Our intention in editing the "Revista de Medicina" is to support students' scientific production and stimulate the reading of scientific articles. Undoubtedly, medical practice requires constant updating and the unquestionable need to read scientific articles. Therefore, it is important to get used to this since Graduation.
Universidade de São Paulo. Faculdade de Medicina
It argues that confronting racism should guide clinical practice, research, and medical education as a quality criterion. It articulates a critical analysis of historical references, institutional documents, and epidemiological indicators on maternal mortality, infant mortality, homicides, hypertension, COVID-19, and mental suffering among Black people in Brazil. It showed that structural and institutional racism produces persistent inequities, distorts health records, restricts access to care, and undermines public policy implementation. The findings remained consistent with previous investigations by reaffirming racism as a social determinant of health and a barrier to equity in the Brazilian Unified Health System. It discusses that antiracist initiatives in teaching, extension, and research, including Race.ID, AfirmaSUS, and AquilombaSUS, offer concrete responses to improve Brazilian medicine and confront racially produced inequalities.
Copyright (c) 2026 Catarina Daniel da Cruz, Rogério Binow Schmidt Andrade, Joyce Cristina Araujo Silva, Júlio César de Oliveira, Ana Claudia Camargo Gonçalves Germani, Bruno Eduardo de Menezes Pequeno, Patricia Lima Ferreira Santa Rosa, Rondinelli Salvador Silva https://creativecommons.org/licenses/by-sa/4.0
From curriculum to care: Libras workload and the readiness for inclusive Primary Health Care
Primary Health Care (PHC) is recognized as the main point of entry for users into Brazil’s Unified Health System (SUS). Therefore, professionals working at this level must be prepared to care for the entire population, including deaf individuals. To fully uphold SUS principles such as universality, humanization, comprehensiveness, and equity, medical training must include the Brazilian Sign Language (Libras) in its curriculum. The 2014 Medical National Curriculum Guidelines recommend Libras as mandatory content, but its implementation still requires evaluation. The objective was to examine the workload dedicated to Libras in medical schools in São Paulo. This was a descriptive, cross-sectional study exempt from ethics approval because it used public data. Seventy-five medical schools (MS) were identified through the e-MEC system; available pedagogical documents were analyzed for references to Libras and workload. Of the 66 MS included in the study, 41 mentioned Libras instruction, and 33 provided workload information. A wide variation was observed, from 27 to 80 hours, with a mean of 44.75 hours and a median/mode of 40 hours. Even in institutions where Libras is mandatory, there was no standardized workload. Libras instruction remains limited and heterogeneous, lacking standardization and showing documentation gaps, reflecting the absence of detailed guidelines.
Copyright (c) 2026 Sheyla Ribeiro Rocha, Claudia Aparecida Stefane, Bianca Caseiro Chiuratto https://creativecommons.org/licenses/by-sa/4.0
Angiosarcoma of the scalp: report of an aggressive case
Angiosarcoma is a rare and highly aggressive type of malignant neoplasm that originates from the endothelial cells of blood or lymphatic vessels and can affect the head and neck regions. We report the case of a 63-year-old woman who presented with a rapidly progressive ulcerated plaque on the scalp and whose diagnosis of scalp angiosarcoma was confirmed by histopathological and immunohistochemical examination. Furthermore, the importance of early diagnosis and appropriate therapeutic management in such cases is emphasized so that the patient may have a better prognosis and quality of life
Copyright (c) 2026 Nivin Mazen Said, Airton Kenji Motizuki, Adriani Ferreira do Carmo, Mariana Bastos Amanajás, Rossana Ruth Garcia da Veiga, Maraya de Jesus Semblano Bittencourt https://creativecommons.org/licenses/by-sa/4.0
Women's Health in Focus: Challenges and Possibilities in Communication between a Gynecologist and a Deaf Patient
Objective: To understand the challenges and possibilities in medical care between gynecologists and deaf patients in the municipality of Itumbiara-GO, in preventive care for women's health. Method: This is a qualitative study involving gynecologists and deaf patients in the municipality of Itumbiara-GO. Data collection took place in March and April 2024, using semi-structured interviews as a data collection tool, containing questions about the challenges and potential encountered by deaf patients and what gynecologists find in the medical care of these patients. Three gynecologists and two deaf women who use Brazilian Sign Language (Libras) took part in the study. The research was submitted to and approved by the Ethics Committee and all the participants signed an informed consent form. Results: The results of the research show significant challenges in communication between gynecologists and deaf patients in Itumbiara-GO, highlighting the urgent need for more inclusive medical training. The interviews reveal that, although there is a mutual effort to overcome communication barriers, the lack of knowledge in Libras on the part of health professionals often results in dependence on companions or interpreters, which compromises patients' autonomy. Conclusion: In order to improve public health in gynecological care for deaf women, it is crucial to implement public and educational policies that encourage the continuous training of health professionals in Libras and the hiring of qualified interpreters in health services
Copyright (c) 2026 Barbara Antunes Braga, Ana Clara Leal, Isabela Samara Gomes, Jéssica Antonieta Reis Borges, Rogério Pacheco Rodrigues https://creativecommons.org/licenses/by-sa/4.0
Mortality in myocardial revascularization surgery: an overview of systematic reviews
The analysis of mortality rates associated with coronary artery bypass grafting (CABG), with or without cardiopulmonary bypass, is relevant, as is its comparison with other therapeutic approaches for severe coronary artery disease, such as percutaneous coronary intervention (PCI), hybrid coronary revascularization (HCR), and medical therapy. This study is an overview of systematic reviews, based on the selection of full-text, open-access articles from three databases (LILACS, PubMed, and Cochrane Library), published between October 2013 and October 2023, in English, Portuguese, and Spanish. Of the 117 reviews identified, 10 were included in the final analysis. CABG showed lower mortality compared with PCI, especially in diabetic patients. The comparison between on-pump and off-pump CABG showed a 72% reduction in 30-day postoperative mortality in the off-pump group among patients at high risk for acute myocardial infarction. No statistically significant differences were found between mortality rates in CABG and HCR. The combination of CABG with medical therapy reduced mortality from cardiac causes, although it did not demonstrate a significant difference in all-cause mortality. Bilateral internal thoracic artery grafting was associated with lower long-term mortality. Complete arterial revascularization showed a lower risk of mortality compared with incomplete revascularization. The compiled results indicate that CABG appears to be the best option for certain outcomes and clinical situations. However, the choice among different approaches and surgical techniques should be individualized, with careful evaluation of the cost-benefit-risk balance in each clinical context.
