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ABSTRACT BACKGROUND: Coronavirus disease 2019 (COVID-19) can cause cytokine release syndrome (CRS), which leads to high mortality rates. Tocilizumab suppresses CRS by blocking the signal transduction of interleukin-6 (IL-6). OBJECTIVE: To evaluate the clinical and laboratory parameters associated with mortality among patients receiving tocilizumab treatment. DESIGN AND SETTING: Retrospective observational study conducted in the chest disease departments of two different training and research hospitals in the center of Ankara, Turkey. METHODS: Patients who were hospitalized and treated with tocilizumab in September 2020 were retrospectively analyzed. Their laboratory parameters and clinical characteristics were obtained from the hospital information system database. Comparative analyses were performed between the patients who died and the ones who survived. RESULTS: A total of 58 patients who received tocilizumab treatment were included in this study, among whom 35 (60.3%) died. There was no difference between the mortality and survival groups in terms of white blood cell (WBC), neutrophil, lymphocyte, ferritin or C-reactive protein (CRP) levels detected on admission. WBC, lymphocyte, neutrophil and CRP levels measured on the third and fifth days after tocilizumab administration were found to be significantly lower in the survival group (P < 0.05). In multiple logistic regression analysis, age and oxygen saturation were determined to be independent risk factors for mortality. CONCLUSION: Persistently high WBC, CRP and neutrophil levels and low lymphocyte levels could be considered to be valuable indicators of mortality among COVID-19 patients treated with tocilizumab. Age and low oxygen saturation are independent risk factors for mortality among patients receiving tocilizumab treatment.

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ABSTRACT BACKGROUND: Maritime transportation is an activity of vital importance for societies. The Mar Grande-Salvador crossing is an intercity waterway transport line in Brazil that transports 3,500 passengers/day, including residents and tourists. In 2017, an accident on this crossing was considered to be the biggest maritime tragedy in Bahia in the last decade. OBJECTIVE: To describe the clinical and epidemiology characteristics of victims of this maritime accident, with analysis on bodily injuries, causes of death and means/instruments that caused the fatal injuries. DESIGN AND SETTING: Case-series study at the Forensic Medical Institute of Bahia, Brazil. METHODS: Reports on 73 victims who were examined for bodily injury or were necropsied by the Forensic Medical Institute were analyzed. This study was approved by the institution’s Research Ethics Committee (protocol 04012218.1.0000.5032). RESULTS: The victims’ mean age was 33.0 years [95% confidence interval, CI, 26.3-47.0]. The mean age of those who died was 43.0 years [95% CI, 30.5-53.5]. Bodily injuries were found in 74% of the victims. The most frequent bodily injuries were ecchymoses among females (69.7%) and abrasions among males (76.2%). Blunt instruments produced most bodily injuries (85.2%). Among the victims who died, 68.4% were female. Mechanical asphyxiation through drowning was the leading cause of death (89.4%). The overall lethality rate was 26%, and this was higher among females (28.2%). CONCLUSION: Women were the main victims of this maritime accident. Bodily injuries occurred more frequently than death, but these injuries proved to be quite significant, thus demonstrating the importance of measures to improve the safety of navigation.

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ABSTRACT BACKGROUND: New medical schools and new medical residencies in Brazil, mainly in its interior, were opened under the justification of collaborating towards distribution of these healthcare professionals and specialist doctors across the national territory. However, this proposal did not guarantee that medical practitioners would become established in the place where they graduated and specialized. OBJECTIVE: To calculate, through interviews, how many specialists who graduated in the state of Tocantins stayed there after finishing their medical residency; and to analyze the factors that made them stay or leave the place. DESIGN AND SETTING: Cross-sectional exploratory study conducted at a Brazilian federal public higher education institution. METHODS: All graduates from medical residencies in Tocantins, who graduated between 2013 and 2019, were contacted by telephone and, after obtaining consent, an interview was conducted. The interviews took place between June 2020 and January 2021. RESULTS: The permanence of medical residency graduates in the state increased from 50% in an earlier study to 55.8% in the current study, thus showing a situation of stability. In addition, we detected some reasons for staying or not. In a multivariate analysis, only working in the state capital was related to staying in the state of Tocantins, showing a 5.6 times greater chance. CONCLUSIONS: The percentage of those who remained was just over 50%, even some years after implementation of the first programs. Most specialists remained working for the state health department, with a smaller proportion in municipal health departments, and were concentrated in the state capital.

