Radiologist preferences for faculty development initiatives to improve resident feedback in the era of competency-based medical education.

INTRODUCTION: Since 2022, all Canadian post-graduate medical programs have transitioned to a Competence by Design (CBD) model within a Competency-Based Medical Education (CBME) framework. The CBME model emphasized more frequent, formative assessment of residents to evaluate their progress towards predefined competencies in comparison to traditional medical education models. Faculty members therefore have increased responsibility for providing assessments to residents on a more regular basis, which has associated challenges. Our study explores faculty assessment behaviours within the CBD framework and assesses their openness to opportunities aimed at improving the quality of written feedback. Specifically, we explore faculty's receptiveness to routine metric performance reports that offer comprehensive feedback on their assessment patterns. METHODS: Online surveys were distributed to all 28 radiology faculty at Queen's University. Data were collected on demographics, feedback practices, motivations for improving the teacher-learner feedback exchange, and openness to metric performance reports and quality improvement measures. Following descriptive statistics, unpaired t-tests and one-way analysis of variance were conducted to compare groups based on experience and subspecialty. RESULTS: The response rate was 89% (25/28 faculty). 56% of faculty were likely to complete evaluations after working with a resident. Regarding the degree to which faculty felt written feedback is important, 62% found it at least moderately important. A majority (67%) believed that performance reports could influence their evaluation approach, with volume of written feedback being the most likely to change. Faculty expressed interest in feedback-focused development opportunities (67%), favouring Grand Rounds and workshops. CONCLUSION: Assessment of preceptor perceptions reveals that faculty recognize the importance of offering high-quality written feedback to learners. Faculty openness to quality improvement interventions for curricular reform relies on having sufficient time, knowledge, and skills for effective assessments. This suggests that integrating routine performance metrics into faculty assessments could serve as a catalyst for enhancing future feedback quality.

Protocol for a prospective, randomized, controlled trial of Mental Contrasting with Implementation Intentions (MCII) to enhance the effectiveness of VA's MOVE! weight management program: WOOP (Wish, Outcome, Obstacle, Plan) VA.

INTRODUCTION: Intensive weight management programs are effective but often have low enrollment and high attrition. Lack of motivation is a key psychological barrier to enrollment, engagement, and weight loss. Mental Contrasting with Implementation Intentions (MCII) is a unique imagery technique that increases motivation for behavior change. We describe our study protocol to assess the efficacy and implementation of MCII to enhance the effectiveness of VA's MOVE! or TeleMOVE! weight management programs using a procedure called "WOOP" (Wish, Outcome, Obstacle, Plan) for Veterans. We hypothesize that WOOP+MOVE! or TeleMOVE! (intervention) will lead to greater MOVE!/TeleMOVE! program engagment and consequently weight loss than MOVE!/TeleMOVE! alone (control). METHOD: Veterans are randomized to either the intervention or control. Both arms receive the either MOVE! or TeleMOVE! weight management programs. The intervention group receives an hour long WOOP training while the control group receives patient education. Both groups receive telephone follow up calls at 3 days, 4 weeks, and 2 months post-baseline. Eligible participants are Veterans (ages 18-70 years) with either obesity (BMI ≥ 30 kg/m2) or overweight (BMI ≥ 25 kg/m2) and an obesity-associated co-morbidity. At baseline, 6 and 12 months, we assess weight, diet, physical activity in both groups. The primary outcome is mean percent weight change at 6 months. Secondary outcomes include changes in waist circumference, diet, physical activity, and dieting self-efficacy and engagement in regular physical activity. We assess implementation using the RE-AIM framework. CONCLUSION: If WOOP VA is found to be efficacious, it will be an important tool to facilitate weight management and improve weight outcomes. CLINICAL TRIAL REGISTRATION: NCT05014984.

Implementing an Experiential Telehealth Training and Needs Assessment for Residents and Faculty at a Veterans Affairs Primary Care Clinic.

Background: The transition to telehealth during the COVID-19 pandemic revealed a lack of preexisting telehealth training for clinicians. As a workplace-based simulation methodology designed to improve virtual clinical skills, announced standardized patients (ASPs) may help meet evolving educational needs to sustain quality telehealth care. Objective: We describe the development and implementation of an ASP program to assess and provide feedback to resident and faculty clinicians in virtual practice, and report on performance, feasibility, and acceptability. Methods: From June 2021 to April 2022, resident and faculty clinicians at a VA primary care clinic participated in a video visit in which an ASP portrayed either a 70-year-old man with hearing loss and hypertension or a 60-year-old man with hypertension and financial stress. Following the visit, ASPs provided verbal feedback and completed a behaviorally anchored checklist to rate telehealth and communication skills, chronic disease management, and use of resources. Domain summary scores were calculated as the mean percentage of "well done" items. Participants completed a feedback survey on their experience. Results: Seventy-six televisits (60 primary care residents [postgraduate year 1-3], 16 internal medicine faculty) were conducted from August 2021 to April 2022. Clinicians performed well in communication skills: information gathering (79%, 60 of 76, well done), relationship development (67%, 51 of 76), education and counseling (71%, 54 of 76), and patient satisfaction (86%, 65 of 76). They performed less well in telemedicine skills (38%, 29 of 76). Participants agreed that the experience was a good use of their time (88%, 67 of 76). Conclusions: An ASP-facilitated training for resident and faculty clinicians assessed telehealth skills and clinical practice and identified areas for intervention. Clinicians responded well to the training and feedback.

