Abstract Objective The purpose of this study was to evaluate the clinical-epidemiological profile, associated risk factors and clinical outcomes of patients with acute myeloid leukemia (AML), identifying the main causes of morbidity and mortality and overall survival rate of patients at five years of follow-up. Method This was a retrospective cohort study evaluating the prognosis and clinical outcomes of 222 patients diagnosed with AML at three large hematology centers in Ceará (northeastern Brazil) over a period of five years. Results The mean age at diagnosis was 44.1 ± 16 years, with a female prevalence of 1.3:1. No additional relevant risk factors associated with the development of AML were found, except for the well-established cytogenetic assessment. The overall 5-year survival rate was 39.4% (95%CI: 35.47 - 42.17). The main causes of death were disease progression (37.72%; n = 84) and sepsis (31.58%; n = 70). Conclusion The clinical outcomes in our sample of AML patients were similar to those of other reported groups. Disease progression and infection were the main causes of death. Access to diagnostic flow cytometry and karyotyping was greater in our sample than in the national average. As expected, overall survival differed significantly according to the risk, as determined by cytogenetic testing. clinicalepidemiological epidemiological profile AML, , (AML) followup. followup follow up. up follow-up 22 northeastern Brazil 441 44 1 44. 1.31. 131 1.3 1. 3 1.3:1 found wellestablished well established assessment 5year year 5 394 39 4 39.4 95%CI 95CI CI 95 (95%CI 3547 35 47 35.4 42.17. 4217 42.17 . 42 17 42.17) 37.72% 3772 37 72 (37.72% 84 31.58% 3158 31 58 (31.58% 70. 70 70) groups average expected testing (AML 2 1.31 13 1.3: 39. 9 354 35. 421 42.1 37.72 377 7 (37.72 8 31.58 315 (31.58 42. 37.7 (37.7 31.5 (31.5 37. (37. 31. (31. (37 (31 (3 (

Resumo Introdução: Avaliação e manejo adequados da dor têm se tornado uma preocupação cada vez maior dos profissionais de saúde. Segundo a definição de cuidados paliativos da Organização Mundial da Saúde, são importantes a identificação precoce, a avaliação e o tratamento da dor. Objetivo: Este estudo teve como objetivos desenvolver e avaliar um aplicativo para dispositivos móveis voltado para o ensino de abordagem da dor em cuidados paliativos. Método: Foi desenvolvido um aplicativo móvel, seguido de sua utilização por médicos residentes e de avaliação qualiquantitativa prospectiva. Aplicou-se o teste de conhecimento. Obtiveram-se a usabilidade do aplicativo, por meio da System Usability Scale (SUS), e a satisfação, por meio do Net Promoter Score (NPS). Os dados foram tabulados no Microsoft Office Excel® e exportados para o software Statistical Package for the Social Sciences (SPSS) versão 20.0 (IBM): na realização das análises, adotou-se uma confiança de 95%. Para a análise qualitativa das avaliações, o conteúdo das respostas foi transcrito e organizado em nuvens de palavras para destacar as ideias centrais. O estudo foi aprovado pelo Comitê de Ética do Centro Universitário Christus. Resultado: Desenvolveu-se o PaliPain App, aplicativo constituído de casos clínicos de pacientes em cuidados paliativos com manifestações de dor, além de questões, vídeos e imagens, disponibilizado nas plataformas Android e iOS. Utilizaram o aplicativo 13 médicos residentes. A média de acertos de questões no pré-teste sobre dor em cuidados paliativos aumentou de 6,08 para 7,54 após manuseio do aplicativo. Na avaliação sobre a usabilidade do aplicativo, obtivemos na SUS uma média de 89,2, acima do nível considerado adequado de 70,0. Na avaliação de satisfação, 54% dos médicos responderam com pontuação 10 à pergunta: “Em uma escala de 0 a 10, quanto você recomendaria o aplicativo PaliPain a um amigo ou colega?”. Conclusão: O PaliPain App, desenvolvido e disponibilizado nas plataformas Android e iOS, foi bem avaliado pelos médicos residentes, apresentando ótimos escores de usabilidade e de satisfação. Identificamos que houve ganho de conhecimento, com pontuação média na resolução de questões aumentando de 6,08 para 7,54 após livre uso da aplicação. O PaliPain App pode ser uma ferramenta útil para ensino de abordagem de dor para médicos residentes. Introdução saúde Saúde precoce Objetivo Método móvel prospectiva Aplicouse Aplicou conhecimento Obtiveramse Obtiveram SUS, , (SUS) satisfação NPS. NPS . (NPS) Excel SPSS (SPSS 200 20 20. IBM (IBM) análises adotouse adotou 95 95% avaliações centrais Christus Resultado Desenvolveuse Desenvolveu imagens iOS 1 préteste pré 608 6 08 6,0 754 7 54 7,5 892 89 2 89,2 700 70 70,0 pergunta Em colega. colega colega?” Conclusão aplicação (SUS (NPS (IBM 9 60 6, 75 5 7, 8 89, 70, colega?

