poblacional de la ciudad de Guarulhos que se queja de disfonía. Método: Se trata de un estudio transversal que utiliza una muestra correspondiente a 2564 exámenes, videolaringoscópicos o nasofibrolaringoscópicos, de pacientes mayores de 5 años, en el municipio de Guarulhos de la región metropolitana de São Paulo, realizados por el mismo otorrinolaringólogo y el mismo logopeda, entre abril de 2011 y abril de 2012. Los cambios en el diagnóstico de voz se evaluaron teniendo en cuenta la edad y el sexo de las personas. Los sexos de las personas se describieron de acuerdo con los diagnósticos utilizando frecuencias absolutas y relativas, y la existencia de una asociación entre el sexo y el diagnóstico se verificó mediante el uso de pruebas de razón de probabilidad (Kirkwood y Sterne, 2006). Las edades se describieron de acuerdo con los diagnósticos utilizando mediciones resumidas (media, desviación estándar, mediana, mínima y máxima), y se compararon las edades entre los diagnósticos, utilizando el análisis de varianza (ANOVA) seguido de comparaciones múltiples de Tukey (Neter et al., 1996). Las pruebas se realizaron con un nivel de significancia del 5%. Resultados: Hay una mayor frecuencia de hombres diagnosticados con neoplasias o cáncer que en otros diagnósticos. De las 2.564 pruebas, 477 presentaban laringitis crónica, el 69% en mujeres; 279 disfonía funcional, el 63,4% mujeres; 137 alteraciones estructurales mínimas (AEM), el 69,3% mujeres; 36 disfunciones neurológicas, estando divididas por igual entre géneros; y 12 presentaban neoplasias, el 83,3% en varones. Conclusión: Hubo un mayor número de alteraciones benignas en el género femenino. Las neoplasias y las disfunciones neurológicas predominaron en los varones. La disfonía funcional y la AEM ocurren en pacientes menores de 40 años de edad, mientras que las otras ocurren incluso a edades avanzadas, por encima de los 50 años de edad.

Incidence and Predictors of Progression to Chagas Cardiomyopathy: Long-Term Follow-Up of Trypanosoma cruzi-Seropositive Individuals.

BACKGROUND: There are few contemporary cohorts of Trypanosoma cruzi-seropositive individuals, and the basic clinical epidemiology of Chagas disease is poorly understood. Herein, we report the incidence of cardiomyopathy and death associated with T. cruzi seropositivity. METHODS: Participants were selected in blood banks at 2 Brazilian centers. Cases were defined as T. cruzi-seropositive blood donors. T. cruzi-seronegative controls were matched for age, sex, and period of donation. Patients with established Chagas cardiomyopathy were recruited from a tertiary outpatient service. Participants underwent medical examination, blood collection, ECG, and echocardiogram at enrollment (2008-2010) and at follow-up (2018-2019). The primary outcomes were all-cause mortality and development of cardiomyopathy, defined as the presence of a left ventricular ejection fraction <50% or QRS complex duration ≥120 ms, or both. To handle loss to follow-up, a sensitivity analysis was performed using inverse probability weights for selection. RESULTS: We enrolled 499 T. cruzi-seropositive donors (age 48±10 years, 52% male), 488 T. cruzi-seronegative donors (age 49±10 years, 49% male), and 101 patients with established Chagas cardiomyopathy (age 48±8 years, 59% male). The mortality in patients with established cardiomyopathy was 80.9 deaths/1000 person-years (py) (54/101, 53%) and 15.1 deaths/1000 py (17/114, 15%) in T. cruzi-seropositive donors with cardiomyopathy at baseline. Among T. cruzi-seropositive donors without cardiomyopathy at baseline, mortality was 3.7 events/1000 py (15/385, 4%), which was no different from T. cruzi-seronegative donors with 3.6 deaths/1000 py (17/488, 3%). The incidence of cardiomyopathy in T. cruzi-seropositive donors was 13.8 (95% CI, 9.5-19.6) events/1000 py (32/262, 12%) compared with 4.6 (95% CI, 2.3-8.3) events/1000 py (11/277, 4%) in seronegative controls, with an absolute incidence difference associated with T. cruzi seropositivity of 9.2 (95% CI, 3.6-15.0) events/1000 py. T. cruzi antibody level at baseline was associated with development of cardiomyopathy (adjusted odds ratio, 1.4 [95% CI, 1.1-1.8]). CONCLUSIONS: We present a comprehensive description of the natural history of T. cruzi seropositivity in a contemporary patient population. The results highlight the central importance of anti-T. cruzi antibody titer as a marker of Chagas disease activity and risk of progression.

