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ABSTRACT The SPIRIT 2013 statement aims to improve the completeness of clinical trial protocol reporting by providing evidence-based recommendations for the minimum set of items to be addressed. This guidance has been instrumental in promoting transparent evaluation of new interventions. More recently, there has been a growing recognition that interventions involving artificial intelligence (AI) need to undergo rigorous, prospective evaluation to demonstrate their impact on health outcomes. The SPIRIT-AI (Standard Protocol Items: Recommendations for Interventional Trials–Artificial Intelligence) extension is a new reporting guideline for clinical trial protocols evaluating interventions with an AI component. It was developed in parallel with its companion statement for trial reports: CONSORT-AI (Consolidated Standards of Reporting Trials–Artificial Intelligence). Both guidelines were developed through a staged consensus process involving literature review and expert consultation to generate 26 candidate items, which were consulted upon by an international multi-stakeholder group in a two-stage Delphi survey (103 stakeholders), agreed upon in a consensus meeting (31 stakeholders) and refined through a checklist pilot (34 participants). The SPIRIT-AI extension includes 15 new items that were considered sufficiently important for clinical trial protocols of AI interventions. These new items should be routinely reported in addition to the core SPIRIT 2013 items. SPIRIT-AI recommends that investigators provide clear descriptions of the AI intervention, including instructions and skills required for use, the setting in which the AI intervention will be integrated, considerations for the handling of input and output data, the human–AI interaction and analysis of error cases. SPIRIT-AI will help promote transparency and completeness for clinical trial protocols for AI interventions. Its use will assist editors and peer reviewers, as well as the general readership, to understand, interpret and critically appraise the design and risk of bias for a planned clinical trial.

RESUMO A declaração SPIRIT 2013 tem como objetivo melhorar a integralidade dos relatórios dos protocolos de ensaios clínicos, fornecendo recomendações baseadas em evidências para o conjunto mínimo de itens que devem ser abordados. Essas orientações têm sido fundamentais para promover uma avaliação transparente de novas intervenções. Recentemente, tem-se reconhecido cada vez mais que intervenções que incluem inteligência artificial (IA) precisam ser submetidas a uma avaliação rigorosa e prospectiva para demonstrar seus impactos sobre os resultados de saúde. A extensão SPIRIT-AI (Standard Protocol Items: Recommendations for Interventional Trials - Artificial Intelligence) é uma nova diretriz de relatório para protocolos de ensaios clínicos que avaliam intervenções com um componente de IA. Essa diretriz foi desenvolvida em paralelo à sua declaração complementar para relatórios de ensaios clínicos, CONSORT-AI (Consolidated Standards of Reporting Trials - Artificial Intelligence). Ambas as diretrizes foram desenvolvidas por meio de um processo de consenso em etapas que incluiu revisão da literatura e consultas a especialistas para gerar 26 itens candidatos. Foram feitas consultas sobre esses itens a um grupo internacional composto por 103 interessados diretos, que participaram de uma pesquisa Delphi em duas etapas. Chegou-se a um acordo sobre os itens em uma reunião de consenso que incluiu 31 interessados diretos, e os itens foram refinados por meio de uma lista de verificação piloto que envolveu 34 participantes. A extensão SPIRIT-AI inclui 15 itens novos que foram considerados suficientemente importantes para os protocolos de ensaios clínicos com intervenções que utilizam IA. Esses itens novos devem constar dos relatórios de rotina, juntamente com os itens básicos da SPIRIT 2013. A SPIRIT-AI preconiza que os pesquisadores descrevam claramente a intervenção de IA, incluindo instruções e as habilidades necessárias para seu uso, o contexto no qual a intervenção de IA será integrada, considerações sobre o manuseio dos dados de entrada e saída, a interação humano-IA e a análise de casos de erro. A SPIRIT-AI ajudará a promover a transparência e a integralidade nos protocolos de ensaios clínicos com intervenções que utilizam IA. Seu uso ajudará editores e revisores, bem como leitores em geral, a entender, interpretar e avaliar criticamente o delineamento e o risco de viés de um futuro estudo clínico.

https://doi.org/10.26633/rpsp.2024.12

Directrices para presentación de informes de ensayos clínicos sobre intervenciones con inteligencia artificial: extensión CONSORT-AI
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Liu, Xiaoxuan

; Cruz Rivera, Samantha

; Moher, David

; Calvert, Melanie J.

; Denniston, Alastair K.

; Chan, An-Wen

; Darzi, Ara

; Holmes, Christopher

; Yau, Christopher

; Moher, David

; Ashrafian, Hutan

; Deeks, Jonathan J.

; Ferrante di Ruffano, Lavinia

; Faes, Livia

; Calvert, Melanie J.

; Keane, Pearse A.

; Cruz Rivera, Samantha

; Vollmer, Sebastian J.

; Liu, Xiaoxuan

; Lee, Aaron Y.

; Jonas, Adrian

; Esteva, Andre

; Beam, Andrew L.

; Chan, An-Wen

; Panico, Maria Beatrice

; Lee, Cecilia S.

; Haug, Charlotte

; Kelly, Christophe J.

; Yau, Christopher

; Mulrow, Cynthia

; Espinoza, Cyrus

; Fletcher, John

; Moher, David

; Paltoo, Dina

; Manna, Elaine

; Price, Gary

; Collins, Gary S.

; Harvey, Hugh

; Matcham, James

; Monteiro, Joao

; Khair ElZarrad, M.

; Ferrante di Ruffano, Lavinia

; Oakden-Rayner, Luke

; Calvert, Melanie J.

; McCradden, Melissa

; Keane, Pearse A.