Abstract Introduction: Pain evaluation has become an increasingly relevant concern for healthcare workers. According to the World Health Organization’s definition of Palliative Care, early identification, evaluation, and treatment of pain are important. Objective: Developing and rating an app for mobile devices that focuses on teaching the subject of pain management in Palliative Care. Research Methodology: The app was developed as a learning tool and tested by resident physicians while undergoing a qualitative and quantitative prospective evaluation. Mock tests were taken. The usability of the app was rated through the System Usability Scale (SUS), and satisfaction with the app was rated through the Net Promoter Score (NPS). The data was charted by using Microsoft Office Excel ® and was exported to the Statistical Package for the Social Sciences (SPSS) version 20.0 (IBM) software: an analysis was run with a 95% confidence interval. As for the qualitative analysis of the resident physicians’ evaluations, all available content was transcribed and properly organized in word clouds in order to highlight the most important pieces of feedback that the physicians presented regarding the app. The study was approved by the Ethics Committee. Main Results: The PaliPain App was developed as a database filled with clinical cases of patients undergoing palliative care who were experiencing varying levels of pain, and also presents analysis of test questions, videos and images. It was made available for the Android and iOS platforms. The average correct answers in a mock test about pain management during palliative care rose from 6.08 to 7.54. Thirteen resident physicians made use of the app. In the evaluation of the app’s usability, the average SUS score was 89.2. In the evaluation of user satisfaction, 54% of the resident physicians answered the question “from a scale of 0 to 10, what is the likelihood of you recommending the PaliPan app to a friend or colleague?” with a score of 10. Conclusion: The PaliPain App, developed and available on Android and iOS platforms, was well evaluated by resident physicians, presenting excellent scores for both usability and satisfaction. We identified that there was a gain in knowledge, with an average score in the resolution of questions increasing from 6.08 to 7.54 after free use of the application. The PaliPan app could be a useful tool to teach the subject of pain to resident physicians. Introduction workers Organizations Organization s Care identification Objective Methodology taken SUS, , (SUS) NPS. NPS . (NPS) SPSS (SPSS 200 20 20. IBM (IBM software 95 interval evaluations Committee Results images platforms 608 6 08 6.0 754 7 54 apps 892 89 2 89.2 10 colleague colleague? Conclusion knowledge 7.5 application (SUS (NPS 9 60 6. 75 5 8 89. 1 7.

Abstract Introduction Chronic back pain (CBP) is a major cause of years lived with disability. Social inequalities increase the prevalence and burden of CBP. Management of CBP was affected by restricted access to non-pharmacological treatments and outdoor activities during COVID-19 pandemic. Objectives To determine the prevalence of CBP among patients with COVID-19 as well as the impact of having CBP in COVID-19 outcome in our low-income population. Methods Retrospective cohort of individuals with confirmed COVID diagnosis from May 2020 - March 2021, at Hospital Regional UNIMED (HRU) in Fortaleza, Ceará, Brazil. Data included comorbidities and household income. Results Among 1,487 patients, 600 (40.3%) were classified as having CBP. Mean age as well as income were similar in CBP and non-CBP groups, with more women in the CBP group. Hypertension and asthma, but not diabetes, were more prevalent in those with CBP. Need for emergency care, hospitalization, and admission to intensive care unit were similar regardless of having CBP. Dyspnea was more common in CBP vs. non-CBP groups, with 48.8% vs. 39.4% percentages, respectively (p = 0.0004). Conclusion Having CBP prior to COVID did not impact the acute clinical outcome of COVID individuals of a low- income population. (CBP disability nonpharmacological non pharmacological COVID19 19 COVID-1 pandemic lowincome low population 202 2021 HRU (HRU Fortaleza Ceará Brazil 1487 1 487 1,48 60 40.3% 403 40 3 (40.3% nonCBP groups group asthma diabetes hospitalization vs 488 48 8 48.8 394 39 4 39.4 percentages p 0.0004. 00004 0.0004 . 0 0004 0.0004) COVID1 COVID- 20 148 1,4 6 40.3 (40.3 48. 39. 0000 0.000 000 2 14 1, 40. (40. 0.00 00 (40 0.0 (4 0. (