Acute kidney injury in patients with Covid-19 in a Brazilian ICU: incidence, predictors and in-hospital mortality / Lesão renal aguda em pacientes com Covid-19 de uma UTI no Brasil: incidência, preditores e mortalidade hospitalar

Abstract Introduction: There is little data in the literature on acute kidney injury (AKI) in Covid-19 cases, although relevant in clinical practice in the ICU, especially in Brazil. Our goal was to identify the incidence of AKI, predictive factors and impact on hospital mortality. Method: Retrospective cohort of patients with Covid-19 admitted to the ICU. AKI was defined according to KDIGO criteria. Data was collected from electronic medical records between March 17 and April 26. Results: Of the 102 patients, 55.9% progressed with AKI, and the majority (66.7%) was classified as stage 3. Multivariate logistic regression showed age (RC 1.101; 95% CI 1.026 - 1.181; p = 0.0070), estimated glomerular filtration rate - eGFR (RC 1.127; 95% CI 1.022 - 1.243; p = 0.0170) and hypertension (RC 3.212; 95% CI 1.065 - 9.690; p = 0.0380) as independent predictors of AKI. Twenty-three patients died. In the group without kidney injury, there were 8.9% deaths, while in the group with AKI, 33.3% of patients died (RR 5.125; 95% CI 1.598 - 16.431; p = 0.0060). The average survival, in days, was higher in the group without AKI. Cox multivariate analysis showed age (RR 1.054; 95% CI 1.014 - 1.095; p = 0.0080) and severe acute respiratory distress syndrome (RR 8.953; 95% CI 1.128 - 71.048; p = 0.0380) as predictors of hospital mortality. Conclusion: We found a high incidence of AKI; and as predictive factors for its occurrence: age, eGFR and hypertension. AKI was associated with higher hospital mortality.

Resumo Introdução: A lesão renal aguda (LRA)na Covid-19, apesar de relevante na prática clínica em UTI, dispõe de poucos dados na literatura, sobretudo no Brasil. Objetivo foi identificar a incidência de LRA, fatores preditores e impacto na mortalidade hospitalar. Método: Coorte retrospectiva de pacientes com Covid-19 internados em UTI. LRA foi definida segundo critérios de KDIGO. Dados coletados de registros de prontuários eletrônicos entre 17 de março e 26 de abril. Resultados: Dos 102 pacientes, 55,9% evoluíram com LRA e a maioria (66,7%) foi classificada como estágio 3. Regressão logística multivariada mostrou idade (RC 1,101; IC 95% 1,026 - 1,181; p = 0,0070), taxa de filtração glomerular estimada - TFGe (RC 1,127; IC 95% 1,022 - 1,243; p = 0,0170) e hipertensão (RC 3,212; IC 95% 1,065 - 9,690; p = 0,0380) como preditores independentes de LRA. Vinte e três pacientes faleceram. No grupo sem lesão renal ocorreu 8,9% de óbitos, enquanto que no grupo com LRA 33,3% dos pacientes morreram (RR 5,125; IC 95% 1,598 - 16,431; p = 0,0060). A média de sobrevida, em dias, foi maior no grupo sem LRA. Análise multivariada de Cox mostrou idade (RR 1,054; IC 95% 1,014 - 1,095; p = 0,0080) e síndrome do desconforto respiratório agudo grave (RR 8,953; IC 95% 1,128 - 71,048; p = 0,0380) como preditores de mortalidade hospitalar. Conclusão: Encontramos alta incidência de LRA; e como fatores preditores para sua ocorrência: idade, TFGe e hipertensão. A LRA estava associada a maior mortalidade hospitalar.

Acute kidney injury in patients with Covid-19 in a Brazilian ICU: incidence, predictors and in-hospital mortality.

INTRODUCTION: There is little data in the literature on acute kidney injury (AKI) in Covid-19 cases, although relevant in clinical practice in the ICU, especially in Brazil. Our goal was to identify the incidence of AKI, predictive factors and impact on hospital mortality. METHOD: Retrospective cohort of patients with Covid-19 admitted to the ICU. AKI was defined according to KDIGO criteria. Data was collected from electronic medical records between March 17 and April 26. RESULTS: Of the 102 patients, 55.9% progressed with AKI, and the majority (66.7%) was classified as stage 3. Multivariate logistic regression showed age (RC 1.101; 95% CI 1.026 - 1.181; p = 0.0070), estimated glomerular filtration rate - eGFR (RC 1.127; 95% CI 1.022 - 1.243; p = 0.0170) and hypertension (RC 3.212; 95% CI 1.065 - 9.690; p = 0.0380) as independent predictors of AKI. Twenty-three patients died. In the group without kidney injury, there were 8.9% deaths, while in the group with AKI, 33.3% of patients died (RR 5.125; 95% CI 1.598 - 16.431; p = 0.0060). The average survival, in days, was higher in the group without AKI. Cox multivariate analysis showed age (RR 1.054; 95% CI 1.014 - 1.095; p = 0.0080) and severe acute respiratory distress syndrome (RR 8.953; 95% CI 1.128 - 71.048; p = 0.0380) as predictors of hospital mortality. CONCLUSION: We found a high incidence of AKI; and as predictive factors for its occurrence: age, eGFR and hypertension. AKI was associated with higher hospital mortality.

Determinants of COVID-19 Mortality in Patients With Cancer From a Community Oncology Practice in Brazil.

