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We tackle the philosophical implications of post-2020 music practices. To situate our discussion, we address pending issues in current definitions of music-making. Our analysis indicates that post-2020 definitions of music should feature sonic information and events, framed through social interactions and through the material grounding of the musical activity. Ubiquitous music (ubimus) furnishes a promising playing field for the emerging aspects of creative music-thinking. New frameworks that encompass the dynamic, multimodal and situated characteristics of music while skewing an anthropocentric perspective on creativity may provide meaningful targets for ubimus research toward a new notion of musicality. Three artistic projects serve to exemplify key aspects of this proposal: Atravessamentos, Memory Tree and Lyapunov Time. We address the philosophical implications of these artistic endeavors toward the construction of ubimus philosophical frameworks.

Information regarding the interaction between biological nitrogen fixation (BNF) with Azospirillum brasilense inoculation and the use of silicon (Si) is needed. Silicon exerts numerous benefits on grasses, especially when the plants are subjected to biotic and abiotic stresses, affecting plant nutrition. The aim of this research was to determine if there is a synergistic effect between the inoculation with A. brasilense and Si use, on macro-nutrient content in corn shoot and root. The field trial was performed in Selvíria, Brazil, on a Typic Rhodic Hapludox soil under no-till system. The experimental design was a completely randomized block design with four replicates arranged in a 2 × 5 × 2 triple factorial arrangement, consisting of two soil acidity corrective sources (dolomitic limestone and Ca and Mg silicate as sources of Si); five N doses (0, 50, 100, 150 and 200 kg ha-1 applied in topdressing); with and without seed inoculation with A. brasilense. The inoculation favored N concentration in shoots and increased the N and S concentration even when associated to high N rates in topdressing. The Si as Ca and Mg silicate associated with the increment of N rates does not promote an increase in the macronutrients uptake. Although it did not favor the N use, the Si also did not negatively affect the benefits of the A. brasilense.

Point-of-care ultrasound (POCUS) stands as a safe, portable, and cost-effective imaging modality for swift bedside patient examinations. Specifically, lung ultrasonography (LUS) has proven useful in evaluating both acute and chronic pulmonary conditions. Despite its clinical value, automatic LUS interpretation remains relatively unexplored, particularly in multi-label contexts. This work proposes a novel deep learning (DL) framework tailored for interpreting lung POCUS videos, whose outputs are the finding(s) present in these videos (such as A-lines, B-lines, or consolidations). The pipeline, based on a residual (2+1)D architecture, initiates with a pre-processing routine for video masking and standardisation, and employs a semi-supervised approach to harness available unlabeled data. Additionally, we introduce an ensemble modeling strategy that aggregates outputs from models trained to predict distinct label sets, thereby leveraging the hierarchical nature of LUS findings. The proposed framework and its building blocks were evaluated through extensive experiments with both multi-class and multi-label models, highlighting its versatility. In a held-out test set, the categorical proposal, suited for expedite triage, achieved an average F1-score of 92.4%, while the multi-label proposal, helpful for patient management and referral, achieved an average F1-score of 70.5% across five relevant LUS findings. Overall, the semi-supervised methodology contributed significantly to improved performance, while the proposed hierarchy-aware ensemble provided moderate additional gains., Competing Interests: Declarations. Ethics Approval: Approval for retrospective data collection was obtained from the Ethics Committee for Research (ECR) in Life and Health Sciences of the University of Minho (CEICVS 039/202) and the ECR of Hospital Clínicas de Porto Alegre (5.334.879). Conflict of Interest: The authors declare no competing interests., (© 2024. The Author(s).)

Polyploid varieties have been suggested as an alternative approach to promote drought tolerance in citrus crops. In this study, we compared the responses of diploid and tetraploid Sunki 'Tropical' rootstocks to water deficit when grafted onto 'Valencia' sweet orange trees and subjected to water withholding in isolation or competition experiments under potted conditions. Our results revealed that, when grown in isolation, tetraploid rootstocks took longer to show drought symptoms, but this advantage disappeared when grown in competition under the same soil moisture conditions. The differences in drought responses were mainly associated with variations in endogenous leaf levels of abscisic acid (ABA), hydrogen peroxide (H₂O₂) and carbohydrates among treatments. Overall, tetraploids were more affected by drought in individual experiments, showing higher H₂O₂ production, and in competition experiments, rapidly increasing ABA production to regulate stomatal closure and reduce water loss through transpiration. Therefore, our results highlight the crucial importance of evaluating diploid and tetraploid rootstocks under the same soil moisture conditions to better simulate field conditions, providing important insights to improve selection strategies for more resilient citrus rootstocks., (© 2024 John Wiley & Sons Ltd.)