ABSTRACT Introduction: The increasing worldwide number of adults with congenital heart disease (CHD) demands greater attention from health professionals. The purpose of this report is to describe the clinical demographic profile, frequency, and invasive treatment status of adults with CHD in a public reference hospital in northeastern Brazil. Methods: This is a retrospective cross-sectional study including 704 patients attended between August 2016 and August 2020. Data were collected from virtual database. Results: Patients’ age varied from 17 to 81 years (mean 32±14; median 27 years); 294 (41.8%) patients were male, and 410 (58,2%) were female; 230 (32,7%) had diagnosis from age 18 and up. Cardiac complexity categories were “simple defects” (134 [19%] patients), “moderate complexity” (503 [71.5%]), and “great complexity” (67 [9.5%]). Atrial septal defect (ASD) was diagnosed in 216 (30.7%) patients, ventricular septal defect (VSD) in 101 (14.3%), tetralogy of Fallot in 93 (13.2%), and other CHD in 294 (41.8%). New York Heart Association (NYHA) functional classes were I (401 [57%]), II (203 [28.8%]), III (76 [10.8%]), and IV (24 [3.4%]). Complications were arrhythmias (173 [24%]) and severe pulmonary hypertension (69 [9.8%]). Invasive treatments were corrective surgery (364 (51.6%]), reoperation (28 [4.0%]), palliation (11 [1.6%]), interventional catheterization (12 [1.7%]), surgery plus interventional catheterization (5 [0.7%]), and preoperation (91 [12.9%]). Treatment was not required in 102 (14,5%) patients, and 91 (12.9%) were inoperable. Conclusion: The leading diagnosis was ASD. Frequency of unrepaired patients was high, mainly ASD, due to late diagnosis, which favored complications and denotes a matter of great concern. Introduction (CHD professionals profile frequency Brazil Methods crosssectional cross sectional 70 201 2020 database Results Patients 1 8 mean 32±14 3214 32 14 2 years) 29 41.8% 418 41 (41.8% male 58,2% 582 58 (58,2% female 23 32,7% 327 7 (32,7% up simple defects 134 (13 19% 19 [19% , patients) moderate 503 (50 71.5%, 715 71.5% 71 5 [71.5%]) 67 (6 9.5%. 95 9.5% . 9 [9.5%]) ASD (ASD 21 30.7% 307 30 (30.7% VSD (VSD 10 14.3%, 143 14.3% 3 (14.3%) 13.2%, 132 13.2% 13 (13.2%) 41.8%. NYHA (NYHA 401 (40 57%, 57 57% [57%]) 203 (20 28.8%, 288 28.8% 28 [28.8%]) 76 (7 10.8%, 108 10.8% [10.8%]) 24 (2 3.4%. 34 3.4% 4 [3.4%]) 173 (17 24% [24%] 69 9.8%. 98 9.8% [9.8%]) 364 (36 51.6%, 516 51.6% 51 6 (51.6%]) 4.0%, 40 4.0% 0 [4.0%]) 11 (1 1.6%, 16 1.6% [1.6%]) 12 1.7%, 1.7% [1.7%]) ( 0.7%, 07 0.7% [0.7%]) (9 12.9%. 129 12.9% [12.9%]) 14,5% 145 (14,5% (12.9% inoperable Conclusion high concern 20 202 32±1 321 41.8 (41.8 58,2 (58,2 32,7 (32,7 [19 50 71.5 [71.5%] 9.5 [9.5%] 30.7 (30.7 14.3 (14.3% 13.2 (13.2% (4 [57%] 28.8 [28.8%] 10.8 [10.8%] 3.4 [3.4%] [24% 9.8 [9.8%] 36 (3 51.6 (51.6%] 4.0 [4.0%] 1.6 [1.6%] 1.7 [1.7%] 0.7 [0.7%] 12.9 [12.9%] 14,5 (14,5 (12.9 32± 41. (41. 58, (58, 32, (32, [1 71. [71.5% 9. [9.5% 30. (30. 14. (14.3 13. (13.2 [57% 28. [28.8% 10. [10.8% 3. [3.4% [24 [9.8% 51. (51.6% 4. [4.0% 1. [1.6% [1.7% 0. [0.7% 12. [12.9% 14, (14, (12. (41 (58 (32 [ [71.5 [9.5 (30 (14. (13. [57 [28.8 [10.8 [3.4 [2 [9.8 (51.6 [4.0 [1.6 [1.7 [0.7 [12.9 (14 [71. [9. [5 [28. [10. [3. (51. [4. [1. [0. [12. [71 [9 [28 [10 [3 (51 [4 [0 [12 [7

Resumo Este estudo explora o cotidiano das famílias com filhos de 0 a 6 anos, residentes em Fortaleza, no Ceará, durante o período de distanciamento físico, estipulado pelo Governo do Estado do Ceará. Esta pesquisa qualitativa se utilizou do referencial da teoria de formação de vínculos na adversidade. Foram entrevistadas 30 mães, entre os meses de julho e agosto de 2020, utilizando videochamadas ou telefonemas. Para análise do material empírico, recorreu-se à análise de conteúdo de Bardin, possibilitando a criação de duas categorias temáticas: (1) o exercício do cuidado parental em tempos de covid-19; (2) o cotidiano das crianças diante da pandemia. A interpretação das narrativas revelou que alguns cuidadores buscaram realizar brincadeiras e atividades manuais com os filhos, e explicavam o que estava acontecendo no cenário mundial, exercendo a parentalidade positiva. Ademais, o distanciamento físico favoreceu o aumento da tolerância dos pais no tempo em que os filhos ficaram expostos às telas. Percebeu-se que os pais influenciaram a prática de hábitos alimentares não saudáveis entre as crianças e a manifestação de mudanças no comportamento dos filhos. Como conclusão, destaca-se a necessidade de um acompanhamento contínuo dos aspectos referentes ao desenvolvimento dessas crianças e do retorno delas às atividades presenciais.

Abstract This study sought to explore the daily life of families with children aged 0 - 6 years old, living in Fortaleza, Ceará - Brazil, during the period of social distancing stipulated by the State Government. This qualitative research was conducted with data collected by means of video or phone interviews with thirty mothers, between July and August 2020. The empirical material was analyzed in the light of Bardin’s content analysis, generating two thematic categories: (1) the exercise of parental care in Covid-19 times; and (2) the daily life of children in the face of the pandemic. The narratives revealed that some caregivers tried to play games and practice arts and crafts with their children, besides explaining what was happening in the world scenario - thus exercising positive parenting. Moreover, the social distancing measures promoted parental tolerance during the time children were exposed to screens, and parents showed to influence the practice of unhealthy eating habits and the manifestation of behavior changes in their children. These findings highlight the need for a continuous monitoring of aspects related to these children’s development, as well as for their return to face-to-face activities.

Resumo Este estudo explora o cotidiano das famílias com filhos de 0 a 6 anos, residentes em Fortaleza, no Ceará, durante o período de distanciamento físico, estipulado pelo Governo do Estado do Ceará. Esta pesquisa qualitativa se utilizou do referencial da teoria de formação de vínculos na adversidade. Foram entrevistadas 30 mães, entre os meses de julho e agosto de 2020, utilizando videochamadas ou telefonemas. Para análise do material empírico, recorreu-se à análise de conteúdo de Bardin, possibilitando a criação de duas categorias temáticas: (1) o exercício do cuidado parental em tempos de covid-19; (2) o cotidiano das crianças diante da pandemia. A interpretação das narrativas revelou que alguns cuidadores buscaram realizar brincadeiras e atividades manuais com os filhos, e explicavam o que estava acontecendo no cenário mundial, exercendo a parentalidade positiva. Ademais, o distanciamento físico favoreceu o aumento da tolerância dos pais no tempo em que os filhos ficaram expostos às telas. Percebeu-se que os pais influenciaram a prática de hábitos alimentares não saudáveis entre as crianças e a manifestação de mudanças no comportamento dos filhos. Como conclusão, destaca-se a necessidade de um acompanhamento contínuo dos aspectos referentes ao desenvolvimento dessas crianças e do retorno delas às atividades presenciais.

