Challenges in the care of children born to mothers diagnosed with COVID-19 during the pandemic.

OBJECTIVE: To understand the challenges in the care of children born to mothers with COVID-19 during the pandemic. METHOD: Qualitative research, conducted from November 2020 to May 2021, in two public maternity hospitals, with women who had children during the first wave of the pandemic, diagnosed with COVID-19 during pregnancy and/or childbirth. There were nineteen semi-structured interviews with thematic analysis. Symbolic Interactionism was used as a theoretical framework. RESULTS: Changes in the care for newborn children were identified. In the domestic environment, hygiene measures with the newborn children were intensified, social isolation restricted the support network and mothers felt alone and overwhelmed. In terms of health care, there was a setback in neonatal care and interruption of professional care, such as the suspension of appointments. CONCLUSION: The pandemic has restructured traditional models of family care, intensified difficulties in accessing healthcare, and exposed children to inherent risks due to a lack of proper follow-up.

Surgery in Bilateral Wilms Tumor-A Single-Center Experience.

The treatment of bilateral Wilms tumors (BWT) involves curing the cancer, preserving long-term renal function, and maintaining a good quality of life. Established methods for achieving these goals include preoperative chemotherapy and nephron-sparing surgery (NSS). This study aimed to evaluate the experience of a single institution in treating patients with BWT. We analyzed cases of BWT treated at the Pediatric Oncology Institute-GRAACC-Federal University of São Paulo over a period of 35 years. Bleeding control was performed with manual compression of the renal parenchyma. Thirty-three patients were included in the study. Thirty cases were synchronous tumors. The mean age at diagnosis was 30.4 months (±22 m) and 66.7% were girls. The median follow-up period was 83 months. Neoadjuvant chemotherapy was the primary approach in most patients (87.9%), with a simultaneous upfront surgical approach performed in 84.8%. Most patients underwent bilateral NSS (70.4%). There were no early complications in this series, but 39.4% had clinical complications. The five-year survival rate was 76%. Therefore, it is clear that the surgical approach to BWT plays a crucial role in achieving good outcomes. However, it is difficult to standardize surgical techniques and technology may have the potential to enhance safety.

Maternal health during the COVID-19 pandemic: Experiences of health workers in three Brazilian municipalities.

OBJECTIVE: To analyze the experiences of maternal health workers in three Brazilian cities, located in the Northeast (São Luís), Southeast (Niterói), and South (Pelotas) regions during the first year of the COVID-19 pandemic. METHODS: Qualitative research carried out between December 2020 and February 2021. Interviews were conducted, in person or remotely, with 30 health workers, doctors and nurses, working in maternity hospitals of different degrees of complexity. RESULTS: Sociodemographic characteristics, employment relationships and professional qualification of the interviewees were described. Two thematic axes were identified: 1) changes in hospital organization and dynamics in the pandemic; 2) Illness and suffering of health workers. The majority of respondents were women. Most physicians had work relationships in the public and private sectors. In Niterói, health workers had better professional qualifications and more precarious work relationships (as temporary hires), compared to São Luís and Pelotas. In the context of the uncertainties resulting from the pandemic, this situation generated even more insecurity for those workers. The statements at the beginning of the pandemic covered topics such as changes in the organizational dynamics of services, healthcare, telemedicine, and interaction between health workers and users. In the health workers' perception, the initial period of the health emergency, which resulted in intense changes in the provision of services, was marked by an increase in preterm births, perinatal mortality, and fetal losses. Work overload, fear of contamination, concern for family members and uncertainties regarding the new disease caused intense suffering in health workers who had little institutional support in the cities studied. The suffering experienced by health workers went beyond the work dimension, reaching their private life. CONCLUSION: Changes caused by the pandemic required immediate adjustments in professional practices, generating insecurities in healthcare regardless of the location studied. The method of hiring health workers remained the same as the previously practiced one in each city. Due to the risk of disease transmission, measures contrary to humanization practices, and more restrictive in São Luís, were reported as harmful to obstetric care. The Covid-19 pandemic was a huge challenge for the Brazilian health system, aggravating the working conditions experienced by health workers. In addition to the work environment, it was possible to briefly glimpse its effects on private life.

Survival analysis and prognostic factors in posterior fossa ependymomas in children and adolescents.