PURPOSE: The COVID-19 pandemic remains a public health emergency of global concern. Determinants of mortality in the general population are now clear, but specific data on patients with cancer remain limited, particularly in Latin America. MATERIALS AND METHODS: A longitudinal multicenter cohort study of patients with cancer and confirmed COVID-19 from Oncoclínicas community oncology practice in Brazil was conducted. The primary end point was all-cause mortality after isolation of the SARS-CoV-2 by Real-Time Polymerase Chain Reaction (RT-PCR) in patients initially diagnosed in an outpatient environment. We performed univariate and multivariable logistic regression analysis and recursive partitioning modeling to define the baseline clinical determinants of death in the overall population. RESULTS: From March 29 to July 4, 2020, 198 patients with COVID-19 were prospectively registered in the database, of which 167 (84%) had solid tumors and 31 (16%) had hematologic malignancies. Most patients were on active systemic therapy or radiotherapy (77%), largely for advanced or metastatic disease (64%). The overall mortality rate was 16.7% (95% CI, 11.9 to 22.7). In univariate models, factors associated with death after COVID-19 diagnosis were age ≥ 60 years, current or former smoking, coexisting comorbidities, respiratory tract cancer, and management in a noncurative setting (P < .05). In multivariable logistic regression and recursive partitioning modeling, only age, smoking history, and noncurative disease setting remained significant determinants of mortality, ranging from 1% in cancer survivors under surveillance or (neo)adjuvant therapy to 60% in elderly smokers with advanced or metastatic disease. CONCLUSION: Mortality after COVID-19 in patients with cancer is influenced by prognostic factors that also affect outcomes of the general population. Fragile patients and smokers are entitled to active preventive measures to reduce the risk of SARS-CoV-2 infection and close monitoring in the case of exposure or COVID-19-related symptoms.

Trace metals in estuarine organisms from a port region in southern Brazil: consumption risk to the local population.

Metal contamination is a threat to estuarine environments. They can accumulate in the food chain and cause toxic effects on aquatic organisms and human health. This study evaluated the concentrations of metals (Cd, Cr, Cu, Fe, Ni, Pb, and Zn) in aquatic organisms of Antonina Bay (southern Brazil) to analyze whether the metal concentrations were in accordance with Brazilian food legislation and estimate the human risk of local seafood consumption. All analyzed organisms (Centropomus parallelus, Mugil curema, Genidens genidens, Crassostrea brasiliana, and Xiphopenaeus kroyeri) showed traces of metals in their tissues with different metal concentrations among species. Metal concentrations were generally higher in oyster C. brasiliana, and biomagnification was not observed. Cr and Zn concentrations were above the limits established by legislation for all species in at least one sample. The concentrations of the other metals were within permitted levels. However, concentrations of Cd, Cr, Fe, and Zn posed a human consumption risk. In general, the C. brasiliana oyster presented the highest risk for human consumption, probably due to its filtering habit. Thus, the results indicated that metal concentrations in the tissues of the Antonina Bay seafood can pose a risk to human health, and this chronic exposure to metals also can cause toxic effects on local aquatic biota.

Customization and external validation of the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU) in Brazilian critically ill patients.

PURPOSE: To customize and externally validate the recently proposed Simplified Mortality Score for the ICU (SMS-ICU, a simple score for 90-day mortality that has no need for ancillary testing results) for in-hospital mortality and to compare its performance to SAPS 3. MATERIAL AND METHODS: We used data from two distinct large cohorts of adult Brazilian patients with unplanned ICU admissions to perform a first-level customization (43,017 patients admitted to 78 ICUs) of the original SMS-ICU score for in-hospital mortality and, sequentially, externally validate it (313,365 patients admitted to 99 ICUs). Performance of SMS-ICU was assessed through measurements of discrimination and calibration and compared with SAPS 3. RESULTS: In the validation cohort, median SMS-ICU was 13 (IQR 8-16) points and median SAPS 3 was 44 (IQR 36-51). Discrimination of SMS-ICU was good (AUC 0.817; 95% CI 0.814-0.819) but slightly lower than of SAPS 3 (AUC 0.845; 95% CI 0.843-0.848;). The customized SMS-ICU predictions were comparable to SAPS 3 in terms of calibration. CONCLUSION: In this external validation of the SMS-ICU in a large Brazilian cohort, we observed good discrimination of SMS-ICU and acceptable calibration after first-level customization. SMS-ICU can be used as a measure of illness severity for acutely admitted ICU patients in clinical studies.

Percepções sobre o ensino de ética na medicina: estudo qualitativo / Perceptions about the teaching of ethics in medicine: a qualitative study / Percepciones sobre la enseñanza de ética en medicina: un estudio cualitativo

Resumo Por meio de pesquisa qualitativa, este trabalho buscou identificar as percepções de estudantes de medicina sobre o ensino da ética na graduação. Foram entrevistados 24 alunos de universidade pública e realizada análise categorial temática, preservando o anonimato das informações por códigos. Duas categorias foram destacadas. A primeira expõe a importância da reflexão sobre a complexidade do processo ensino-aprendizagem. Nela, entrevistados relatam a desvalorização e dissociação do ensino de ética em relação à prática, ressaltando a necessidade de qualificação dos docentes. A segunda categoria apresenta sugestões, como aprofundar e exigir o conteúdo em humanidades durante todo o curso. Conclui-se que, para qualificar o ensino de ética, é preciso criar mais oportunidades de interação entre educadores e estudantes, favorecendo assim a construção do conhecimento e o reconhecimento da abrangência dos problemas identificados. Dessa forma, o processo de ensino-aprendizagem aperfeiçoaria o indivíduo ao desenvolver a dimensão ética necessária aos profissionais de saúde.

