New findings useful for clinical practice using swept-source optical coherence tomography angiography in the follow-up of active ocular toxoplasmosis.

BACKGROUND: Ocular toxoplasmosis is one of the most common causes of intraocular inflammation and posterior uveitis in immunocompetent patients. This paper aims to investigate swept-source optical coherence tomography angiography (SS-OCTA) findings in eyes with active toxoplasmic retinochoroiditis. METHODS: This case series was conducted from November 2017 through October 2019 in two Brazilian centers. 15 eyes of 15 patients with active toxoplasmic retinochoroiditis were included, and were imaged at baseline and after at least 4 weeks of follow-up. All patients underwent ophthalmic examinations and multimodal imaging including SS-OCT and SS-OCTA before and after treatment of ocular toxoplasmosis. The differential diagnoses included toxoplasmosis, syphilis, and human immunodeficiency virus, which were eliminated through serologic and clinical evaluations. RESULTS: All 15 patients presented with positive anti-Toxoplasma gondii immunoglobulin G titers and three also presented with positive anti-T. gondii immunoglobulin M titers. The mean age at examination was 32.4 years ± 12.7 years (range 15-59 years). Sixty percent of the patients were female. In all eyes, the inner retinal layers were abnormally hyperreflective with full-thickness disorganization of the retinal reflective layers at the site of the active toxoplasmic retinochoroiditis. At baseline, 80% of eyes had focal choroidal thickening beneath the retinitis area, and all eyes had a choroidal hyporeflective signal. Before treatment, SS-OCTA showed no OCTA decorrelation signal next to the lesion site in all eyes, and flow signal improvement was noticed after treatment. Three eyes presented with intraretinal vascular abnormalities during follow-up. SS-OCTA showed retinal neovascularization in one patient and a presumed subclinical choroidal neovascular membrane in another patient. CONCLUSIONS: SS-OCT and SS-OCTA are useful for assessing unexpected structural and vascular retinal and choroidal changes in active and post-treatment toxoplasmic retinochoroiditis and these findings are useful for clinical practice.

Acompanhamento na terceira etapa do método canguru: desafios na articulação de dois níveis de atenção / Follow-up during the third stage of the kangaroo method: challenges in articulation at two levels of care / Acompañamiento de la tercera etapa del método canguro: desafíos en la articulación entre dos niveles de atención

Este artigo analisa a percepção de trabalhadores de saúde sobre a articulação entre os serviços de Unidade Neonatal e da atenção primária em saúde (APS) no acompanhamento de crianças na terceira etapa do Método Canguru. Trata-se de pesquisa qualitativa, exploratória, realizada em capital do Nordeste brasileiro, com profissionais de uma unidade neonatal de referência e de sete Unidades de Saúde. Foram realizadas entrevistas semiestruturadas abordando questões gerais sobre o Método Canguru, com ênfase na terceira etapa. Fez-se análise de conteúdo na modalidade temática. Foram entrevistados 47 trabalhadores de saúde, sendo 14 da atenção especializada e 33 da atenção primária. Os profissionais de ambos os níveis de atenção perceberam os recém-nascidos pré-termo e/ou baixo peso como permanentemente frágeis, devendo ser sempre acompanhados no setor hospitalar. Durante a internação não é construída a vinculação da família com a APS e os trabalhadores da APS não reconhecem seu papel na atenção à criança egressa de unidade neonatal. No entanto, foi possível observar um movimento no sentido de promover o cuidado compartilhado. A percepção dos profissionais de saúde sobre risco das crianças que nasceram pré-termo ou de baixo peso faz, muitas vezes, com que os profissionais da APS não reconheçam a sua importância nos cuidados comuns a todas as crianças, contribuindo para a fragmentação do cuidado. A terceira etapa do Método Canguru deve acontecer com articulação entre o acompanhamento especializado e o realizado pelas equipes da APS. Assim, será possível estabelecer uma linha de cuidado que promova a continuidade da atenção.

This study analyzes the perception of health workers about the articulation between the services of the Neonatal Unit and primary healthcare (PHC) in the monitoring of children in the third stage of the Kangaroo Method. This qualitative, exploratory research was performed in a capital of the Northeast Region of Brazil involving professionals of a reference neonatal unit and seven basic health units. Semi-structured interviews were conducted addressing general questions focusing on the third stage of the Kangaroo Method. Content analysis was performed in the thematic modality. A total of 47 health workers were interviewed, of which 14 were from specialized care and 33 from primary care. Professionals at both levels of care perceived preterm and/or low birth weight as permanently fragile and should be followed up at the hospital. During hospitalization, the family is not tied to PHC, and PHC workers do not recognize their role in the care of Neonatal Unit children. However, it was possible to observe a movement to promote shared care. The perception of risk of children who were born preterm and/or low birth weight by health professionals often causes PHC professionals to fail to recognize their importance in the care common to all children, which contributes to the fragmentation and discontinuity of care. The third stage of the Kangaroo Method must happen in articulation with specialized care and the care performed by the PHC teams. This should thus allow to establish a line of care that promotes the continuity of care.

