ABSTRACT Background: The intensity of dengue virus (DV) replication and circulating non-structural protein 1 (NS1) levels may promote changes in the human immune response and favor severe forms of infection. We investigated the correlations between NS1 with CXCL-8, CXCL-10, IFN-γ, and IL-12p40 serum levels, and IFN-γ receptor α chain (CD119) expression, and CXCL10 production by peripheral blood mononuclear cells (PBMCs) stimulated with recombinant IFN-γ in DV-infected patients with different clinical forms. Methods: Dengue virus NS1, CXCL-8, CXCL-10, IFN-γ, and IL-12p40 serum levels were measured in 152 DV-infected patients with different clinical forms and 20 non-infected individuals (NI) using enzyme-linked immunosorbent assay (ELISA). In addition, we investigated the CXCL-10 production after in vitro IFN-γ stimulation of PBMCs from 48 DV-infected individuals (with different clinical forms of dengue fever) and 20 NI individuals using ELISA, and CD119 expression on CD14+ cells with flow cytometry. Results: Patients with dengue hemorrhagic fever (DHF) had significantly higher NS1, CXCL-8, and CXCL-10 serum levels than those with classic dengue fever (DF). The response of PBMCs to IFN-γ stimulation was lower in patients with DHF than in those with DF or dengue with complications (DWC), with lower CD119 expression and reduced CXCL-10 synthesis. In addition, these alterations are associated with high NS1 serum levels. Conclusions: Patients with DHF reported high NS1 levels, low CD119 expression, and low CXCL-10 synthesis in PBMCs, which may be associated with infection progression and severity. Background DV (DV nonstructural non structural NS (NS1 CXCL8, CXCL8 CXCL 8, 8 CXCL-8 CXCL10, 10, 10 IFNγ, IFNγ IFN γ, γ IL12p40 ILp IL 12p40 p IL-12p4 CD (CD119 CXCL1 (PBMCs DVinfected infected Methods 15 2 noninfected (NI enzymelinked enzyme linked ELISA. ELISA . (ELISA) addition CXCL-1 4 CD11 CD14 cytometry Results (DHF DF. (DF) DWC, DWC , (DWC) Conclusions severity (NS CXCL- IL12p4 12p4 IL-12p (CD11 (ELISA CD1 (DF (DWC IL12p 12p (CD1 (CD

ABSTRACT Background: Snakebite is a neglected global health problem with high morbidity. We describe compartment syndrome (CS) cases related to snakebites by Bothrops spp. Methods: The medical records of patients admitted with snakebites envenomation were reviewed. Results: Of 47 patients with Bothrops spp. envenomation (4 male; mean age: 42 years), 7 (15%) developed CS. The mean time to antivenom administration was 9.5 hours. The time to fasciotomy was variable. Seven patients developed infection and four had acute kidney injury. Conclusions: The incidence of CS is higher than that reported previously. This may be due to the clinical severity and long delay before administering antivenom. Background morbidity (CS spp Methods reviewed Results 4 ( male age years, years , years) 15% 15 (15% 95 9 5 9. hours variable injury Conclusions previously 1 (15 (1

ABSTRACT Clinical similarities among viral diseases become even more relevant considering the current scenario, especially in Brazil, where there is a high incidence of these diseases and overlapping seasonality. We report the case of a patient with acute clinical manifestations composed of predominant respiratory symptoms and alveolar hemorrhage in which three etiologies (dengue, influenza and COVID-19) were investigated concomitantly. Only the diagnosis of dengue was confirmed. Then, the patient’s immunological profile in response to stimulation of mononuclear cells with dengue virus antigen was analyzed in an attempt to identify specific characteristics that could be associated with the clinical manifestation.