OBJECTIVE: In this study, the authors aimed to analyze the overall survival (OS) and progression-free survival (PFS) of patients younger than 18 years of age who were diagnosed with posterior fossa ependymomas, and to identify prognostic factors such as the degree of resection, tumor topography, and involvement of the lesion in the hindbrain. METHODS: The authors performed a retrospective cohort study of patients younger than 18 years of age, treated beginning in 2000, with a diagnosis of posterior fossa ependymoma. Ependymomas were separated into three groups: tumors restricted to the fourth ventricle, tumors inside the fourth ventricle and exiting from the foramen of Luschka, and tumors inside the fourth ventricle and completely surrounding the hindbrain. Furthermore, the tumors were classified by molecular group using the staining method for H3K27me3. Statistical analysis was performed using Kaplan-Meier survival curves, with p < 0.05 considered statistically significant. RESULTS: Of 1693 patients who underwent surgical treatment between January 2000 and May 2021, 55 patients who met the inclusion criteria were included. The median age at diagnosis was 2.98 years. The median OS was 44 months, and the survival rates at 1, 5, and 10 years were 92.5%, 49.1%, and 38.3%, respectively. The cases were assigned to two posterior fossa ependymoma molecular groups: 35 (63.6%) cases to group A and 8 (14.5%) to group B. The median ages in groups A and B were 2.94 and 2.85 years and the median OS values were 44 and 38 months, respectively (p = 0.9245). Statistical analysis was performed on multiple variables, including age, sex, histological grade, Ki-67 expression, tumor volume, extent of resection, and adjuvant therapies. The median PFS of patients with dorsal-only involvement was 28 months; for dorsolateral involvement, it was 15 months; and for total involvement, it was 9.5 months (p = 0.0464). No statistically significant difference was found for OS. There was a statistically significant difference between the proportion of patients in whom gross-total resection was achieved in the dorsal-only involvement group (73.1%, 19/26) and those in the total involvement group (0%, 0/6) (p = 0.0019). CONCLUSIONS: This study confirmed that the extent of resection has an impact on OS and PFS. The authors found that adjuvant radiotherapy resulted in a higher OS but did not prevent progression, that the pattern of involvement of the brainstem in the tumor at diagnosis could elicit important information regarding the patient's prognosis regarding PFS, and that the total involvement of the rhombencephalon impaired the gross-total resection of these tumors.

[Do depressive symptoms, anxiety and stressful symptoms during pregnancy affect gestational weight gain?] / Sintomas depressivos, ansiedade e os sintomas estressantes durante a gravidez afetam o ganho de peso gestacional?

The scope of this article is to estimate the effects of symptoms of mental disorders during pregnancy (depressive symptoms, anxiety and stress) on gestational weight gain (kg). It is a longitudinal study, carried out with data from the BRISA Birth Cohort, which was launched in 2010 in São Luís, Maranhão. Gestational weight gain was classified according to the Institute of Medicine. The independent variable was a construct (latent variable) referred to as symptoms of mental disorders, made up of the depressive symptoms, anxiety and stressful symptoms variables (all on an ongoing basis). Structural equation modeling was used to investigate the association between mental health and weight gain. Regarding the association between symptoms of mental disorders and weight gain during pregnancy, no total effect was found (PC=0.043; p=0.377). Regarding indirect effects, no effect was found either through risk behaviors (PC=0.03; p=0.368) or through physical activity (PC=0.00; p=0.974). Finally, the data did not show a direct effect of symptoms of mental disorders during pregnancy such as gestational weight gain (PC=0.050; p=0.404). Gestational weight gain had no direct, indirect or total effect on symptoms of mental disorders in pregnant women.

O objetivo deste artigo é estimar os efeitos dos sintomas de transtornos mentais na gravidez (sintomas depressivos, ansiedade e estresse) no ganho de peso gestacional. Estudo longitudinal, realizado com dados da Coorte de nascimento BRISA, iniciada em 2010 em São Luís, Maranhão. O ganho de peso gestacional foi classificado de acordo com Institute of Medicine. A variável independente foi um construto (variável latente) nomeado de sintomas de transtornos mentais, englobando as variáveis sintomas depressivos, a ansiedade e os sintomas estressantes (todas de forma contínua). Utilizou-se modelagem de equações estruturais, a fim de investigar a associação entre a saúde mental e ganho de peso. Em relação a associação entre sintomas de transtornos mentais e ganho de peso na gestação, não se encontrou efeito total (CP=0,043; p=0,377). Em relação aos efeitos indiretos, também não se encontrou efeito através dos comportamentos de risco (CP=0,03; p=0,368) e através da atividade física (CP=0,00; p=0,974). Finalmente os dados não evidenciaram efeito direto dos sintomas de transtornos mentais durante a gravidez como o ganho de peso gestacional (CP=0,050; p=0,404). O ganho de peso gestacional não apresentou efeito direto, indireto e total nos sintomas de transtornos mentais de gestantes.

Sintomas depressivos, ansiedade e os sintomas estressantes durante a gravidez afetam o ganho de peso gestacional? / Do depressive symptoms, anxiety and stressful symptoms during pregnancy affect gestational weight gain?