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ABSTRACT BACKGROUND: The frequency of coronavirus disease 2019 (COVID-19) cases among asthmatics has been reported to be reduced. However, the findings regarding the association between asthma and the risk of severe COVID-19 have been divergent. OBJECTIVE: To investigate whether asthma is associated with a reduced risk of development of severe COVID-19. DESIGN AND SETTING: Retrospective analysis on COVID-19 surveillance databases at two tertiary-level hospitals in São Paulo, Brazil. METHODS: The medical records of patients hospitalized due to COVID-19 between March and August 2020 were reviewed in accordance with the clinical, laboratorial, radiological and epidemiological criteria for COVID-19, and for comorbidities. RESULTS: Among the adult patients included (> 18 years of age) there were 52 asthmatics and 1,318 non-asthmatics. Their median ages and interquartile ranges (IQR) were, respectively, 54 (41-69) and 60 (44-72) years. At least one comorbidity was seen in 73% of asthmatics and 56% of the non-asthmatics. Among the asthmatics, most presented mild asthma (92%) and the prevalence of chronic obstructive pulmonary disease (COPD) was high (27%). The asthmatics presented an unadjusted odds ratio (OR) for severe COVID-19 of 0.89 (95% confidence interval, CI 0.5-1.56); and OR 0.88 (95% CI 0.5 -1.68) after multivariable adjustment. Age > 60 years, male sex, hypertension, diabetes, cancer and homelessness were covariates associated with increased odds for severe COVID-19. Kaplan-Meier estimated survival over hospitalization of up to 30 days did not differ between the groups (log-rank P = 0.09). CONCLUSIONS: The association between asthma and decreased risk of severe COVID-19 or increased survival was statistically non-significant.

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ABSTRACT BACKGROUND: Many factors may negatively impact physical activity (PA), but studies lack evidence of individual predictors of perceived barriers to PA among adults in primary healthcare units. OBJECTIVE: To analyze associations between sociodemographic characteristics, health conditions, leisure-time physical activity (LTPA), PA counseling and perceived barriers to LTPA among adult patients in primary healthcare units of the National Health System in Brazil. DESIGN AND SETTING: Cross-sectional study on a representative sample of adults in primary healthcare units in São José dos Pinhais, Paraná, Brazil. METHODS: This study was conducted in 2019, among 779 adults (70% women). Barriers to LTPA, sociodemographic characteristics (sex, age, marital status, skin color, education and income), health conditions (body mass index, hypertension, diabetes, dyslipidemia, coronary disease and medications), LTPA level and PA counseling received were measured using validated, standardized procedures. The data were analyzed using chi-square and Mann-Whitney U tests. RESULTS: The most prevalent barriers were “feeling too tired” (53%) and “lack of time” (52%). PA counseling was inversely associated with “lack of time” (45% versus 57%; P < 0.001) but positively associated with “injury or disease” (38% versus 29%; P = 0.008). There was an inverse linear trend between the number of barriers and LTPA (walking and total) (P < 0.001). Most barriers differed in comparisons of sociodemographic characteristics, health conditions, LTPA and counseling (P < 0.05). CONCLUSIONS: The barriers vary according to the individual predictors. Counseling strategies need to be specific for each barrier and may be promising for promoting LTPA within primary healthcare.