Abstract This study sought to identify the perceptions of medical students regarding the teaching of ethics in undergraduate courses. It is a qualitative approach research which interviewed 24 public university students. Thematic categorical analysis was carried out, preserving the anonymity of the information by the use of alphanumeric codes. Two categories of analysis were highlighted. The first describes perceptions regarding ethics teaching, showing that it is necessary to reflect on the complexity of the teaching-learning process. There are perceptions of devalued education, dissociated from the practice and highlighting the need for the qualification of educators. The second category presents suggestions for the teaching of ethics, among them, to deepen and demand the humanities content throughout the course. To qualify the teaching of ethics, it is necessary to provide interactive and participative moments, between educators and students, that favor the knowledge and comprehensiveness of the problems identified. Thus, the teaching-learning process leads to the improvement of the individual, by contributing to improve the ethical dimension required for health professionals.

Resumen Por medio de una investigación cualitativa, este trabajo identificó las percepciones de los estudiantes de medicina sobre la enseñanza de la ética en la carrera de grado. Se entrevistó a 24 estudiantes de una universidad pública y se realizó un análisis categorial temático, preservando el anonimato de las informaciones mediante códigos. Se destacaron dos categorías de análisis. La primera, expone la importancia de la reflexión sobre la complejidad del proceso enseñanza-aprendizaje. En ella, los entrevistados relatan la desvalorización y la disociación de la enseñanza de ética en relación con la práctica, resaltando la necesidad de cualificación de los docentes. La segunda categoría analítica presenta sugerencias, como profundizar y exigir contenido de humanidades durante toda la carrera. Se concluye que, para cualificar la enseñanza de la ética, se hace necesario crear más oportunidades de interacción entre educadores y estudiantes, favoreciendo así la construcción del conocimiento y el reconocimiento del alcance de los problemas identificados. De esta forma, el proceso de enseñanza-aprendizaje, impactaría en el perfeccionamiento del individuo al desarrollar la dimensión ética necesaria para los profesionales de salud.

The Influence of Auditory Feedback and Vocal Rehabilitation on Prelingual Hearing-Impaired Individuals Post Cochlear Implant.

OBJECTIVE: To verify changes in the perceptual and acoustic vocal parameters in prelingual hearing-impaired adults with cochlear implants after vocal rehabilitation. HYPOTHESIS: Auditory feedback restoration alone after cochlear implant is not enough for vocal adjustments. A targeted and specific voice therapy intervention is required. STUDY DESIGN: Prospective and pre-post repeated measures design. METHODS: Twenty literate adults with severe to profound prelingual bilateral sensorineural hearing loss participated in the study; individuals were implanted late and were fluent users of oral language. Ages ranged from 17 to 48 years. All individuals presented normal results in laryngoscopy, and hearing thresholds with the cochlear implant were over 40 dB HL. Individuals were randomly distributed into two groups: Group 1 (treatment group) and Group 2 (control group), both with ten patients each, five men and five women, matching mean age and hearing deprivation time before the cochlear implantation. Patients from Group 1 underwent a protocol of vocal therapy including 12 individual sessions with the same clinician. Group 2 only underwent vocal recordings. The vocal recordings occurred before and after the participation in the therapy protocol for Group 1 and after the same period, 3 months later, without any intervention, for Group 2. The recording sessions used the Consensus Auditory-Perceptual Evaluation of Voice protocol sentence reading and emission of sustained vowel /a/. Auditory-perceptual evaluation of voices was performed by three judges, and the acoustical analysis used the Praat program. RESULTS: Statistically significant reductions in the overall vocal degree, vocal instability, and degree of resonance change were observed after vocal rehabilitation in Group 1. Statistically, individuals from Group 1 did not differ in regard to the modification of acoustic parameters. Group 2 did not present significant changes in any of the analyzed parameters. CONCLUSIONS: The cochlear implanted adults submitted to vocal rehabilitation presented changes in the auditory-perceptual parameters, with reduction of the overall voice severity, vocal instability, and degree of resonance after vocal intervention. There were no changes in the acoustic parameters in the implanted prelingual hearing-impaired adult subjects.

Ethical Conflicts Experienced by Medical Students / Conflitos Éticos Vivenciados por Estudantes de Medicina

ABSTRACT The current study aimed to identify and analyze the prevalence of ethical conflicts experienced by medical students. This study is a cross-sectional and analytical research that was conducted in a public school in the state of Minas Gerais, Brazil. The instrument used for the data collection was a self-administered questionnaire. The data collected were presented in absolute and percentage values. For the analytical statistical treatment of the data, the level of significance was considered p <0.05. The outcome variables were: Experiences of ethical conflicts in interpersonal relations within the medical course and Ethical conduct in health care. The identification of the prevalence of ethical conflicts in the undergraduate program adopted the perspective of different interpersonal relations (academic-teaching, academic-academic, academic-employee, academic-patient, teacher-teacher, teacher-patient, teacher-employee and employee-patient). (Importance of identifying themselves to the health services user and requesting consent to perform the physical examination, assistance without the supervision of the teacher, issuance of health documents without the signature of the professional responsible and use of social networks to share data Of patient). It was verified the association of the outcome variables with sex, year of graduation and course evaluation. A total of 281 undergraduate students enrolled in all undergraduate courses in Medicine of both sexes, with a predominance of female (52.7%). The students reported having experienced conflicting situations in interpersonal relations with teachers (59.6%), provided assistance without proper supervision of a teacher (62.6%), reported having issued health documents without the accompaniment of teachers (18, 5%). The highest frequency was observed among those enrolled in the most advanced years of the undergraduate program (p <0.05). The use of social networks for the purpose of sharing patient data (25.1%) was prevalent in the most advanced years of medical graduation and among those who evaluated the course as regular (p <0.05). It is concluded that undergraduate medical students experienced ethical conflicts during their medical training, with a prevalence of conflicts in the advanced years of the course. From this perspective, it is necessary to provide a space for discussion and collective reflection on the ethical problems experienced by students, during their graduation in Medicine, in order to build a professional ethical practice.