Copyright (c) 2026 Letícia Martins Cavalcanti, Luana Gomes Ribeiro, Rafaella Montagnier Eskenazi de Lima, Yanne Luisa Leite Barros, Gabriela de Andrade Lima Molina, Aurélio Molina da Costa https://creativecommons.org/licenses/by-sa/4.0
Child Neurodevelopment at 36 Months of Age: The Role Early Life Adversities Analysis
Early life adversities (ELAs) represent a major public health concern due to their long-term consequences for clinical and developmental outcomes (1). Understanding how ELAs shape child development is essential for informing effective prevention and intervention strategies aimed at improving both individual and population-level development outcomes. The Dimensional Model of Adversity and Psychopathology (DMAP) offers a neurobiologically grounded framework to conceptualize how distinct environmental experiences influence neurodevelopment via partially unique mechanisms (2). Moreover, DMAP also contemplates the examination of multiple, co-occurring adversities that children are exposed to (3), especially in underdeveloped countries, where certain forms of adversity remain insufficiently studied (4). Here, we report our contribution to this discussion by examining how the dimensions of threat and deprivation relate to neurodevelopment at 36 months within a context of multiple overlapping adversities. We analyzed data from 36-month-old participants of the São Paulo Western Region Birth Cohort (ROC) (5). Composite measures of threat and deprivation were derived from validated caregiver-reported questionnaires. The threat dimension captured exposure to domestic and community violence, whereas deprivation reflected indicators of household quality, food security, and caregiver education. Multivariable regression models adjusted for contextual confounders were used to assess associations between ELA dimensions and neurodevelopmental outcomes, including effortful control, global development, and internalizing and externalizing problems. Of the 3,619 children enrolled, 1,567 met eligibility criteria based on data availability and absence of comorbidities. Bootstrapped estimates revealed that threat exposure was significantly associated only with internalizing problems (β = 0.43, 95% CI [0.11–0.74], p = 0.008). In contrast, deprivation showed consistent associations across all assessed outcomes, including internalizing problems (β = 0.17, 95% CI [0.03–0.29], p = 0.022), externalizing problems (β = 0.29, 95% CI [0.11–0.47], p = 0.002), reduced effortful control (β = –1.46, 95% CI [–2.08 to –0.88], p < 0.001), and poorer global development (β = –2.44, 95% CI [–3.11 to –1.80], p < 0.001).
Copyright (c) 2025 Tiago Choi; Alexandra Brentani, Verônica Euclydes, Helena Brentani https://creativecommons.org/licenses/by-sa/4.0
The hazing gap: The concealed burden in Brazilian medical schools and the need for validated assessment tools
The university learning environment plays a crucial role in shaping students’ mental health and overall well-being. Although these settings are often associated with personal and academic growth, they can also expose students to conditions that contribute to psychological distress1. Recent evidence shows that certain aspects of college life, especially in medical schools, are linked to high rates of anxiety and depression among medical students. Factors such as academic pressure, performance demands, and the broader institutional culture help explain these findings2,3. For newly admitted students, these factors are predominantly linked to the process of entering a new environment. The transition into university often involves seeking belonging within groups such as sports teams, student organizations, and residence communities4. Initiation rituals are part of this integration process and can range from welcoming and harmless to violent and abusive5. These violent and potentially abusive practices are collectively known as “hazing”, which includes various forms of violence, such as gender or racial violence, bullying, and institutional violence6.
Juliane Piasseschi de Bernardin Gonçalves
Copyright (c) 2025 Euripedes Constantino Miguel, Giancarlo Lucchetti, Rodolfo Furlan Damiano, Clarissa Garcia, Laura Fernandes Berto, Rodrigo Hadade, Juliane Piasseschi de Bernardin Gonçalves, Bianca Besteti Fernandes Damiano, Elizabeth J. Allan, David Kerschner, Oscarina da Silva Ezequiel, Alessandra Lamas Granero Lucchetti, Lisabeth F. Dilalla, Homero Vallada https://creativecommons.org/licenses/by-sa/4.0
Epidemiological profile of sickle cell trait in blood collection units in the North and Northeast regions of Brazil: a narrative review
Introduction: Sickle cell trait is a condition caused by a mutation in hemoglobin, leading to the formation of a variant molecule, hemoglobin S (HbS). Its prevalence among blood donors in Brazil is higher in men and is present in 2.49% of the national population. Objective: To investigate the epidemiological profile of sickle cell trait in blood collection units in the North and Northeast regions of Brazil, based on the scientific literature. Method: This is a narrative literature review. The searches were conducted in six databases, using the following Health Sciences Descriptors (DeCS/MeSH): Sickle Cell Trait, Blood Donors and Brazil, applying the Boolean operator AND. Original qualitative and quantitative studies conducted in blood collection units, systematic reviews with or without meta-analyses, case studies, and technical notes published from 2014 to 2024 in English or Portuguese were included. Duplicate studies, course completion papers, master's dissertations and doctoral theses were excluded. Results: Ten articles were selected, of which two refer to studies conducted in the North Region and eight refer to studies in the Northeast Region. In the blood centers of the North Region, there is a prevalence of 1.3 to 1.41% of donors affected by the HbAS allele, with a predominance of black and mixed-race males, while in the Northeast Region there is a variable prevalence of 0.79% to 3.92% of carriers of the sickle cell trait, with a predominance of mixed-race or mixed-race men aged between 20 and 40 years. Conclusion: A similar epidemiological pattern was observed in the North and Northeast regions, with a predominance of male donors and of mixed-race individuals. In addition, there is a scarcity of studies on the sickle cell trait in these regions, highlighting the need for further research on this subject.
Francisco Dimitre Rodrigo Pereira Santos
Copyright (c) 2026 João Pedro Ferreira Duarte, Ana Alice Coutinho de Oliveira, Lucas dos Santos, Francisco Dimitre, Saulo Meira, Beatriz Roriz https://creativecommons.org/licenses/by-sa/4.0
Rare case of recurrent thymoma with invasion of the thoracolumbar spine.
Does not apply - letter to the editor.