Resumo Este ensaio teórico tem por objetivo propor reflexões acerca da morte e do morrer sob o prisma de possíveis antagonismos, do adoecimento e das ocupações humanas envolvidas nesse processo. Os antagonismos são colocados em pauta obedecendo ao sentido de oposição mútua entre vida e morte, nascimento e morte, bem como entre sua previsão e sua negação. O adoecimento é discutido sob o prisma dos modelos dinâmico e ontológico de Laplantine, abrindo-se reflexões sobre o significado do adoecimento para o doente, muitas vezes expropriado de seu processo de morrer. Também aborda como a morte é impelida, atualmente, para os bastidores da vida social. Por último, são abordadas as ocupações da morte pautadas nos “princípios da boa morte”, sob o olhar da terapia ocupacional, sendo discorridos os preparativos e os ritos fúnebres desenvolvidos pelo morrente, seu círculo social e pelos profissionais da saúde, religiosos, agentes fúnebres e funcionários de cemitérios. Depreendemos que a morte é um processo social.

Abstract This theoretical essay aims to propose reflections on death and dying through the prism of possible antagonisms, illness and human occupations involved in this process. The antagonisms are put up for discussion obeying the sense of mutual opposition between life and death, birth and death, as well as between their prediction and their negation. Illness is discussed from the perspective of Laplantine's dynamic and ontological models, opening up reflections on the meaning of illness for the patient, who is often expropriated from their dying process. It also addresses how death is currently pushed behind the scenes of social life. Finally, the occupations of death based on the “principles of good death” are approached from the perspective of occupational therapy, discussing funeral preparations and rites developed by the deceased, their social circle and by health professionals, religious people, funeral agents and cemetery workers. We understand that death is a social process.

Resumo: Introdução: Programas de mentoria têm se mostrado estratégias para o aprimoramento da formação dos futuros médicos, com alcance em aspectos pouco contemplados nos currículos formais. Este relato discute a experiência docente do exercício da mentoria para uma turma de graduação em Medicina, durante o período de seis anos (de 2014 a 2020). Relato de experiência: As ações da mentoria foram planejadas semestralmente, em reuniões entre mentor e mentorados. As temáticas elegíveis foram escolhidas por meio de tempestade de ideias para convergir nas principais demandas coletivas. Abordaram-se os seguintes assuntos: visão do paciente ante a interação com estudantes das profissões da saúde, futuro dos médicos recém-formados, matriz de competências essenciais para a formação do médico, entre outros. Utilizaram-se mais frequentemente as seguintes ferramentas: rodas de conversa, atividades baseadas em metodologias ativas em pequenos e grandes grupos, encontros informais com a turma, encontros individuais, e espaços formais e informais de tecnologia da informação. As ações foram realizadas, ao longo dos seis anos, pelo mesmo docente, o que permitiu a construção e consolidação do vínculo entre mentor e mentorados. Discussão: Assim, a mentoria se configurou como uma potente estratégia, conduzida com flexibilidade para permear as necessidades dos educandos, direcionando-as para o desenvolvimento individual e coletivo de profissionalismo. Entre os ganhos paralelos, destaca-se o estímulo ao desenvolvimento docente, condição que exigiu receptividade à interação e reconhecimento dos saberes dos aprendizes. Conclusão: Por meio desta experiência, foi possível compreender que a essência da mentoria está relacionada ao vínculo e ao preparo de seres humanos para lidar com seres humanos, independentemente do papel social que estejam ocupando.

Abstract: Introduction: Mentoring programs have been strategies for improving the training of future doctors, covering aspects rarely contemplated in formal curriculum. This report discusses the teaching experience of mentoring for an undergraduate medicine class over the course of a six-year period (2014 to 2020). Experience report: The mentoring actions were planned every six months in a meeting between mentor and mentees. The eligible themes were chosen through brainstorming to converge on the main collective demands. The topics included, for example: The patient’s view of interaction with health students; The future of recently graduated doctors; Core skills of a doctor. The most frequently used tools were: Circle learning; Activities based on methodologies in small and large groups; Informal meetings with the whole class; Individual meetings; Formal and informal digital spaces. The actions were developed, over the six years, by the same teacher, which helped construct and consolidate the bond between mentor and mentees. Discussion: Mentoring was configured as a powerful strategy, conducted with flexibility to permeate the needs of students, directing them towards the individual and collective development of professionalism. Among the secondary gains, the stimulation of teacher development stands out, a condition that required receptivity to interaction and recognition of the learners’ experience. Conclusion: This experience demonstrated that the essence of mentoring is related to the connection and the preparation of humans to deal with humans, regardless of the social role they are playing.