RESUMO O atual estudo teve como objetivo identificar e analisar a prevalência de conflitos éticos vivenciados por estudantes de Medicina. Este estudo trata-se de pesquisa com delineamento transversal e analítico e que foi conduzida em uma escola pública do estado de Minas Gerais, Brasil. O instrumento utilizado para a coleta de dados foi um questionário autoaplicado. Os dados coletados foram apresentados em valores absolutos e percentuais. Para o tratamento estatístico analítico dos dados considerou-se o nível de significância p<0,05. As variáveis desfecho foram: Vivência de conflitos éticos em relações interpessoais no âmbito do curso médico e Condutas éticas na assistência em saúde. A identificação da prevalência dos conflitos éticos na graduação adotou a perspectiva das diferentes relações interpessoais (acadêmico-docente, acadêmico-acadêmico, acadêmico-funcionário, acadêmico-paciente, docente-docente, docente-paciente, docente-funcionário e funcionário-paciente) e condutas na assistência médica (importância de identificar-se ao usuário dos serviços de saúde e dele solicitar consentimento para realizar o exame físico, assistência sem supervisão do docente, emissão de documentos de saúde sem assinatura do profissional responsável e uso de redes sociais para compartilhar dados de paciente). Foi verificada associação das variáveis desfecho com sexo, ano da graduação e avaliação do curso. Participaram da pesquisa 281 acadêmicos matriculados em todos os anos da graduação em Medicina, de ambos os sexos, sendo predominante o sexo feminino (52,7%). Os estudantes relataram ter vivenciado situações conflituosas nas relações interpessoais com os professores (59,6%), prestaram assistência sem a devida supervisão de um professor (62,6%), afirmaram ter emitido documentos de saúde sem o acompanhamento de professores (18,5%), sendo a maior frequência observada entre aqueles matriculados nos anos mais avançados da graduação (p<0,05). O uso das redes sociais com a finalidade de compartilhar os dados de pacientes (25,1%) foi prevalente nos anos mais avançados da graduação em medicina e entre os que avaliaram o curso como regular (p<0,05). Conclui-se que os estudantes de graduação em Medicina vivenciaram conflitos éticos durante a sua formação médica, com prevalência de vivência dos conflitos nos anos mais avançados do referido curso. Nessa perspectiva, faz-se necessário propiciar um espaço de discussão e de reflexão coletiva acerca dos problemas éticos vivenciados pelos estudantes, ao longo da graduação em Medicina, a fim de se construir um agir profissional eticamente correto.

Elaboração coletiva do código de ética do estudante de medicina / Collective drafting of the medical student's code of ethics / Elaboración colectiva del código de ética del estudiante de medicina

Resumo Este artigo descreve a elaboração do Código de Ética do Estudante de Medicina comparando o processo com o descrito na literatura. Os dados foram levantados em pesquisa de campo qualitativa, por meio de entrevista com 24 estudantes, e quantitativa, com aplicação de questionário sobre conflitos éticos a 281 acadêmicos. A partir das opiniões dos estudantes e pesquisa bibliográfica, identificaram-se temáticas essenciais para elaboração do código de ética do estudante de graduação. Como resultado, o código abordou direitos e deveres de professores, pacientes, instituições e sociedade em geral, considerando inclusive problemas contemporâneos, como o uso de redes sociais e trote universitário. Concluiu-se que a elaboração coletiva do código corresponde ao início de processo que pretende estimular a reflexão sobre assistência médica e dimensão social para se tomar decisões coerentes com princípios éticos e morais em respeito à dignidade do ser humano.

Abstract This article describes the drafting of the Medical Student's Code of Ethics comparing the process with what is described in literature. Data was collected through qualitative field research, by means of interviews with 24 students, and quantitative field research, using a questionnaire regarding ethical conflicts with a sample of 281 medical students. Based on the students' views and bibliographic research, key issues regarding the preparation of the undergraduates' code of ethics were identified. As a result, the code dealt with rights and duties of lecturers, patients, the institution and society as a whole, considering even contemporary problems such as the use of social networks and college hazing. The study concludes that the collective drafting of the code is the beginning of a process that intends to encourage reflection on health care and social perspective in order to take decisions consistent with ethical and moral principles, respecting human dignity.

Resumen Este artículo describe la elaboración del Código de Ética del Estudiante de Medicina comparando este proceso con lo que se describe en la literatura. Se recolectaron datos a partir de una investigación cualitativa, mediante entrevistas con 24 estudiantes, y de una cuantitativa a través de la aplicación de un cuestionario sobre conflictos éticos a 281 universitarios. A partir de las opiniones de los estudiantes y de la investigación bibliográfica se identificaron temáticas esenciales para la elaboración del código de ética del estudiante de grado. En consecuencia, el código abordó los derechos y deberes de los profesores, los pacientes, las instituciones y la sociedad en general, considerando, además, los problemas contemporáneos como el uso de redes sociales y los ritos de iniciación universitarios. Se concluye que la elaboración colectiva del código corresponde al inicio de un proceso que pretende estimular la reflexión sobre la asistencia médica y la dimensión social para la toma de decisiones coherentes con los principios éticos y morales, respetando la dignidad del ser humano.