Context: At the beginning of clinical practice, medical students face complex end-of-life (EoL) decisions, such as limiting life-sustaining therapies, which may precipitate emotionally charged moral dilemmas. Previous research shows these dilemmas may cause identity dissonance and impact students' personal and professional development. Despite the prevalence of such dilemmas, medical educators have limited insight into how students navigate these often emotional experiences. This study explores how medical students make sense of and deal with moral dilemmas lived during EoL's care., Methods: This cross-sectional qualitative study used thematic analysis (Braun and Clarke) to analyse interviews with 11 Brazilian final-year medical students. The interviews followed the drawing of a rich picture representing moral dilemmas experienced by medical students when engaging with EoL care. The reporting of this study follows the Standards for Reporting Qualitative Research (SRQR)., Results: Participants highlighted four main themes when engaging with EoL care: 'experiencing death', 'making decisions at the end-of-life', 'connecting versus detaching: an upsetting dilemma' and 'being transformed'. They described the emotional overwhelm of experiencing death and the uncertainty in navigating EoL decisions. The central moral dilemma faced was whether to connect with or detach from patients. This dilemma was lived in the context of a hidden curriculum that preaches emotional distancing as a coping mechanism. Developing the moral courage to overcome this barrier and choosing to connect became a transformative experience, significantly impacting their personal and professional development and reinforcing their commitment to patient-centred care., Conclusion: Connecting with patients in EoL care involves breaking cultural norms to establish meaningful connections with patients aiming for compassionate care. This process may lead to identity dissonance and also represents an opportunity for transformative learning. Educators can support this transformative process by legitimating students' connections with patients, teaching emotional regulation strategies, and leveraging personal experiences to foster trust., (© 2024 The Author(s). Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Despite the ubiquity of healthcare simulation and the humanities in medical education, the two domains of learning remain unintegrated. The stories suffused within healthcare simulation have thus remained unshaped by the developments of narrative medicine and the health humanities. Healthcare simulation, in turn, has yet to utilize concepts like co-construction and narrative competence to enrich learners' understanding of patient experience alongside their clinical competencies. To create a conceptual bridge between these two fields (including narrative-based inquiry more broadly), we redescribe narrative competence via Ronald Heifetz's distinction of "technical" and "adaptive" challenges outlined in his adaptive leadership model. Heifetz, we argue, enriches learners' self-understanding of the unique demands of cultivating narrative competence, which can be both elucidated on the page and tested within the charged yet supportive simulation environment. We introduce Co-constructive Patient Simulation (CCPS) to demonstrate how working with simulated patients can support narrative work by drawing on the clinical vicissitudes of learners in the formulation and enactment of case studies. The three movements of CCPS-resensing, retelling, and retooling-told through learner experiences, describe the affinities and divergences between narrative medicine's sequence of attention, representation, and affiliation; Montello's three forms of narrative competence (departure, performance, change), and Heifetz's three steps (observe, interpret, and intervene) of adaptive leadership., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Citrus plants are grown in diverse regions of the world, from subtropical to semi-arid and humid tropical areas. Through mechanisms essential for their survival, they adapt to the environmental conditions to which they are subjected. Although there is vast literature on adaptation of citrus plants to individual stresses, plant responses to interaction among different types of stresses have not been clearly examined. Abiotic or biotic stresses, or a combination of these stresses, result in reorganization of plant energy resources for defense, whether it be for resistance, tolerance, or prevention of stress. Plants generally respond to these stress factors through production of secondary metabolites, such as volatile compounds, derived from different biosynthesis and degradation pathways, which are released through distinct routes. Volatile compounds vary among plant species, meeting the specific needs of the plant. Simultaneous exposure to the stress factors of water deficit and herbivory leads to responses such as qualitative and quantitative changes in the emission of secondary metabolites, and compounds may accumulate within the leaves or predispose the plant to more quickly respond to the stress brought about by the herbivore. The genetic makeup of citrus plants can contribute to a better response to stress factors; however, studies on the emission of volatile compounds in different citrus genotypes under simultaneous stresses are limited. This review examines the effects of abiotic stress due to water deficit and biotic stress due to herbivory by Diaphorina citri in citrus plants and examines their connection with volatile compounds. A summary is made of advances in knowledge regarding the performance of volatile compounds in plant defense against both stress factors, as well as the interaction between them and possible findings in citrus plants. In addition, throughout this review, we focus on how genetic variation of the citrus species is correlated with production of volatile compounds to improve stress tolerance., Competing Interests: Declaration of Competing Interest On behalf of all the authors, we declare that we have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Diagnostic errors have been attributed to reasoning flaws caused by cognitive biases. While experiments have shown bias to cause errors, physicians of similar expertise differed in susceptibility to bias. Resisting bias is often said to depend on engaging analytical reasoning, disregarding the influence of knowledge. We examined the role of knowledge and reasoning mode, indicated by diagnosis time and confidence, as predictors of susceptibility to anchoring bias. Anchoring bias occurs when physicians stick to an incorrect diagnosis triggered by early salient distracting features (SDF) despite subsequent conflicting information., Methods: Sixty-eight internal medicine residents from two Dutch university hospitals participated in a two-phase experiment. Phase 1: assessment of knowledge of discriminating features (ie, clinical findings that discriminate between lookalike diseases) for six diseases. Phase 2 (1 week later): diagnosis of six cases of these diseases. Each case had two versions differing exclusively in the presence/absence of SDF. Each participant diagnosed three cases with SDF (SDF+) and three without (SDF-). Participants were randomly allocated to case versions. Based on phase 1 assessment, participants were split into higher knowledge or lower knowledge groups., Main Outcome Measurements: frequency of diagnoses associated with SDF; time to diagnose; and confidence in diagnosis., Results: While both knowledge groups performed similarly on SDF- cases, higher knowledge physicians succumbed to anchoring bias less frequently than their lower knowledge counterparts on SDF+ cases (p=0.02). Overall, physicians spent more time (p<0.001) and had lower confidence (p=0.02) on SDF+ than SDF- cases (p<0.001). However, when diagnosing SDF+ cases, the groups did not differ in time (p=0.88) nor in confidence (p=0.96)., Conclusions: Physicians apparently adopted a more analytical reasoning approach when presented with distracting features, indicated by increased time and lower confidence, trying to combat bias. Yet, extended deliberation alone did not explain the observed performance differences between knowledge groups. Success in mitigating anchoring bias was primarily predicted by knowledge of discriminating features of diagnoses., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