Abstract INTRODUCTION: Patients with acute respiratory failure due to influenza require ventilatory support. However, mechanical ventilation itself can exacerbate lung damage and increase mortality. METHODS: The aim of this study was to describe a feasible and protective ventilation protocol, with limitation of the tidal volume to ≤6 mL/kg of the predicted weight and a driving pressure ≤15 cmH2O after application of the alveolar recruitment maneuver and PEEP titration. RESULTS: Initial improvement in oxygenation and respiratory mechanics were observed in the four cases submitted to the proposed protocol. CONCLUSIONS: Our results indicate that the mechanical ventilation strategy applied could be optimized.

RESUMO A formação de médicos especialistas no Brasil vem sofrendo uma série de interferências ao longo do tempo, entre as quais a recomendação de pautar a oferta/ampliação de vagas de residência médica em necessidades regionais. Para direcionar a ampliação de vagas de residência de determinada região, foi realizado um diagnóstico da realidade local de atendimento especializado. Para isso, neste estudo, avaliou-se ao longo de cinco anos: a demanda de consultas por médicos especialistas na rede municipal de saúde, a quantidade de vagas de residência ofertadas nas universidades do município e sua ocupação conforme especialidade, e o número de médicos especialistas atuantes no setor público e privado. Constatou-se que existe grande demanda por consultas de médicos especialistas sem acolhimento pela rede pública de saúde. As especialidades com maior número de encaminhamentos não atendidos foram Oftalmologia, Neurologia, Endocrinologia, Cardiologia, Cirurgia Vascular e Gastroenterologia. Em paralelo, a oferta de vagas de residência foi relevante para o número de egressos locais. No entanto, constatou-se manutenção de vagas ociosas em todos os anos avaliados, especialmente para residência de Medicina de Família e Comunidade. Por fim, o número de médicos especialistas atuantes no setor privado foi muito superior ao dos atuantes no setor público, inclusive para as especialidades com maior carência de atendimento na rede pública. Mesmo com a mobilidade que caracteriza a formação médica complementar por meio da residência, as necessidades locais poderiam influenciar a fixação dos médicos especialistas. Cabe uma discussão sobre os parâmetros norteadores da oferta/ampliação de vagas de residência médica, ao se considerar inclusive que o reduzido número de especialistas em Medicina da Família e Comunidade atuante na rede pode interferir no aumento de encaminhamento a outras especialidades. Assim, a identificação das demandas em saúde é insuficiente para nortear a oferta de vagas de residência, em especial ao se considerar a formação do médico especialista frente ao mercado de trabalho.

ABSTRACT The training of medical specialists in Brazil has suffered a series of interferences over time, including the recommendation that the offer/expansion of medical residency be based on regional needs. With a view to directing the expansion of residency vacancies in a given region, a diagnosis of the local reality of specialized care was proposed. To that end, this study was evaluated over five years: the demand for consultations by specialists in the municipal health network, the number of vacancies offered in the universities of the municipality and their occupation according to specialty, and the number of practicing medical specialists in the public and private sector. It was verified that there is a great demand for specialist consultations not met by the public health network. Ophthalmology, Neurology and Endocrinology were the specialties with the highest number of unattended referrals. In parallel, the offer of residency places was relevant to the number of local graduates; however, it was observed that vacancies remained idle in all evaluated years, especially for Family and Community Medicine residency. Finally, the number of specialist physicians working in the private sector was much higher than the number of those working in the public sector, including those with the greatest deficiency in public health care. Even with the mobility that characterizes the complementary medical training through residency, local necessities could influence the placement of the specialist physician. The discussion about the parameters of the offer/expansion of medical residency vacancies is considered, bearing in mind that the reduced number of specialists in Family and Community Medicine working in the network can interfere in the increased referrals to other specialties. Thus, the identification of health demands is insufficient to guide the expansion of residency vacancies, especially considering the training of the specialist physician in relation to the labor market.

