Experience report about the regional internship of the UFSM's medicine course in Brazil

Background

The Regional Internship (RI) is an extension project provided by the Federal University of Santa Maria (Brazil) that gives the medicine students a real experience of how the Primary Health Care (PHC) works, offering them a chance to grow as professionals, gaining self-trust and autonomy while being supervised by the preceptors. The cities where the program operates are small and they suffer with lack of high-quality healthcare professionals, which makes this internship also important for these communities. Worldwide, mainly in developing countries, the deficiency of proper PHC is a problem that can be attenuated by this proposal of introducing updated doctors eager to improve their skills and benefit the society.

Objective

The aim of the present study is to report, through the interns' exposition, how the internship was capable of contributing for the life and formation of the medicine student.

Results

Based on an extension project that gives the students an opportunity of a more embracing experience with the community, it is possible to notice the importance of the extension on the curricular complementation. Moreover, with the interaction between students and community, the knowledge exchange and the experience with different cultures benefit and contribute to the medical formation of these students, as well as in the population health context.

Conclusions

This is a part of the portfolio delivered by an academic: 'At the end of the two months of Regional Internship I have the sensation of mission accomplished and satisfaction. The experience offered by this phase of the course is incomparable, I feel more secure, more autonomous, it's like the growth that was in a constant acceleration before now suffered an exponential improve.'

Key messages

The benefits of Regional Internship cannot be evaluated only by quantitative indicators, but also by the individual experiences lived by interns, preceptors and a general community. After the internship period, academics conclude that they feel more confident and encouraged to face the challenges of medical life.

Short- and long-term theory-based predictors of physical activity in women who participated in a weight-management program

This study analyzed psychosocial predictors of the Theory of Planned Behavior (TPB) and Self-Determination Theory (SDT) and evaluated their associations with short- and long-term moderate plus vigorous physical activity (MVPA) and lifestyle physical activity (PA) outcomes in women who underwent a weight-management program. 221 participants (age 37.6 ± 7.02 years) completed a 12-month SDT-based lifestyle intervention and were followed-up for 24 months. Multiple linear regression analyses tested associations between psychosocial variables and self-reported short- and long-term PA outcomes. Regression analyses showed that control constructs of both theories were significant determinants of short- and long-term MVPA, whereas affective and self-determination variables were strong predictors of short- and long-term lifestyle PA. Regarding short-term prediction models, TPB constructs were stronger in predicting MVPA, whereas SDT was more effective in predicting lifestyle PA. For long-term models, both forms of PA were better predicted by SDT in comparison to TPB. These results highlight the importance of comparing health behavior theories to identify the mechanisms involved in the behavior change process. Control and competence constructs are crucial during early adoption of structured PA behaviors, whereas affective and intrinsic sources of motivation are more involved in incidental types of PA, particularly in relation to behavioral maintenance.

Effects of vagal stimulation on induction and termination of atrial fibrillation in an in vivo rabbit heart model

INTRODUCTION

Vagal activity is thought to influence atrial electrophysiological properties and play a role in the initiation and maintenance of atrial fibrillation (AF). In this study, we assessed the effects of acute vagal stimulation (vagus_stim) on atrial conduction times, atrial and pulmonary vein (PV) refractoriness, and vulnerability to induction of AF in the rabbit heart with intact autonomic innervation.

METHODS

An open-chest epicardial approach was performed in 11 rabbits (New Zealand; 3.9-5.0 kg), anesthetized and artificially ventilated after neuromuscular blockade. A 3-lead ECG was obtained. Atrial electrograms were recorded along the atria, from right to left (four monopolar electrodes), together with a circular electrode adapted for proximal left PV assessment. Acute vagus nerve stimulation was obtained with bipolar electrodes (20 Hz). Epicardial activation was recorded in sinus rhythm, and the conduction time from right (RA) to left atrium (LA), and from RA to PVs, was measured in basal conditions and during vagus_stim. The atrial effective refractory period (ERP) and dispersion of refractoriness (Disp_A) were analyzed. Vulnerability to AF induction was assessed at the right (RAA) and left (LAA) atrial appendages and the PVs. Atrial stimulation (50 Hz) was performed alone or combined with vagus_stim. Heart rate and blood pressure were monitored.

RESULTS

In basal conditions, there was a significant delay in conduction from RA to PVs, not influenced by vagus_stim, and the PV ERPs were shorter than those measured in LA and LAA, but without significant differences compared to RA and RAA. During vagus_stim, conduction times between RA and LA increased from 16+8 ms to 27+6 ms (p < 0.05) and ERPs shortened significantly in RA, LAA and LA (p < 0.05), but not in RAA. There were no significant differences in Disp_A. AF induction was reproducible in 45% of cases at 50 Hz and in 100% at 50 Hz+vagus_stim (p < 0.05). The duration of inducible AF increased from 1.0 +/- 0.2 s to 12.0 +/- 4.5 s with 50 Hz+vagus_stim (p < 0.01). AF lasted >10 s in 45.4% of rabbits during vagus_stim, and ceased after vagus_stim in 4 out of these 5 cases. In 3 animals, PV tachycardia, with fibrillatory conduction, induced with 50 Hz PV pacing during vagus_stim.