Abstract This study sought to explore the daily life of families with children aged 0 - 6 years old, living in Fortaleza, Ceará - Brazil, during the period of social distancing stipulated by the State Government. This qualitative research was conducted with data collected by means of video or phone interviews with thirty mothers, between July and August 2020. The empirical material was analyzed in the light of Bardin’s content analysis, generating two thematic categories: (1) the exercise of parental care in Covid-19 times; and (2) the daily life of children in the face of the pandemic. The narratives revealed that some caregivers tried to play games and practice arts and crafts with their children, besides explaining what was happening in the world scenario - thus exercising positive parenting. Moreover, the social distancing measures promoted parental tolerance during the time children were exposed to screens, and parents showed to influence the practice of unhealthy eating habits and the manifestation of behavior changes in their children. These findings highlight the need for a continuous monitoring of aspects related to these children’s development, as well as for their return to face-to-face activities.

RESUMO OBJETIVO Identificar os fatores determinantes para infecções relacionadas à assistência à saúde (IRAS) tardias em terapia intensiva neonatal e multirresistência bacteriana. MÉTODOS Estudo caso-controle em unidade de terapia intensiva neonatal do Estado do Ceará, entre janeiro de 2013 e dezembro de 2017. Considerado caso o recém-nascido notificado como IRAS tardia e, controle, aquele sem infecção. Variáveis com valor de p ≤ 0,05 em análise regressiva bivariada inicial foram incluídas em modelo logístico hierarquizado não condicional para análise multivariada. Valores de p menores que 0,01 foram considerados significativos. RESULTADOS Dos 1.132 participantes, 427 (37,7%) tiveram infecções tardias relacionadas a assistência à saúde, com 54 (12,6%) hemoculturas positivas e 14,9% dessas foram bactérias multirresistentes. Na análise bivariada observou-se efeito protetor do sexo feminino (OR = 0,71; IC95% 0,56–0,90) e recém-nascido ≥ 34 semanas (OR = 0,48; IC95% 0,30–0,75). Nos mais prematuros, as infecções tardias tiveram chance dezoito vezes maior em menores do que 30 semanas (OR = 18,61; IC95% 9,84–35,22); e nos menores de 1.500g, quatro vezes maior (OR = 4,18; IC95% 3,12–5,61). O uso de ventilação mecânica aumentou em mais de sete vezes a chance (OR = 7,14; IC95% 5,26–9,09); o mesmo aconteceu com o recurso da nutrição parenteral (OR = 5,88; IC95% 4,54–7,69), com o cateter venoso central (OR = 10,00; IC95% 6,66–16,66); o número de cateteres utilizado (OR = 3,93; IC95% 3,02–5,12); a realização de cirurgia (OR = 4,00; IC95% 2,27–7,14) e o tempo de internamento (OR = 1,06; IC95% 1,05–1,07). Permaneceram significativos após ajuste: prematuro menor do que 30 semanas (OR = 5,62; IC95% 1,83–17,28); uso de ventilação (OR = 1,84; IC95% 1,26–2,68); uso de cateter venoso central (OR = 2,48; IC95% 1,40–4,37) e tempo de internamento (OR = 1,06; IC95% 1,05–1,07). Dentre os óbitos, 41 (55,4%) foram associados às infecções tardias. CONCLUSÃO Melhores práticas devem ser adotadas no cuidado da prematuridade e o uso racional de procedimentos, para evitar infecções tardias relacionadas a assistência à saúde, óbitos preveníveis e riscos de multirresistência bacteriana e contaminação ambiental.

ABSTRACT OBJECTIVES To assess the determining factors of late healthcare-associated infections (HAIs) and bacterial multiple drug resistance in neonatal intensive care. METHODS This is a case-control study, conducted between January 2013 and December 2017, in a neonatal intensive care unit in the state of Ceará, Brazil. Newborns showing late HAIs were considered cases and those without infection, the control. Variables with p-values ≤ 0.05 in our initial bivariate regressive analysis were included in a non-conditional hierarchical logistic model for multivariate analysis. P-values below 0.01 were considered significant. RESULTS Of the 1,132 participants, 427 (37.7%) showed late healthcare-associated infections. Of these, 54 (12.6%), positive blood cultures, of which 14.9% contained multidrug-resistant bacteria. Bivariate analysis showed the protective effect of the feminine phenotype (OR = 0.71; 95%CI: 0.56–0.90) and of gestational ages ≥ 34 weeks (OR = 0.48; 95%CI: 0.30–0.75). In earlier-born preterm infants, late infections were 18 times more likely in those with less than 30 week-gestations (OR = 18.61; 95%CI: 9.84–35.22) and four times higher in those weighing less than 1,500 g (OR = 4.18; 95%CI: 3.12–5.61). Mechanical ventilation increased infection odds by more than seven times (OR = 7.14; 95%CI: 5.26–9.09); as did parenteral nutrition (OR = 5.88; 95%CI: 4.54–7.69); central venous catheters (OR = 10.00; 95%CI: 6.66–16.66); the number of catheters used (OR = 3.93; 95%CI: 3.02–5.12); surgery (OR = 4.00; 95%CI: 2.27–7.14); and hospitalization time (OR = 1.06; 95%CI: 1.05–1.07). The association between preterm infants with less than 30 week-gestations (OR = 5.62; 95%CI: 1.83–17.28); mechanical ventilation (OR = 1.84; 95%CI: 1.26–2.68); central venous catheters (OR = 2.48; 95%CI: 1.40–4.37); and hospitalization time (OR = 1.06; 95%CI: 1.05–1.07) remained significant after adjustment. Among deaths, 41 (55.4%) were associated with late infections. CONCLUSION Better practices should be adopted in caring for the premature, as well as in the rational use of procedures, to avoid late healthcare-associated infections, preventable deaths, and risks of bacterial multiple drug resistance and environmental contamination.