Resumo O objetivo deste artigo é estimar os efeitos dos sintomas de transtornos mentais na gravidez (sintomas depressivos, ansiedade e estresse) no ganho de peso gestacional. Estudo longitudinal, realizado com dados da Coorte de nascimento BRISA, iniciada em 2010 em São Luís, Maranhão. O ganho de peso gestacional foi classificado de acordo com Institute of Medicine. A variável independente foi um construto (variável latente) nomeado de sintomas de transtornos mentais, englobando as variáveis sintomas depressivos, a ansiedade e os sintomas estressantes (todas de forma contínua). Utilizou-se modelagem de equações estruturais, a fim de investigar a associação entre a saúde mental e ganho de peso. Em relação a associação entre sintomas de transtornos mentais e ganho de peso na gestação, não se encontrou efeito total (CP=0,043; p=0,377). Em relação aos efeitos indiretos, também não se encontrou efeito através dos comportamentos de risco (CP=0,03; p=0,368) e através da atividade física (CP=0,00; p=0,974). Finalmente os dados não evidenciaram efeito direto dos sintomas de transtornos mentais durante a gravidez como o ganho de peso gestacional (CP=0,050; p=0,404). O ganho de peso gestacional não apresentou efeito direto, indireto e total nos sintomas de transtornos mentais de gestantes.

Abstract The scope of this article is to estimate the effects of symptoms of mental disorders during pregnancy (depressive symptoms, anxiety and stress) on gestational weight gain (kg). It is a longitudinal study, carried out with data from the BRISA Birth Cohort, which was launched in 2010 in São Luís, Maranhão. Gestational weight gain was classified according to the Institute of Medicine. The independent variable was a construct (latent variable) referred to as symptoms of mental disorders, made up of the depressive symptoms, anxiety and stressful symptoms variables (all on an ongoing basis). Structural equation modeling was used to investigate the association between mental health and weight gain. Regarding the association between symptoms of mental disorders and weight gain during pregnancy, no total effect was found (PC=0.043; p=0.377). Regarding indirect effects, no effect was found either through risk behaviors (PC=0.03; p=0.368) or through physical activity (PC=0.00; p=0.974). Finally, the data did not show a direct effect of symptoms of mental disorders during pregnancy such as gestational weight gain (PC=0.050; p=0.404). Gestational weight gain had no direct, indirect or total effect on symptoms of mental disorders in pregnant women.

Delays in obtaining hospital care and abortion-related complications within a context of illegality.

Abortion, particularly when illegal, highlights inequities in different populations. Although abortion-related mortality is lower compared to other obstetric causes, abortion complications tend to be more lethal. Delays in seeking and obtaining care are determinants of negative outcomes. This study, nested within the GravSus-NE, analyzed healthcare delays and their association with abortion-related complications in three cities of northeastern Brazil (Salvador, Recife and São Luís). Nineteen public maternity hospitals were involved. All eligible women ≥18 years old hospitalized between August and December 2010 were evaluated. Descriptive, stratified and multivariate analyses were performed. Youden's index was used to determine delay. One model was created with all the women and another with those admitted in good clinical conditions, thus determining complications that occurred during hospitalization and their associated factors. Of 2,371 women, most (62.3%) were ≤30 years old (median 27 years) and 89.6% reported being black or brown-skinned. Most (90.5%) were admitted in good condition, 4.0% in fair condition and 5.5% in poor/very poor condition. Median time between admission and uterine evacuation was 7.9 hours. After a cut-off time of 10 hours, the development of complications increased considerably. Black women and those admitted during nightshifts were more likely to experience a wait time ≥10 hours. Delays were associated with severe complications (OR 1.97; 95%CI: 1.55-2.51), including in the women admitted in good condition (OR 2,56; 95%CI: 1.85-3.55), and even following adjustment for gestational age and reported abortion type (spontaneous/induced). These findings corroborate the literature, highlighting the social vulnerability of women hospitalized within Brazil's public healthcare system in a situation of abortion. The study strongpoints include having objectively measured the time between admission and uterine evacuation and having established a cut-off time defining delay based on conceptual and epidemiological criteria. Further studies should evaluate other settings and new measurement tools for effectively preventing life-threatening complications.

Experiences of women in prenatal, childbirth, and postpartum care during the COVID-19 pandemic in selected cities in Brazil: The resignification of the experience of pregnancy and giving birth.