Copyright (c) 2025 Giovanni Scorzoni Paro, Italo Gerardo Rotondo, Douglas Kenji Narazaki, Matheus Augusto Maciel Santiago https://creativecommons.org/licenses/by-sa/4.0
Understanding how Nonsuicidal Self-injury occurs in low- or middle-income countries
Nonsuicidal self-injury (NSSI), defined as the deliberate destruction of body tissue without suicidal intent, represents a major public health concern among adolescents and young adults worldwide [1]. However, data from low- and middle-income countries (LMICs) remain scarce, particularly from community-based samples. In this context, Souza et al. conducted the first representative community-based study on NSSI in Brazil, using data from the Brazilian High-Risk Cohort Study (BHRC) [2]. This research provides novel findings on the six-month prevalence and psychopathological correlates of occasional and repetitive NSSI among Brazilian youth. Weighted analyses revealed patterns consistent with global findings, highlighting the importance of understanding NSSI in diverse sociocultural contexts. Importantly, the study demonstrated a robust association between NSSI and psychiatric comorbidities, particularly depressive and anxiety disorders, as well as a dose–response relationship between the number of concurrent diagnoses and NSSI severity. While occasional NSSI was not significantly associated with psychopathology, repetitive NSSI showed strong correlations with mood, anxiety, and externalizing disorders, highlighting distinct clinical trajectories and developmental pathways [3]. By integrating survey-weighted models and zero-inflated negative binomial regressions, this study contributes essential epidemiological evidence on NSSI in a large LMIC population. These findings emphasize the need for early detection and preventive strategies, as well as longitudinal investigations to understand how NSSI evolves from adolescence into adulthood. Overall, this work represents a significant contribution to developmental psychiatry, bridging an important knowledge gap in the epidemiology of self-injurious behaviors in emerging countries.
Copyright (c) 2025 Gabriel Ângelo Ferreira Faria de Souza, Caio Fernandes Lins Peixoto , Giovanni Abrahão Salum, Pedro Mario Pan, Marcelo José Abduch Ada Brañas, Euripedes Constantino Miguel, Marcos Signoretti Croci https://creativecommons.org/licenses/by-sa/4.0
The Impact of the MadAlegria Project on Humanized Training and the Development of Empathy among Alumni
In recent decades, the remarkable scientific and technological progress in healthcare has been accompanied by a marked distancing in interpersonal relationships within care settings. This scenario contrasts with the definition of health proposed by the World Health Organization — as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity¹ — and with the principles of Brazil’s National Humanization Policy (Política Nacional de Humanização, PNH) within the Unified Health System, which recognizes the centrality of the individual in all dimensions of care². In Brazil, the concept of health was further expanded in 1990, when it was established as a fundamental human right under the Law 8.080/1990³. In 2003, the National Humanization Policy was created to value all subjects involved in the care process — including users, professionals, and managers — guided by principles such as transversality, inseparability between care and management, and autonomy, co-responsibility, and protagonism of individuals and collectives²,⁴. Humanization is therefore an essential component of both clinical practice and the education of healthcare professionals. In the training of such professionals, the development of competencies such as empathy, active listening, and receptiveness is fundamental to ensuring patient-centered care⁵⁻⁷. However, the growing gap between technical-scientific advancement and the quality of human interactions in healthcare underscores the need for educational strategies focused on humanized training⁸⁻¹². Within this context, the MadAlegria Project was created to foster humanized practices in both learning and professional behavior. Established in 2011 by students and faculty members at the University of São Paulo (USP), MadAlegria is a Culture and University Extension Project aimed at promoting humanization in healthcare education—particularly at the undergraduate level—and at improving the hospital environment, making it more welcoming for patients, families, and healthcare staff. Since 2012, the project has incorporated two artistic and playful languages: hospital clowning and storytelling. These approaches are used as pedagogical tools to enhance relational competencies such as empathy, active listening, teamwork, and sensitivity to others’ experiences¹³⁻¹⁵.
Copyright (c) 2025 Elizabeth Alves Gonçalves Ferreira, Lorena Cristina São Leão Ribeiro, Priscila Berenice da Costa, Jéssica Almeida dos Santos https://creativecommons.org/licenses/by-sa/4.0
MadAlegria: An academic outreach project restoring humanization in healthcare through the art of presence, connection, and empathy
Introduction: IIllness often provokes distress in patients and their support networks. Humanization should be part of the training of healthcare professionals. Founded in 2011 by undergraduate students in Medicine, Physical Therapy, Occupational Therapy, Speech-Language Pathology, Nursing, and Nutrition, MadAlegria draws on storytelling and hospital clowning to foster empathy, promote humanized care, create more welcoming hospital environments, and expand students’ understanding of illness beyond its biological aspects. Objectives: To describe the MadAlegria Project, that promotes humanization in the education of healthcare professionals. Methods: MadAlegria develops two main activities: (1) annual training in Hospital Clowning or Storytelling; and (2) weekly visits to inpatients in oncology, dermatology, and obstetrics units. Teams engage in brief, respectful interactions guided by consent and institutional availability. Other actions include organizing the Humanization in Healthcare Symposium, participating in institutional events, promoting blood donation and integrative workshops. Results: Between 2017 and 2023, MadAlegria trained 578 volunteers, conducted 2.345 visits, involving 1.193 companions and 2,354 healthcare professionals. Data collected via REDCap® revealed that 99% of participants reported a positive impact, mainly in terms of empathy, humanization, and attentive listening. Only 6% of volunteers remain active. Discussion: MadAlegria has been achieving its goal of humanizing the training of healthcare professionals with empathy, while also conducting a large number of visits and interactions with patients, companions, and healthcare professionals in the hospital. Keeping volunteers active in the project for many years is a challenge influenced by other variables such as time and priority. Even if the volunteer does not continue with the project's activities, it is considered a success if they have become a more empathetic healthcare professional. Conclusion: MadAlegria strengthens humanized practice in healthcare education, promoting empathy and compassion in the hospital environment. The continuation of the project depends on institutional support.