Conflitos Éticos Vivenciados por Estudantes de Medicina / Ethical Conflicts Experienced by Medical Students

RESUMO O atual estudo teve como objetivo identificar e analisar a prevalência de conflitos éticos vivenciados por estudantes de Medicina. Este estudo trata-se de pesquisa com delineamento transversal e analítico e que foi conduzida em uma escola pública do estado de Minas Gerais, Brasil. O instrumento utilizado para a coleta de dados foi um questionário autoaplicado. Os dados coletados foram apresentados em valores absolutos e percentuais. Para o tratamento estatístico analítico dos dados considerou-se o nível de significância p<0,05. As variáveis desfecho foram: Vivência de conflitos éticos em relações interpessoais no âmbito do curso médico e Condutas éticas na assistência em saúde. A identificação da prevalência dos conflitos éticos na graduação adotou a perspectiva das diferentes relações interpessoais (acadêmico-docente, acadêmico-acadêmico, acadêmico-funcionário, acadêmico-paciente, docente-docente, docente-paciente, docente-funcionário e funcionário-paciente) e condutas na assistência médica (importância de identificar-se ao usuário dos serviços de saúde e dele solicitar consentimento para realizar o exame físico, assistência sem supervisão do docente, emissão de documentos de saúde sem assinatura do profissional responsável e uso de redes sociais para compartilhar dados de paciente). Foi verificada associação das variáveis desfecho com sexo, ano da graduação e avaliação do curso. Participaram da pesquisa 281 acadêmicos matriculados em todos os anos da graduação em Medicina, de ambos os sexos, sendo predominante o sexo feminino(52,7%). Os estudantes relataram ter vivenciado situações conflituosas nas relações interpessoais com os professores (59,6%), prestaram assistência sem a devida supervisão de um professor (62,6%), afirmaram ter emitido documentos de saúde sem o acompanhamento de professores (18,5%), sendo a maior frequência observada entre aqueles matriculados nos anos mais avançados da graduação (p<0,05). O uso das redes sociais com a finalidade de compartilhar os dados de pacientes (25,1%) foi prevalente nos anos mais avançados da graduação em medicina e entre os que avaliaram o curso como regular (p<0,05). Conclui-se que os estudantes de graduação em Medicina vivenciaram conflitos éticos durante a sua formação médica, com prevalência de vivência dos conflitos nos anos mais avançados do referido curso. Nessa perspectiva, faz-se necessário propiciar um espaço de discussão e de reflexão coletiva acerca dos problemas éticos vivenciados pelos estudantes, ao longo da graduação em Medicina, a fim de se construir um agir profissional eticamente correto.

ABSTRACT The current study aimed to identify and analyze the prevalence of ethical conflicts experienced by medical students. This study is a cross-sectional and analytical research that was conducted in a public school in the state of Minas Gerais, Brazil. The instrument used for the data collection was a self-administered questionnaire. The data collected were presented in absolute and percentage values. For the analytical statistical treatment of the data, the level of significance was considered p <0.05. The outcome variables were: Experiences of ethical conflicts in interpersonal relations within the medical course and Ethical conduct in health care. The identification of the prevalence of ethical conflicts in the undergraduate program adopted the perspective of different interpersonal relations (academic-teaching, academic-academic, academic-employee, academic-patient, teacher-teacher, teacher-patient, teacher-employee and employee-patient). (Importance of identifying themselves to the health services user and requesting consent to perform the physical examination, assistance without the supervision of the teacher, issuance of health documents without the signature of the professional responsible and use of social networks to share data Of patient). It was verified the association of the outcome variables with sex, year of graduation and course evaluation. A total of 281 undergraduate students enrolled in all undergraduate courses in Medicine of both sexes, with a predominance of female (52.7%). The students reported having experienced conflicting situations in interpersonal relations with teachers (59.6%), provided assistance without proper supervision of a teacher (62.6%), reported having issued health documents without the accompaniment of teachers (18, 5%). The highest frequency was observed among those enrolled in the most advanced years of the undergraduate program (p <0.05). The use of social networks for the purpose of sharing patient data (25.1%) was prevalent in the most advanced years of medical graduation and among those who evaluated the course as regular (p <0.05). It is concluded that undergraduate medical students experienced ethical conflicts during their medical training, with a prevalence of conflicts in the advanced years of the course. From this perspective, it is necessary to provide a space for discussion and collective reflection on the ethical problems experienced by students, during their graduation in Medicine, in order to build a professional ethical practice.

The effects of performance status one week before hospital admission on the outcomes of critically ill patients.