CONCLUSIONS

Vagus_stim reduces interatrial conduction velocity and significantly shortens atrial ERP, contributing to the induction and duration of AF episodes in the in vivo rabbit heart. This model may be useful for the assessment of autonomic influence on the pathophysiology of AF,

Evolution of nutritional status of infants infected with the human immunodeficiency virus

CONTEXT

There are today only a limited number of studies defining growth parameters and nutritional status for HIV children.

OBJECTIVE

To study the nutritional status of infants infected with the human immunodeficiency virus.

TYPE OF STUDY

Longitudinal study.

SETTING

Department of Pediatrics, Faculty of Medical Sciences, UNICAMP, Campinas, Brazil.

PARTICIPANTS

One hundred and twenty-four children born to HIV infected mothers were evaluated from birth until the age of two years. They were subdivided into two groups: 71 infected children and 53 non-infected children.

MAIN MEASUREMENTS

Growth was evaluated in both groups by comparing Z-scores for weight/age (w/a), length/age (H/a) and weight/length (w/H) (using the NCHS curves as reference).

RESULTS

The Z-score analyses showed that there was a significant difference between the two groups for all the variables studied, except for the H/a value at 3 months of age and the W/H value at 21 months of age, which showed P > 0.05.

CONCLUSIONS

The growth of infected infants was observed to be severely affected in comparison with that of seroreversed infants in the same age groups. Although clinical manifestations may take time to appear, the onset of growth changes begin soon after birth.

Comparative performance of magnetic resonance angiography and conventional angiography in moyamoya disease

Patients with moyamoya disease verified by conventional cerebral angiography (CCA) were evaluated by means of magnetic resonance angiography (MRA), in order to clarify its advantages and limitations in comparison with CCA. This retrospective study was carried out in 13 hemispheres of seven patients with moyamoya disease (including one atypical patient). In MRA, magnetisation transfer contrast (MTC) and maximal intensity projection (MIP) techniques were used. A good correspondence between MRA and CCA was noted in 11 hemispheres (86.4%) on evaluating stenotic lesions and overestimation in the remaining 2. Underestimation of moyamoya vessels in MRA was noted in 3 hemispheres, since well developed moyamoya vessels were detectable, while poorly developed ones were not. No difference between MRA and CCA findings was found in 10 hemispheres (76.9%). MRA tends to overestimate the stenosis and underestimate moyamoya vessels. These characteristics may lead to wrong classification in the angiographic grade of patients with early and advanced stages and should be taken into consideration in interpreting MRA images of moyamoya disease (compatible rate of grade between MRA and CCA; 84.6%). In conclusion MRA with MTC and MIP techniques offers an acceptable quality of assessment of stenotic lesions and moyamoya vessels. MRA is a useful follow up method at present and in the near future it may replace CCA as the initial diagnostic tool.

Unusual cranial nerve palsy caused by cavernous sinus aneurysms. Clinical and anatomical considerations reviewed

BACKGROUND

Two cases of intracavernous internal carotid artery aneurysm with unusual clinical findings are reported. The pathomechanism and clinical significance are discussed.

CASE DESCRIPTION

The first patient was a 49-year-old woman who presented with 6th nerve palsy and Horner's syndrome caused by a posteriorly located intracavernous aneurysm. The symptoms improved gradually in proportion to the size of the aneurysm. The second patient was a 69-year-old woman with isolated oculomotor superior division palsy caused by an anteriorly located large aneurysm.

CONCLUSION

In the first case, a local aneurysmal compression at both the 6th nerve and the sympathetic fibers sent from the plexus on the intracavernous internal carotid artery is the most probable explanation. In the second case, the aneurysm might have selectively compressed the superior division of the oculomotor nerve at the anterior cavernous sinus. Clinical recognition of these syndromes results in a better diagnostic orientation. The authors discuss the pertinent anatomy and pathophysiology of the lesions because these findings are rarely seen clinically or in the literature.

Longevity of naturally acquired antibody responses to the N- and C-terminal regions of Plasmodium vivax merozoite surface protein 1

In an earlier study, we found that individuals with patent infection had significantly higher IgG antibody titers to the 19-kD C-terminal region of Plasmodium vivax merozoite surface protein 1 (PvMSP1) than individuals treated for malaria 1-4 months earlier. These results suggested that the antibody levels decreased rapidly following treatment. The present study was designed to determine the persistence of antibody response to the N- and C-terminal regions of PvMSP1 after infection with P. vivax in individuals from the city of Bélem in northern Brazil. Our results demonstrated that the vast majority of individuals had a significant decrease in antibody titers to the C-terminal region of PvMSP1 in a period of two months following treatment. Among responders to the C-terminal region, 44.4% became serologically negative and 44.4% had their antibody titers reduced by an average of 13-fold. Only 11.2% of the individuals had their antibody titers maintained or slightly increased during that period. A decrease in the antibody response to the recombinant protein representing the N-terminal region of PvMSP1 was also noted; however, it was not as dramatic. The rapid decrease in the antibody levels to the C-terminal region of PvMSP1 might contribute to the high risk of reinfection in these individuals.