; Savage, Richard

; Golub, Robert

; Sarkar, Rupa

; Rowley, Samuel

Revista Panamericana de Salud Pública

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2024, Volume 48 elocation e13

Abstract: Es En Pt | Text: Es En Pt | PDF: Es | PDF: En | PDF: Pt

resumen está disponible en el texto completo

ABSTRACT The CONSORT 2010 statement provides minimum guidelines for reporting randomized trials. Its widespread use has been instrumental in ensuring transparency in the evaluation of new interventions. More recently, there has been a growing recognition that interventions involving artificial intelligence (AI) need to undergo rigorous, prospective evaluation to demonstrate impact on health outcomes. The CONSORT-AI (Consolidated Standards of Reporting Trials–Artificial Intelligence) extension is a new reporting guideline for clinical trials evaluating interventions with an AI component. It was developed in parallel with its companion statement for clinical trial protocols: SPIRIT-AI (Standard Protocol Items: Recommendations for Interventional Trials–Artificial Intelligence). Both guidelines were developed through a staged consensus process involving literature review and expert consultation to generate 29 candidate items, which were assessed by an international multi-stakeholder group in a two-stage Delphi survey (103 stakeholders), agreed upon in a two-day consensus meeting (31 stakeholders) and refined through a checklist pilot (34 participants). The CONSORT-AI extension includes 14 new items that were considered sufficiently important for AI interventions that they should be routinely reported in addition to the core CONSORT 2010 items. CONSORT-AI recommends that investigators provide clear descriptions of the AI intervention, including instructions and skills required for use, the setting in which the AI intervention is integrated, the handling of inputs and outputs of the AI intervention, the human–AI interaction and provision of an analysis of error cases. CONSORT-AI will help promote transparency and completeness in reporting clinical trials for AI interventions. It will assist editors and peer reviewers, as well as the general readership, to understand, interpret and critically appraise the quality of clinical trial design and risk of bias in the reported outcomes.

RESUMO A declaração CONSORT 2010 apresenta diretrizes mínimas para relatórios de ensaios clínicos randomizados. Seu uso generalizado tem sido fundamental para garantir a transparência na avaliação de novas intervenções. Recentemente, tem-se reconhecido cada vez mais que intervenções que incluem inteligência artificial (IA) precisam ser submetidas a uma avaliação rigorosa e prospectiva para demonstrar seus impactos sobre os resultados de saúde. A extensão CONSORT-AI (Consolidated Standards of Reporting Trials – Artificial Intelligence) é uma nova diretriz para relatórios de ensaios clínicos que avaliam intervenções com um componente de IA. Ela foi desenvolvida em paralelo à sua declaração complementar para protocolos de ensaios clínicos, a SPIRIT-AI (Standard Protocol Items: Recommendations for Interventional Trials – Artificial Intelligence). Ambas as diretrizes foram desenvolvidas por meio de um processo de consenso em etapas que incluiu revisão da literatura e consultas a especialistas para gerar 29 itens candidatos. Foram feitas consultas sobre esses itens a um grupo internacional composto por 103 interessados diretos, que participaram de uma pesquisa Delphi em duas etapas. Chegou-se a um acordo sobre os itens em uma reunião de consenso que incluiu 31 interessados diretos, e os itens foram refinados por meio de uma lista de verificação piloto que envolveu 34 participantes. A extensão CONSORT-AI inclui 14 itens novos que, devido à sua importância para as intervenções de IA, devem ser informados rotineiramente juntamente com os itens básicos da CONSORT 2010. A CONSORT-AI preconiza que os pesquisadores descrevam claramente a intervenção de IA, incluindo instruções e as habilidades necessárias para seu uso, o contexto no qual a intervenção de IA está inserida, considerações sobre o manuseio dos dados de entrada e saída da intervenção de IA, a interação humano-IA e uma análise dos casos de erro. A CONSORT-AI ajudará a promover a transparência e a integralidade nos relatórios de ensaios clínicos com intervenções que utilizam IA. Seu uso ajudará editores e revisores, bem como leitores em geral, a entender, interpretar e avaliar criticamente a qualidade do desenho do ensaio clínico e o risco de viés nos resultados relatados.

https://doi.org/10.26633/rpsp.2024.13

Ultrasonography of the stomach and small intestine in healthy Mangalarga Marchador horses from birth to 5 years of age
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Pessoa, G.O.

; Botelho, J.H.V.

; Lacreta Junior, A.C.C.

; Ferrante, M.

; Sousa, T.M.

; Peconick, A.P.

Arquivo Brasileiro de Medicina Veterinária e Zootecnia

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mar 2023, Volume 75 N. 2 Pages 191 - 198

Abstract: En Pt | Text: En Pt | PDF: En | PDF: Pt

ABSTRACT The aim of the study was to describe location, sonographic characteristics and measures of the stomach and small intestine of equines at different ages. Abdominal ultrasonography was performed on 88 healthy equines of either sex, aged 1, 7 and 15 days, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 months and 1, 3 and 5 years, with 20 animals per group. Location, characteristics and measurements of stomach, duodenum and jejunum were evaluated. Descriptive statistics were performed for each measurement and the percentile for each age was analyzed. The work showed the growth and characteristics of the organs evaluated over time. Adult animals showed a minimum of 4 duodenal movements per minute. It was possible to locate the organs evaluated in all animals. The detailed ultrasound examination of these organs allowed gathering information that could be used to assist in the care of future patients.

RESUMO O objetivo deste estudo foi descrever localização topográfica, características e medidas ultrassonográficas de estômago e intestino delgado de equinos em diferentes idades. Foi realizado um exame ultrassonográfico abdominal em 20 equinos saudáveis de ambos os sexos, com idades de um, sete e 15 dias, um, dois, três, quatro, cinco, seis, sete, oito, nove, 10 e 11 meses e um, três e cinco anos. A localização, as características e as medidas de estômago, duodeno e jejuno foram avaliadas. Foi realizada a estatística descritiva para cada medida e analisado o percentil para cada idade. O trabalho mostrou o crescimento e as características dos órgãos avaliados ao longo do tempo. Animais adultos apresentaram um mínimo de quatro movimentos por minuto de duodeno. Foi possível localizar os órgãos avaliados em todos os animais. O exame ultrassonográfico detalhado desses órgãos permitiu agrupar informações que poderão ser usadas para auxiliar no atendimento a futuros pacientes.

https://doi.org/10.1590/1678-4162-12814

Directrices para los protocolos de ensayos clínicos de intervenciones con inteligencia artificial: la extensión SPIRIT-AI
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Cruz Rivera, Samantha

; Liu, Xiaoxuan

; Chan, An-Wen

; Denniston, Alastair K.

; Calvert, Melanie J.

; Denniston, Alastair K.

; Chan, An-Wen

; Darzi, Ara

; Holmes, Christopher

; Yau, Christopher

; Moher, David

; Ashrafian, Hutan

; Deeks, Jonathan J.

; Ferrante di Ruffano, Lavinia

; Faes, Livia

; Calvert, Melanie J.

; Keane, Pearse A.

; Cruz Rivera, Samantha

; Vollmer, Sebastian J.

; Liu, Xiaoxuan

; Lee, Aaron Y.