Peering Into the Future: A First Look at the CBME Transition to Practice Stage in Diagnostic Radiology.

RATIONALE AND OBJECTIVES: Queen's University (Kingston, ON, Canada) adopted a competency-based medical education (CBME) curriculum for Diagnostic Radiology residency training in an accelerated manner in 2017, with the curriculum comprised of four stages of training. This article focuses on the final stage (Transition to Practice), during which assessment methods of the new national curriculum (implemented in July 2022) were piloted. This study aims to highlight the challenges and opportunities associated with the implementation of CBME in Diagnostic Radiology training and specific considerations for programs undergoing this curricular transition. MATERIALS AND METHODS: Ethics approval was provided by the affiliated hospital Research Ethics Board. All relevant electronic assessments pertaining to all trainees who had completed the Transition to Practice stage (n = 3) were collated, deidentified, analyzed, and presented in tabulated format. RESULTS: A total of 39 evaluations completed by 13 assessors were assessed, with an average time of 3 minutes and 6 seconds to complete an assessment form. Also, 95% of evaluations were rated as entrustments. However, no residents met the minimum number of required entrustments for all five stage-specific Entrustable Professional Activities. These 39 evaluations included 219 milestone rating scores, with 86% rated as "achieved." Following review by the residency program Competence Committee, all three residents were promoted from the Transition to Practice stage. CONCLUSION: Challenges in CBME implementation include the number and quality of resident assessments. Strategies for success may include providing clear guidelines and training for both faculty and residents, early identification and intervention, and adopting a holistic evaluation strategy. CBME has the potential to enhance medical education quality by emphasizing learner progress toward competency and providing personalized feedback and support.

Patient Perceptions on Barriers and Facilitators to Accessing Low-acuity Surgery During COVID-19 Pandemic.

BACKGROUND: The onset of the COVID-19 pandemic led to the postponement of low-acuity surgical procedures in an effort to conserve resources and ensure patient safety. This study aimed to characterize patient-reported concerns about undergoing surgical procedures during the pandemic. METHODS: We administered a cross-sectional survey to patients who had their general and plastic surgical procedures postponed at the onset of the pandemic, asking about barriers to accessing surgical care. Questions addressed dependent care, transportation, employment and insurance status, as well as perceptions of and concerns about COVID-19. Mixed methods and inductive thematic analyses were conducted. RESULTS: One hundred thirty-five patients were interviewed. We identified the following patient concerns: contracting COVID-19 in the hospital (46%), being alone during hospitalization (40%), facing financial stressors (29%), organizing transportation (28%), experiencing changes to health insurance coverage (25%), and arranging care for dependents (18%). Nonwhite participants were 5 and 2.5 times more likely to have concerns about childcare and transportation, respectively. Perceptions of decreased hospital safety and the consequences of possible COVID-19 infection led to delay in rescheduling. Education about safety measures and communication about scheduling partially mitigated concerns about COVID-19. However, uncertainty about timeline for rescheduling and resolution of the pandemic contributed to ongoing concerns. CONCLUSIONS: Providing effective surgical care during this unprecedented time requires both awareness of societal shifts impacting surgical patients and system-level change to address new barriers to care. Eliciting patients' perspectives, adapting processes to address potential barriers, and effectively educating patients about institutional measures to minimize in-hospital transmission of COVID-19 should be integrated into surgical care.

Peer-Assisted Lifestyle (PAL) intervention: a protocol of a cluster-randomised controlled trial of a health-coaching intervention delivered by veteran peers to improve obesity treatment in primary care.

INTRODUCTION: Among US veterans, more than 78% have a body mass index (BMI) in the overweight (≥25 kg/m2) or obese range (≥30 kg/m2). Clinical guidelines recommend multicomponent lifestyle programmes to promote modest, clinically significant body mass (BM) loss. Primary care providers (PCPs) often lack time to counsel and refer patients to intensive programmes (≥6 sessions over 3 months). Using peer coaches to deliver obesity counselling in primary care may increase patient motivation, promote behavioural change and address the specific needs of veterans. We describe the rationale and design of a cluster-randomised controlled trial to test the efficacy of the Peer-Assisted Lifestyle (PAL) intervention compared with enhanced usual care (EUC) to improve BM loss, clinical and behavioural outcomes (aim 1); identify BM-loss predictors (aim 2); and increase PCP counselling (aim 3). METHODS AND ANALYSIS: We are recruiting 461 veterans aged 18-69 years with obesity or overweight with an obesity-associated condition under the care of a PCP at the Brooklyn campus of the Veterans Affairs NY Harbor Healthcare System. To deliver counselling, PAL uses in-person and telephone-based peer support, a tablet-delivered goal-setting tool and PCP training. Patients in the EUC arm receive non-tailored healthy living handouts. In-person data collection occurs at baseline, month 6 and month 12 for patients in both arms. Repeated measures modelling based on mixed models will compare mean BM loss (primary outcome) between study arms. ETHICS AND DISSEMINATION: The protocol has been approved by the Institutional Review Board and the Research and Development Committee at the VA NY Harbor Health Systems (#01607). We will disseminate the results via peer-reviewed publications, conference presentations and meetings with stakeholders. TRIAL REGISTRATION NUMBER: NCT03163264; Pre-results.