Copyright (c) 2025 Lorena Cristina São Leão Ribeiro, Jéssica Almeida dos Santos, Priscila Berenice da Costa, Elizabeth Alves Gonçalves Ferreira https://creativecommons.org/licenses/by-sa/4.0
Letter to the editor - Hypoparathyroidism after parathyroidectomy in patients with multiple endocrine neoplasia type 1
Multiple endocrine neoplasia type 1 (MEN1) is a genetic syndrome caused by inactivation of the MEN1 tumor suppressor gene, which confers increased susceptibility to the development of neoplasms, especially endocrine tumors such as parathyroid adenomas.¹ Although it is a rare disease, primary hyperparathyroidism resulting from hyperplasia and/or neoplasia of the parathyroid glands occurs in up to 97% of individuals with the syndrome.² The treatment for hyperparathyroidism is surgical, and the two main techniques currently used are subtotal parathyroidectomy, involving the removal of 3.5 glands, and total parathyroidectomy with autotransplantation, in which all four glands are removed and a graft is prepared in the forearm.³ Although both approaches are employed, the choice of the optimal surgical technique for this condition remains under debate. A single study with a small cohort of 32 participants compared these two procedures and found no significant differences between them.⁴ The choice of surgical technique must consider the risk of recurrent hyperparathyroidism, given the multiglandular nature of the disease, and the risk of complications for example, hypoparathyroidism — defined by inappropriately low PTH levels in the presence of hypocalcemia.⁵ Traditionally, postoperative hypoparathyroidism is considered permanent when it persists for more than six months after surgery.⁶ However, this arbitrary definition is based on patients undergoing thyroidectomy and who do not have MEN1. Patients with MEN1 may have additional factors that delay the recovery of parathyroid function, such as previous malabsorptive surgeries, prolonged hungry bone syndrome, and removal of multiple glands. The latest international hypoparathyroidism guideline, published in 2022, proposed extending this limit to twelve months⁷, recognizing that functional recovery may be slower in specific contexts.
Copyright (c) 2025 Rafaela Mendes Battiferro, Delmar Muniz Lourenço Junior, Felipe Ferraz Magnabosco, Fábio Luiz de Menezes Montenegro, Marília D'Elboux Guimarães Brescia https://creativecommons.org/licenses/by-sa/4.0
Forklift-Induced Thoracic Trauma with Bronchial Rupture: A Survival Case Report in a Referral Center
Tracheobronchial injuries are rare but potentially fatal events, usually associated with high-energy chest trauma and often diagnosed late. Proper airway management is essential for survival in such cases. This report describes the case of a 34-year-old man who sustained thoracic crush trauma after being struck by a forklift, presenting with a penetrating wound to the right hemithorax, subcutaneous emphysema, and severe respiratory failure. He was intubated in the prehospital setting and transferred by air to a trauma referral center. Upon admission, he exhibited hemodynamic instability and refractory hypoxemia, prompting immediate transfer to the operating room. During the procedure, a complete transection of the trachea approximately 3 cm above the carina was identified, associated with extensive laceration of the right main bronchus. It was noted that the patient had been selectively intubated into the left bronchus, which unintentionally allowed effective ventilation of the left lung, maintaining minimal oxygenation until surgical repair. A tracheobronchial anastomosis was performed, followed by vascular evaluation that revealed vertebral artery dissection. The patient progressed with respiratory stability but developed sequelae, including posterior circulation ischemic stroke, partial visual deficit, tracheal stenosis, and motor-sensory impairment of the right upper limb. This case highlights the importance of early recognition of tracheobronchial injuries, appropriate airway management, and timely transfer to specialized centers. The accidental left main bronchus intubation played a crucial role in survival, serving as a temporarily protective ventilation strategy in the setting of complete tracheal rupture.
Copyright (c) 2025 Lara Leiro Passos Santos, Amanda Uneida Vieira, Flávio Roberto da Silva, Sérgio Henrique Bastos Damous, Fernando da Costa Ferreira Novo, Edivaldo Massazo Utiyama https://creativecommons.org/licenses/by-sa/4.0
Registration of the epidemiological and cunctional clinical profile of patients post traumatic brain injury at a high complexity hospital in the interior of the state of São Paulo
Traumatic Brain Injury (TBI) results from physical forces that cause brain lesions and functional impairment. Although the Glasgow Coma Scale (GCS) is widely used, it fails to capture all neurological deficits, leading to the development of the Neurological Outcome Scale for Traumatic Brain Injury (NOS-TBI), based on the NIHSS and designed to assess post-TBI sequelae. This prospective study aimed to create a clinical registry of TBI cases at FSCMF (Franca, São Paulo, Brazil), characterize the clinical and functional profile of patients, and analyze predictive factors for six-month outcomes. Adults with TBI admitted between October 2023 and December 2024 were included. Clinical assessments were conducted at admission, during hospitalization, and six months after discharge using the GCS, NOS-TBI, TICS-M, Modified Rankin Scale, and Edinburgh Handedness Inventory. The final sample consisted of 40 patients, predominantly male (72.5%), with a median age of 51 years. The main causes of TBI were traffic accidents (44.7%) and falls (31.6%). Regarding severity, 70% had mild TBI, 12.5% moderate, and 17.5% severe. The NOS-TBI demonstrated excellent internal consistency (α>0.9) and high interrater reliability (K>0.8), with perfect agreement in some items (K=1). Despite the strong reliability of the scale, only nine patients completed the six-month follow-up, limiting the analysis of functional outcomes. Most showed satisfactory recovery, although severe TBI, older age, and high-impact trauma mechanisms were associated with poorer prognosis. This study reinforces the utility of the NOS-TBI as a sensitive tool for early identification of neurological deficits and as a complement to the GCS. Difficulties in patient follow-up highlight the need to improve post-discharge tracking strategies and strengthen the integration of care within the Brazilian Unified Health System (SUS).
Copyright (c) 2026 Leonardo Ribela de Alvarenga, Mariana de Oliveira Lima, Giovanna Dorneles e Silva, Maria Júlia Sindou Siqueira https://creativecommons.org/licenses/by-sa/4.0
Complicated diabetic foot and multidisciplinary management: a case report from iatrogenesis to resolution
Diabetic foot infections, or diabetes-related foot disease (DRFD), represent one of the leading causes of emergency hospital admissions among patients with diabetes and often precede unfavorable outcomes such as amputations. These complications may be associated with iatrogenic initial management, which can be prevented or mitigated through an appropriate multidisciplinary approach. We report the case of an 80-year-old male patient with type 2 diabetes mellitus, well controlled with oral antidiabetic agents, who developed tissue necrosis following a laceration of the second toe of the left foot. Upon seeking care at his local Primary Health Unit, he underwent an amputation of the affected region under suboptimal aseptic and antiseptic conditions, performed by a non-specialist physician, which resulted in severe forefoot infection and sepsis. This evolution prompted an orthopedic consultation and subsequent transmetatarsal amputation. From that point onward, with the implementation of well-established multidisciplinary strategies, the clinical outcome was satisfactory. This case illustrates a peculiar situation, in which an initial iatrogenic intervention evolved favorably after appropriate multidisciplinary management was instituted.