RESUMO OBJETIVO Identificar os fatores determinantes para infecções relacionadas à assistência à saúde (IRAS) tardias em terapia intensiva neonatal e multirresistência bacteriana. MÉTODOS Estudo caso-controle em unidade de terapia intensiva neonatal do Estado do Ceará, entre janeiro de 2013 e dezembro de 2017. Considerado caso o recém-nascido notificado como IRAS tardia e, controle, aquele sem infecção. Variáveis com valor de p ≤ 0,05 em análise regressiva bivariada inicial foram incluídas em modelo logístico hierarquizado não condicional para análise multivariada. Valores de p menores que 0,01 foram considerados significativos. RESULTADOS Dos 1.132 participantes, 427 (37,7%) tiveram infecções tardias relacionadas a assistência à saúde, com 54 (12,6%) hemoculturas positivas e 14,9% dessas foram bactérias multirresistentes. Na análise bivariada observou-se efeito protetor do sexo feminino (OR = 0,71; IC95% 0,56–0,90) e recém-nascido ≥ 34 semanas (OR = 0,48; IC95% 0,30–0,75). Nos mais prematuros, as infecções tardias tiveram chance dezoito vezes maior em menores do que 30 semanas (OR = 18,61; IC95% 9,84–35,22); e nos menores de 1.500g, quatro vezes maior (OR = 4,18; IC95% 3,12–5,61). O uso de ventilação mecânica aumentou em mais de sete vezes a chance (OR = 7,14; IC95% 5,26–9,09); o mesmo aconteceu com o recurso da nutrição parenteral (OR = 5,88; IC95% 4,54–7,69), com o cateter venoso central (OR = 10,00; IC95% 6,66–16,66); o número de cateteres utilizado (OR = 3,93; IC95% 3,02–5,12); a realização de cirurgia (OR = 4,00; IC95% 2,27–7,14) e o tempo de internamento (OR = 1,06; IC95% 1,05–1,07). Permaneceram significativos após ajuste: prematuro menor do que 30 semanas (OR = 5,62; IC95% 1,83–17,28); uso de ventilação (OR = 1,84; IC95% 1,26–2,68); uso de cateter venoso central (OR = 2,48; IC95% 1,40–4,37) e tempo de internamento (OR = 1,06; IC95% 1,05–1,07). Dentre os óbitos, 41 (55,4%) foram associados às infecções tardias. CONCLUSÃO Melhores práticas devem ser adotadas no cuidado da prematuridade e o uso racional de procedimentos, para evitar infecções tardias relacionadas a assistência à saúde, óbitos preveníveis e riscos de multirresistência bacteriana e contaminação ambiental.

ABSTRACT OBJECTIVES To assess the determining factors of late healthcare-associated infections (HAIs) and bacterial multiple drug resistance in neonatal intensive care. METHODS This is a case-control study, conducted between January 2013 and December 2017, in a neonatal intensive care unit in the state of Ceará, Brazil. Newborns showing late HAIs were considered cases and those without infection, the control. Variables with p-values ≤ 0.05 in our initial bivariate regressive analysis were included in a non-conditional hierarchical logistic model for multivariate analysis. P-values below 0.01 were considered significant. RESULTS Of the 1,132 participants, 427 (37.7%) showed late healthcare-associated infections. Of these, 54 (12.6%), positive blood cultures, of which 14.9% contained multidrug-resistant bacteria. Bivariate analysis showed the protective effect of the feminine phenotype (OR = 0.71; 95%CI: 0.56–0.90) and of gestational ages ≥ 34 weeks (OR = 0.48; 95%CI: 0.30–0.75). In earlier-born preterm infants, late infections were 18 times more likely in those with less than 30 week-gestations (OR = 18.61; 95%CI: 9.84–35.22) and four times higher in those weighing less than 1,500 g (OR = 4.18; 95%CI: 3.12–5.61). Mechanical ventilation increased infection odds by more than seven times (OR = 7.14; 95%CI: 5.26–9.09); as did parenteral nutrition (OR = 5.88; 95%CI: 4.54–7.69); central venous catheters (OR = 10.00; 95%CI: 6.66–16.66); the number of catheters used (OR = 3.93; 95%CI: 3.02–5.12); surgery (OR = 4.00; 95%CI: 2.27–7.14); and hospitalization time (OR = 1.06; 95%CI: 1.05–1.07). The association between preterm infants with less than 30 week-gestations (OR = 5.62; 95%CI: 1.83–17.28); mechanical ventilation (OR = 1.84; 95%CI: 1.26–2.68); central venous catheters (OR = 2.48; 95%CI: 1.40–4.37); and hospitalization time (OR = 1.06; 95%CI: 1.05–1.07) remained significant after adjustment. Among deaths, 41 (55.4%) were associated with late infections. CONCLUSION Better practices should be adopted in caring for the premature, as well as in the rational use of procedures, to avoid late healthcare-associated infections, preventable deaths, and risks of bacterial multiple drug resistance and environmental contamination.