Estratégias reprodutivas e evolução da fronteira agrícola na Amazônia brasileira: um estudo qualitativo em Machadinho d'Oeste / Reproductive strategies and development of the Brazilian Amazon agricultural frontier: a qualitative study in Machadinho d'Oeste / Estrategias reproductivas y evolución de la frontera agrícola en la Amazonía brasileña: un estudio cualitativo en Machadinho d'Oeste

Analisam-se as estratégias reprodutivas de duas coortes de mulheres que viveram seu período reprodutivo em diferentes estágios de evolução de uma região de fronteira agrícola na Amazônia brasileira. Entende-se por estratégia reprodutiva a adoção de determinado comportamento reprodutivo e contraceptivo segundo as possibilidades e adversidades oferecidas no contexto da fronteira. O objetivo é avaliar as mudanças nessa estratégia ao longo do processo de desenvolvimento desse tipo de fronteira. As distintas condições socioeconômicas que os estágios de desenvolvimento da fronteira oferecem tornariam as estratégias reprodutivas diferenciadas, influenciando as decisões das mulheres que viveram seu período reprodutivo nas fases iniciais ou nas mais avançadas da fronteira. Foram realizadas entrevistas semiestruturadas em Machadinho d'Oeste, Rondônia, com 60 mulheres. Os resultados apontam que, contrariamente ao referido na literatura, não haveria uma relação direta entre uso da terra e o número de filhos. O comportamento reprodutivo de cada coorte se relaciona mais à infraestrutura de serviços de saúde sexual e reprodutiva e às condições socioeconômicas individuais e da fronteira. Para ambos os grupos, porém, a união e a maternidade são precoces e existem elevada falha contraceptiva e alta proporção de laqueadura.

We analyze the reproductive strategies of two cohorts of women whose reproductive period was experienced in different stages of the agricultural frontier evolution in the Brazilian Amazon. Reproductive strategy consists of certain reproductive and contraceptive behaviors adjusted to the possibilities and adversities offered in the context of the frontier. We evaluate changes in reproductive and contraceptive strategies throughout the development process of the agricultural frontier. The different conditions throughout the development stages offered by the frontier would trigger different reproductive strategies, thus decisions would be different for women that lived their reproductive period during initial or more advanced stages of the frontier. We carried out semi-structured interviews with 60 women in Machadinho d'Oeste, Rondônia. Despite what the literature claims, the results indicate that there is no direct relationship between land use and number of children. Rather, the reproductive behavior of each cohort is related to the infrastructure of sexual and reproductive health services and to individual and frontier socioeconomic conditions. Despite the differences, union and childbearing occur at young ages in either stage, with a reasonable proportion of pregnancy due to contraceptive failure as well as a high rate of female surgical sterilization.

Se analizan las estrategias reproductivas de dos cohortes de mujeres que vivieron en diferentes etapas de evolución de una región de frontera agrícola en la Amazonia brasileña. Se entiende por estrategia reproductiva la adopción de ciertos comportamientos reproductivos y anticonceptivos de acuerdo a las posibilidades y adversidades del contexto de la frontera. Se busca evaluar los cambios en las mencionadas estrategias en la medida en que evoluciona una región de este tipo. Las diferentes condiciones socioeconómicas por las que pasa la frontera agrícola durante este proceso diferenciarían a las estrategias reproductivas al influir en las decisiones tomadas por las mujeres que vivieron su período reproductivo en las primeras o en las fases más avanzadas de la frontera. Se realizaron entrevistas semiestructuradas en Machadinho d'Oeste, Rondônia, a sesenta mujeres, cuyos resultados muestran —a diferencia de lo que señala la literatura— que no habría relación directa entre el uso de la tierra y el número de hijos. El comportamiento reproductivo de cada cohorte está más relacionado con la infraestructura de los servicios de salud sexual y reproductiva y con las condiciones socioeconómicas individuales y fronterizas. No obstante, para ambos grupos, la unión y la maternidad son precoces, se observan alta falla anticonceptiva y alta proporción de esterilización.

A transição da fecundidade no Brasil ao longo do século XX - uma perspectiva regional / Fertility transition in Brazil across the 20th century - a regional perspective / La transición de la fecundidad en Brasil durante el siglo XX. Una perspectiva regional

A essência da transição da fecundidade consiste na mudança de um padrão de intensiva reprodução, quando muitas crianças nascem, mas muitas morrem, para uma reversão desse cenário, passando os nascimentos a serem planejados. Grande parte da literatura sobre a transição da fecundidade no Brasil indica que esse processo teria começado na segunda metade da década de 1960, caracterizando a transição brasileira como tardia e rápida. Apesar desse aparente consenso, o objetivo do presente estudo é indicar quando e onde começou a transição da fecundidade no Brasil, reestimando a transição da fecundidade regional do país. Aplica-se a técnica proposta por Frias e Oliveira, nos anos 1990, aos dados dos Censos Demográficos de 1940, 1950 e 1970 a 2010. Os resultados indicam que a transição da fecundidade já vinha em curso, em parte considerável do Brasil, desde o início da década de 1930, mais especificamente no Rio de Janeiro, em São Paulo e no extremo sul do país. Como consequência desse cenário heterogêneo, foram identificadas duas fases da transição da fecundidade. Na primeira, a transição foi lenta, similar ao modelo europeu, sendo precursores as regiões do Rio de Janeiro, São Paulo e o extremo sul. A segunda fase foi muito rápida, em consonância com a transição da fecundidade dos países retardatários no processo.