; Jonas, Adrian

; Esteva, Andre

; Beam, Andrew L.

; Chan, An-Wen

; Panico, Maria Beatrice

; Lee, Cecilia S.

; Haug, Charlotte

; Kelly, Christophe J.

; Yau, Christopher

; Mulrow, Cynthia

; Espinoza, Cyrus

; Fletcher, John

; Moher, David

; Paltoo, Dina

; Manna, Elaine

; Price, Gary

; Collins, Gary S.

; Harvey, Hugh

; Matcham, James

; Monteiro, Joao

; Khair ElZarrad, M.

; Ferrante di Ruffano, Lavinia

; Oakden-Rayner, Luke

; Calvert, Melanie J.

; McCradden, Melissa

; Keane, Pearse A.

; Savage, Richard

; Golub, Robert

; Sarkar, Rupa

; Rowley, Samuel

Revista Panamericana de Salud Pública

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2023, Volume 47 elocation e149

Abstract: Es En Pt | Text: Es En Pt | PDF: Es | PDF: En | PDF: Pt

resumen está disponible en el texto completo

https://doi.org/10.26633/rpsp.2023.149

Nodular lymphocytic conjunctivitis in a horse - case report
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Carrara, C.B.

; Ferrante, M.

; Zapata, G.L.

Arquivo Brasileiro de Medicina Veterinária e Zootecnia

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2023, Volume 75 N. 1 Pages 113 - 116

Abstract: En Pt | Text: En Pt | PDF: En | PDF: Pt

ABSTRACT The case of an equine with nodular lymphocytic conjunctivitis is described. A 14-year-old crossbred mare was seen presenting with development of a mass in the nasal angle of the right eye, behind the third eyelid. The tutor reported slow growth over 4 years, always accompanied by epiphora, and that no treatment had been performed prior to consultation. The histopathological and immunohistochemical results found a nodular, subepithelial structure, composed predominantly of densely packed small lymphocytes. Through the exams, associated with studies with monoclonal anti B lymphocyte antibodies and polyclonal anti T lymphocyte antibodies, the diagnosis of nodular lymphocytic conjunctivitis was reached. Only clinical pharmacological treatment was chosen, based on the use of topical and intralesional hydrocortisone acetate. After one month of treatment the mass completely disappeared without sequelae.

RESUMO Descreve-se o caso de um equino com conjuntivite linfocítica nodular. Uma égua, mestiça, de 14 anos, foi atendida apresentando desenvolvimento de uma massa no ângulo nasal do olho direito, atrás da terceira pálpebra. O tutor relatou um crescimento lento durante 4 anos, sempre acompanhado de epífora, para o qual não foi realizado tratamento prévio à consulta. Os resultados histopatológico e imuno-histoquímico constataram uma estrutura nodular e subepitelial, composta predominantemente por linfócitos pequenos densamente agrupados. Por meio dos exames, associados a estudos com anticorpos monoclonais antilinfócitos B e anticorpos policlonais antilinfócitos T, chegou-se ao diagnóstico de conjuntivite linfocítica nodular. Optou-se apenas pelo tratamento clínico farmacológico, baseando-se na utilização de acetato de hidrocortisona tópica e intralesional. Após um mês de tratamento, a massa involuiu por completo, sem deixar sequelas.

https://doi.org/10.1590/1678-4162-12838

PK/PD integration for intramuscular dose determination of intramuscular sodium cloxacillin for infections caused by Staphylococcus spp in goat
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Felix, L.A.

; Gonzaga, L.W.F.

; Soares, B.C.F.

; Suárez, G.

; Brandão, H.M.

; Faccioli-Martins, P.Y.

; Ferrante, M.

Arquivo Brasileiro de Medicina Veterinária e Zootecnia

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2023, Volume 75 N. 6 Pages 1087 - 1096

Abstract: En Pt | Text: En Pt | PDF: En | PDF: Pt

ABSTRACT This study aims to determine therapeutic protocols of intramuscular sodium cloxacillin (IM) in goats with potential antibacterial effects against Staphylococcus spp. We constructed a pharmacokinetic (PK) model of IM, followed by a pharmacokinetic/pharmacodynamic integration (PK/PD). Simulations of different therapeutic protocols were then performed, with the doses ranging from 30 to100 mg/kg every 8, 12, or 24 hours. We calculated the probability to target attainment (PTA) of reach protocol's therapeutic according to the minimum inhibitory concentration (MIC) range of 0.06 to 4 μg/mL. The PK/PD index (PDT) used was "time above the MIC for 40% of the time" (T>MIC ≥40%). Protocols with single administration per day were incapable of achieving PTA ≥ 90% for any of the estimated MICs. However, by decreasing the administration interval, the PTA was increased. Thus, from the dose of 50 mg/kg every 12 hours, a PTA≥ 90% for MICs ≤ 0.5 μg/mL was achieved, while the 30 mg/kg dose every 8 hours was able to achieve a PTA≥ 90% for MICs of 2 μg/mL. The results suggest using 30 mg/kg dose every 8 hours in clinical studies of agents with MICs ≤ 2μg/mL; Nevertheless, the practitioner should adjust the dose in severe patients.

RESUMO Objetivou-se determinar protocolos terapêuticos sistêmicos de cloxacilina sódica, via intramuscular, em caprinos, com potencial efeito antibacteriano contra Staphylococcus spp. Construiu-se um modelo farmacocinético (PK) de cloxacilina sódica em caprino; a partir deste, realizou-se a integração farmacocinéticas/farmacodinâmicas (PK/PD) e simulações de diferentes protocolos terapêuticos, variando de 30-100 mg/kg com administração a cada oito, 12 ou 24 horas. Foram calculadas as probabilidades de atingir o alvo (PTA) para cada protocolo, segundo uma distribuição de concentração inibitória mínima (CIM) de 0,06 a 4 μg/mL. O alvo PK/PD (PDT) utilizado foi de T>CIM ≥ 40%. Protocolos com uma administração por dia não foram capazes de atingir a PTA ≥ 90% para nenhuma das CIMs. A diminuição do intervalo aumentou os PTAs, assim, a partir da dose de 50 mg/kg a cada 12 horas, foi possível atingir PTA≥ 90% para CIMs ≤ 0,5 μg/mL, enquanto uma dose de 30 mg/kg a cada oito horas foi capaz de atingir PTA≥ 90% para uma CIM de 2 μg/mL. Os resultados sugerem que a dose de 30 mg/kg a cada oito horas pode ser utilizada em estudos clínicos de agentes com CIMs ≤ 2 μg/mL, porém é preciso ser avaliado como os parâmetros farmacocinéticos serão alterados em pacientes críticos.

https://doi.org/10.1590/1678-4162-12944

Safety and effectiveness of COVID-19 SPUTNIK V vaccine in dialysis patients
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Rosa-Diez, Guillermo

; Papaginovic Leiva, María Marina

; Lombi, Fernando

; Crucelegui, María Soledad

; Martínez, Ricardo D.