RESUMO O componente teórico-prático do internato do curso de Medicina pode ser abordado por meio de estratégias de ensino em ambiente virtual. Neste aspecto, a flexibilidade de tempo e espaço para o estabelecimento do processo de ensino-aprendizagem apresenta-se vantajosa no período em que há predomínio absoluto de atividades práticas. O ambiente virtual pode-se firmar como espaço para convergência de experiências e discussões com estudantes em diferentes cenários de prática. O objetivo deste estudo foi avaliar a percepção de aprendizagem de internos sobre duas atividades em ambiente Moodle. A primeira intervenção consistiu em discussão de casos clínicos de pacientes com doenças infecciosas e parasitárias provenientes de atenção primária e secundária, previamente atendidos por outros colegas do internato. A segunda intervenção referia-se ao preenchimento do portfólio reflexivo, com devolutiva docente, das atividades realizadas pelos internos durante o estágio de Saúde Coletiva. Para ambas as intervenções, foram avaliadas sistematicamente a expectativa prévia, a satisfação posterior e a autopercepção de ganho de conhecimento/habilidades atribuída às atividades. Como resultado, foram avaliadas respostas de 36 estudantes na primeira intervenção e de 30 estudantes na segunda, o que representou mais de 97% dos estudantes convidados. A maioria considerou o ambiente Moodle adequado e referiu ganho de conhecimento/habilidades em ambas as intervenções. Os principais ganhos apontados foram melhoria nas competências para elaboração do raciocínio clínico e para a reflexão sobre a prática clínica na atenção primária. Ao longo das discussões de casos clínicos, houve aumento significativo do envolvimento dos estudantes depois que foi atribuída nota à participação qualificada destes. No caso do portfólio reflexivo, o feedback docente foi considerado um fator motivador importante para os estudantes. No entanto, nesta atividade, 51% das postagens não receberam devolutiva do docente responsável. Conclui-se que o ambiente Moodle é uma ferramenta útil para o aprendizado dos estudantes durante o internato, faltando ainda cuidar do desenvolvimento docente dos tutores que conduzirão este processo.

ABSTRACT The theoretical and practical experience of medical school can be approached using virtual environment learning strategies. In this respect, flexible time and space would appear advantageous for the establishment of the teaching-learning process in the period where there is a predominance of practical activities. The virtual environment can represent a space for sharing experiences and discussions with students in different practical scenarios. This case study aims at evaluating how medical interns perceived learning in two different scenarios using the Moodle virtual environment. The first intervention consisted of discussing clinical cases of patients with infectious and parasitic diseases who had been treated or assessed in primary or secondary health care by other interns. The second intervention involved completing the reflective portfolio, with teacher feedback regarding the activities performed by the interns during their public health internship. In both cases prior expectations, subsequent satisfaction and self-perceived learning were systematically analyzed. As a result, the responses of 36 students were evaluated in the first intervention, and of 30 students in the second, accounting for more than 97% of the students invited. Most of them considered the Moodle environment suitable and reported knowledge/skill gain in both interventions. The main gains pointed to were improved skills for clinical reasoning and reflection on clinical practice in primary care. In the discussion of clinical cases, student involvement increased significantly once they were awarded marks for qualified participation in the activity. In the reflective portfolio, teacher feedback was considered an important motivating factor for the students. However, 51% of their posts received no teacher feedback. In conclusion, the virtual environment was considered useful for student learning during internship, but there remains a need to develop the tutors’ role in this process.

ABSTRACT Dengue is an arboviral infection clinically recognized as an acute and self-limited disease. Persistence of dengue symptoms is known, but it has been little studied. The aim of this study was to characterize persistent symptoms in 113 patients with dengue followed up clinically and by laboratory testing at a tertiary hospital. Symptoms that persisted for more than 14 days were observed in 61 (54.0%) patients, and six (6.2%) of them had symptoms for 6 months or more. The persistent symptoms identified were myalgia, weakness, hair loss, memory loss, reduced resistance to physical effort, headache, reasoning problems, arthralgia, sleepiness- and emotional lability. The progression to persistent symptoms was significantly associated with hospitalization, older age, more severe disease, the presence of bleeding and comorbidities upon univariate analysis. Upon multivariate analysis, the presence of persistent symptoms continued to be significantly associated only with increased age and dengue with warning signs. The platelet count during the acute phase of the disease was significantly lower in the group with persistent symptoms. In conclusion, the frequency of progression to persistent symptoms in dengue is relevant in patients seen at a tertiary hospital and the persistence of symptoms is more common in patients with dengue with warning signs.