The COVID-19 pandemic has impacted public and private health systems around the world, impairing good practices in women's health care. However, little is known about the experiences, knowledge, and feelings of Brazilian women in this period. The objective was to analyze the experiences of women, seen at maternity hospitals accredited by the Brazilian Unified Health System (SUS, acronym in Portuguese), regarding health care during pregnancy, childbirth, and postpartum periods, their interpersonal relationships, and perceptions and feelings about the pandemic. This was a qualitative, exploratory research, carried out in three Brazilian municipalities with women hospitalized in 2020, during pregnancy, childbirth, or postpartum period, with COVID-19 or not. For data collection, semi-structured individual interviews (in person, by telephone, or by digital platform) were conducted, recorded and transcribed. The content analysis of thematic modalities was displayed as per the following axes: i) Knowledge about the disease; ii) Search for health care in prenatal, childbirth, and postpartum periods; iii) Experience of suffering from COVID-19; iv) Income and work; and v) Family dynamics and social support network. A total of 46 women were interviewed in São Luís-MA, Pelotas-RS, and Niterói-RJ. Use of media was important to convey information and fight fake news. The pandemic negatively impacted access to health care in the prenatal, childbirth, and postpartum periods, contributing to worsening of the population's social and economic vulnerabilities. Women experienced diverse manifestations of the disease, and psychic disorders were very frequent. Social isolation during the pandemic disrupted the support network of these women, who found social support strategies in communication technologies. Women-centered care-including qualified listening and mental health support-can reduce the severity of COVID-19 cases in pregnant, parturient, and postpartum women. Sustainable employment and income maintenance policies are essential to mitigate social vulnerabilities and reduce risks for these women.

Pharmacogenetics of the Primary and Metastatic Osteosarcoma: Gene Expression Profile Associated with Outcome.

Osteosarcoma (OS) is the most common malignant bone tumor in children and adolescents. In recent decades, OS treatment has reached a plateau and drug resistance is still a major challenge. Therefore, the present study aimed to analyze the expression of the genes related to pharmacogenetics in OS. The expression of 32 target genes in 80 paired specimens (pre-chemotherapeutic primary tumor, post-chemotherapeutic primary tumor and pulmonary metastasis) obtained from 33 patients diagnosed with OS were analyzed by the real-time PCR methodology. As the calibrators (control), five normal bone specimens were used. The present study identified associations between the OS outcome and the expression of the genes TOP2A, DHFR, MTHFR, BCL2L1, CASP3, FASLG, GSTM3, SOD1, ABCC1, ABCC2, ABCC3, ABCC5, ABCC6, ABCC10, ABCC11, ABCG2, RALBP1, SLC19A1, SLC22A1, ERCC1 and MSH2. In addition, the expression of the ABCC10, GGH, GSTM3 and SLC22A1 genes were associated with the disease event, and the metastasis specimens showed a high expression profile of ABCC1, ABCC3 and ABCC4 genes and a low expression of SLC22A1 and ABCC10 genes, which is possibly an important factor for resistance in OS metastasis. Therefore, our findings may, in the future, contribute to clinical management as prognostic factors as well as possible therapeutic targets.

Quantitative expression evaluation of PRAME gene in osteosarcoma.

BACKGROUND: In a previous study, our group observed that 68% of the osteosarcoma (OS) samples presented PRAME (Preferentially Expressed Antigen in Melanoma) gene expression. In this work, we propose to investigate quantitatively gene expression of PRAME in distinct patients groups. METHODS AND RESULTS: 61 osteosarcoma samples, from 3 distinct patients groups were selected for this study: (1) Patients younger than 10 years old at diagnosis, (2) Patients that had poor evolution of disease and (3) Patients that were in remission of disease and had treatment with no intercurrences) PRAME gene expression levels were obtained using quantitative Real-Time Polymerase Chain Reaction method (qRT-PCR). Clinical parameters were collected from patient's medical charts. Results demonstrated an increase in PRAME gene expression in all samples, with high variation in expression levels, when considering all samples and when analyzed in each group. In addition, no statistical difference was found when considering clinical data collected or patients groups. CONCLUSION: PRAME gene expression quantitative investigation did not bring any complementary information beyond of what had already been observed in other qualitative investigations published by our group, there is no relation between PRAME gene expression levels and disease evolution. However, the findings in this work contribute for validation PRAME gene expression as a good biomarker to OS, which, in the future, may allow identification circulating tumor cell or molecules to contribute with early diagnostic of metastasis, a genuine problem in OS that determinate flattening in survival curves.

Para além do imaginável: experiências vividas por profissionais de saúde em UTI durante a pandemia da Covid-19 / Beyond the imaginable: experiences lived by ICU health professionals during the Covid-19 pandemic

Resumo Objetivou-se analisar experiências de profissionais relacionadas às mudanças no trabalho em saúde em Unidade de Terapia Intensiva, durante o período crítico da primeira onda da pandemia da Covid-19 no Maranhão. Estudo descritivo-exploratório, de abordagem qualitativa, desenvolvido nas Unidades de Terapia Intensiva de hospitais públicos no Maranhão, de novembro de 2020 a janeiro de 2021. Participaram do estudo 15 profissionais. A técnica utilizada para coleta de dados foi a entrevista semiestruturada, com amostra definida pelo critério de saturação dos sentidos. Utilizaram-se da análise de conteúdo e do software NVIVO® 12. Evidenciou-se que sobrecarga de trabalho, escassez de profissionais e o medo do contágio afetaram a qualidade da assistência e geraram novas formas de produção do cuidado. Naquele contexto, ofertar a assistência de "alto padrão" foi um desafio que perpassou os espaços social e técnico da terapia intensiva. Vivenciar as mortes em maior escala afetou as relações intersubjetivas nas esferas pessoal e profissional. As mudanças na organização do espaço, a assistência e as relações interprofissionais podem indicar caminhos para se repensar os efeitos desse fenômeno para agentes, usuários e serviços, além de fornecer maiores habilidades para lidar com cenários emergenciais futuros.