El presente estudio analiza la percepción de los trabajadores de la salud sobre la articulación entre los servicios de Unidad Neonatal y de la atención primaria de salud (APS) en el acompañamiento de niños en la tercera etapa del método Canguro. Es una investigación cualitativa del tipo exploratoria, realizada en una capital en el Nordeste brasileño, con profesionales de una unidad neonatal de referencia y de siete unidades básicas de salud. Se realizaron entrevistas semiestructuradas abordando cuestiones generales sobre el método Canguro, con énfasis en la tercera etapa. Se realizó el análisis de contenido en la modalidad temática. Se entrevistaron a 47 trabajadores de la salud, de estos, 14 eran de la atención especializada; y 33, de la atención primaria. Los profesionales de ambos niveles de atención percibieron los recién nacidos pretérmino y/o bajo peso como permanentemente frágiles, quienes debían recibir acompañamiento integral en el sector hospitalario. Durante la internación no se construye el vínculo de la familia con la APS, y los trabajadores de la APS no reconocen su papel en la atención al niño egresado de Unidad Neonatal. Sin embargo, fue posible observar un movimiento en el sentido de promover el cuidado compartido. La percepción de los profesionales de la salud acerca del riesgo de los niños que nacieron prematuros o de bajo peso a menudo los hace no reconocer su importancia en la atención común a todos los niños, lo que contribuye a la fragmentación y discontinuidad del cuidado. La tercera etapa del método Canguro debe ocurrir en articulación entre el acompañamiento especializado y el realizado por los equipos de la APS. Así, será posible establecer una línea de cuidado que promueva la continuidad de la atención prestada.

Prevalência e Fatores Associados ao Consumo de Álcool e Tabaco entre Estudantes de Medicina no Nordeste do Brasil / Prevalence and Associated Factors of Alcohol Consumption and Smoking among Medical Students in Northeastern Brazil

RESUMO Introdução O consumo de derivados de tabaco e álcool é apontado como importante causa de doenças e agravos no mundo. No Brasil, há um aumento no consumo dessas drogas entre os jovens, principalmente estudantes universitários. Objetivo Conhecer a prevalência e os fatores associados ao tabagismo e consumo de bebidas alcoólicas entre estudantes de Medicina, além do nível de conhecimento acerca das técnicas de cessação do hábito tabagista em diferentes momentos da vida acadêmica. Métodos Estudo analítico, de prevalência, envolvendo estudantes de Medicina de Fortaleza, Ceará, Brasil. Foram selecionadas todas as escolas médicas e os estudantes do primeiro ano (S1/S2), quarto ano (S7/S8) e aqueles do último ano do internato (I3/I4). A amostra foi calculada considerando uma frequência esperada de 10% de pessoas fumantes, com um erro de 3%, estimando 726 estudantes das quatro instituições. Foi aplicado um questionário estruturado, com 46 perguntas. Os dados foram analisados pelo software Stata 11.2. Resultados Foram entrevistados 1.035 estudantes, distribuídos proporcionalmente nos três períodos, 392 (37,9%) do primeiro ano (S1-S2), 319 (30,8%) do quarto ano (S7-S8) e 324 (31,3%) do internato (I3-I4). Quinhentos e cinquenta e três (53,4%) eram do sexo feminino, a maioria era solteira (993; 96,3%), nascidos em Fortaleza (748; 72,4%), residiam com os pais (896; 86,8%) e com renda familiar acima de dez salários mínimos (652; 61,8%). Ao todo, 533 (51,5%) eram alunos de instituições particulares. Do total, 254 (24,6%) já haviam fumado. Esse consumo foi significativamente maior entre o sexo masculino (p = 0,025), sem diferença em relação ao estado civil (p = 0,247) ou renda familiar (p = 0,191). Todos os acadêmicos que experimentaram alguma substância derivada do tabaco já haviam ingerido bebida alcoólica alguma vez na vida (p < 0,000). O consumo de álcool foi referido por mais de 80% dos estudantes, sendo maior entre aqueles cuja família apresentou renda superior a nove salários mínimos (p = 0,001). Houve relato de embriaguez em mais de 70% dos estudantes, tendo esse fato ocorrido antes dos 18 anos. Cerveja e vodca são as bebidas mais consumidas. Apenas 39,5% afirmaram estar aptos a aconselhar um paciente a não ingerir bebidas alcoólicas e apenas 28,4% receberam algum treinamento sobre o assunto em sua universidade. Conclusão A prevalência do consumo de álcool é muito elevada entre os estudantes de Medicina, principalmente entre aqueles que relataram fumar. Esses temas são abordados de forma incipiente em sua formação. É preciso reforçar esses aspectos na formação desses futuros profissionais de saúde.