; Trimarchi, Hernán

; Schiavelli, Rubén

; Grizzo, Mercedes

; Raño, Miguel

; Heguilén, Ricardo M.

; Jones, Rocío A.

; González Paganti, Luciana

; Ferrrari, Matías

; Kjohede, Victoria

; Zingoni, Paula

; Geffner, Jorge R.

; Ferrante, Daniel

; González Bernaldo de Quirós, Fernán

; Pagotto, Vanina

Medicina (Buenos Aires)

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oct 2022, Volume 82 N. 5 Pages 631 - 640

Abstract: Es En | Text: Es En | PDF: Es | PDF: En

Resumen Introducción: Dada la vulnerabilidad al SARS-CoV-2 de las personas con enfermedad renal crónica, las sociedades de nefrología han emitido declaraciones pidiendo priorizar a estos pacientes para la vacunación. Aún no se sabe si las vacunas COVID-19 confieren el mismo nivel de protección en pacientes con enfermedad renal. Los objetivos de este estudio fueron evaluar la seguridad, medida por eventos supuestamente atribuidos a las vacunas (ESAVI) y la efectividad, evaluada por la presencia de anticuerpos en pacientes en diálisis inmuniza dos con la vacuna COVID-19 Sputnik V. Métodos: estudio multicéntrico, observacional y analítico de una cohorte prospectiva de pacientes en hemodiálisis, en la Ciudad Autónoma de Buenos Aires, con plan de vacunación. Se incluyeron pacientes mayores de 18 años en diálisis que recibieron ambos componentes de la vacuna COVID-19. Resultados: 491 pacientes fueron incluidos en el análisis de seguridad. Se detectó ESAVI con el primer o el segundo componente en 186 (37.9% IC 95%: 33.6%-42.3%). La efectividad medida por presencia de anticuerpos IgG contra SARS-Cov-2 se realizó en 102 pacientes, 98% presentaba IgG contra SARS-CoV-2, 21 días después del segundo componente. En pacientes con COVID-19 previo a la vacunación, los anticuerpos al día 21 del primer componente alcanzaron niveles casi mayores que en aquellos que no habían sufrido COVID-19, aunque el aumento de los niveles a los 21 días del segundo componente fue menor que en los pacientes sin COVID-19 previo. Conclusión: Los pacientes en diálisis constituyen una población vulnerable para la infección por SARS-CoV-2, por lo tanto, más allá de las recomendaciones implementadas por las unidades de diálisis, la vacunación completa es mandatoria. Se ha demostrado que la vacuna Sputnik V es segura y eficaz en esta población de pacientes.

Abstract Introduction: Given the vulnerability of chronic kidney disease individuals to SARS-CoV-2, nephrology societies have issued statements calling for prioritization of these patients for vaccination. It is not yet known whether COVID-19 vaccines grant the same high level of protection in patients with kidney disease compared to the non-dialysis population. The aims of this study were to evaluate the safety - measured by the adverse events potentially attributed to vaccines (ESAVI) - and the effectiveness - evaluated by the presence of antibodies - in dialysis patients immunized with the COVID-19 Sputnik V vaccine. Methods: multicenter, ob servational and analytical study of a prospective cohort of hemodialysis patients from the Ciudad Autónoma de Buenos Aires participating in an official vaccination program. Dialysis requiring individuals older than 18 years, who received both components of the COVID-19 vaccine were included. Results: Data from 491 patients were included in the safety analysis. ESAVI with either the first or second component was detected in 186 (37.9%, 95% CI 33.6%-42.3%). Effectiveness analysis measuring antibodies levels against SARS-CoV-2 were performed in 102 patients; 98% presented these IgG antibodies at day 21 after the second component. In patients with COVID-19 prior to vaccination, antibodies at day 21 after the first component reached almost the highest levels compared to patients without previous COVID-19, but IgG rise among patients with previous COVID-19 was lower than in those without this previous disease. Conclusion: The Sputnik V vaccine has been shown to be safe and effective in this patient’s population.

Evidence of mutagenic and lethal effects of herbicides on Amazonian frogs
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FERRANTE, Lucas

; FEARNSIDE, Philip M.

Acta Amazonica

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dec 2020, Volume 50 N. 4 Pages 363 - 366

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO Os anfíbios são ótimos bioindicadores porque são sensíveis à poluição química, indicando alterações ecossistêmicas pela presença de ou pela exposição a compostos químicos. Aqui nós relatamos evidências do impacto de herbicidas, incluindo glifosato, em anfíbios em uma localidade na Amazônia central brasileira e as comparamos com dados de outros biomas no Brasil. Nós observamos malformações em três espécies de Leptodactylus e extinção local de Scinax ruber e Rhinella marina em sítios reprodutivos próximos a uma área onde herbicidas haviam sido aplicados. Os resultados observados na Amazônia são semelhantes aos observados na Mata Atlântica do Brasil, com alterações morfológicas e mortalidade em anfíbios expostos a herbicidas. Alertamos para a ameaça de expansão de culturas para a produção de biocombustíveis na Amazônia, devido ao fato de o cultivo estar associado a agroquímicos, incluindo o glifosato, representando uma ameaça à biodiversidade do bioma Amazônia.

ABSTRACT Amphibians are excellent bioindicators because they are sensitive to chemical pollution and can indicate ecosystem changes due to the presence of or exposure to chemical compounds. Here we report evidence of the impact of herbicides, including glyphosate, on amphibians in a locality in the central Brazilian Amazon and compare it with data from other biomes in Brazil. We observed malformations in three species of Leptodactylus and local extinctions of Scinax ruber and Rhinella marina from reproductive sites close to an area where herbicides had been applied. The observations in the Amazon are similar to reports from Brazil’s Atlantic forest on morphological anomalies and mortality in amphibians exposed to herbicides. We warn of the threat of expanding crops for the production of biofuels in the Amazon due to their cultivation being associated with agrochemicals, including glyphosate, posing a threat to the biodiversity of the Amazon biome.

https://doi.org/10.1590/1809-4392202000562 1334 downloads

Antimicrobial resistance evaluation of bacteria isolated from infections in small animals in the Umuarama region, Paraná
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Souza, Marilia M.