The essence of fertility transition is the shift from intensive reproduction, when many children are born but few survive, to a new pattern where births are fewer and planned. Some articles discussing fertility transition in Brazil indicate that this process began in the second half of the 1960s, characterizing the Brazilian transition as late and fast. Despite this consensus, the objective of this paper was to identify "when" and "where" fertility transition started in Brazil, reassessing regional fertility transition. We used the method proposed by Frias and Oliveira (1991) applied to Brazilian census data (1940, 1950 and 1970 to 2010) Results indicate that fertility transition had been underway since, at least the 1930s in some of Brazil's most important regions like Rio de Janeiro, São Paulo, and the far South. Because of this complex scenario, we argue that Brazil experienced two phases of fertility transition. The first one would have been long and slow, like the European fertility transition, pioneered by Rio de Janeiro, São Paulo, and the far South, whereas the second one was short and fast, in line with the fertility transition observed in countries where the process began later.

La esencia de la transición de la fecundidad es el cambio de un patrón de reproducción intensiva -cuando nacen muchos niños y pocos sobreviven- a otro en el cual la mayor parte de los nacimientos son planificados. Gran parte de la literatura sobre la transición de la fecundidad en Brasil indica que este proceso comenzó en la segunda mitad de la década del sesenta, lo que la caracateriza como tardía y rápida. A pesar de este aparente consenso, el objetivo de este trabajo es determinar cuándo y dónde comenzó esta transición, identificando este proceso desde el punto de vista regional. Se aplica el método de Frias y Oliveira, originalmente propuesto en 1991, a los datos de fecundidad reciente de los censos demográficos de Brasil de 1940, 1950 y 1970 a 2010. Los resultados indican que la transición de la fecundidad ya estaba en curso, en parte de Brasil, desde principios de la década del treinta en Río de Janeiro, en San Pablo y en el extremo sur del país. Como consecuencia de este escenario heterogéneo, habría dos fases de la transición: la primera, larga y lenta, similar al modelo europeo, cuyos precursores fueron Río de Janeiro, San Pablo y el extremo Sur; la segunda, corta y rápida, como la transición de los países rezagados en el proceso.

Attitudes Toward and Management of Fibromyalgia: A National Survey of Canadian Rheumatologists and Critical Appraisal of Guidelines.

BACKGROUND: Canadian rheumatologists' attitudes toward and management of fibromyalgia remain uncertain. OBJECTIVE: The aim of this study was to explore management strategies and attitudes of Canadian rheumatologists toward fibromyalgia and concordance with guideline recommendations. METHODS: We administered a 17-item cross-sectional survey to Canadian rheumatologists and explored the concordance between respondents' management practices with the 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia. RESULTS: Among 331 Canadian rheumatologists who were approached, 140 returned the survey for a 42% response rate. The majority felt that fibromyalgia was a useful clinical diagnosis (110/138 [80%]) but was divided as to whether fibromyalgia was objectively defined (75/138 [54%]) or a psychosocial condition (42/138 [30%]) or could result in an inability to work (37/138 [27%]). Contrary to guideline recommendations, most (82/134 [61%]) endorsed that tender points were useful for diagnosis. Half endorsed potentially refusing consultations with fibromyalgia patients, and only 42% (59/139) agreed that there were effective therapies for this syndrome. Consistent with the guideline, most respondents managed fibromyalgia with education, exercise therapy, antidepressants, and nonnarcotic analgesics (≥89% for all); however, fewer than half agreed that any of these modalities were effective (endorsement ranged from 9% to 47%). Assessment of the 2012 guideline revealed a number of important limitations. CONCLUSIONS: Canadian rheumatologists largely do not provide primary care for fibromyalgia. Most adhere to guideline recommendations for management of fibromyalgia, but few endorse these interventions as effective. Further research, including updating of the 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia, is required to inform this disconnect.

Alice in Wonderland: Unrealized fertility and satisfaction with number of children according to couples' point of view in a city in Brazil / Alice no País das Maravilhas: fecundidade não realizada e satisfação com o número de filhos tidos de acordo com o ponto de vista dos casais em uma cidade do Brasil / Alicia en el País de las Maravillas: fecundidad no realizada y satisfacción con el número de hijos tenidos de acuerdo con el punto de vista de las parejas en una ciudad de Brasil

The gap between ideal and observed fertility is a very common phenomenon in Brazil. However, given the severe criticism of indicators on desired and ideal family sizes, it is important to reflect on how well fertility preferences are grasped by traditional questions. This paper discusses whether having fewer children than desired is a matter of choice or if it represents an inability to implement reproductive preferences, generating dissatisfaction with one´s fertility behavior. Data come from 62 in-depth interviews conducted with 31 couples with high educational levels, living in Belo Horizonte, Brazil, with up to two children. Negative discrepant fertility was predominant among most couples interviewed. Many of them, however, are fully satisfied with their current fertility situation and do not seem to be willing to implement their desire for more children.