ABSTRACT Introduction Tobacco and alcohol consumption is considered a major cause of diseases and disorders in the world. In Brazil, there has been increased consumption of these drugs among young people, especially university students. Objective To discover the prevalence of and factors associated to smoking and alcohol consumption among medical students, as well as their level of knowledge about techniques to stop smoking at different times of their academic life. Methods Analytical study of prevalence among medical students in Fortaleza, Ceará, Brazil. The study sample included all the city's medical schools and their first year (S1/S2) and fourth year (S7/S8) students and students in the final year of their internship (I3/I4). The sample was calculated considering an expected smoker frequency of 10%, with a 3% margin of error, estimating 726 students in the four institutions. A structured questionnaire containing 46 questions was applied. Data were analyzed using Stata 11.2 software. Results 1,035 students were interviewed, distributed proportionally in the three periods: 392 (37.87%) from the first year (S1 / S2), 319 (30.82%) from the fourth year (S7/S8) and 324 (31.30%) interns (I3/I4). 553 students (53.4%) were female; most of the students were single (993; 96.3%), born in Fortaleza (748; 72.4%), living with their parents (896; 86.8%) and with a household income of more than 10 minimum wages (652; 61.8%). In total, 533 (51.5%) were students at private institutions. Of the total, 254 (24.6%) had smoked. This consumption was significantly higher among males (p = 0.025), with no difference in relation to marital status (p = 0.247) or household income (p = 0.191). All the students who reported having experienced any tobacco derivative also reported using alcohol in their lifetime (p < 0.000). Alcohol consumption was reported by more than 80% of the students, and was higher among those whose family income was more than nine times the minimum wage (p = 0.001). Alcoholic intoxication was reported by over 70% of the students - where this had occurred before the age of 18 years. Beer and vodka are the most consumed beverages. Only 39.5% said they were inclined to advise a patient to avoid alcoholic beverages and only 28.4% had received training on the subject at their university. Conclusion The prevalence of alcohol consumption is very high among medical students, especially among those who reported smoking. These issues are addressed in a primitive manner in their training. We must strengthen these aspects in the training of future health professionals.

Kidney Disease Improving Global Outcomes or creatinine kinetics criteria in acute kidney injury: a proof of concept study.

BACKGROUND: It has been recently mathematically demonstrated that the percentage increase in serum creatinine (SCr) can delay acute kidney injury (AKI) diagnosis in patients with previous chronic kidney disease (CKD). Based on creatinine (Cr) kinetics, it was suggested a new AKI classification using absolute increase in SCr elevation over specified time periods. However, this classification has not been evaluated in clinical studies. METHODS: A prospective cohort study evaluated myocardial infarction patients during the first 7 days of hospital stay with daily SCr measurements. They were classified using Kidney Disease Improving Global Outcomes (KDIGO) and Cr kinetics systems. Both classifications were compared by net reclassification improvement (NRI) and area under the receiver operator characteristic (AuROC) curve regarding hospital mortality. RESULTS: A total of 584 patients were included, of which 34.1% had previous CKD. Patients had more AKI by KDIGO than by Cr kinetics criteria (25.7 versus 18.0%, P < 0.001) and 81 patients (13.9%) had different AKI severity classification. Patients with AKI by KDIGO criteria and non-AKI by Cr kinetics had higher hospital mortality rates than patients with non-AKI using both classifications [adjusted mortality odds ratios (ORs): 4.753; 95% confidence interval (CI): 1.119-9.023, P = 0.014]. In patients with previous CKD, NRI analysis was 6.2% favoring Cr kinetics criteria. However, there was no difference using the AuROC curve analysis. In patients with no previous CKD, NRI analysis was 33.0%, favoring KDIGO, and this was in accordance with a better AuROC curve (0.828 versus 0.664, P < 0.05). CONCLUSIONS: AKI classification proposed by a Cr kinetics model can be superior when diagnosing patients with previous CKD. However, KDIGO had a better performance in patients with no previous CKD.