Resumo em Inglês:

ABSTRACT BACKGROUND: The Respiratory Syndromes Surveillance System was created by the Brazilian Ministry of Health in 2000 to monitor influenza in this country. With the emergence of the new coronavirus pandemic, it became incorporated into the surveillance network for influenza and other respiratory viruses. OBJECTIVE: To analyze the transmission of coronavirus disease 2019 (COVID-19) and severe acute respiratory syndrome (SARS) in the state of Acre through its hierarchical urban network. DESIGN AND SETTING: Cross-sectional, descriptive and ecological study, using a spatiotemporal approach and using secondary data. This study was conducted in the state of Acre, northern Brazil. METHODS: This study used secondary data, and epidemiological weeks and municipalities were taken to be the units of analysis. Incidence rates and kernel intensities were calculated for four study periods. Spatiotemporal analysis was performed using scan statistics to identify clusters of SARS cases and considering the population of each municipality. RESULTS: In general, it could be observed that there were higher kernel rates and intensities in municipalities located in the north and south of this state (i.e. its most populous municipalities). CONCLUSION: Priority areas for interventions to control transmission of COVID-19 were highlighted, with the aim of reducing the risks of transmission to more distant areas in the urban hierarchy of the state of Acre.

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ABSTRACT BACKGROUND: Advanced age, multiple chronic diseases and frailty have been correlated with worse prognosis among coronavirus disease 2019 (COVID-19) inpatients. OBJECTIVE: To investigate potential risk factors for hospitalization and death due to COVID-19 among frail community-dwelling elderly people. DESIGN AND SETTING: Retrospective cohort study of patients followed up at a geriatric outpatient clinic in Belo Horizonte, Minas Gerais, Brazil. METHODS: The associations of demographic characteristics (age and sex) and clinical characteristics (frailty, multimorbidity, number of medications with long-term use, obesity, smoking, diabetes mellitus, pulmonary diseases, cardiovascular diseases, cerebrovascular disease, and chronic kidney disease) with the risk of hospitalization and death due to COVID-19 were explored using a multivariable logistic regression model. RESULTS: 5,295 patients (mean age 78.6 ± 9.4 years; 72.6% females) were included. After adjustments, the number of medications with long-term use was found to increase the odds of hospitalization due to COVID-19 (odds ratio, OR: 1.13; 95% confidence interval, CI: 1.06-1.22). Frailty, multimorbidity and diabetes mellitus also increased the odds of hospitalization (OR: 1.06, 95% CI: 1.02-1.09; OR: 1.17, 95% CI: 1.09-1.26; and OR: 2.27, 95% CI: 1.45-3.54, respectively) and the odds of death due to COVID-19 (OR: 1.07, 95% CI: 1.00-1.14; OR: 1.16, 95% CI: 1.03-1.32; and OR: 2.69, 95% CI: 1.79-6.14, respectively). CONCLUSIONS: Multimorbidity, frailty and diabetes mellitus increased the odds of hospitalization and death due to COVID-19 and the number of medications with long-term use increased the odds of hospitalization due to COVID-19 among frail community-dwelling elderly people.

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ABSTRACT BACKGROUND: During childhood and adolescence, there are significant increases in bone mineral content (BMC) and bone mineral density (BMD). OBJECTIVE: To investigate physical growth parameters associated with BMD and BMC among children and adolescents diagnosed with human immunodeficiency virus (HIV). DESIGN AND SETTING: Cross-sectional study conducted in Florianópolis, Brazil, among 63 children and adolescents (aged 8-15 years) diagnosed with HIV. METHOD: BMD, BMC and fat percentage z score were evaluated using dual X-ray absorptiometry. Age/height z score and body mass index (BMI)/age z score were obtained in accordance with international recommendations, and bone age was obtained through hand-wrist radiography. Sex, family income, information on HIV infection (T CD4+ lymphocyte count, viral load and type of antiretroviral therapy, moderate-vigorous physical activity and sedentary behavior) were used as adjustment variables in the analyses. Simple and multiple linear regression analyses were performed, with a significance level of P ≤ 0.05. RESULTS: Subtotal BMD (without the head region) was directly associated with bone age, BMI/age z score and fat percentage z score, even after adjusting for covariates. Subtotal BMC/height was directly associated with bone age, height/age z score, BMI/age z score and fat percentage z score, even after adjusting for covariates. CONCLUSION: Subtotal BMD and subtotal BMC/height were directly associated with physical growth indicators among children and adolescents diagnosed with HIV.