Abstract The study aimed to analyze the experiences lived by professionals related to changes in health work in the Intensive Care Unit, during the critical period of the first wave of the Covid-19 pandemic in Maranhão. This is a descriptive-exploratory study with a qualitative approach, carried out in the Intensive Care Units of public hospitals in Maranhão, from November 2020 to January 2021. Fifteen professionals took part in the study. Data collection was done through semi-structured interviews, with the sample defined by the criterion of saturation of meanings. Content analysis and NVIVO® 12 software were used. It emerged that work overload, shortage of professionals and fear of contagion affected the quality of care and generated new ways of producing care. In that context, providing "high standard" care was a challenge cutting across the social and technical spaces of intensive care. Experiencing deaths on a larger scale affected intersubjective relationships in personal and professional spheres. Changes in the organization of space, care and interprofessional relationships may indicate ways to rethink the effects of this phenomenon on agents, users and services, as well as providing greater skills to deal with future emergency scenarios.

Challenges in the care of children born to mothers diagnosed with COVID-19 during the pandemic / Desafíos en la atención de niños nacidos de madres diagnosticadas con COVID-19 durante la pandemia / Desafios no cuidado de crianças nascidas de mães com diagnóstico de COVID-19 durante a pandemia

ABSTRACT Objective: To understand the challenges in the care of children born to mothers with COVID-19 during the pandemic. Method: Qualitative research, conducted from November 2020 to May 2021, in two public maternity hospitals, with women who had children during the first wave of the pandemic, diagnosed with COVID-19 during pregnancy and/or childbirth. There were nineteen semi-structured interviews with thematic analysis. Symbolic Interactionism was used as a theoretical framework. Results: Changes in the care for newborn children were identified. In the domestic environment, hygiene measures with the newborn children were intensified, social isolation restricted the support network and mothers felt alone and overwhelmed. In terms of health care, there was a setback in neonatal care and interruption of professional care, such as the suspension of appointments. Conclusion: The pandemic has restructured traditional models of family care, intensified difficulties in accessing healthcare, and exposed children to inherent risks due to a lack of proper follow-up.

RESUMEN Objetivo: Comprender los desafíos en el cuidado de niños nacidos de madres con COVID-19 durante una pandemia. Método: Investigación cualitativa, realizada de noviembre de 2020 a mayo de 2021, en dos maternidades públicas, con mujeres que tuvieron hijos durante la primera ola de la pandemia, diagnosticadas con COVID-19 durante el embarazo y/o parto. Se realizaron diecinueve entrevistas semiestructuradas con análisis temático. Se utilizó como marco teórico el Interaccionismo Simbólico. Resultados: Se identificaron cambios en el cuidado del recién nacido. En el ámbito doméstico, se redoblaron las medidas de higiene con el recién nacido, el aislamiento social restringió la red de apoyo y las madres se sintieron solas y abrumadas. En cuanto a la atención, hubo retroceso en la atención neonatal e interrupción de la atención profesional, como la suspensión de citas. Conclusión: La pandemia ha reestructurado los modelos tradicionales de cuidado familiar, intensificado las dificultades de acceso a la salud y expuesto a los niños a los riesgos inherentes a la falta de seguimiento.

RESUMO Objetivo: Compreender os desafios no cuidado de crianças nascidas de mães com COVID-19 durante a pandemia. Método: Pesquisa qualitativa, realizada de novembro de 2020 a maio de 2021, em duas maternidades públicas, com mulheres que tiveram filhos na primeira onda da pandemia, diagnosticadas com COVID-19, durante a gestação e/ou parto. Realizaram-se 19 entrevistas semiestruturadas com análise temática. Utilizou-se do Interacionismo Simbólico como referencial teórico. Resultados: Identificaram-se mudanças nos cuidados a crianças recém-nascidas. No ambiente doméstico, as medidas de higiene com o recém-nascido foram redobradas, o isolamento social restringiu a rede de apoio e as mães se sentiram sozinhas e sobrecarregadas. No âmbito assistencial, houve retrocesso no cuidado neonatal e interrupção de cuidados profissionais, como suspensão de consultas. Conclusão: A pandemia reestruturou os modelos tradicionais de cuidados familiares, intensificou as dificuldades de acesso à saúde e expôs as crianças a riscos inerentes à falta de acompanhamento.