There is a long and impressive scholarly history evidencing why it is important to address professional identity formation (PIF) in medical curricula. In this AMEE Guide, the authors present an evidence-informed pedagogical approach to assist educators in developing educational practices to foster a healthy PIF in medical students. The authors first describe the theoretical framework that underpin this approach. At the core of this framework is the recognition that, for a healthy PIF, students need to become aware that they have the autonomy, but also responsibility, to form their professional identity in a way that fits both their personality and their (future) professional role. In other words, students need to learn to navigate the interplay between socialization and subjectification. Next, the authors outline the six-step structure of their pedagogical approach, designed to help students: (1) undergo a PIF-related experience, (2) observe their responses to the experience, (3) externalize their reflections, (4) share their reflections, (5) broaden their perspective, and (6) explore their freedom of choice through experimentation. The authors also describe six conducive conditions to facilitate the implementation of the pedagogical approach. These conditions include (1) creating a setting that enables students to slow down, (2) adopting a longitudinal approach, (3) making it part of the formal curriculum, (4) refraining from grading, (5) establishing an interdisciplinary expert team, and (6) providing teacher training. The authors conclude that the theoretical framework leads to a coherent and consistent pedagogical approach that, when implemented according to the conducive conditions, enables students to gradually internalize the reflective process and help them to cultivate a reflective attitude towards their PIF.