; Bordin, Jéssica T.

; Pavan, Ana Cláudia L.

; Rodrigues, Raquel G.A.

; Sfaciotte, Ricardo A.P.

; Vignoto, Vanessa K.C.

; Ferrante, Marcos

; Wosiacki, Sheila R.

Pesquisa Veterinária Brasileira

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oct 2020, Volume 40 N. 10 Pages 804 - 813

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO: A resistência bacteriana, mostra-se como um efeito colateral inevitável pelo excessivo uso de antibióticos, tornando-se alvo de grande preocupação mundial. O conhecimento dos perfis de resistência bacteriana regionais possibilita o desenvolvimento de práticas de controle de infecções específicas para cada localidade, fazendo uso consciente e moderado dos antibióticos disponíveis no mercado. O objetivo deste estudo foi a avaliação retrospectiva do perfil de resistência antimicrobiana de bactérias isoladas de infecções de animais de companhia na região de Umuarama/PR, no período de 2013 a 2017. Esta pesquisa foi realizada por meio da análise do banco de dados pertencente ao Laboratório de Microbiologia Animal da Universidade Estadual de Maringá (UEM). Os Staphylococcus spp. representaram 45,53% das bactérias isoladas de infecções clínicas em pequenos animais no período e local avaliado, seguido por enterobactérias (34,04%), bacilos Gram-negativos não fermentados (BGNNF, 11,06%) e Streptococcus/Enterococcus (9,36%). Um número elevado de resistência antimicrobiana frente aos antibióticos utilizados na medicina veterinária foi encontrado. As menores resistências associadas aos melhores valores do fator de impacto foram encontrados para aminoglicosídeos, em especial amicacina, cloranfenicol, fluoroquinolonas (norfloxacina e ciprofloxacina). Já resultados intermediários foram encontrados para ampicilina associada a sulbactam, ceftriaxona, amoxacilina com ácido clavulônico e enrofloxacina. Conforme o número de drogas antimicrobianas resistentes, foram classificados como multirresistentes 64,26% (151/235) dos isolados, sendo 15.32% extensivamente resistentes. Já considerando a resistência a classes de antimicrobianos, 68,94% (162/235) dos isolados foram classificados como multirresistentes, sendo 19.15% extensivamente resistentes. Nenhum isolado bacteriano foi caracterizado como pan-resistente, porém 10 bactérias foram resistentes a todas as classes testadas, com susceptibilidade isolada a determinadas drogas. Por meio da avaliação dos perfis de resistência encontrados no período e local estudados e de literatura pertinente, percebe-se que há um aumento crescente no número de bactérias multirresistentes entre os animais domésticos o que caracteriza um grave risco à saúde pública. O arsenal terapêutico está se tornando cada vez mais diminuto e há mais dificuldade na seleção empírica de drogas, tornando essencial a realização de testes de susceptibilidade antimicrobiana para uma seleção mais específica na terapêutica antimicrobiana. Medidas educativas sobre o uso consciente dos antibióticos, controle de infecções e prevenção de zoonoses específicas para as localidades precisam ser instituídas para conhecimento dos profissionais do setor da saúde e acesso geral da população.

ABSTRACT: Bacterial resistance is shown to be an inevitable side effect due to the excessive use of antibiotics, becoming a significant concern worldwide. Knowledge of regional bacterial resistance profiles enables the development of site-specific infection control practices, making conscious and moderate use of commercially available antibiotics. The aim of this study was the retrospective evaluation of the antimicrobial resistance profile of bacteria isolated from companion animal infections in the region of Umuarama/PR, from 2013 to 2017. This research was performed by analyzing the database belonging to the “Laboratório de Microbiologia Animal” at the “Universidade Estadual de Maringá” (UEM). Staphylococcus spp. represented 45.53% of the bacteria isolated from clinical infections in small animals in the period and place evaluated, followed by enterobacteria (34.04%), non-fermenting Gram-negative bacilli (NFGNB, 11.06%) and Streptococcus/Enterococcus (9.36%). A high number of antimicrobial resistance to antibiotics used in veterinary medicine was found. The lowest resistances associated with the best impact factor values were found for aminoglycosides, especially amikacin, chloramphenicol, and fluoroquinolones (norfloxacin and ciprofloxacin). Intermediate results were found for sulbactam-associated ampicillin, ceftriaxone, amoxicillin-clavulanic acid, and enrofloxacin. According to the number of resistant antimicrobial drugs, 64.26% (151/235) of the isolates were classified as multidrug-resistant, being 15.32% extensively resistant. Considering the resistance to antimicrobial classes, 68.94% (162/235) of the isolates were classified as multiresistant, being 19.15% extensively resistant. No bacterial strains were characterized as pan-resistant, but ten bacteria were resistant to all classes tested, with isolated susceptibility to certain drugs. Through the evaluation of resistance profiles found in the period and place studied and relevant literature, it is clear that there is a growing increase in the number of multiresistant bacteria among domestic animals which characterizes a serious risk to public health. The therapeutic arsenal is becoming increasingly diminished, and there is more difficulty in empirical drug selection, making antimicrobial susceptibility testing essential for more specific selection in antimicrobial therapy. Educational measures on the conscious use of antibiotics, infection control, and prevention of local specific zoonoses need to be instituted for the knowledge of health professionals and general access of the population.

https://doi.org/10.1590/1678-5150-pvb-6420 767 downloads

10.