Copyright (c) 2026 Thais Cristina de Aquino Lima, Dr. Tiago Soares Baumfeld, Dr. Ávila Souza Júnior https://creativecommons.org/licenses/by-sa/4.0
Therapeutic Management of Exocrine Pancreatic Insufficiency in Patients with Cystic Fibrosis: An Integrative Review
The study analyzed evidence on therapy for exocrine pancreatic insufficiency in patients with cystic fibrosis, based on a search conducted in the PubMed and Virtual Health Library (Biblioteca Virtual de Saúde) databases. Studies published between 2019 and 2024 were included, resulting in a final selection of 48 articles, 24 of which focused on therapeutic interventions. The management of pancreatic insufficiency relies on three pillars: pancreatic enzyme replacement therapy (PERT), nutritional support, and continuous monitoring. PERT is essential for correcting malabsorption, utilizing enzymes derived from pigs, but it faces challenges such as patient adherence and variability in treatment response. The need to take multiple capsules and errors in administration are obstacles that require ongoing follow-up. Nutritional support is crucial, involving high-calorie diets and supplementation with fat-soluble vitamins. Despite the importance of nutrition, patient adherence to interventions remains low. CFTR modulators, such as ivacaftor, have emerged as innovative alternatives, but treatment discontinuation reverses the benefits, highlighting the need for further research. The article underscores the importance of integrated and personalized strategies for managing pancreatic insufficiency in cystic fibrosis.
Copyright (c) 2025 Helena Meurer Heidemann, Laís Corrêa de Carvalho, Bruna Eduarda Weirich, Yasmin Guimarães Rodrigues https://creativecommons.org/licenses/by-sa/4.0
Aspecto linear da hanseníase borderline em paciente do sexo feminino: uma apresentação atípica de lesão no tegumento
Leprosy is a chronic infection influenced by the immune response of each host, and its inflammatory immunopathology can present both neural and dermatological manifestations. This case involves a 17-year-old female patient, phototype IV, diagnosed with leprosy, who developed a hypochromic, erythematous, infiltrated linear plaque along the ulnar pathway, accompanied by claw hand deformity in the right upper limb. Additionally, complementary examinations, including histopathological analysis, confirmed the diagnosis of borderline leprosy. During the second month of clinical follow-up, the patient’s β-HCG test returned positive, indicating pregnancy. Literature suggests that the heterogeneous cutaneous presentation observed in DD leprosy reflects an intensely variable immune response, with lesions oscillating between the multibacillary and paucibacillary poles of the disease spectrum. This leprous lesion exhibits a unique aspect not documented in the literature, highlighting the need for further investigation into these diverse manifestations in order to prevent misdiagnosis and facilitate early treatment.
Copyright (c) 2025 Nivin Mazen Said, Airton Kenji Motizuki, Nirlando Igor Fróes Miranda, Marília Brasil Xavier https://creativecommons.org/licenses/by-sa/4.0
Association between glucose homeostasis and mental disorders in type 1 diabetic patients
Introduction: Type 1 diabetes mellitus (DM1) is a disease characterized by autoimmune degeneration of insulin-producing pancreatic cells. Thus, glycemic control in DM1 patients is difficult to achieve due to a complete insulin deficiency. Hyperglycemia, hypoglycemia, and ketoacidosis are common complications of DM1, and the stress of living with these disorders has been associated with detrimental effects on mental health and quality of life. Objective: The study aimed to evaluate the quality of life and mental health of community-dwelling patients with DM1. Method: This was an analytical cross-sectional study involving adults with DM1. Mental health was assessed using the Depression Anxiety and Stress Scale (DASS-21) and the Quality of Life Assessment Questionnaire (SF-36). Results: Significant correlations were observed between elevated glycated hemoglobin (HbA1c) levels and worse quality of life indices, as well as higher levels of anxiety, stress, and depression. Complications of DM1 impact mental health, increase cardiovascular risks, hospitalizations and healthcare costs, and reduce life expectancy and quality, treatment adherence, and the adequate glycemic control. Conclusion: The research highlights the importance of screening for mental disorders in patients with type 1 diabetes to promote treatment adherence and prevent complications.
Copyright (c) 2025 Karen Coelho, Lucas Gomes de Souza, Mariana Soares Gaudio, Letícia Medeiros de Oliveira, Maria Paula Maia Mariano, Aline Bomfim Madeira, Gabriela Leandro Alves, Aluana Santana Carlos, Joana da Costa Pinto d’Avila https://creativecommons.org/licenses/by-sa/4.0
Burnout syndrome's impact on hospital pharmacists in a brazilian state during the covid-19 pandemic
Burnout Syndrome is characterized by emotional and physical exhaustion resulting from chronic occupational stress and is prevalent among healthcare professionals. This study aims to identify the presence of Burnout Syndrome and classify its levels among pharmacists working in hospital pharmacies in the state of Espírito Santo, Brazil. This interventional, descriptive, and cross-sectional study was conducted in three stages: pre-questionnaire, intervention through weekly message delivery via WhatsApp, and post-questionnaire. The initial sample consisted of 31 pharmacists, 74% of whom were female, with a mean age of 36 years. In the pre-questionnaire, 61.3% of participants showed high levels of Emotional Exhaustion, 54.8% high levels of Depersonalization, and 67.7% high levels of Personal Accomplishment. Women presented moderate to high levels of Personal Accomplishment, while men predominantly reported high levels, with no statistically significant difference between sexes. Variables such as age group, weekly working hours, work shift, use of personal protective equipment (PPE), training, and changes in sleep patterns were also analyzed, with no relevant statistical associations found. The intervention was adhered to by 11 pharmacists, and the post-questionnaire was completed by 10 participants. When comparing scores before and after the intervention, no statistically significant differences (p≥0.05) were observed in the dimensions of Emotional Exhaustion, Depersonalization, and Personal Accomplishment. Although no statistically significant results were found after the intervention, the data reveal high levels of emotional strain among these professionals, highlighting the urgent need for occupational health promotion strategies for hospital pharmacists, as well as further studies on Burnout Syndrome in this specific context.