No Brasil, o hiato entre fecundidade ideal e observada é cada vez mais comum. Paralelamente, perante as severas críticas feitas aos indicadores disponíveis sobre o tamanho desejado/ideal de família, torna-se relevante refletir sobre até que ponto as respostas das pessoas refletem adequadamente suas preferências. O objetivo deste artigo é discutir se ter menos filhos do que o desejado é fruto de uma escolha ou se representa, de fato, uma incapacidade de implementação das preferências reprodutivas e uma insatisfação com o seu comportamento de fecundidade. Utilizam-se dados de 62 entrevistas em profundidade realizadas com 31 com casais de alta escolaridade com até dois filhos, residentes em Belo Horizonte, Brasil. Pode-se verificar que a fecundidade discrepante negativa predominou para a maioria dos casais entrevistados. Nota-se, porém, que uma parte importante destes casais está totalmente satisfeita com a situação atual de fecundidade, já que não pareciam dispostos a efetivar o desejo de aumentar o número de filhos.

La brecha entre ideales de fecundidad y fecundidad observada es cada vez más común en Brasil. Complementariamente, ante las severas críticas a los indicadores disponibles sobre el tamaño deseado e ideal de familia, es importante reflexionar hasta qué punto las respuestas de las personas reflejan adecuadamente sus preferencias reproductivas. El objetivo de este artículo es discutir si tener menos hijos de los deseados se configura como opción o si, de hecho, representa una incapacidad de implementación de las preferencias reproductivas y un descontento con su comportamiento de fecundidad. Se utilizarán datos de entrevistas en profundidad hechas a 31 parejas con alta escolarización, residentes en Belo Horizonte, Brasil, con hasta dos hijos. Si bien se observa que la fecundidad discrepante negativa predomina en la mayoría de las parejas entrevistadas, también se observa que, dentro de esta mayoría, existe una proporción importante totalmente satisfecha con esta situación, que no parecía estar dispuesta a aumentar su número de hijos.

Sensitivity, Specificity, Predictive Values, and Accuracy of Three Diagnostic Tests to Predict Inferior Alveolar Nerve Blockade Failure in Symptomatic Irreversible Pulpitis.

INTRODUCTION: The inferior alveolar nerve block (IANB) is the most common anesthetic technique used on mandibular teeth during root canal treatment. Its success in the presence of preoperative inflammation is still controversial. The aim of this study was to evaluate the sensitivity, specificity, predictive values, and accuracy of three diagnostic tests used to predict IANB failure in symptomatic irreversible pulpitis (SIP). METHODOLOGY: A cross-sectional study was carried out on the mandibular molars of 53 patients with SIP. All patients received a single cartridge of mepivacaine 2% with 1 : 100000 epinephrine using the IANB technique. Three diagnostic clinical tests were performed to detect anesthetic failure. Anesthetic failure was defined as a positive painful response to any of the three tests. Sensitivity, specificity, predictive values, accuracy, and ROC curves were calculated and compared and significant differences were analyzed. RESULTS: IANB failure was determined in 71.7% of the patients. The sensitivity scores for the three tests (lip numbness, the cold stimuli test, and responsiveness during endodontic access) were 0.03, 0.35, and 0.55, respectively, and the specificity score was determined as 1 for all of the tests. Clinically, none of the evaluated tests demonstrated a high enough accuracy (0.30, 0.53, and 0.68 for lip numbness, the cold stimuli test, and responsiveness during endodontic access, resp.). A comparison of the areas under the curve in the ROC analyses showed statistically significant differences between the three tests (p < 0.05). CONCLUSION: None of the analyzed tests demonstrated a high enough accuracy to be considered a reliable diagnostic tool for the prediction of anesthetic failure.

Migração dos médicos: uma análise dos movimentos migratórios dos profissionais da saúde no Brasil segundo Unidades de Federação (2000-2010) / Migration of physicians: an analysis of the migratory movements of health professionals in Brazil according to Federation Units (2000-2010)

O objetivo do trabalho é identificar os principais padrões migratórios dos profissionais médicos segundo as Unidades de Federação (UFs) do Brasil, a partir dos Censos Demográficos dos anos 2000 e 2010. Construíram-se matrizes de migração para cada um dos pontos do tempo e se estimam taxas liquidas de migração para cada UF. Os resultados mostram que, apesar da identificação de um aumento no número de médicos que migram para outras UFs durante o período de estudo, continuam existindo diferenças significativas entre as regionais e UFs, em relação à alocação de médicos. A região Sudeste, especificamente, São Paulo, Minas Gerais e Rio de Janeiro são as principais UFs, fornecedoras de médicos para outros Estados e também são as principais receptoras. Realidade oposta é a de Amapá, a UF que recebe a menor quantidade de médicos imigrantes. Acreditamos que os resultados desta natureza permitem que o conhecimento sobre os deslocamentos dos médicos contribua a melhorar desenhos de planos estratégicos para estabelecer a quantidade mínima de médicos que cada Unidade de Federação do Brasil possa ter e monitorar estas correntes migratórias de mão de obra tão qualificada e específica como são os médicos.