RESUMO Objetivo: Analisar o retardo ou a não procura por atenção primária à saúde por parte do bionômio mãe-filho durante a pandemia de COVID-19, uma prática que apresenta elevado potencial de aumentar a morbimortalidade materno-infantil. Métodos: Dados de três levantamentos do estudo longitudinal Iracema-COVID, realizados aos seis, 12 e 18 meses após o parto, identificaram padrões de procura por consultas na Atenção Primária à Saúde (APS) por parte do binômio mãe-filho. A regressão multinomial bruta e adjustada com variância robusta foi utilizada para avaliar os fatores associados com a não procura. Resultados: Entre as 314 mães da coorte, 25% não realizaram nenhuma consulta na APS durante o período de 18 meses pós-parto, enquanto 30% das mães o fizeram nos três contatos do seguimento. Com relação à consulta da criança, 75% realizaram consultas de APS nos três momentos, ao passo que 4% não realizaram nenhuma consulta em seus primeiros 18 meses de vida. Ao fim da primeira onda de COVID-19, a proporção de consultas na APS de mães e crianças caiu 23 e 18%, respectivamente. Os principais fatores associados à não procura por APS foram mães com idade abaixo de 25 anos e mães com mais de um filho. Conclusão: Houve importante retardo ou não procura por APS pelo bionômio mãe-filho durante a pandemia de COVID-19. Essa prática, com elevado potencial de aumentar a morbimortalidade materno-infantil, foi mais frequente entre mães mais jovens e com mais de um filho.

ABSTRACT Objective: To analyze the delay or failure to seek primary health care by the mother-child dyads during the COVID-19 pandemic, a practice that has a high potential to increase maternal and child morbidity and mortality. Methods: Data from three survey rounds of the Iracema-COVID cohort study, collected 6, 12, and 18 months after birth, showed the patterns of postpartum attendance to primary health care consultation of the mother-child dyad. Crude and adjusted multinomial logistic regressions with robust variance were used to assess factors associated with nonattendance. Results: Among the 314 cohort mothers, 25% did not attend any primary health care consultation during the 18-months postpartum, while 30% of the mothers did all three. Regarding the child, 75% had regular primary health care consultations in all three survey rounds, while 4% did not attend any in their first 18 months of life. By the end of the first COVID-19 wave, the proportion of mother and child who attended the consultations had fallen by 23 and 18%, respectively. The main factors associated with nonattendance were mothers aged below 25 years, and mothers with more than one child. Conclusion: An important delay or nonattendance to primary health care consultation by the mother-child dyad was observed during the COVID-19 pandemic. Such practice, with a high potential to increase maternal and child morbidity and mortality, was particularly frequent among younger mothers and those with more than one child.

RESUMO Objetivo: Estimar a prevalência de experiências adversas na infância e identificar fatores associados. Métodos: O estudo transversal de base populacional compreendeu os dados de uma amostra de 3.200 domicílios com 3.566 crianças menores de seis anos, representativa do estado do Ceará, Brasil. Foi utilizado um processo de amostragem multiestágio, com estratificação entre a capital do estado, Fortaleza, e os 28 municípios do interior, nos quais foram sorteados 160 setores censitários, cada qual com um conglomerado de 20 domicílios. A variável desfecho foi estruturada com base nas situações de experiências adversas na infância sugeridas pelo grupo Centers for Disease Control and Prevention, de acordo com o número de situações a que a criança foi exposta: 0–2, 3–5 e 6–9. O modelo multivariado de regressão logística ordinal foi utilizado para avaliar as associações. Resultados: Das 3.566 crianças estudadas, 89,7% (intervalo de confiança — IC95% 88,7–90,7) foram expostas a pelo menos uma experiência adversa, sendo as mais prevalentes negligência e abuso emocional/físico. Os principais fatores associados às experiências adversas na infância foram a idade materna mais elevada e o tabagismo materno, a ausência paterna, a baixa escolaridade do chefe da família, a insegurança alimentar e a falta de rede de apoio social. Conclusão: O estudo encontrou alta ocorrência de experiências adversas na primeira infância, principalmente entre crianças nascidas de mães de idade mais elevada e tabagistas, sem a presença paterna, e em situação de vulnerabilidade social e econômica, como a insegurança alimentar, que deve ser alvo prioritário de medidas de prevenção e controle.

ABSTRACT Objective: To estimate the prevalence of adverse childhood experiences and identify associated factors. Methods: A population-based cross-sectional study comprised data from a sample of 3,200 households with 3,566 children under 6 years of age, representative of the state of Ceará, Brazil. A multistage sampling approach was used, with stratification among the state capital, Fortaleza, and the 28 countryside municipalities, in which 160 census tracts were randomly selected, each one with a cluster of 20 households. The outcome variable was structured based on adverse childhood experiences as suggested by the Center for Disease Control and Prevention, according to the number of situations to which the child was exposed: 0–2, 3–5, and 6–9. Ordinal logistic regression multivariate model was applied to assess associations. Results: Among the 3,566 children studied, 89.7% (95%CI 88.7–90.7) were exposed to at least one adverse experience, of which the most prevalent were neglect, and emotional/physical abuse. The main factors associated were maternal advanced age and smoking, paternal absence, low education level of the head of the family, food insecurity and lack of a social support network. Conclusion: The study found a high occurrence of adverse early childhood experiences, particularly among preschool children born to mothers of older age, solo, who smoke and in a situation of social and economic vulnerability, including food insecurity, who should be target of control and prevention measures.