Biochemical adjustments to hypoxia by Amazon cichlids

The isozyme distribution of cichlid lactate dehydrogenase (LDH) is related to species environmental preferences. Cichlasoma amazonarum occurs in different environments and presents LDH tissue distribution patterns that correlate with oxygen tension at the capture location. Cichlasoma amazonarum was exposed to long-term severe hypoxia (51 days at 36.4 +/- 5.9 mmHg), tissue LDH isozyme distribution was analyzed by electrophoresis and enzyme activities were measured by monitoring the oxidation of NADH as pyruvate was reduced to lactate. The exposure of Cichlasoma amazonarum to long-term severe hypoxia resulted in changes in the tissue distribution of LDH isozymes. The major changes in response to hypoxia occurred in heart, liver and brain: isozyme A4 was activated in heart and brain, whereas isozyme B4 was activated in liver. The most significant quantitative change occurred in brain LDH of hypoxia-exposed animals which adopted muscle type kinetics, reflecting a new LDH isozyme distribution. LDH activity was significantly reduced (P < 0.05) in animals exposed to hypoxia (N = 8), suggesting an overall LDH suppression. Pyruvate inhibition decreased in all hypoxia-exposed tissues. Thus, the ability of Cichlasoma amazonarum to regulate LDH tissue expression according to oxygen availability allows the animal to survive chronic hypoxic environments. This phenotypic plasticity may occur in other hypoxia-tolerant fish species.

Neutrophil-macrophage cooperation in the host defence against mycobacterial infections

CD-1 mice inoculated intraperitoneally with Mycobacterium avium, M. bovis, M. microti or M. kansasii showed a persistent peritoneal granulocytosis (above 10(6) cells, i.e. more than 15% of total cells) throughout the 3 month period of infection studied. By contrast, in mice inoculated with the non-pathogenic M. aurum or with heat-killed M. avium the number of granulocytes decreased progressively after the first 15 days. No mycobacteria were found in granulocytes except in the first 2 days of infection. The mycobacteria-induced chronic granulocytosis was accompanied by phagocytosis of granulocytes by macrophages. Throughout the 3 months of infection, macrophages were found to contain intracellular lactoferrin. Macrophages with lactoferrin were also found in subcutaneous infection caused by M. marinum and in systemic infection caused by M. avium or M. kansasii. The in vitro activity of mouse peritoneal macrophages against M. avium and M. microti was increased after ingestion of granulocyte material by macrophages. These results lead us to propose that granulocytes participate in the host response to mycobacterial infections, not as phagocytes but rather through an indirect mechanism, as a source for the macrophages of molecules involved in antimicrobial mechanisms (e.g., lactoferrin and myeloperoxidase) lacking in the mature macrophage.

In vivo killing and degradation of Mycobacterium aurum within mouse peritoneal macrophages

We studied the in vivo killing and degradation of Mycobacterium aurum, a nonpathogenic, acid-fast bacillus, within macrophages after inoculation into the peritoneal cavity of CD-1 mice. The degradative process could be divided in five successive steps that were characterized on ultrastructural and cytochemical grounds and the relative contributions of which were determined by quantitative electron microscopy of samples taken at different times. The main ultrastructural alterations observed during the degradative process were ribosome disaggregation, coagulation of the cytoplasmic matrix, and change in the membrane profile from asymmetric to symmetric, with loss of the polysaccharide components from the outer layer, followed by membrane solubilization and intracellular clearing, followed by digestion of the innermost (peptidoglycan) layer of the cell wall, and at the end of the process, disorganization and collapse of the remaining layers of the cell wall. The correlation between viability and morphology indicated that the first ultrastructural signs of viability loss are cytoplasmic coagulation, change in the membrane geometry, and disappearance of ribosomes. The labeling of lysosomes of peritoneal macrophages with ferritin or by the cytochemical demonstration of inorganic trimetaphosphatase showed that fusion of lysosomes with phagosomes containing mycobacteria occurs in the phagocytes in the mouse peritoneal cavity and is already extensive as soon as 1 h after the inoculation of the bacilli.

Changes in the lipid composition of erythrocytes during prolonged fasting in lizard (Tropidurus torquatos) and rat (Rattus norvegicus)

During prolonged fasting in lizard and rat, plasma levels of unesterified cholesterol (UC) and phospholipids (TPL) decreased and there were reductions and increases, respectively, in the molar ratios of lecithin (PC) to sphingomyelin (SPH) and UC to TPL. Plasma lecithin: cholesterol acyltransferase (LCATase) activity in lizard and rat plasma was reduced during prolonged fasting. Erythrocyte lipid composition for fasted animals was also characterized by a reduction in the molar ratio PC/SPH and an increase in UC/TPL, and in both species there were positive correlations between these molar ratios in red cells and those in plasma. In both species these were changes in the morphology of the erythrocytes, and those from fasted rats showed alterations in osmotic fragility and permeability which correlated with alterations in lipid composition. These results suggest that changes in plasma lipoprotein lipid composition, linked to reduced LCATase activity, may cause similar alterations in the lipid composition of red cell membranes leading to altered membrane properties.