The aim of this study is to identify the main migration patterns of medical professionals according to the Brazilian Federative Units (UFs), based on Demographic Census data of the years 2000 and 2010. Migration matrices for each of point in time are produced, and net migration rates for each UF are estimated. The results show that despite the increase in the number of physicians out flowing to other UFs during the study period, there are still significant differences between Regions and UFs related to the allocation of physicians. The Southeast Region, particularly, São Paulo, Minas Gerais and Rio de Janeiro are the main UFs providing these professionals to other states and are also the main attractors. Amapá shows opposite reality: it is the UF that receives the lowest inflow of physicians. Results suggest that the sort of knowledge presented about spatial movements of physicians may contribute to the design of strategic plans that allow each Federation Units of Brazil count on a minimum quantity of physicians. It is also am important tool for monitoring in-outflows of highly qualified and specific labor force as the physicians are.

Tendências da fecundidade dos povos indígenas nos Censos Demográficos brasileiros de 1991 a 2010 / Indigenous population fertility trends according to the Brazilian Demographic Censuses from 1991 to 2010 / Tendencias de la fecundidad de los pueblos indígenas en los censos demográficos brasileños del 1991 al 2010

O artigo aborda a fecundidade das mulheres autodeclaradas indígenas com base nos censos brasileiros de 1991 a 2010. Inicialmente - como uma aproximação das limitações que a qualidade do dado pode impor às análises - observa-se um viés de autodeclaração para 2000 mais acentuado na população urbana, o que compromete as comparações com 2010, mas não invalida o prosseguimento das análises sobre fecundidade. Constata-se que, efetivamente, a fecundidade dos povos indígenas está diminuindo inclusive entre a população rural, isto é, aquela que reside em Terras Indígenas. A fecundidade indígena urbana é altamente diferenciada da rural e as suspeitas de o viés estar contaminando as medidas produzidas evidenciam a necessidade de um investimento maior no estudo desta população: quem são os indígenas urbanos? Estimativas por ordem de parturição e filhos tidos sinalizam acentuadas quedas de fecundidade para o futuro próximo. A fecundidade das mulheres indígenas jovens - sem muitas diferenciações segundo residência urbana ou rural - continua em níveis muito altos se comparados com os de populações contemporâneas. Esta análise clama por estudos multidisciplinares para o melhor entendimento do processo reprodutivo dos povos indígenas brasileiros.

Abstract Fertility of the self-declared indigenous women is analyzed based on Brazilian censuses from 1991 to 2010. Initially, as an approximation to the limitation that the quality of data may impose, population growth captured by these data sources is analyzed. There has been a bias on the self-declaration for 2000, more pronounced for the urban population, which may compromise the comparison with the 2010 data. In any case, this does not invalidate the analyses on fertility trends. Effectively, indigenous population fertility is decreasing even among the rural population living on the formal demarcation Indian lands. Also, urban indigenous fertility is highly differentiated from the rural. In this context, and adding the probable bias that might have contaminated the estimates in 2000, the need for more investment in the study of this population is critical to answer, for instance who are the urban indigenous population captured in the censuses. Estimates of fertility according to birth order and parity indicate sharp fertility declines in the near future. Fertility of young indigenous women, without much differentiation at urban or rural places of residence, remains at very high levels compared to contemporary populations. This analysis calls for multidisciplinary studies to better understand the reproductive process of the Brazilian indigenous population.

Resumen Se considera la fecundidad de las mujeres autodeclaradas indígenas a partir de los censos brasileños de 1991 a 2010. Inicialmente -como una aproximación a la limitación de que la calidad de los datos puede imponer al análisis- se constata un sesgo de autodeclaración para 2000, más pronunciado en la población urbana lo que compromete la comparación con datos del 2010, con todo, esto no invalida la continuación del análisis sobre fecundidad. Son fuertes los indicativos de una disminución de la fecundidad de los pueblos indígenas, incluso entre la población rural, es decir, el que reside en tierras indígenas. La fecundidad indígena urbana es muy diferenciada comparada con el rural; esto, junto con la sospecha de que los sesgos hayan contaminado las medidas producidas, apunta hacia la necesidad de una mayor inversión en el estudio de esta población: ¿quién es la población indígena urbana? Las estimaciones por orden de nacimiento y paridez indican, para un futuro próximo, disminución de la fecundidad. La fecundidad de las mujeres indígenas jóvenes, sin mucha diferenciación entre residencia urbana o rural, se mantiene en niveles muy elevados si comparados con poblaciones contemporáneas. Este análisis clama por estudios multidisciplinarios para comprender mejor el proceso reproductivo de los pueblos indígenas brasileños.

Comprendiendo y combatiendo el fracaso anestésico en odontología / Understanding and combatting anesthetic failures in dentistry

El fracaso anestésico en odontología es un tema de constante investigación, ya que se presenta con frecuencia a la hora de realizar bloqueos del nervio alveolar inferior (BNAI) y en pacientes con pulpitis irreversible o procesos infecciosos. Son múltiples las causas que se han asociado al fracaso, entre las que destacan: factores anatómicos, bioquímicos, fisiológicos, patológicos, psicológicos, operatorios y aquellos relacionados con la solución anestésica per se. Una buena anestesia es un punto crítico a lograr en cualquier tratamiento dental y por eso se han propuesto diversas estrategias clínicas y farmacológicas como uso de técnicas suplementarias, utilización de dispositivos y coadyuvantes anestésicos, empleo de soluciones anestésicas distintas, modifi cación de los anestésicos, utilización de premedicación analgésica e incluso la aplicación local de analgésicos y otro tipo de fármacos; todo con el fin de compensar y tratar de disminuir el fracaso anestésico

Failures in anesthesia in dental practice are a topic of ongoing research due to the fact that these occur frequently when performing an inferior alveolar nerve block (IANB) in patients with irreversible pulpitis or infectious processes. Multiple causes have been associated with this problem, including anatomical, biochemical and physiological, patho-logical, psychological, and operative factors, as well as issues related to the anesthetic solution itself. Good anesthesia is critical in any dental treatment that involves pain, which is why various clinical and pharmacological strategies have been proposed in order to decrease the likelihood of anesthetic failure (such as the use of supplementary techniques, devices and aids, alternative anesthetic solutions, changing anesthetics, analgesic premedication, and even the local application of analgesics and other drugs).