ABSTRACT Objective: To analyze the delay or failure to seek primary health care by the mother-child dyads during the COVID-19 pandemic, a practice that has a high potential to increase maternal and child morbidity and mortality. Methods: Data from three survey rounds of the Iracema-COVID cohort study, collected 6, 12, and 18 months after birth, showed the patterns of postpartum attendance to primary health care consultation of the mother-child dyad. Crude and adjusted multinomial logistic regressions with robust variance were used to assess factors associated with nonattendance. Results: Among the 314 cohort mothers, 25% did not attend any primary health care consultation during the 18-months postpartum, while 30% of the mothers did all three. Regarding the child, 75% had regular primary health care consultations in all three survey rounds, while 4% did not attend any in their first 18 months of life. By the end of the first COVID-19 wave, the proportion of mother and child who attended the consultations had fallen by 23 and 18%, respectively. The main factors associated with nonattendance were mothers aged below 25 years, and mothers with more than one child. Conclusion: An important delay or nonattendance to primary health care consultation by the mother-child dyad was observed during the COVID-19 pandemic. Such practice, with a high potential to increase maternal and child morbidity and mortality, was particularly frequent among younger mothers and those with more than one child.

RESUMO Objetivo: Analisar o retardo ou a não procura por atenção primária à saúde por parte do bionômio mãe-filho durante a pandemia de COVID-19, uma prática que apresenta elevado potencial de aumentar a morbimortalidade materno-infantil. Métodos: Dados de três levantamentos do estudo longitudinal Iracema-COVID, realizados aos seis, 12 e 18 meses após o parto, identificaram padrões de procura por consultas na Atenção Primária à Saúde (APS) por parte do binômio mãe-filho. A regressão multinomial bruta e adjustada com variância robusta foi utilizada para avaliar os fatores associados com a não procura. Resultados: Entre as 314 mães da coorte, 25% não realizaram nenhuma consulta na APS durante o período de 18 meses pós-parto, enquanto 30% das mães o fizeram nos três contatos do seguimento. Com relação à consulta da criança, 75% realizaram consultas de APS nos três momentos, ao passo que 4% não realizaram nenhuma consulta em seus primeiros 18 meses de vida. Ao fim da primeira onda de COVID-19, a proporção de consultas na APS de mães e crianças caiu 23 e 18%, respectivamente. Os principais fatores associados à não procura por APS foram mães com idade abaixo de 25 anos e mães com mais de um filho. Conclusão: Houve importante retardo ou não procura por APS pelo bionômio mãe-filho durante a pandemia de COVID-19. Essa prática, com elevado potencial de aumentar a morbimortalidade materno-infantil, foi mais frequente entre mães mais jovens e com mais de um filho.

ABSTRACT Objective: To estimate the prevalence of adverse childhood experiences and identify associated factors. Methods: A population-based cross-sectional study comprised data from a sample of 3,200 households with 3,566 children under 6 years of age, representative of the state of Ceará, Brazil. A multistage sampling approach was used, with stratification among the state capital, Fortaleza, and the 28 countryside municipalities, in which 160 census tracts were randomly selected, each one with a cluster of 20 households. The outcome variable was structured based on adverse childhood experiences as suggested by the Center for Disease Control and Prevention, according to the number of situations to which the child was exposed: 0–2, 3–5, and 6–9. Ordinal logistic regression multivariate model was applied to assess associations. Results: Among the 3,566 children studied, 89.7% (95%CI 88.7–90.7) were exposed to at least one adverse experience, of which the most prevalent were neglect, and emotional/physical abuse. The main factors associated were maternal advanced age and smoking, paternal absence, low education level of the head of the family, food insecurity and lack of a social support network. Conclusion: The study found a high occurrence of adverse early childhood experiences, particularly among preschool children born to mothers of older age, solo, who smoke and in a situation of social and economic vulnerability, including food insecurity, who should be target of control and prevention measures.

RESUMO Objetivo: Estimar a prevalência de experiências adversas na infância e identificar fatores associados. Métodos: O estudo transversal de base populacional compreendeu os dados de uma amostra de 3.200 domicílios com 3.566 crianças menores de seis anos, representativa do estado do Ceará, Brasil. Foi utilizado um processo de amostragem multiestágio, com estratificação entre a capital do estado, Fortaleza, e os 28 municípios do interior, nos quais foram sorteados 160 setores censitários, cada qual com um conglomerado de 20 domicílios. A variável desfecho foi estruturada com base nas situações de experiências adversas na infância sugeridas pelo grupo Centers for Disease Control and Prevention, de acordo com o número de situações a que a criança foi exposta: 0–2, 3–5 e 6–9. O modelo multivariado de regressão logística ordinal foi utilizado para avaliar as associações. Resultados: Das 3.566 crianças estudadas, 89,7% (intervalo de confiança — IC95% 88,7–90,7) foram expostas a pelo menos uma experiência adversa, sendo as mais prevalentes negligência e abuso emocional/físico. Os principais fatores associados às experiências adversas na infância foram a idade materna mais elevada e o tabagismo materno, a ausência paterna, a baixa escolaridade do chefe da família, a insegurança alimentar e a falta de rede de apoio social. Conclusão: O estudo encontrou alta ocorrência de experiências adversas na primeira infância, principalmente entre crianças nascidas de mães de idade mais elevada e tabagistas, sem a presença paterna, e em situação de vulnerabilidade social e econômica, como a insegurança alimentar, que deve ser alvo prioritário de medidas de prevenção e controle.