Processo de trabalho em Clínicas Populares de Saúde na perspectiva de médicos / El proceso de trabajo en Clínicas Populares de Salud bajo la perspectiva de médicos / Work process in Low-Cost Health Clinics from the perspective of physicians

O objetivo deste estudo foi compreender a perspectiva de médicos acerca do processo de trabalho em Clínicas Populares de Saúde. Para isso, realizamos uma pesquisa qualitativa na qual foram entrevistados oito jovens médicos especialistas que atuam nessas empresas em São Luís, Maranhão. Identificamos condições precarizadas de trabalho, mas com pouca resistência por parte dos médicos, considerando que essas empresas são encaradas como espaços de projeção no mercado de trabalho local. Devido às limitações do modelo assistencial do tipo queixa-conduta, os entrevistados acionam uma rede informal e os usuários das Clínicas Populares de Saúde são encaminhados para o Sistema Único de Saúde (SUS). Assim, o processo de trabalho do médico é desafiado por esse modelo assistencial fragmentado, o que faz borrar os limites nas interfaces público-privado na medida em que uma dupla porta de entrada para o SUS é naturalizada.(AU)

El objetivo de este estudio fue comprender la perspectiva de médicos sobre el proceso de trabajo en Clínicas Populares de Salud. Para ello, realizamos una investigación cualitativa en la que fueron entrevistados ocho jóvenes médicos especialistas que actúan en esas empresas en São Luís, Maranhão. Identificamos condiciones precarias de trabajo, pero con poca resistencia por parte de los médicos, considerando que esas empresas son consideradas como espacios de proyección en el mercado de trabajo local. Debido a las limitaciones del modelo asistencial del tipo queja-conducta, los entrevistados ponen en acción una red informal y los usuarios de las Clínicas Populares de Salud son derivados para el Sistema Brasileño de Salud (SUS). De tal forma, el proceso de trabajo del médico es desafiado por ese modelo asistencial fragmentado, lo que borra los límites de las interfaces público-privado a medida que se naturaliza una doble puerta de entrada al SUS.(AU)

The objective of the study was to understand the perspective of doctors regarding the work process in Low-cost Health Clinics. To this end, we conducted qualitative research interviewing 8 young specialist doctors who work in these business firms in São Luís, Maranhão. We identified precarious working conditions, although presenting little resistance from the doctors, considering that these businesses are seen as spaces of projection in the local job market. Due to the limitations of the complaint-driven model of care, the interviewees activate an informal network, and the users of the Low-Cost Health Clinics are referred to the Brazilian National Health System (SUS). Thus, the physician's work process is challenged by this fragmented care model, which blurs the boundaries in the public-private interfaces leading to a naturalized double gateway to the SUS.(AU)

Association between violence and depression during pregnancy with perinatal outcomes: a moderated mediation analysis.

OBJECTIVE: To assess the direct, indirect, and total effects of violence during pregnancy on perinatal outcomes, and to evaluate the effect of violence as a moderator of the mediated relationship of depression with perinatal outcomes. METHODS: Data was collected from the prenatal study and follow-ups of the BRISA cohort, São Luís, Maranhão, Brazil. The perinatal outcomes investigated were: birth weight (BW), intrauterine growth restriction (IUGR) and gestational age (GA). Violence against women was evaluated using the World Health Organization Violence against Women instrument (Violence during pregnancy - regardless of the type of violence; Physical violence during pregnancy; Psychological violence during pregnancy). Depressive symptoms during pregnancy were evaluated as a mediating variable. Moderated mediation analysis was performed to estimate the effects of violence and depression on perinatal outcomes. RESULTS: Three types of violence analyzed by depression had an indirect effect in BW and GA. None of the types of violence showed an association with IUGR. All types of violence analyzed showed a moderated mediation effect with BW and GA. Only among women who experienced violence were birth weight and gestational age lower the higher the values of depressive symptoms. CONCLUSION: Violence and depression are only associated with lower BW and GA when they occur simultaneously.

Characteristics associated with drug resistant epilepsy in children up to 36 months old with Congenital Zika Syndrome.