In this article, we propose developing a "pedagogy of connection" based on the history and evolution of medical education in Brazil. This pedagogy emerged from the intersection of the healthcare and higher educational systems, both dedicated to the principles of social justice and universal access, in response to the country's efforts to address the enduring impacts of slavery and social inequality. Following the "Sanitary Reformation" movement-a foundational moment for Brazil's healthcare and medical education systems-Brazil established the Unified Public Healthcare System (Sistema Único de Saúde - SUS). SUS is founded on principles of universality, integrality, equity, community participation, political and administrative decentralisation, hierarchisation and regionalisation. Aligned with these core principles and inspired by critical pedagogy, Brazilian medical education has evolved with a profound commitment to social justice, critical consciousness, professional presence and compassion. This evolution has given rise to a "pedagogy of connection," which imbues medical education with a sense of purpose and joy, preparing future medical professionals to address the challenges of our ever-evolving society and healthcare systems. The connections fostered by this pedagogy occur in complementary dimensions: (a) healthcare system and society, (b) community, (c) profession, (d) patients, and (e) ourselves. This innovative pedagogy enhances medical education discourse and practice by emphasising the development of a professional identity grounded in social justice and patient-centred care, which remain challenges for current medical education systems. As the global medical education community embraces decolonisation, this pedagogy offers a framework that can be adapted and enriched in various contexts worldwide, fostering opportunities for mutual learning from diverse educational systems in a dialogical and democratic manner., (© 2024 The Author(s). Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Problem: Although the practice of medicine is often emotionally challenging, medical curricula seldom systematically address the emotional development of medical students. To fill this gap, the authors developed and evaluated an innovative pedagogical activity based on music to nurture medical students' emotional development. The authors believe that the metaphoric nature of music offers an efficient venue for exploring emotion perception, expression, and regulation., Approach: The pedagogical activity Emotions in Medicine was carried out throughout 2020 and 2021 and consisted of 4 encounters to explore: (1) emotion perception, (2) emotion expression, (3) emotion regulation, and (4) the role of emotions in medical practice. During all encounters, the authors used music to evoke students' emotions and focused the discussions on the relevance of emotions for meaningful medical practice. Emotional intelligence before and after the workshop was tested using the Schutte Self-Report Emotional Intelligence Test (SSEIT), a validated psychometric scale., Outcomes: The workshop facilitated emotional connection among students and created a safe space to explore the role of emotions in medical practice. The mean total pretest SSEIT score was 110 (SD = 14.2); it increased to 116.8 (SD = 16.1) in the posttest ( P < .001). This increase was true across its 4 dimensions: (1) perception of emotions, (2) management of own emotions (3) management of others' emotions, and (4) use of emotions., Next Steps: Music can be an active tool to explore the role of emotions in medical practice. It fosters students' capacity to identify and reflect on emotions while exploring their role in patient care. Further (qualitative) research is needed to explore the mechanisms by which music facilitates learning emotion perception, expression, and regulation., (Copyright © 2024 the Association of American Medical Colleges.)

Background: The incidence of olfactory disorders has increased in recent years, mainly related to COVID-19 infection. In Brazil, over 37 million cases of COVID-19 have been reported, and approximately 10 % of those cases continue to experience olfactory disorders for more than one month. Despite the significant negative impact on well-being, there is currently no validated instrument to assess how olfactory disorders impact the quality of life in Brazil., Objectives: This study aimed to validate the Questionnaire of Olfactory Disorders (QOD) for Brazilian Portuguese., Methods: The authors first performed translation, back-translation, expert review, pre-testing, psychometric evaluation and cultural adaptation of the English version of the questionnaire. To assure linguistic and conceptual equivalence of the translated questionnaire, 126 participants from two Brazilian states and varying degrees of olfactory loss answered the QOD and the World Health Organization Quality of Life bref (WHOQOL-bref) questionnaires. The University of Pennsylvania Smell Identification Test (UPSIT®) was used to quantify the olfactory loss. Furthermore, to evaluate the reliability of the Portuguese version a test-retest was performed on a subgroup of patients. The authors observed a high Cronbach's alpha (α = 0.86) for internal consistency of the quality of Life (QOD-QOL) statements., Findings: As expected, there was a negative correlation between QOD-QOL and UPSIT® (Spearman's ρ = -0.275, p = 0.002), since QOL score increases and UPSIT® score decreases with worsening of olfactory function. Correlations were moderate between QOD-QOL and WHOQOL-bref mean (Spearman's ρ = -0.374, p < 0.001) and weak to moderate between the QOD-QOL and Visual Analog Scale of the QOD regarding professional life, leisure, and private life (Spearman's ρ = -0.316, p = 0.000; Spearman's ρ = -0.293, p = 0.001; Spearman's ρ = -0.261, p = 0.004; respectively)., Conclusion: In conclusion, the authors have demonstrated a high internal consistency and validity of the Brazilian Portuguese version of the QOD for evaluating the quality of life in individuals with olfactory disorders., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest. The authors have no personal or financial affiliations that could compromise the objectivity or integrity of the information presented in this study. This article follows the STROBE statement (Strengthening the Reporting of Observational Studies in Epidemiology)., (Copyright © 2024 HCFMUSP. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: Feedback is crucial to promote learning and improve performance. However, we lack a nuanced understanding of how medical teachers reflect on and internalise (or not) student feedback (SF). This study aims to fill this gap by exploring how teachers make sense of SF to improve their performance and nurture their personal and professional development., Methods: In this cross-sectional qualitative study based on a constructivist paradigm, 14 medical teachers individually drew a Rich Picture (RP) of a feedback experience in which they received informal or formal feedback from students, resulting in a personal or professional change. After the drawing, we interviewed the participants to deepen our understanding of teachers' experiences. We analysed the drawings and interview transcripts using an iterative process of thematic analysis., Results: SF that culminated in personal or professional change is a highly emotional experience for teachers, often with long-lasting consequences. It may threaten or reassure their self-concept and professional identity, generating feedback avoidance or feedback-seeking behaviour. SF is particularly powerful in transforming teaching practices when teachers feel connected to students through an honest and constructive relationship. Remarkably, some teachers intentionally build relationships with certain (selected) students to get 'qualified' feedback. SF acceptance also increases when teachers are open to receiving feedback and there is an institutional culture that values feedback. Finally, medical teachers believe that formal (planned) feedback is relevant to improve the curriculum, while informal (spontaneous) feedback is important for promoting teachers' personal and professional development., Discussion: SF has the potential to become a transformative learning experience for teachers. The student-teacher relationship and teachers' emotional reactions affect the way teachers make sense of and internalise SF and enact behavioural change. Understanding the complexity surrounding SF is vital for supporting teachers in seizing opportunities for growth and in nurturing a meaningful relationship with the act of teaching., (© 2023 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