A formação do aluno no curso de Medicina precisa se aproximar dos campos de prática vivenciados pelo médico atualmente. Este estudo objetivou caracterizar as experiências educacionais dos internos dentro de atividades em Atenção Primária, Secundária e Terciária à saúde, com vistas a otimizá-las. Inicialmente, foi descrita a criação de um estágio em atendimento secundário, antes inexistente na instituição, e avaliada a percepção dos alunos envolvidos. Posteriormente, foram caracterizados os atendimentos prestados pelos alunos em três cenários (primário, secundário e terciário) durante 30 dias. A criação do estágio na Unidade de Pronto Atendimento foi bem recebida pelos alunos, que sentiram necessidade de investir mais carga horária neste cenário. Foram avaliadas 201 consultas realizadas por internos, sendo a maioria na Atenção Primária. Houve grande diversificação dos motivos das consultas conforme o cenário de prática, e a preceptoria do interno ocorreu em todos os atendimentos. Concluímos que os diferentes cenários realmente oferecem oportunidades de aprendizado complementares que devem ser valorizadas institucionalmente.

There is a need for undergraduate medical training to bring students closer to the real clinical settings they will face early in their professional lives. This study aims to review and improve student interns’ experience in different clinical scenarios: primary health care; secondary outpatient clinic (a new rotation) and the emergency room of a tertiary hospital. This new rotation is an opportunity for students to see acutely ill patients before they are referred to the hospital. Following a 30-day period, the students’ perceptions were surveyed and, based on student records, a list of all the patients (and diagnoses) which they saw was composed. The final result was a list of clinical conditions from these three different scenarios. Students acknowledge that the new rotation added to their clinical learning, especially because it was based on non-referred patients. They also felt that 4 hours/week is not enough and asked for more time in this rotation. During their 30 days, 7 students performed 201 consultations, most of them in the primary health care setting. There was a wide variety of clinical cases, which was possible because the students rotate among those three settings. Some experiences were only possible due to the new outpatient clinic rotation, indicating how this approach offer complementary learning opportunities which should be institutionally valued.

INTRODUÇÃO: No município de Porteirinha, Estado de Minas Gerais, foram registrados 23 casos humanos de leishmaniose visceral (LV) nos anos de 1998 e 1999. MÉTODOS: Foi realizado um estudo envolvendo a tríade de ações preconizadas no controle da LV. Pacientes com leishmaniose humana foram tratados e cães sorologicamente positivos foram eutanasiados, trimestralmente. O inseticida piretróide α-cipermetrina foi aplicado nos bairros onde casos humanos foram registrados. RESULTADOS: Houve uma redução da soroprevalência canina e de flebotomíneos capturados, após a implementação das medidas de controle, refletindo na diminuição de casos humanos de leishmaniose visceral. CONCLUSÕES: Os resultados mostraram a eficiência destas medidas quando empregadas em conjunto.

INTRODUCTION: In the town of Porteirinha, State of Minas Gerais, 23 human cases of visceral leishmaniasis (VL) in 1998 and 1999 were recorded. METHODS: A study was conducted involving the triad of action recommended for the control of VL. Patients were treated and serologically positive dogs were euthanized quarterly. The pyrethroid insecticide α-cypermethrin was applied in the neighborhoods where human cases were recorded. RESULTS: A reduction in canine seroprevalence and sand flies occurred following the implementation of control measures, reflecting in a reduction in human cases of VL. CONCLUSIONS: The results show the efficiency of such control measures when used in association.