Resumo Fundamento Alterações do substrato elétrico e anatômico do coração são fatores que originam e perpetuam a fibrilação atrial (FA), porém, os mecanismos envolvidos não foram totalmente elucidados ainda. Objetivo: Avaliar o papel do remodelamento do sistema nervoso cardíaco intrínseco (SNCI), incluindo fibras nervosas e receptores muscarínicos e β-adrenérgicos, na FA permanente humana. Métodos Foram avaliadas 4 amostras em átrios de 13 corações obtidos em necrópsias de pacientes com doença cardíaca e FA permanente, e em 13 controles com as mesmas doenças, porém, sem FA. Utilizando imunoperoxidase e histomorfometria, quantificamos a densidade das fibras do SNCI, bem como a porcentagem positiva de miocárdio para receptores β-adrenérgicos 1, 2 e 3, receptor quinase 5 acoplado à proteína G (GRK-5), e receptores muscarínicos 1 a 5. Os resultados foram comparados usando ANOVA e ANOVA hierarquizada e ajustados pelo volume do átrio esquerdo e, para avaliação da expressão de receptores β e GRK-5, pelo uso de β-bloqueadores. Adotamos como significativo α = 0,05. Resultados Houve aumento na densidade das fibras ( p <0,01), especialmente nas fibras simpáticas ( p =0,02). Quanto aos receptores muscarínicos, só houve diferença nos M1, que estavam aumentados (5,87±4,52 vs 2,85±2,40; p =0,03). Quanto aos componentes do sistema adrenérgicos analisados, houve expressão aumentada de β-3 (37,41 vs 34,18, p =0,04) e GRK-5 (51,16 vs 47,66; p<0,01). O uso de β-bloqueadores não teve impacto na expressão de receptores beta. Conclusão O aumento na inervação do SNCI e a alteração na expressão de receptores em regiões suscetíveis de desencadear FA podem ter um papel na fibrilação atrial permanente.

Abstract Background The primary factors that originate and perpetuate atrial fibrillation (AF) are electrical and anatomical substrate alterations. However, the central mechanisms governing AF perpetuation have not been elucidated yet, which is reflected on the modest results of the treatment in patients with long persistent AF. Objective To evaluate if human intrinsic cardiac autonomic nervous system (ICANS) remodeling, including nervous system fibers and muscarinic and β-adrenergic receptors, play a role in permanent AF. Methods Heart necropsy samples from thirteen patients with heart disease and permanent AF and thirteen controls without AF were used. By using immunoperoxidase and histomorphometry quantification, we identified the following: the density of all fibers of the ICANS, sympathetic and parasympathetic fibers; and the percentage of myocardium positive for β-adrenergic receptors 1, 2 and 3; G protein-coupled receptor kinase-5 (GRK-5); and muscarinic receptors M1 to M5. The results were compared using ANOVA and nested ANOVA and were adjusted according to the left atrium volume for all variables, and β-blocker use to evaluate the expression of β-receptors and GRK-5. Results There was an overall increase in the density of fibers of the ICANS (p=0.006), especially in atrial sympathetic nerve fibers (p=0.017). Only M1 muscarinic receptors were increased (5.87 vs 2.35, p=0.032). For adrenergic receptors, the results were positive for increased expression of β-3 (37.41 vs 34.18, p=0.039) and GRK-5 (51.16 vs 47.66; p<0.001). β-blocker use had no impact on β-receptor expression. Conclusion Increased ICANS innervation and remodeling receptor expression in regions prone to triggering AF may play a role in permanent AF.

ABSTRACT OBJECTIVE To assess the perceptions of pregnant women about COVID-19 and the prevalence of common mental disorders during the implemented social distancing period. METHODS This was an observational, cross-sectional study using digital media, of pregnant women exposed to social distancing due to the COVID-19 pandemic, in Fortaleza, Ceará, Northeastern Brazil. Common mental disorders were estimated using the modified Self-Report Questionnaire-20 (SRQ-20) scale, and the feelings towards COVID-19 were assessed using the Fear of COVID-19 scale through telephone calls made in May 2020. COX multivariate regression models were used to verify the associations. RESULTS Of the 1,041 pregnant women, 45.7% (95%CI: 42.7–48.8) had common mental disorders (CMD). All items of the Fear of COVID-19 Scale showed a significant association with the prevalence of CMD (p < 0.001). A CMD risk gradient was observed, going from a prevalence ratio of 1.52 (95%CI: 1.13–2.04) in pregnant women with two positive items to 2.70 (95%CI: 2.08–3.51) for those with four positive items. Early gestational age and the lack of prenatal care were also associated with CMD. CONCLUSIONS The prevalence of common mental disorders in pregnant women was high during the period of social distancing and was aggravated by negative feelings towards COVID-19.

ABSTRACT Purpose To develop and validate a chest cavity simulator for teaching video-assited thoracic surgery (VATS). Methods The first phase of the study consisted of developing a chest cavity simulator. A quasi-experimental study was performed in the second phase, and 25 surgeons and residents participated in a three-stage pulmonary suture experiment. The videos were recorded and timed. Generalized linear regression models for repeated measures were used to analyze the outcome change over time. Results The chest cavity simulator consists of a console simulating the left hemithorax. Among the participants, 96% rated the design, visual aspect, positioning ergonomics, and triangulation of the portals as very good or excellent (face validity). There was a decrease in suturing time in step 1 from 435.7 ± 105 to 355.6 ± 76.8 seconds compared to step 3 (p = 0.001). The evaluation of the simulation effectiveness and performance (content validity) was rated as very good or excellent by 96% ofparticipants. The most experienced surgeon showed significant reduction in procedure time (p = 0.021) (construct validity). Conclusions The thoracic cavity simulator is realistic, showing content and construct validity, and can be used in VATS training. The simulation model allowed skill gain in the endoscopic suture.