Copyright (c) 2025 Liliani Travezani Martins, Marcelita França Marques, Mônica Cola Cariello Brotas Corrêa, Denise Coutinho Endringer https://creativecommons.org/licenses/by-sa/4.0
Analysis of the profile of gynecological and obstetric procedures in a hospital in the Vale do Jequitinhonha
Epidemiology is essential for assessing the quality and adequacy of healthcare services and becomes even more relevant in the Jequitinhonha Valley (Minas Gerais - MG), where there is a significant disparity in cultural wealth and economic reality. This article aimed to explore the epidemiological profile of patients who underwent gynecological and obstetric surgeries in the city of Gouveia, MG. The study was conducted through the analysis of medical records of obstetric and gynecological surgeries in the mentioned city between the years 2020 and 2023, with the aim of analyzing the performed interventions, age, race, and other parameters. Of the 272 medical records, 92.5% corresponded to gynecological procedures, while only 1.4% were obstetric. Among these, the predominant age group was 41 to 50 years. Regarding race, the vast majority self-identified as mixed-race, accounting for 73.1% of the patients. The two most performed procedures in the hospital in question were hysterectomy, representing 26.1% of cases, and tubal ligation, with 25.7%, followed by procedures such as semiotic curettage (with and without cervical dilation), type 3 cervical excision, and colpoperineoplasty. Additionally, 99.2% of the procedures were covered by the Sistema Único de Saúde (SUS) (Brazil’s Unified Health System). Based on this, there is a noticeable demand for family planning among women in the region, particularly those who self-identify as black, through permanent procedures. Furthermore, the real accessibility of healthcare services for the entire female population in the area can be questioned, considering that there are 5,746 women but only 272 procedures recorded for the period. Thus, this study highlights the need for further research on the population and the procedures performed, in order to develop new policies and protocols aimed at increasing inclusion, accessibility, and the quality of care for all women who rely on this healthcare system.
Copyright (c) 2025 Bárbara Silva Vicentini, Letícia Couto Freitas, Breno Wesley da Cunha Oliveira, Bruna Fonseca dos Santos, Laryssa Balmant Lima, Letícia Leite dos Santos, Maria Isabel Martins de Castro, Bianca Cristina Lopes da Silva, Ramon Wellison da Silva Leite https://creativecommons.org/licenses/by-sa/4.0
Evaluation of the prevalence and prognosis of the association between subclinical hypothyroidism and heart failure in hospitalized elderly patients
Subclinical hypothyroidism (SCH) presents as raised TSH with normal free T4. It may be associated with long-term cardiovascular complications, such as heart failure (HF), although this relationship remains uncertain. This study aims to better understand the association between SCH and HF, focusing on prevalence and prognosis in hospitalized elderly patients. This is a retrospective, cross-sectional observational study conducted with patients aged ≥ 60 years hospitalized with HF in a cardiology reference hospital. TSH levels and additional tests were assessed in 241 elderly patients who met the study's inclusion and exclusion criteria. The mean age of the participants was 70.59 years, with the majority being male and of mixed ethnicity. SCH was present in 15.8% of the participants, and in-hospital mortality occurred in 9.5%. Although the mean left ventricular ejection fraction (LVEF) was lower in the SCH group, the difference between the groups was not statistically significant. Notably, 18.4% of patients with SCH died during hospitalization, compared to 7.9% in the control group; however, this difference was also not statistically significant. Therefore, in elderly patients hospitalized for heart failure, the presence of HSC did not result in worse laboratory and imaging test outcomes, nor in more severe clinical outcomes.
Copyright (c) 2025 Paulo Daniel Medeiros Braulino, Mathaus Matos Santos, Bianca Xavier Torres Ferreira, Humberto Caldas de Oliveira Melo, Luiz Henrique Maciel Griz, Irina Gomes Maia Maia, Athina Gomes Maia, Luiz Felipe Nunes Palhares https://creativecommons.org/licenses/by-sa/4.0
Tranexamic acid in postpartum hemorrhage: clinical evidence and its use in prophylaxis and treatment
Introduction: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. In this context, tranexamic acid (TXA), an antifibrinolytic agent, has been studied as an effective strategy for the prevention and management of PPH. The impact of PPH is significant, especially in low- and middle-income countries, where limited access to emergency obstetric care contributes to increased maternal morbidity and mortality. Therefore, investigating accessible and easily administered therapies, such as TXA, is essential for improving clinical protocols and enabling favorable maternal outcomes. Objective: To evaluate the efficacy of TXA in the prophylaxis and treatment of PPH. Methods: This is an integrative literature review conducted in March 2025, with searches in the PubMed and WHO ICTRP databases. In the PubMed database, the search strategy used the descriptors ("Tranexamic Acid"[Mesh] OR "Tranexamic Acid/therapeutic use"[MAJR] OR "TXA"[tiab]) AND ("Postpartum Hemorrhage"[Mesh] OR "Postpartum Hemorrhage/drug therapy"[MAJR] OR "Obstetric Hemorrhage"[tiab]). Randomized clinical trials published in English between 2020 and 2025 were included. In the WHO ICTRP, a search was conducted with the descriptor "tranexamic acid," using the "With results only" filter, yielding 77 articles (28 from PubMed and 49 from WHO ICTRP). After screening by title and abstract, and full-text reading, 7 clinical trials were included. Additionally, one study was manually added due to its exceptional historical relevance, totaling 8 articles for analysis. Variables were collected using a previously validated form. Results: Based on this data, prophylaxis studies consistently demonstrated that TXA, administered before cesarean incision or after vaginal delivery, significantly reduced blood loss and/or the incidence of PPH. However, the impact on reducing the need for blood transfusion was not uniformly significant in these prophylactic studies, with no statistical difference reported. Regarding the treatment of established PPH, a large-scale clinical trial showed a significant reduction in mortality from bleeding when TXA was administered early (ideally within the first three hours), but it did not find a significant reduction in the hysterectomy rate. In contrast, a later study focusing on women with PPH and pre-existing moderate to severe anemia found no benefit of TXA in reducing the progression to severe PPH or in bleeding-related mortality in this specific subpopulation. None of the eight studies analyzed reported a significant increase in thromboembolic events associated with TXA use, and there was no evidence of an increase in puerperal infections. Conclusion: This review indicates that TXA selectively improves maternal prognosis. In prophylaxis, it consistently reduces blood loss, although its impact on reducing transfusions is less clear. In the treatment of established PPH, the medication may decrease mortality from bleeding, but this benefit was not confirmed in anemic women, and the effects on transfusions or surgical interventions were inconsistent. The validation of these approaches through future studies is crucial for the development of safer and more effective clinical guidelines.