OBJECTIVES: To verify characteristics associated with drug resistant epilepsy in children up to 36 months of age with Congenital Zika Syndrome (CZS). METHODS: This is a prospective cohort study with children aged up to 36 months diagnosed with CZS. Obstetric, demographic, phenotype and other clinical signs, cranial tomography, growth and motor development of the children were collected. RESULTS: Of a total of 109 children diagnosed with CZS, 100 (91.7%) had epilepsy and 68 (68%) with drug resistant seizures. The types of seizures associated with drug resistant epilepsy were focal seizures from the occipital lobe, generalized tonic and generalized tonic-clonic seizures. There was an association between drug resistant epilepsy and microcephaly at birth, severe microcephaly at birth, excess nuchal skin, ventriculomegaly, reduced brain parenchyma volume, and hypoplasia or malformation of the cerebellum. Difficulty sleeping, irritability, continuous crying, dysphagia and gross motor function were clinical signs associated with drug resistant epilepsy, as were the presence of ocular abnormalities, low head circumference in the first year of life and low weight in the first six months. CONCLUSIONS: The prevalence of drug resistant epilepsy in children up to 36 months with CZS was 62.4% and was associated with the severity of the child's neurological damage, with emphasis on the reduction of brain parenchyma volume and damage to the cerebellum.

The consumption of culinary preparations and ultra-processed food is associated with handgrip strength in teenagers.

BACKGROUND: A nutrient-poor and hypocaloric diet may be associated with lower handgrip strength (HGS), whereas a high-quality or balanced diet may be associated with higher HGS. However, no study has used the NOVA system for classifying food by their degree of processing. OBJECTIVE: To analyze the association between food consumption according to the degree of food processing and HGS in Brazilian teenagers. METHODS: This cross-sectional study included teenagers aged 18 and 19 years old from the 1997/98 São Luís' birth cohort, Maranhão, Brazil. HGS (kilogram-force) was measured via a Jamar Plus + dynamometer. Food consumption was assessed using a semiquantitative food frequency questionnaire. The energy intake of culinary preparations (unprocessed or minimally processed food and processed culinary ingredients), processed, and ultra-processed foods was evaluated in percentages and categorized in tertiles. The associations between each food group intake and HGS was estimated via crude and adjusted linear regression models. A directed acyclic graph was used to identify confounding factors. RESULTS: We evaluated 2,433 teenagers, 52.1% of which were girls. For boys, adjusted analysis showed an association between the highest HGS and the 3rd tertile of culinary preparation consumption (ß: 1.95; 95%CI: 0.80; 3.10) and between the lowest HGS and the 3rd tertile of ultra-processed food consumption (ß: -2.25; 95%CI: -3.40; -1.10). Among girls, the consumption of culinary preparations in the 3rd tertile was associated with higher HGS (ß: 0.76; 95%CI: 0.05; 1.46). CONCLUSIONS: Higher consumption of culinary preparations and lower consumption of ultra-processed foods can contribute to reduce the chance of lower HGS in adult life. Interventions to promote the development and preservation of muscle strength should include dietary recommendations.

Physical activity in birth cohorts of three Brazilian cities (Ribeirão Preto, Pelotas, and São Luís): A cross-sectional study.

OBJECTIVE: To describe the prevalence of physical activity among subjects from birth cohorts of three cities located in different regions of Brazil according to sociodemographic characteristics and sex, comparing the relationships within and between cohorts. METHODS: Cross-sectional study involving 12,724 adolescents and young adults who participated in five birth cohorts: Ribeirão Preto [1978/79 (37/39 years old in 2016) and 1994 (22 years in 2016)]; Pelotas [1982 (30 years in 2012) and 1993 (22 years in 2015)], and São Luís [1997/98 (18/19 years in 2016)]. Leisure-time physical activity was evaluated with questionnaires (insufficiently active: <150 min/week and active: ≥150 min/week) and moderate and vigorous physical activity (MVPA) was objectively measured by accelerometry. Those, in each city, were evaluated accordingly to skin color, socioeconomic classification, and study/work activities. RESULTS: The prevalence of leisure-time physical activity ranged from 29.2% at 30 years old in Pelotas to 54.6% among adolescents from São Luís. The prevalence of leisure-time physical activity was higher among younger people (54.6% in São Luís 1997), while the same was not observed for total physical activity. MVPA (3rd tercile) was higher in the cohorts from Pelotas and São Luís. The prevalence of leisure-time physical activity and MVPA was higher in men. The data showed that the variation in physical activity was associated with sex and sociodemographic conditions in all cohorts. CONCLUSION: Sociodemographic characteristics should be considered when promoting leisure-time physical activity and actions aimed at young people, and adults who are more socioeconomically vulnerable should be encouraged.

The multiple uses of telemedicine during the pandemic: the evidence from a cross-sectional survey of medical doctors in Brazil.