Artemin promotes functional long-distance axonal regeneration to the brainstem after dorsal root crush.

Recovery after a spinal cord injury often requires that axons restore synaptic connectivity with denervated targets several centimeters from the site of injury. Here we report that systemic artemin (ARTN) treatment promotes the regeneration of sensory axons to the brainstem after brachial dorsal root crush in adult rats. ARTN not only stimulates robust regeneration of large, myelinated sensory axons to the brainstem, but also promotes functional reinnervation of the appropriate target region, the cuneate nucleus. ARTN signals primarily through the RET tyrosine kinase, an interaction that requires the nonsignaling coreceptor GDNF family receptor (GFRα3). Previous studies reported limited GFRα3 expression on large sensory neurons, but our findings demonstrate that ARTN promotes robust regeneration of large, myelinated sensory afferents. Using a cell sorting technique, we demonstrate that GFRα3 expression is similar in myelinated and unmyelinated adult sensory neurons, suggesting that ARTN likely induces long-distance regeneration by binding GFRα3 and RET. Although ARTN is delivered for just 2 wk, regeneration to the brainstem requires more than 3 mo, suggesting that brief trophic support may initiate intrinsic growth programs that remain active until targets are reached. Given its ability to promote targeted functional regeneration to the brainstem, ARTN may represent a promising therapy for restoring sensory function after spinal cord injury.

Two patients with Hashimoto's encephalopathy and uncontrolled diabetes successfully treated with levetiracetam.

Hashimoto's encephalopathy (HE) is a rare syndrome of progressive or relapsing-remitting encephalopathy associated with elevated serum anti-thyroid antibody concentrations. It is thought to be an autoimmune process that generally responds well to high-dose corticosteroids and other immunomodulatory therapies. However, some patients are unresponsive to steroids or are unable to receive immune therapy. A viable alternative is needed for this group. Given that seizure and EEG abnormalities are commonly associated with this syndrome, we postulate that treatment with levetiracetam, which has duel anti-inflammatory and anti-seizure mechanisms, might show clinical benefit. We present the cases of two patients who met the criteria for HE but were unable to receive steroids due to labile diabetes. They were both successfully treated with levetiracetam.

An in-tumor genetic screen reveals that the BET bromodomain protein, BRD4, is a potential therapeutic target in ovarian carcinoma.

High-grade serous ovarian carcinoma (HGSOC) is the most common and aggressive form of epithelial ovarian cancer, for which few targeted therapies exist. To search for new therapeutic target proteins, we performed an in vivo shRNA screen using an established human HGSOC cell line growing either subcutaneously or intraperitoneally in immunocompromised mice. We identified genes previously implicated in ovarian cancer such as AURKA1, ERBB3, CDK2, and mTOR, as well as several novel candidates including BRD4, VRK1, and GALK2. We confirmed, using both genetic and pharmacologic approaches, that the activity of BRD4, an epigenetic transcription modulator, is necessary for proliferation/survival of both an established human ovarian cancer cell line (OVCAR8) and a subset of primary serous ovarian cancer cell strains (DFs). Among the DFs tested, the strains sensitive to BRD4 inhibition revealed elevated expression of either MYCN or c-MYC, with MYCN expression correlating closely with JQ1 sensitivity. Accordingly, primary human xenografts derived from high-MYCN or c-MYC strains exhibited sensitivity to BRD4 inhibition. These data suggest that BRD4 inhibition represents a new therapeutic approach for MYC-overexpressing HGSOCs.

Estimating pregnancy-related mortality from census data: experience in Latin America.

OBJECTIVE: To assess the feasibility of measuring maternal mortality in countries lacking accurate birth and death registration through national population censuses by a detailed evaluation of such data for three Latin American countries. METHODS: We used established demographic techniques, including the general growth balance method, to evaluate the completeness and coverage of the household death data obtained through population censuses. We also compared parity to cumulative fertility data to evaluate the coverage of recent household births. After evaluating the data and adjusting it as necessary, we calculated pregnancy-related mortality ratios (PRMRs) per 100 000 live births and used them to estimate maternal mortality. FINDINGS: The PRMRs for Honduras (2001), Nicaragua (2005) and Paraguay (2002) were 168, 95 and 178 per 100 000 live births, respectively. Surprisingly, evaluation of the data for Nicaragua and Paraguay showed overreporting of adult deaths, so a downward adjustment of 20% to 30% was required. In Honduras, the number of adult female deaths required substantial upward adjustment. The number of live births needed minimal adjustment. The adjusted PRMR estimates are broadly consistent with existing estimates of maternal mortality from various data sources, though the comparison varies by source. CONCLUSION: Census data can be used to measure pregnancy-related mortality as a proxy for maternal mortality in countries with poor death registration. However, because our data were obtained from countries with reasonably good statistical systems and literate populations, we cannot be certain the methods employed in the study will be equally useful in more challenging environments. Our data evaluation and adjustment methods worked, but with considerable uncertainty. Ways of quantifying this uncertainty are needed.