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ABSTRACT BACKGROUND: Clinical judgment of initial baseline laboratory tests plays an important role in triage and preliminary diagnosis among coronavirus disease 2019 (COVID-19) patients. OBJECTIVES: To determine the differences in laboratory parameters between COVID-19 and COVID-like patients, and between COVID-19 and healthy children. Additionally, to ascertain whether healthy children or patients with COVID-like symptoms would form a better control group. DESIGN AND SETTING: Cross-sectional study at the Institute for Child and Youth Health Care of Vojvodina, Novi Sad, Serbia. METHODS: A retrospective study was conducted on 42 pediatric patients of both sexes with COVID-19. Hematological parameters (white blood cell count, absolute lymphocyte count and platelet count) and biochemical parameters (natremia, kalemia, chloremia, aspartate aminotransferase [AST], alanine aminotransferase [ALT], lactate dehydrogenase [LDH] and C-reactive protein [CRP]) were collected. The first control group was formed by 80 healthy children and the second control group was formed by 55 pediatric patients with COVID-like symptoms. RESULTS: Leukocytosis, lymphopenia, thrombocytosis, elevated systemic inflammatory index and neutrophil-lymphocyte ratio, hyponatremia, hypochloremia and elevated levels of AST, ALT, LDH and CRP were present in COVID patients, in comparison with healthy controls, while in comparison with COVID-like controls only lymphopenia was determined. CONCLUSIONS: The presence of leukocytosis, lymphopenia, thrombocytosis, elevated systemic inflammatory index and neutrophil-lymphocyte ratio, hyponatremia, hypochloremia and elevated levels of AST, ALT, LDH and CRP may help healthcare providers in early identification of COVID-19 patients. Healthy controls were superior to COVID-like controls since they provided better insight into the laboratory characteristics of children with novel betacoronavirus (SARS-CoV-2) infection.

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Abstract BACKGROUND: The worldwide prevalences of anxiety and depressive disorders are 3.6% and 4.4%, respectively. Among medical students, many studies have indicated that the prevalences of these mental disorders vary between 19.7% and 47.1%, but there is a lack of information on psychotropic drug usage in this group of students. OBJECTIVE: To evaluate the prevalence of psychotropic drug use, adherence to therapy and main clinical and diagnostic indications relating to psychotropic drug use among medical students. DESIGN AND SETTING: Cross-sectional study at a Brazilian private university in the city of Sorocaba, state of São Paulo. METHODS: Observational analytical cross-sectional study, conducted during the second semester of 2019, through a semi-structured online questionnaire, answered by first to sixth-year medical students. RESULTS: Among the 263 participants (41.7% of the 630 enrolled students), the current prevalence of psychotropic drug usage was 30.4%. This prevalence increased over the course and 90.7% of the drugs were prescribed at regular medical consultations (85.5% by psychiatrists). The main indications for psychotropic drug usage were anxiety (30.0%), depression (22.8%), insomnia (7.2%), panic (5.3%) and attention deficit hyperactivity disorder (3.8%). Women were more likely to present diagnoses of depression and panic. Most of the participants used antidepressants and had good adherence to medications. Adequate sleep and regular physical activity were identified as protective factors against mental disorders. CONCLUSION: The prevalence of mental disorders among medical students is high, which justifies the use of psychotropic drugs. This study provides valuable information and recommendations for institutional educational actions to improve students’ mental health.