BACKGROUND: The use of telemedicine, or the provision of healthcare and communication services through distance-based technologies, has increased substantially since the 2019 novel coronavirus (COVID-19) pandemic. However, it is still unclear what are the innovative features of the widespread use of such modality, its forms of employment and the context in which it is used across pluralist health systems, particularly in low- and middle-income settings. We have sought to provide empirical evidence on the above issues by analysing the responses of medical doctors in a representative cross-sectional survey in two states in Brazil: São Paulo and Maranhão. METHODS: We analysed the responses of 1,183 physicians to a survey on the impact of COVID-19 on their livelihood and working practice. Two independent samples per state were calculated based on a total of 152,511 active medical registries in São Paulo and Maranhão. Proportional stratified sampling was performed and the distributions for gender, age, state and location of address (capital or countryside) were preserved. The survey contained questions on the frequency of physicians' employment of telemedicine services; the specific activities where these were employed, and; the forms in which the pandemic had influenced the adoption or consolidation of this technology. We performed descriptive and univariate analysis based on the chi-square test or Fisher's exact test for the qualitative data, and the Mann-Whitney test in the quantitative cases. Data were shown as absolute frequency and proportion with a 95% confidence interval. RESULTS: In our sample of physicians, telemedicine was employed as a form of clinical collaboration by most doctors (76.0%, 95 CI 73.6-78.5), but only less than a third of them (30.6%, 95 CI 28.0-33.3) used it as a modality to provide healthcare services. During the pandemic, telemedicine was used predominantly in COVID-19-related areas, particularly for hospital-based in-patient services, and in private clinics and ambulatory settings. Male, younger doctors used it the most. Doctors in São Paulo employed telemedicine more frequently than in Maranhão (p < 0.001), in urban settings more than in rural areas (p < 0.001). Approximately three-quarters of doctors in large hospitals reported using telemedicine services (78.3%, 95 CI 75.9-80.6), followed by doctors working for smaller private clinics (66.4%, 95 CI 63.7-69.1), and by a smaller proportion of primary care doctors (58.4%, 95 CI 55.6-61.2). CONCLUSIONS: Our study suggests that telemedicine may have helped ensure and expand the range of communication and healthcare services in low- and middle-income settings during the COVID-19 pandemic. However, the modality appears to lend itself to be disproportionally used by doctors working in specific, priviledged sections of pluralistic health systems, and presumably by patients seeking care there. Regulation and incentives will be required to support the use of the technology across health systems in low- and middle-income countries in order to increase access to services for less disadvantaged populations.

The Impact of the COVID-19 Pandemic on Physicians' Working Hours and Earnings in São Paulo and Maranhão States, Brazil.

Evidence exists on the health impacts of the current COVID-19 pandemic on health workers, but less is known about its impact on their work dynamics and livelihoods. This matters, as health workers-and physicians in particular-are a scarce and expensive resource in low- and middle-income countries (LMICs). Our cross-sectional survey set out to explore changes in working hours and earnings during the second year of the pandemic in a representative sample of 1183 physicians in Brazil's São Paulo (SP) and Maranhão (MA) states. Descriptive analysis and inferential statistics were employed to explore differences in working hours and earnings among public and private sector physicians across the two locations. The workloads and earnings of doctors working exclusively in the public sector increased the most in the second year of the epidemic, particularly in MA. Conversely, the largest proportion of private-only doctors in our sample saw a decrease in their working hours (48.4%, 95% CI 41.8-55.0), whereas the largest proportion of public-only doctors in MA saw an increase in their working hours (44.4%, 95% CI 38.0-50.8). Although earnings remained broadly stable in the public sector, a third of public sector-only physicians in MA saw an increase in their earnings (95% CI 24.4-36.2). More than half of private-only doctors across both states saw a decrease in their earnings (52.2%, 95% CI 45.6-58.8). The largest proportion of dual practitioners (the majority in Brazil and in our sample) maintained their pre-pandemic levels of income (38.8%, 95% CI 35.3-42.3). As public-sector doctors have been key in the fight against the pandemic, it is critical to invest in these cadres in order to develop epidemic preparedness in LMICs, and to find new ways to harness for-profit actors to deliver social benefits.

Decline in head circumference growth and associated factors in congenital Zika syndrome.

Little is known about the evolution of head circumference (HC) in children with congenital Zika syndrome (CZS). This study aims to evaluate HC growth in children with CZS in the first three years of life and identify associated factors. HC data obtained at birth and in neuropediatric consultations from 74 children with CZS were collected from the Child's Health Handbook, parents' reports, and medical records. Predictors of HC z-score were investigated using different mixed-effects models; Akaike's information criterion was used for model selection. The HC z-score decreased from -2.7 ± 1.6 at birth to -5.5 ± 2.2 at 3 months of age, remaining relatively stable thereafter. In the selected adjusted model, the presence of severe brain parenchymal atrophy and maternal symptoms of infection in the first trimester of pregnancy were associated with a more pronounced reduction in the HC z-score in the first three years of life. The decrease of HC z-score in CZS children over the first three months demonstrated a reduced potential for growth and development of the central nervous system of these children. The prognosis of head growth in the first 3 years of life is worse when maternal infection occurs in the first gestational trimester and in children who have severe brain parenchymal atrophy.