Notas sobre o comportamento reprodutivo da população autodeclarada indígena: Censos Demográficos 1991 e 2000 / Notas sobre el comportamiento reproductivo de la población autodeclarada indígena: Censos Demográficos 1991 y 2000 / Notes on the reproductive behavior of the self-declared indigenous populations in Brazil: Demographic Censuses of 1991 and 2000

Este trabalho apresenta o perfil reprodutivo das mulheres recenseadas em 1991 e 2000 autodeclaradas indígenas, com detalhamento dos níveis e padrões de fecundidade por situação de domicílio, regiões geográficas e tempo de residência. Os dados oferecem evidências sobre as tendências da fecundidade, verificando-se a transição da fecundidade a níveis baixos, o que é determinado pelas mulheres indígenas urbanas, que apresentam TFTs próximas do nível de reposição, particularmente na Região Nordeste. Nas áreas rurais predomina e persiste um nível alto de fecundidade e, em alguns casos, extremamente alto. O padrão por idade da fecundidade revela concentração nas idades mais jovens, seguindo a tendência geral do país. Evidenciam-se forte presença do controle da fecundidade, para as indígenas das áreas urbanas, e ausência deste, nas áreas rurais. Embora seja necessário maior aprofundamento, os achados sugerem - independentemente da discussão sobre a composição da população autodeclarada indígena - uma forte dicotomia entre a população indígena rural e a urbana. As respectivas taxas de fecundidade, muito altas e muito baixas, seriam uma realidade diferenciada de cada um desses contextos. Adicionalmente, se a migração rural-urbano tornar-se uma realidade generalizada na população indígena, é de se esperar que níveis extremamente baixos de fecundidade se consolidem nesta população.

Este trabajo presenta el perfil reproductivo de las mujeres censadas en 1991 y 2000 autodeclaradas indígenas, con la descripción detallada de los niveles y estándares de fecundidad por situación de familia, regiones geográficas y tiempo de residencia. Los datos ofrecen evidencias sobre las tendencias de la fecundidad, verificándose la transición de la fecundidad a niveles bajos, lo que es determinado por las mujeres indígenas urbanas, que presentan TFTs próximas al nivel de reposición, particularmente en la Región Nordeste. En las áreas rurales predomina y persiste un nivel alto de fecundidad y, en algunos casos, extremadamente alto. El estándar por edad de fecundidad revela una concentración en las edades más jóvenes, siguiendo la tendencia general del país. Se evidencia una fuerte presencia del control de la fecundidad para las indígenas de las áreas urbanas, y ausencia de éste, en las áreas rurales. Aunque sea necesaria una mayor profundización, los hallazgos sugieren - independientemente de la discusión sobre la composición de la población autodeclarada indígena - una fuerte dicotomía entre la población indígena rural y la urbana. Las respectivas tasas de fecundidad, muy altas y muy bajas, serían una realidad diferenciada de cada uno de esos contextos. Adicionalmente, si la migración rural-urbana se tornase una realidad generalizada en la población indígena, es de esperar que niveles extremamente bajos de fecundidad se consoliden en esta población.

This article presents the reproductive profile of women enumerated in the Federal Brazilian Censuses of 1991 and 2000 who had declared themselves indigenous. Details are presented of the levels and patterns of fertility by situation of household, geographic region and time of residence. The data, based on urban indigenous women, show a transition to lower fertility levels. This group present TFTs close to replacement level, especially in the northeastern region of the country. Persistently high fertility levels prevail in rural areas and are extremely high in some cases. The pattern of fertility by age shows concentration at younger ages, following the general trend in the country. These data indicate widespread control over fertility by indigenous women in urban areas and lack of such control in the rural areas. Although more research is needed, and without going into details on the composition of this self-declared indigenous population, the findings suggest strong dichotomy between rural and urban indigenous populations. The two respective fertility rates, which are, respectively, very high and very low, may indicate a different reality for each of these sectors. Additionally, if rural-to-urban migration becomes a general trend among the Brazilian indigenous population, it is to be expected that very low levels of fertility will consolidate in this population.

Race and health disparities among seniors in urban areas in Brazil.

Objective. This article examines racial health disparities among the elderly in Sao Paulo, Brazil. It also explores whether these disparities differ among income groups. Methods. The study follows the conceptual framework developed by LaVeist (1994). A multistage analysis and Oaxaca-Blinder decomposition are used to explore the sources of racial disparities in health. Results. White seniors report better health than Black seniors. This is the case even after controlling for baseline health conditions and several demographic, socioeconomic, and family support characteristics. Discussion. This article suggests that the two most important factors driving racial disparities in health among seniors are historical differences in rural living conditions and current income. Present economic conditions are more relevant to racial disparities among poor than among rich seniors. Racial differences in health not attributable to observable characteristics are more important when comparing individuals in the upper half of the income distribution.