Ludoaprendizaje en Anatomía: Impacto en las Concepciones Culturales y el Afrontamiento Cadavérico desde la Neurociencia Cognitiva
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Mazzoglio-y-Nabar, Martín J

; Algieri, Rubén D

; Tornese, Elba B

; Ferrante, M. Soledad

; Broffman, Carolina

; Algieri, Agustín

International Journal of Morphology

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aug 2020, Volume 38 N. 4 Pages 1065 - 1073

Abstract: En Es | Text: En Es | PDF: En | PDF: Es

SUMMARY: The act of playing is as ancient as humanity itself, yet Huizinga was the one who re-signified the concept of “ludic” as a didactive resource related to culture. Play-based learning was developed as a didactic strategy by the forerunners of the New School. Several Authors (Brunner, Frebel, Decroly, Montessori, Cossettini and Freire) have analyzed its pedagogy projections and stressed the impact and formative value in the cognitive strategies involved in problem solving tasks, attention and memory development, as well it’s motivational and creativity elements. The object of the present work is to evaluate the impact of these didactic interventions in the cultural and conceptual conceptions of the students related to cadaveric material in the course of practical working during anatomy classes. Observational and transversal study through a questionnaire applied to 658 medical students (2016, n = 198; 2017, n= 228; 2018 n=232) which included a Modified Templer Death Anxiety Scale, population questions (age, gender, place of birth, situation regarding the subject, work-related aspects, former studies, motivations related to career choice). Terminology related to “cadaveric material” and “anatomic piece” was investigated with Bernard’s free-listing and lot-drawing techniques in order to investigate cultural and imaginary conceptions and groups of conceptual dimensions. The class structure divides the students in two different ckassrooms, in order to evaluate difference with the inclusion of play-based activities in one of them. The results were processed using tests of descriptive and inferencial statistics (SPSS and dendrogram making), to evaluate the terminological analysis, Visual Anthropac Freelists versión: 1.0.1.36 and Visual Anthropac Pilesorts versión: 1.0.2.60. The present research takes into account all current ethical and legal norms. It has been observed that terms such as “cadaveric material” and “anatomic piece” were associated mainly with repugnancy, disgust, fear and study material. It was observed, in the group of student using play based techniques, a lesser number of negative terminology, as well as conceptual dimensions related with the material as a didactic and instructional resource instead of a distress factor. In conclusion the implementation of play-based techniques in the learning process of the Anatomy coursework was positively associated with a lesser negative impact in both associated terminology and in conceptual dimensions related to cadaveric material. Such an impact is of particular importance in the context of teaching and it would relate with the decrease of negative factors in cadaveric affronting.

RESUMEN: El jugar fue resignificado por Huizinga como un recurso didáctico y se lo denominó “ludoaprendizaje”, “aprendizaje mediado por el juego” o “técnicas lúdicas”. Diversos autores estudiaron su aplicación en distintos contextos fue desarrollado como estrategia didáctica por los impulsores de la Escuela Nueva. Distintos autores (Brunner, Frebel, Decroly, Montessori, Cossettini y Freire) han analizado sus proyecciones pedagógicas y resaltaron el valor formativo e impacto en las estrategias cognitivas para la resolución de problemas, desarrollar la atención y memoria, así como elemento motivador y de creatividad. El objetivo es evaluar el impacto de esta intervención didáctica en las concepciones culturales y conceptuales referidas al material cadavérico durante el TP y su afrontamiento. Realizamos un sstudio observacional y transversal mediante una encuesta aplicada a 658 alumnos (año 2016=198; año 2017= 228; año 2018= 232) que incluyó la Escala de ansiedad ante la muerte de Temple -EAM- modificada, preguntas poblacionales (edad, sexo, lugar de nacimiento, situación en la materia, aspectos laborales, estudios previos, motivaciones en relación con la elección de la carrera) y se indagaron términos asociados a los conceptos “material cadavérico” y “pieza anatómica” con la técnica de listados libres de Bernard y la técnica de montones para investigar concepciones culturales e imaginarios y grupos de dimensiones conceptuales. Dado que la arquitectura de la Cátedra divide a los alumnos en 2 salones distintos, para evaluar diferencias con la inclusión de actividades lúdicas en un grupo. Los resultados fueron procesados con pruebas de estadística descriptiva e inferencial (SPSS para dicho análisis y realización de dendogramas), para análisis de los términos Visual Anthropac Freelists versión: 1.0.1.36 y Visual Anthropac Pilesorts versión: 1.0.2.60. El presente trabajo cumple con los reparos ético-legales y normativos vigentes. Observamos que los términos “material cadavérico” y “pieza anatómica” se asociaron con repugnancia, asco, miedo y elemento de estudio, principalmente. En el grupo de alumnos con técnicas lúdicas se objetivó menor cantidad de términos negativos, así como dimensiones conceptuales más relacionadas con el material como recurso instruccional didáctico y no como factor de distrés. En conclusión, la implementación de técnicas lúdicas en la didáctica del proceso enseñanza y aprendizaje con material cadavérico en la materia Anatomía se asoció con un menor impacto negativo en los términos asociados y dimensiones conceptuales referidos al material cadavérico. Dicho impacto tiene injerencia en el contexto de la enseñanza y se asociaría con la disminución de factores negativos en el afrontamiento cadavérico.

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11.

Eficacia de florfenicol para el tratamiento de infecciones por Pasteurela multocida y Mannheimia haemolitica en alpacas (Vicugna pacos)
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Ferrante, Marcos

; Wosiacki, Sheila R.

Revista de Investigaciones Veterinarias del Perú

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jul 2019, Volume 30 N. 3 Pages 1292 - 1300

Abstract: En Es | Text: En Es | PDF: En | PDF: Es

The aim of the study was to evaluate the effect of florfenicol treatment at a dose of 20 mg/kg via i.m. in the treatment of infections caused by Pasteurela multocida and Mannheimia haemolitica in alpacas. The efficacy rate was determined according to the minimum inhibitory concentration (MIC) of the infecting bacterium. For this, a Monte Carlo simulation of pharmacokinetic parameters for 10 000 events and pharmacokinetic/ pharmacodynamic analysis (PK/PD) was performed. The estimated efficacy rates for P. multocida were 99, 20 and 1% and according to the MICs of strains 0.5, 1 and 2, respectively, while the estimated efficacy rates for M. haemolitica were 100, 95 and 3% and according to the CIM of strains 0.5, 1 and 2, respectively. The probability of obtaining the bacteriological cure after treatment decreased in a highly significant way for infections caused by bacteria with MICs higher than 0.5 µg/ml for P. multocida (p<0.01) and 1 µg/ml for M. haemolitica (p<0.01). The results showed the need to incorporate bacteriological isolation, the determination of the MIC and the optimization of the therapeutic dose according to the susceptibility of P. multocida and M. haemolitica strains in the therapeutic protocol to avoid therapeutic failures and consequently promote the development of bacterial resistance