O quadro clínico clássico de dengue caracteriza-se por duração máxima de 14 dias, embora freqüentemente pacientes refiram prolongamento dos sintomas. Este estudo avaliou a ocorrência de sinais e sintomas persistentes (> 14 dias) e seu impacto no cotidiano do indivíduo doente. Foram entrevistados 118 pacientes, cujos principais sintomas ao diagnóstico foram mialgia (98,3%), febre (97,5%) e fraqueza (95,8%). A presença de pelo menos um sintoma persistente foi referida por 77 (65,2%) entrevistados, sendo que 10 (8,5%) relataram sua permanência de maneira intensa e por 30 dias ou mais. Os sintomas persistentes mais mencionados foram fraqueza (58 casos), hiporexia (49) e sonolência (40), ocorrendo mais no gênero feminino, com odds ratio: 5,4 (IC95%: 2,3-12,3). Houve associação significativa entre a persistência dos sintomas e o relato de gastos adicionais (p = 0,02), e com o retorno às atividades habituais (p < 0,001). Assim, foi verificado que o dengue apresentou impacto na vida dos indivíduos, mesmo depois de 14 dias, sendo tal fato associado à presença de sintomas persistentes da doença.

The clinical picture of dengue is characterized by a maximum duration of 14 days despite frequent complaints of longer symptoms. This study evaluated the occurrence of persistent symptoms (> 14 days) and its impact on daily life. A hundred eighteen patients were interviewed, and the main symptoms at diagnosis were mialgia (98.3%), fever (97.5%) and weakness (95.8%). The presence of at least a persistent symptom was related by 77 (65.2%) individuals of wich 10 (8.5%) described it as intense and lasting for 30 days or more. The most persistent symptoms mentioned were weakness (58 cases), hiporexia (49) and sleepiness (40), occurring mostly in women, with odds ratio: 5.4 (IC95%: 2.3-12.3). A significant association between the persistence of the symptoms and the history of extra expenses (p = 0,02) was found, as well as a delay to return to normal activities (p < 0.001). Thus, it was verified that dengue presented a relevant impact on every day life, even after 14 days, a fact wich was associated with the presence of persistent symptoms of the illness.

O quadro clínico clássico de dengue caracteriza-se por duração máxima de 14 dias, embora freqüentemente pacientes refiram prolongamento dos sintomas. Este estudo avaliou a ocorrência de sinais e sintomas persistentes (> 14 dias) e seu impacto no cotidiano do indivíduo doente. Foram entrevistados 118 pacientes, cujos principais sintomas ao diagnóstico foram mialgia (98,3%), febre (97,5%) e fraqueza (95,8%). A presença de pelo menos um sintoma persistente foi referida por 77 (65,2%) entrevistados, sendo que 10 (8,5%) relataram sua permanência de maneira intensa e por 30 dias ou mais. Os sintomas persistentes mais mencionados foram fraqueza (58 casos), hiporexia (49) e sonolência (40), ocorrendo mais no gênero feminino, com odds ratio: 5,4 (IC95%: 2,3-12,3). Houve associação significativa entre a persistência dos sintomas e o relato de gastos adicionais (p = 0,02), e com o retorno às atividades habituais (p < 0,001). Assim, foi verificado que o dengue apresentou impacto na vida dos indivíduos, mesmo depois de 14 dias, sendo tal fato associado à presença de sintomas persistentes da doença.

The clinical picture of dengue is characterized by a maximum duration of 14 days despite frequent complaints of longer symptoms. This study evaluated the occurrence of persistent symptoms (> 14 days) and its impact on daily life. A hundred eighteen patients were interviewed, and the main symptoms at diagnosis were mialgia (98.3%), fever (97.5%) and weakness (95.8%). The presence of at least a persistent symptom was related by 77 (65.2%) individuals of wich 10 (8.5%) described it as intense and lasting for 30 days or more. The most persistent symptoms mentioned were weakness (58 cases), hiporexia (49) and sleepiness (40), occurring mostly in women, with odds ratio: 5.4 (IC95%: 2.3-12.3). A significant association between the persistence of the symptoms and the history of extra expenses (p = 0,02) was found, as well as a delay to return to normal activities (p < 0.001). Thus, it was verified that dengue presented a relevant impact on every day life, even after 14 days, a fact wich was associated with the presence of persistent symptoms of the illness.