Copyright (c) 2026 Maria Eduarda Furieri Machado, Manuela Vilela de Freitas Drumond, Yasmin Ramos Marianelli, Laura Miranda Zandonade, Tainá Goes Pires Kuster, Simone Karla Apolonio Duarte, Hudson Pereira Pinto, Julianna Vaillant Louzada Oliveira, Ludmila Vittoraci Bernardi https://creativecommons.org/licenses/by-sa/4.0
Clinical and epidemiological profile, anesthetic-surgical procedure, and clinical outcomes of neurosurgical patients
Background: Neuroanesthesia and neurosurgery are crucial approaches for managing pathologies of the human nervous system, responsible for minimizing the severity of pain, physical limitations and cognitive-functional impairment. In view of this question, this study aims to describe the clinical-epidemiological profile, anesthetic-surgical procedure, postoperative pain management and clinical evolution. Methods: Descriptive cross-sectional study conducted at a tertiary hospital, involving patients undergoing elective neurosurgery from January 2020 to December 2022, with data collected from electronic medical records. Results: In the sample (n=171), males were predominant (53.8%), aged between 60 and 69 years (21.0%; mean 56.1 ± 2.5 years), white skin color (94.2%), current or previous smoking (33.9%), alcohol consumption (55.6%), non-eutrophic (60.4%), comorbidities (94.2%) and previous surgeries (86.0%). In the anesthetic-surgical procedure, preoperative hospitalization duration was 1 day (46.8%), surgical time ranged between 61 and 120 minutes (26.9%), cranial surgical site (56.7%), with cranioplasty (31.0%), general anesthesia (90.6%), orotracheal intubation (90.6%) and dorsal decubitus (77.1%). Hemocomponent reserve and transfusion occurred in, respectively, 40.4% and 26.3% of procedures. Regarding clinical evolution, the total duration of hospitalization (33.9%; mean 8.7 ± 1.8 days) and preoperative (41.5%; mean 6.4 ± 1.1 days) was between 4 and 5 days, intensive care unit admission (17.0%), hospital discharge (90.1%), and death (2.3%) were highlighted. Conclusion: Elective neurosurgical patients are predominantly men aged 60 to 69 years with non-eutrophic nutritional status, comorbidities, and previous surgeries, undergoing cranial procedures with general anesthesia, orotracheal intubation, multimodal postoperative analgesia, and hospital discharge.
Copyright (c) 2026 Shana Ginar da Silva, Lucas Dalla Maria, Ivana Loraine Lindemann, Eugenio Pagnussatt Neto https://creativecommons.org/licenses/by-sa/4.0
Subacute granulomatous thyroiditis mimicking thyroid carcinoma: diagnostic challenges
Background: Subacute granulomatous thyroiditis (SGT) is a self-limiting inflammatory disease of the thyroid gland, often associated with viral infections. It is typically diagnosed through clinical and laboratory evaluation, although ultrasonography can be a useful adjunct. However, the most common ultrasonographic finding—nodular hypoechoic areas—may raise suspicion for other pathologies, such as thyroid carcinoma. Case Description: A 34-year-old female patient presented with neck pain and progressive odynophagia. Thyroid ultrasound and cytology revealed a suspicious thyroid nodule. Ultrasonography showed a nodule in the right lobe measuring 1,4cm x 1,8cm x 0,6cm, with increased Doppler vascularity, and fine-needle aspiration cytology was classified as Bethesda V, suggestive of neoplasia. A right lobectomy was performed, and histopathological examination confirmed the diagnosis of SGT. Discussion: Although SGT is a benign condition, its clinical and cytological features may mimic those of thyroid carcinoma, posing a diagnostic challenge that may require more invasive procedures for histopathological evaluation and clinical decision-making. Histopathological findings such as the presence of giant cells, follicular atypia, and inflammatory patterns can lead to suspicion of malignancy. Recognizing this entity in histopathological analysis is essential. Conclusion: It is important to correlate clinical, laboratory, and imaging findings in the evaluation of thyroid nodules, especially in the presence of cytological features suggestive of malignancy. In this context, considering SGT as part of the differential diagnosis is crucial to guide appropriate therapeutic decisions.
Copyright (c) 2025 Milena Leite de Oliveira, Michel Antonio Kiyota Moutinho, Roberta Teixeira de Moraes, Lucimar Retto da Silva de Avó, Débora Gusmão de Melo, Carla Maria Ramos Germano, Victor Hugo Maion https://creativecommons.org/licenses/by-sa/4.0
Relationship between functional indicators, muscle strength, and mobility in institutionalized older adults engaged in physical exercise
The aim of this study was to analyze the functional profile and investigate the relationships between muscle strength, mobility, balance, and functional capacity in institutionalized older adults participating in a physical and recreational activity group. This was a quantitative, analytical, observational, cross-sectional study conducted in a Long-Term Care Facility for the Elderly in Ivaiporã-PR, with ethical approval. Eleven older adults with independent gait participated, with a mean age of 68.9 years; most were men (72.7%), White (90.9%), had no falls in the past year (90.9%), and used three or more medications (72.7%). The following instruments were applied: Timed Up and Go (TUG), 8-meter gait speed, handgrip strength, 30-second chair stand test, functional reach test, SARC-Calf questionnaire, and Katz Index. The mean results were: TUG = 18.65s; gait speed = 0.57 m/s; handgrip = 16.1 kgf; chair stand = 9.2 repetitions; functional reach = –8.2 cm; SARC-Calf = 7.6 points; Katz = 5.3 points. Analyses showed significant correlations between mobility, muscle strength, and functional independence. The TUG showed a strong negative correlation with Katz (r = –0.88), indicating that longer execution time is associated with lower independence. Gait speed and upper-limb strength were positively correlated with functional performance. It is concluded that, although engaged in physical and recreational activities, the older adults presented limitations in strength, flexibility, and mobility. The findings highlight the need for continuous interventions focused on muscle strengthening, balance training, and stimulation of functional independence.