DNA methylation plays a key role in the development and plant responses to biotic and abiotic stresses. This work aimed to evaluate the DNA methylation in contrasting cassava genotypes for water deficit tolerance. The varieties BRS Formosa (bitter) and BRS Dourada (sweet) were grown under greenhouse conditions for 50 days, and afterwards, irrigation was suspended. The stressed (water deficit) and non-stressed plants (negative control) consisted the treatments with five plants per variety. The DNA samples of each variety and treatment provided 12 MethylRAD-Seq libraries (two cassava varieties, two treatments, and three replicates). The sequenced data revealed methylated sites covering 18 to 21% of the Manihot esculenta Crantz genome, depending on the variety and the treatment. The CCGG methylated sites mapped mostly in intergenic regions, exons, and introns, while the CCNGG sites mapped mostly intergenic, upstream, introns, and exons regions. In both cases, methylated sites in UTRs were less detected. The differentially methylated sites analysis indicated distinct methylation profiles since only 12% of the sites (CCGG and CCNGG) were methylated in both varieties. Enriched gene ontology terms highlighted the immediate response of the bitter variety to stress, while the sweet variety appears to suffer more potential stress-damages. The predicted protein-protein interaction networks reinforced such profiles. Additionally, the genomes of the BRS varieties uncovered SNPs/INDELs events covering genes stood out by the interactomes. Our data can be useful in deciphering the roles of DNA methylation in cassava drought-tolerance responses and adaptation to abiotic stresses., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Silva Filho et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The aim of this study was to compare the performance, intake, digestibility, ruminal parameters, carcass traits, and the yield of commercial cuts of Santa Ines (SI) and Rabo Largo (RL) breeds fed diets with high or low roughage-to-concentrate ratio (R:C) under a tropical climate. Twenty lambs from each breed were individually housed in covered pens and fed the experimental diets for 58 days. The diets were formulated to meet the growth requirements of lambs with a roughage-to-concentrate ratio of 70:30 and 30:70. Significant interactions of breed × diet for nutrient intake were observed (P < 0.05), with SI lambs fed low R:C diet showing higher intake of dry matter, organic matter, crude protein, and total carbohydrates compared to RL lambs fed the same diet. SI lambs fed high R:C diet had higher intake of neutral detergent fiber than RL lambs (P < 0.05). SI lambs displayed better average daily gain and feed efficiency, regardless of diet (P < 0.05). Carcass traits and gastrointestinal components were influenced by breed and diet (P < 0.05). SI lambs fed low R:C diet showed higher subcutaneous fat thickness and better carcass finishing compared to RL lambs (P < 0.05). SI breed lambs exhibited better growth performance, carcass traits, and gastrointestinal characteristics, even when fed diets with a high roughage-to-concentrate ratio., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: training in critical surgical situations is crucial for a safe outcome. The use of simulators is well established, although many are quite expensive, requiring the search for financially viable solutions for training centers., Methods: we built a low-cost simulator for intra-abdominal bleeding with inexpensive materials, such as a manikin chest, latex tubes, silicone rubber, and waterproof fabric, seeking to mimic the abdominal viscera and vessels and their anatomical correlations. An IV infusion set allowed simulated blood to flow under pressure, and the blood flowed freely during simulation. After obtaining a functional model, we selected general surgeons to validate the simulator and its use in teaching surgery. We used the content validity index (CVI), with a cutoff of 0.9., Results: the cost of building the prototype was US$71,00 in 2021, accounting for the purchase of the various necessary materials. Twelve raters participated in the validation tests. The results obtained from the feedback survey showed a good evaluation of all items, especially the recognition of the injured vessel, access to the vascular injury, hemostasis by manual compression, and hemostatic suturing., Conclusion: the proposed simulator obtained good results in scenarios of intra-abdominal bleeding from large vessels, as well as for hemostasis by manual compression and suturing. It proved to be a useful tool for training in critical intra- abdominal bleeding situations, while maintaining a low cost of building.