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ABSTRACT BACKGROUND: Racial disparities are differences among distinct subgroups of the human species; biologically, there are no scientifically proven reasons for them to exist. OBJECTIVE: To assess the impact of racism or racial discrimination on obstetric outcomes. DESIGN AND SETTING: Systematic review conducted at a tertiary/academic hospital. METHODS: The Cochrane Library, SCOPUS/EMBASE, PubMed, Web of Science and ClinicalTrials.gov databases were searched from inception to June 2020. Studies presenting any type of racial discrimination, or any manifestation of racism that was perceived by women of any age in an obstetric scenario were included. Studies that only assessed racial disparities without including direct racism were excluded. The secondary outcomes evaluated included quality of antenatal care, intra and postpartum care, preterm birth and birthweight. The Risk of Bias In Non-randomized Studies - of Interventions (ROBINS-I) scale was used to assess the quality of evidence from non-randomized studies. RESULTS: A total of 508 records were retrieved and 29 were selected for qualitative synthesis. No meta-analysis could be performed due to the high heterogeneity across studies. Perceived racism was associated as a risk factor in 7/10 studies focusing on pregnancy and postpartum maternal outcomes, five studies on preterm birth, one study on small for gestational age and two studies on low birthweight. Overall, among the 29 studies, the risk of bias was classified as moderate. CONCLUSIONS: Perceived racism presented an association with poor obstetric outcomes. Anti-racist measures are needed in order to address the problems that are causing patients to perceive or experience racism. SYSTEMATIC REVIEW REGISTRATION: PROSPERO database, CRD42020194382

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ABSTRACT BACKGROUND: The prevalence of Helico bacter pylori (H. pylori) infection is decreasing worldwide, but is still high in developing countries. We previously observed an H. pylori infection rate of 52% among children and adolescents with chronic non-ulcer dyspepsia. OBJECTIVE: To investigate the prevalence of H. pylori infection among asymptomatic children living in a single region and to evaluate the risk factors for this infection. DESIGN AND SETTING: Cross-sectional study in which 161 children aged 5-13 years (mean age 7.8 years), at a public school in Botucatu, state of São Paulo, southeastern Brazil, were assessed. METHOD: The children's H. pylori infection status was determined through the urea breath test and the risk factors for acquisition of the infection were determined based on a sociodemographic questionnaire. RESULTS: The overall prevalence of H. pylori infection was 20.5%: 18.7% among females and 22.2% among males. The results from the sociodemographic survey did not differ between children with and without H. pylori infection. 30.9% of the children had previous records of upper gastrointestinal symptoms, which consisted of H. pylori infection in only 26.5% of these cases. Family histories of gastritis and peptic ulcer disease were found in relation to 50% and 32.3% of the children with H. pylori infection respectively. CONCLUSION: The prevalence of H. pylori infection among asymptomatic children in southeastern Brazil is lower than that recorded among symptomatic children in the same region and similar to the prevalence of H. pylori infection observed in developed countries.

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ABSTRACT BACKGROUND: The number of bariatric surgeries performed worldwide is growing. Among the main short, medium or long-term complications after surgery are nutritional deficiencies. Many of these, such as those of Zn, Cu and vitamins A, B1, B3, B6 and B12, are manifested by dermatological lesions before potentially fatal systemic disorders occur. OBJECTIVE: To identify the main dermatological manifestations associated with nutritional deficiencies after bariatric surgery, and the associated variables. DESIGN AND SETTING: Integrative literature review carried out at a public university in Brazil. METHODS: This was a case report and a review of health research portals and databases of national and international biomedical journals, without publication date limitation. The descriptors used for searches followed the ideal methodology for each database/search portal: “bariatric surgery”, “skin”, “skin disease”, “skin manifestation”, “deficiency disease” and “malnutrition”. RESULTS: A total of 59 articles were selected, among which 23 were review articles or articles that addressed specific dermatological manifestations. The other 36 articles described 41 cases, which were organized into a table with the clinical variables. CONCLUSIONS: Although nutritional deficiencies are expected as complications after bariatric surgery, few articles relating them to their dermatological manifestations were found. It is important to recognize skin changes caused by nutritional deficiencies in patients treated via bariatric surgery, as these may occur before systemic complications appear and are easier to diagnose when the patient does not have any systemic symptoms yet. However, there is generally a delay between the appearance of skin lesions and making the diagnosis of nutritional deficiency.