El objetivo del trabajo fue evaluar el efecto del tratamiento con florfenicol en dosis de 20 mg/kg por vía i.m. en el tratamiento de infecciones causadas por Pasteurela multocida y Mannheimia haemolitica en alpacas. Se determinó la tasa de eficacia según la concentración inhibitoria mínima (CIM) de la bacteria infectante. Para esto, fue realizada una simulación de Monte Carlo de los parámetros farmacocinéticos para 10 000 eventos y el análisis farmacocinético/farmacodinámico (PK/PD). Las tasas de eficacia estimadas para P. multocida fueron del 99, 20 y 1% según las CIM de las cepas 0.5, 1 y 2, respectivamente, mientras que las tasas de eficacia estimadas para M. haemolitica fueron de 100, 95 y 3% según las CIM de las cepas 0.5, 1 y 2, respectivamente. La probabilidad de obtener la cura bacteriológica después del tratamiento disminuyó de manera altamente significativa para infecciones causadas por bacterias con CIM superiores a 0.5 µg/ml para P. multocida (p<0.01) y 1 µg/ml para M. haemolitica (p<0.01). Los resultados evidencian la necesidad de incorporar en el protocolo terapéutico el aislamiento bacteriológico, la determinación de la CIM y la optimización de la dosis terapéutica según la susceptibilidad de las cepas de P. multocida y M. haemolitica a fin de evitar fallas terapéuticas y, consecuentemente, potenciar el desarrollo de resistencia bacteriana

https://doi.org/10.15381/rivep.v30i3.15207

12.

On A War Like No Other: The Constitution in a Time of Terror, by Owen Fiss
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Restrepo Saldarriaga, Esteban

; Ferrante, Marcelo

; Luque Sánchez, Pau

Isonomía

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2018, N. 48 Pages 111 - 145

Abstract: En Es | Text: En Es | PDF: En | PDF: Es

Abstract On September 8, 2017, with the co-sponsorship of the Center of Constitutional Studies of the Mexican Supreme Court (CEC-SCJN), the ITAM Department of Law invited Owen M. Fiss, Sterling Professor Emeritus of the Yale Law School. He was appointed Distinguished Visiting Professor of ITAM —the highest academic award in the university— and a seminar on some of his recent work was conducted both at ITAM and at the CEC-SCJN. The program included the presentation and public discussion of Fiss’ book on the erosion that the so-called “war on terror” exerted on the most basic principles of the US Constitution. The book has been recently translated into Spanish by Francisca Pou Giménez (Una guerra sin igual. La constitución en los tiempos del terrorismo, Marcial Pons, 2017). We are now happy to publish the comments of three of the participants in the book panel —Esteban Restrepo Saldarriaga, Marcelo Ferrante and Pau Luque Sánchez— in the order in which they were delivered that day.

Resumen El 8 de septiembre de 2017, con el copatrocinio del Centro de Estudios Constitucionales de la Suprema Corte (CEC-SCJN), el Departamento de Derecho del ITAM invitó a Owen M. Fiss, Profesor Sterling Emérito de la Escuela de Derecho de Yale. El profesor Fiss fue nombrado Profesor Visitante Distinguido del ITAM —la más alta distinción académica otorgada por la universidad— y se celebró un seminario sobre trabajo suyo reciente en el ITAM y en el CEC-SCJN. El programa incluía la presentación y debate público del libro de Fiss sobre la erosión que la llamada “guerra contra el terrorismo” ha tenido sobre los principios más básicos de la Constitución estadounidense. El libro ha sido recientemente traducido al español por Francisca Pou Giménez (Una guerra sin igual. La constitución en los tiempos del terrorismo, Marcial Pons, 2017). Tenemos el gusto de publicar ahora los comentarios de tres de los participantes en la presentacion —Esteban Restrepo Saldarriaga, Marcelo Ferrante y Pau Luque Sánchez— en el orden en que se pronunciaron ese día.

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13.

Gestion de riesgo y eventos adversos en cirugia torácica
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Algieri, Rubén D

; Arribalzaga, Eduardo B

; Segura, Gustavo

; Ferrante, M. Soledad

; Nowydwor, Benjamín

; Fernández, Juan P

Revista argentina de cirugía

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jun 2012, Volume 102 N. 1 Pages 13 - 17

Abstract: En Es | Text: En Es | PDF: En | PDF: Es

Introduction: An adverse event occurs as a result of factors and phenomena conjugated for his appearance (poorly developed processes, poorly applied technologies, inadequate infrastructure or failed human interactions) triggering an incident that can cause injury, disability, morbidity, length prolongation of hospitalization, death, arising from health care and not the underlying disease. Objectives: Identify, analyze and report preventable adverse events that occurred in surgical clinic processes in thoracic surgery as risk prevention. Recognize and analyze factors of adverse events. Encourage continuous education to develop a safety culture. Design: Retrospective, observational statistical study. Materials and methods: a retrospective statistical analysis of adverse events (EA) in thoracic surgery from a General Surgery service, analyzing contributing factors of a total 57 patients of thoracic surgery from December 01 2009 to January 01, 2011. Results: 10 (17.5 %) patients presented EA and all (100 %) were considered preventable. There were temporary disability in 5 cases (50 %) and 4 (40 %) there was no disabilities added to the pathology of base. One (10 %) introduced permanent disability. Mortality associated with the adverse event not occurred. The 100 % of the EA occurred by human factors, 7 (70 %) by inadequate technique, 1 (10 %) by fault in diagnostic procedure,2 (20 %) by complications in postoperative management. Conclusions: When an adverse event occurs, it failed the health system. The checklist is useful and can alert and avoid unsafe actions. Analyzing contributing factors, record and report events in thoracic surgery serve simultaneously for prevention, risk reduction and development of a culture of safety for the patient.