PURPOSE: To assess the impact of performance status (PS) impairment 1 week before hospital admission on the outcomes in patients admitted to intensive care units (ICU). METHODS: Retrospective cohort study in 59,693 patients (medical admissions, 67 %) admitted to 78 ICUs during 2013. We classified PS impairment according to the Eastern Cooperative Oncology Group (ECOG) scale in absent/minor (PS = 0-1), moderate (PS = 2) or severe (PS = 3-4). We used univariate and multivariate logistic regression analyses to investigate the association between PS impairment and hospital mortality. RESULTS: PS impairment was moderate in 17.3 % and severe in 6.9 % of patients. The hospital mortality was 14.4 %. Overall, the worse the PS, the higher the ICU and hospital mortality and length of stay. In addition, patients with worse PS were less frequently discharged home. PS impairment was associated with worse outcomes in all SAPS 3, Charlson Comorbidity Index and age quartiles as well as according to the admission type. Adjusting for other relevant clinical characteristics, PS impairment was associated with higher hospital mortality (odds-ratio (OR) = 1.96 (95 % CI 1.63-2.35), for moderate and OR = 4.22 (3.32-5.35), for severe impairment). The effects of PS on the outcome were particularly relevant in the medium range of severity-of-illness. These results were consistent in the subgroup analyses. However, adding PS impairment to the SAPS 3 score improved only slightly its discriminative capability. CONCLUSION: PS impairment was associated with worse outcomes independently of other markers of chronic health status, particularly for patients in the medium range of severity of illness.

Systematic review of anaemia and inflammatory markers in chronic obstructive pulmonary disease.

This systematic review synthesizes the relevant published articles on the prevalence of anaemia in patients with chronic obstructive pulmonary disease (COPD) and its relationship with inflammatory markers. The upregulation of erythropoietin in anaemia maintains homeostasis. However, anaemic COPD patients do not respond to increased levels of erythropoietin. The increased levels could be an indicator of the peripheral erythropoietin resistance in COPD. Anaemia and inflammation are associated with an increased risk of hospitalization and mortality in these patients. The understanding of anaemia in chronic inflammation is that anaemia is at least partially due to the excessive production of inflammatory cytokines, which can contribute to improvements in the management, prognosis, and survival of patients with COPD and anaemia.

Electrocardiographic abnormalities in Trypanosoma cruzi seropositive and seronegative former blood donors.

BACKGROUND: Blood donor screening leads to large numbers of new diagnoses of Trypanosoma cruzi infection, with most donors in the asymptomatic chronic indeterminate form. Information on electrocardiogram (ECG) findings in infected blood donors is lacking and may help in counseling and recognizing those with more severe disease. OBJECTIVES: To assess the frequency of ECG abnormalities in T.cruzi seropositive relative to seronegative blood donors, and to recognize ECG abnormalities associated with left ventricular dysfunction. METHODS: The study retrospectively enrolled 499 seropositive blood donors in São Paulo and Montes Claros, Brazil, and 483 seronegative control donors matched by site, gender, age, and year of blood donation. All subjects underwent a health clinical evaluation, ECG, and echocardiogram (Echo). ECG and Echo were reviewed blindly by centralized reading centers. Left ventricular (LV) dysfunction was defined as LV ejection fraction (EF)<0.50%. RESULTS: Right bundle branch block and left anterior fascicular block, isolated or in association, were more frequently found in seropositive cases (p<0.0001). Both QRS and QTc duration were associated with LVEF values (correlation coefficients -0.159,p<0.0003, and -0.142,p = 0.002) and showed a moderate accuracy in the detection of reduced LVEF (area under the ROC curve: 0.778 and 0.790, both p<0.0001). Several ECG abnormalities were more commonly found in seropositive donors with depressed LVEF, including rhythm disorders (frequent supraventricular ectopic beats, atrial fibrillation or flutter and pacemaker), intraventricular blocks (right bundle branch block and left anterior fascicular block) and ischemic abnormalities (possible old myocardial infarction and major and minor ST abnormalities). ECG was sensitive (92%) for recognition of seropositive donors with depressed LVEF and had a high negative predictive value (99%) for ruling out LV dysfunction. CONCLUSIONS: ECG abnormalities are more frequent in seropositive than in seronegative blood donors. Several ECG abnormalities may help the recognition of seropositive cases with reduced LVEF who warrant careful follow-up and treatment.

The invertebrate's community in adjacent Alto Iguaçu's anthropic lakes of different environmental factors / A comunidade de invertebrados em lagos antrópicos adjacentes com diferentes fatores ambientais no Alto Iguaçu

Environmental differences occur between lentic and lotic communities' establishment, especially because of water time residence. Here we used a combination of field measurements and statistical analysis to evaluate the influent factors on the aquatic macroinvertebrates' composition and structure in 15 anthropogenic lakes from Alto Iguaçu's region. Macroinvertebrates were sampled from the marginal vegetation (with or without macrophytes) and sediment. Chemical parameters ranged among the anthropogenic lakes, mainly those which are connected to the Iguaçu River, beyond the presence or absence of macrophytes, interfering on the community's structure. Lake's morphometric data were measured in each lake and its relation to community was tested. The community structure was not related to the margin development index (Ds), macrophytes and altitude. Higher equitability was associated to the macrophytes presence in more than 30% of water surface and also where the riparian vegetation was more complex. Chironomids and oligochaetes densities were associated to lakes with the water surface completely covered by macrophytes and complex riparian vegetation. We observed a close association between productivity (phosphorous and nitrogen) and the community equitability (R = 0.3; p < 0.05) and Oligochaeta dominance (R = 0.32; p < 0.05), and not to Ostracoda's (R = 0.33; p > 0.05) and Chironomidae's (R = 0.34; p > 0.05) dominances, although we had not weighty difference among analyzed biological indexes. The obtained values from the BMWP' and EPT indexes resulted in acceptable, doubtful or critical water quality, what corroborates with the macroinvertebrate's structure of the composition and with the environmental variables observed in field.