Copyright (c) 2026 Daniel Vicentini de Oliveira, Ricardo Alexandre Carminato, Gabriela Silva Breda, Danielly Salvador de Mello, Daniela Cunha, Adrian Fellipe Pereira de Oliveira, José Roberto Andrade Nascimento Júnior, Andreia Paula Basei https://creativecommons.org/licenses/by-sa/4.0
Music in the waiting room as a strategy for humanizing Primary Health Care
Introduction: Brazil’s National Humanization Policy within the Unified Health System (SUS) promotes welcoming practices aimed at improving the quality of care, with waiting rooms representing a strategic setting for the implementation of humanizing interventions. In this context, the use of music emerges as a simple and potentially effective strategy to modulate the waiting experience. This study aimed to evaluate the impact of music in waiting rooms as a welcoming strategy in Primary Health Care Units (Unidades Básicas de Saúde - UBS). Methods: This applied, exploratory, descriptive, and explanatory study adopted a mixed-methods approach and was conducted in four UBS in the municipality of Passos, Minas Gerais, Brazil. Forty adult users participated, equally allocated to a group exposed to instrumental classical music in the waiting room for approximately 20-30 minutes and a control group without music. Data collection included semi-structured interviews and systematic observation. Qualitative data were analyzed using Bardin’s content analysis framework, while quantitative data were organized into tables and charts. Results: The sample was predominantly female (85%), aged 40–50 years (32.5%), and of low income (92.5%). Waiting time was identified as the main source of dissatisfaction in both groups; however, users exposed to music reported greater acceptance, resilience, and neutrality toward delays, as well as more positive perceptions of the environment, associated with relaxation, calmness, and a sense of being welcomed. In contrast, the non-music group predominantly reported impatience, tension, and monotony during the waiting period, associated with the lack of environmental stimuli and an intensified perception of time. Conclusion: The use of music in waiting rooms enhanced the subjective waiting experience by promoting well-being and a sense of being welcomed, and proved to be a simple, low-cost, and potentially replicable intervention for the humanization of care in Primary Health Care.
Copyright (c) 2026 Carlos Silva, Isadora Resende, Natália Oliveira, Giovanna Prado, Edna Santos, Mateus Alves https://creativecommons.org/licenses/by-sa/4.0
Mini-percutaneous in transplanted kidney – case report
Introduction: The incidence of de novo lithiasis after kidney transplantation is low. Patients usually do not report pain due to the absence of innervation of the organ, which can result in a late diagnosis. Minimally invasive percutaneous nephrolithotomy (mini-NLPC) is one of the options that can be used in the therapeutic arsenal for the treatment of this disease. We present a case of mini-NLPC in a kidney transplant patient. Case presentation: Patient with a 1.5 cm non-obstructive stone in the kidney graft underwent mini-NLPC (16Fr), performed in two stages due to bleeding, with total removal of the stone. The patient presented with urinary tract infection in the postoperative period, maintained graft function in the follow-up. Conclusion: Mini-NLPC is a therapeutic option indicated for stones ≥15 mm, with the advantage of reducing bleeding, damage to the renal parenchyma and postoperative pain, however, it may require a longer procedure time, which increases the risk of infection.
Copyright (c) 2026 Dr João Pedro Barretto de Andrade, Dr Lenilson Prates da Silva, Dr. João Leandro Rocha Vieira, Dr Bruno Falcão Santos https://creativecommons.org/licenses/by-sa/4.0
Application of the nsofa score in preterm infants with suspected sepsis: a prognostic analysis
This study evaluated the application of the nSOFA score in preterm infants with suspected sepsis, aiming to identify associations with clinical outcomes. A prospective cross-sectional study was conducted between October 2022 and April 2023, including 41 preterm or very low birth weight newborns admitted to a neonatal intensive care unit. A significant association was found between catheter use and late-onset sepsis (p=0.015; OR=8.2), and between non-invasive mechanical ventilation and a lower occurrence of sepsis (p=0.001). In addition, nSOFA scores increased significantly from the first day of hospitalization to the moment of clinical suspicion (p=0.004), and higher scores were associated with an increased likelihood of death. These findings reinforce the potential role of the nSOFA score as an auxiliary tool for assessing disease severity and risk stratification in preterm infants with suspected sepsis, particularly in high-vulnerability clinical contexts.
Copyright (c) 2026 RomuloTarga Pinto, Andressa Ribeiro dos Santos, Anna Leticia Baumel, Giullia Vercesi Beraldi, Cristina Terumy Okamoto, Maria Rigotto de Almeida, Julia Clenk Glodzinski https://creativecommons.org/licenses/by-sa/4.0
Therapeutic approaches for small cell lung cancer: chemotherapy alone or immunochemotherapy?
Lung cancer (LC) was considered the most common type of cancer in the world in 2022, accounting for 12.4% of all new cases, and is the leading cause of cancer death in particular, small cell lung cancer (SCLC) accounts for 15% of lung cancer cases and is characterized by its malignancy and rapid progression, with a high chance of progressing to metastasis. Therefore, this review aims to highlight the results of immunochemotherapy in the treatment of SCLC, compared to the use of chemotherapy alone, as a way of increasing overall survival (OS) and progression-free survival (PFS). This is an integrative literature review carried out using the PubMed database with a survey of 36 articles, using the descriptors Carcinoma Small-Cell Lung; Chemotherapy; Immunotherapy; and Outcomes; excluding Carcinoma non-small-cell lung, published free of charge between 2019 and 2024. In the end, 15 articles were selected for synthesis, using inclusion and exclusion criteria. Analysis of the selected studies shows that immunochemotherapy offers significant advances in the treatment of SCLC, especially for advanced-stage cases. The use of Serplulimab (anti-PD-1) associated with chemotherapy showed significant benefits in OS and PFS, especially in subgroups of patients with specific profiles. These data suggest an advantage in applying personalized treatments based on demographic and molecular characteristics. Among emerging strategies, Cadonilimab has enabled improvement in the immune response of CPPC, while Tarlatamab represents an advance among targeted immunotherapies, promoting a selective and direct immune response against the tumor. The studies also pointed out that although PD-1/PD-L1 inhibitors promote an improvement in survival, these regimens are accompanied by an increase in serious adverse events (AEs). Thus, immunochemotherapy represents a promising alternative for increasing survival and quality of life in patients with extensive-stage small cell lung cancer (ES-SCLC), although adverse events and high costs challenge its widespread application, highlighting the need to identify reliable biomarkers to guide patient selection and improve the cost-effectiveness of treatments.
Copyright (c) 2026 Fabrício Leal Albiero Anéas, Maria Letícia Baptista Salvadori, Beatriz Martins Modesto, Helena Carlesso Franchi https://creativecommons.org/licenses/by-sa/4.0