Introducción: Un evento adverso ocurre como consecuencia de factores y fenómenos conjugados para su aparición (procesos mal desarrollados, tecnologías mal aplicadas, infraestructura inadecuada o interacciones humanas fallidas) desencadenando un incidente/accidente que puede causar lesión, discapacidad, con morbilidad, prolongación de la internación y/o fallecimiento, derivada de la asistencia sanitaria y no de la enfermedad de base. Objetivos: Identificar, analizar e informar eventos adversos evitables ocurridos en procesos clínico-quirúrgicos en Cirugía Torácica como prevención de riesgo. Reconocer y analizar factores causales de eventos adversos. Estimular la educación continua para desarrollar una cultura de seguridad. Diseño: Estadístico retrospectivo, observacional. Material y método: Se realizó un análisis estadístico retrospectivo, de los eventos adversos (EA) en cirugía torácica, en un Servicio de Cirugía General, analizando factores contribuyentes de los mismos, de un total de 57 pacientes de cirugía torácica desde el 01 de Diciembre 2009 al 01 de Enero 2011. Resultados: 10(17,5 %) pacientes presentaron EA y todos (100%) se consideraron prevenibles. En 5 casos (50 %) hubo discapacidad temporal y en 4 (40 %) no hubo discapacidad agregada a la patología de base. Uno (10 %) presentó incapacidad permanente. No se registró mortalidad asociada al evento adverso. El 100% de los EA ocurrieron por factores humanos, 7(70 %) por técnica inadecuada, 1(10%) por falla en diagnóstico, 2 (20 %) por complicaciones en manejo postquirúrgico. Conclusiones: Cuando un evento adverso ocurre, falló el sistema de salud. La lista de chequeo resulta de utilidad pudiendo alertar y evitar acciones inseguras. Analizar factores contribuyentes, registrar e informar eventos ocurridos en cirugía torácica sirven simultáneamente para prevención, disminución de riesgo y desarrollo de una cultura de seguridad para el paciente.

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14.

A general study of commercially pure Ti subjected to severe plastic deformation: microstructure, strength and corrosion resistance
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Mendes Filho, A.A.

; Rovere, C.A.

; Kuri, S.E.

; Sordi, V.L.

; Ferrante, M.

Matéria (Rio de Janeiro)

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2010, Volume 15 N. 2 Pages 254 - 259

Abstract: En | Text: En | PDF: En

Bars of Titanium Grade 2 were subjected to deformation by Equal Channel Angular Pressing, both at room temperature and at 300°C. Additionally, some specimens were cold rolled up to 70% reduction. From tensile tests, data such as yield, maximum strength, elongation and area reduction were obtained. Results show that the best strength - ductility combination is produced by four passes followed by cold rolling. Finally, the corrosion behavior was assessed following ASTM F2129 and no noticeable difference between the starting material and the ECAP-deformed was detected.

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15.

Tabaquismo en médicos y en la población general: Comparación de los resultados del estudio TAMARA y de la Encuesta Nacional de Factores de Riesgo 2005
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Cardone, Alberto J.

; Zylbersztejn, Horacio M.

; Ferrante, Daniel

; Borracci, Raúl A.

Revista argentina de cardiología

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oct 2008, Volume 76 N. 5 Pages 375 - 377

Abstract: En Es | Text: En Es | PDF: En | PDF: Es

The influence of physicians to discourage smoking and to control the addiction on smoker patients has been well demonstrated; nevertheless, this attitude depends mostly on the personal relationship of physician towards tobacco. The aim of this study was to compare the prevalence of smoking habits in physicians reported by the TAMARA trial (Tabaquismo en médicos de la República Argentina) versus the prevalence reported in the 2005 National Survey of Risk Factors (ENFR, Encuesta Nacional de Factores de Riesgo 2005). The population of physicians registered in the database of the TAMARA trial was stratified according to the age intervals reported by the ENFR. From a total of 6,497 physicians originally registered in the TAMARA trial, 5,806 were included in the age interval between 25 to 64 years. Data of the entire survey respondents of the ENFR (9,658 participants) were used. The prevalence of smokers among physicians and in the general population was similar (32.2% versus 32.4%; p=0.403); however, a different pattern was seen when the outcomes were stratified by age. The proportion of smoker physicians was lower than smokers in the general population in the age intervals between 25 and 34 years (30.9% versus 34.6%; p=0.0004) and between 50 and 64 years (21.3% versus 26.8%; p<0.0001), whereas the prevalence of smoking habits among physicians in the intermediate age interval (35-49) years was greater than the prevalence in the ENFR (44.4 versus 35.8%; p<0.0001); besides, this subgroup of physicians were less trained in the management of tobacco cessation. Although the global prevalence of smoking habits among physicians is similar to the general population, the analysis by age intervals demonstrated that the number smoker physicians is greater between 35 and 49 years. Although the prevalence of smokers was lower among the youngest and the eldest physicians, this difference was not as significant as the observed in physicians in the intermediate group. The high prevalence of smoker physicians might constitute a negative influence to the general population, as it acts affecting the adequate perception of the risk of the addiction.

Aunque se demostró la influencia del médico sobre el paciente fumador para desalentar y controlar la adicción, esta actitud depende en gran medida de la relación del propio médico con el tabaco. El objetivo de este estudio fue comparar la prevalencia de tabaquismo en médicos del estudio TAMARA ("Tabaquismo en médicos de la República Argentina") versus la comunicada para la población general en la "Encuesta Nacional de Factores de Riesgo 2005" (ENFR). Se recurrió a la base de datos del estudio TAMARA para estratificar la población de médicos de acuerdo con los intervalos de edad comunicados por la ENFR. De los 6.497 médicos originales del TAMARA, se incluyeron 5.806 en el intervalo de 25 a 64 años, mientras que de la ENFR se utilizaron los datos de 9.658 encuestados de la población general. Se encontraron prevalencias de fumadores similares para los médicos y la población general (32,2% versus 32,4%; p = 0,403); sin embargo, al estratificar por edad se demostró un patrón distinto. La proporción de médicos fumadores fue inferior a la de la población general entre los 25 y los 34 años (30,9% versus 34,6%; p = 0,0004) y entre los 50 y los 64 años (21,3% versus 26,8%; p < 0,0001), mientras que en el grupo de edad intermedia (35- 49 años) el porcentaje de médicos fumadores superó la prevalencia de la ENFR (44,4 versus 35,8%; p < 0,0001). Se observó además que este estrato de edad intermedia fue el que tenía menos formación para el manejo del tabaquismo. En conclusión, si bien la prevalencia global del tabaquismo en médicos no es diferente de la correspondiente a la población general, la estratificación por edad mostró que los médicos eran más fumadores entre los 35 y los 49 años. Aunque en los grupos de menor y mayor edad se encontraron menos fumadores entre los médicos, esta diferencia no fue tan marcada como en el grupo intermedio. La alta prevalencia de fumadores entre los médicos podría constituirse en una influencia negativa, ya que motivaría un patrón de imitación en la población general que puede afectar la percepción adecuada del riesgo de esta adicción.

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