Diferenças ambientais ocorrem entre o estabelecimento de comunidades de ambientes lênticos e lóticos, especialmente por causa do tempo de residência da água. Foi usada uma combinação de métricas de campo e análise estatística para avaliar os fatores influentes sobre a composição e estrutura de macroinvertebrados aquáticos em 15 lagos antropogênicos da região do Alto Iguaçu. Os macroinvertebrados foram amostrados da vegetação marginal (com ou sem macrófitas) e sedimento. Parâmetros químicos variaram entre os lagos antrópicos, principalmente aqueles conectados ao Rio Iguaçu, além da presença ou ausência das macrófitas, interferindo na estrutura da comunidade. Dados de morfometria de lagos foram mensurados e sua relação com a comunidade foi testada. A estrutura da comunidade não foi relacionada ao índice de desenvolvimento da margem (Ds), macrófitas e altitude. Maior equitabilidade foi associada à presença de macrófitas em mais de 30% da superfície da água e também onde a vegetação ripária foi mais complexa. Densidades de quironomídeos e oligoquetas foram associadas a lagos com a superfície completamente coberta por macrófitas e complexa vegetação ripária. Foi observada associação entre a produtividade (fósforo e nitrogênio) e a equitabilidade da comunidade (R = 0.3; p < 0.05) e dominância de Oligochaeta (R = 0.32; p < 0.05) e não para a dominância de Ostracoda (R = 0.33; p > 0,05) e Chironomidae (R = 0.34; p > 0.05), apesar de não haver diferença entre os índices biológicos analisados. Os valores obtidos através do Índice BMWP' e EPT/C resultaram em ambientes de qualidade aceitável, duvidosa ou crítica, o que corrobora com a estrutura da composição de invertebrados e com as características ambientais observadas em campo.

Ten-year incidence of Chagas cardiomyopathy among asymptomatic Trypanosoma cruzi-seropositive former blood donors.

BACKGROUND: Very few studies have measured disease penetrance and prognostic factors of Chagas cardiomyopathy among asymptomatic Trypanosoma cruzi-infected persons. METHODS AND RESULTS: We performed a retrospective cohort study among initially healthy blood donors with an index T cruzi-seropositive donation and age-, sex-, and period-matched seronegatives in 1996 to 2002 in the Brazilian cities of São Paulo and Montes Claros. In 2008 to 2010, all subjects underwent medical history, physical examination, ECGs, and echocardiograms. ECG and echocardiogram results were classified by blinded core laboratories, and records with abnormal results were reviewed by a blinded panel of 3 cardiologists who adjudicated the outcome of Chagas cardiomyopathy. Associations with Chagas cardiomyopathy were tested with multivariate logistic regression. Mean follow-up time between index donation and outcome assessment was 10.5 years for the seropositives and 11.1 years for the seronegatives. Among 499 T cruzi seropositives, 120 (24%) had definite Chagas cardiomyopathy, and among 488 T cruzi seronegatives, 24 (5%) had cardiomyopathy, for an incidence difference of 1.85 per 100 person-years attributable to T cruzi infection. Of the 120 seropositives classified as having Chagas cardiomyopathy, only 31 (26%) presented with ejection fraction <50%, and only 11 (9%) were classified as New York Heart Association class II or higher. Chagas cardiomyopathy was associated (P<0.01) with male sex, a history of abnormal ECG, and the presence of an S3 heart sound. CONCLUSIONS: There is a substantial annual incidence of Chagas cardiomyopathy among initially asymptomatic T cruzi-seropositive blood donors, although disease was mild at diagnosis.

GRBAS and Cape-V scales: high reliability and consensus when applied at different times.

OBJECTIVES: To evaluate whether the overall dysphonia grade, roughness, breathiness, asthenia, and strain (GRBAS) scale, and the Consensus Auditory Perceptual Evaluation-Voice (CAPE-V) scale show the same reliability and consensus when applied to the same vocal sample at different times. STUDY DESIGN: Observational cross-sectional study. METHODS: Sixty subjects had their voices recorded according to the tasks proposed in the CAPE-V scale. Vowels /a/ and /i/ were sustained between 3 and 5 seconds. Reproduction of six sentences and spontaneous speech from the request "Tell me about your voice" were analyzed. For the analysis of the GRBAS scale, the sustained vowel and reading tasks of the sentences was used. Auditory-perceptual voice analyses were conducted by three expert speech therapists with more than 5 years of experience and familiar with both the scales. RESULTS: A strong correlation was observed in the intrajudge consensus analysis, both for the GRBAS scale as well as for CAPE-V, with intraclass coefficient values ranging from 0.923 to 0.985. A high degree of correlation between the general GRBAS and CAPE-V grades (coefficient=0.842) was observed, with similarities in the grades of dysphonia distribution in both scales. The evaluators indicated a mild difficulty in applying the GRBAS scale and low to mild difficulty in applying the CAPE-V scale. The three evaluators agreed when indicating the GRBAS scale as the fastest and the CAPE-V scale as the most sensitive, especially for detecting small changes in voice. CONCLUSIONS: The two scales are reliable and are indicated for use in analyzing voice quality.