Background: Patient simulation has been used in medical education to provide a safe and supportive learning environment for learners to practice clinical and interpersonal skills. However, simulation involving pediatric populations, particularly in child and adolescent psychiatry, is rare and generally does not reflect the child-caregiver dyad or the longitudinal aspects of this care, nor does it provide learners with an opportunity to engage with and reflect on these dynamics., Methods: We organized as an educational opportunity a series of seven observed patient simulation sessions with a cohort of a dozen child and adolescent psychiatrists (eight fellows approaching graduation and four senior educators). In these sessions, we utilized the co-constructive patient simulation model to create the simulation cases. We included the use of at least two patient actors in most sessions, and two of the case narratives were longitudinally followed across multiple simulation sessions. We approached the data collected during the simulations and their respective debriefings by using thematic analysis informed by a symbolic interactionist approach., Results: Based on data from the debriefing sessions and longitudinal narratives, we identified four overarching themes: (1) Reflecting on dyadic challenges: role reversal and individuation; (2) Centering the child, allying with the parent, and treating the family system; (3) Ambivalence in and about the parent-child dyad; and (4) Longitudinal narratives and ambivalence over time., Conclusion: The emotional experience of the simulations, for interviewers and observers alike, provided an opportunity to reflect on personal and professional experiences and triggered meaningful insights and connections between participants. These simulated cases called for emotional labor, particularly in the form of creating holding environments; in this way, the simulated encounters and the debriefing sessions became dialogic experiences, in which the patient and provider, parent and child, and learner and instructor could co-construct meaning and foster professional development as reflective practitioners., (© 2023. BioMed Central Ltd., part of Springer Nature.)

The aim of this research was to investigate the existence of associations between habitual physical activity and cardiovascular risk in people living with HIV; and to identify self-perceived barriers to physical activity. The sample of 104 subjects was composed of people living with HIV and treatment for at least 6 months in a Specialized Care Service. Baeck's survey, a self-perceived barrier questionnaire, medical records, and equations from Framingham's Cardiovascular Disease were used. Linear regression models were used to investigate the association between Habitual Physical Activity score (HPA) and predicted cardiovascular risk, and descriptive statistics to investigate prevalence of self-perceived barriers. In the first model ( r ² = 0.212, F = 4.34, p  < 0.001), increasing 1 point in the HPA score predicts the decrease by 1.04 percentage points (p.p.) Cardiovascular risk for the next 10 years. In the second model ( r 2  = 0. 244, F = 4. 99, p  < 0.001), increase one point the HPA score decreases by 3.729 p.p. Predicted cardiovascular risk for the next 30 years. The results confirmed an inverse association between HPA and predicted cardiovascular risk in PLHIV.

COVID-19 struck the world and stretched the healthcare system and professionals. Medical students engaged in the pandemic effort, making personal and professional sacrifices. However, the impact of these sacrifices on students` professional development is still unknown. We applied constructivist grounded theory to individual audio diaries (total time = 5h38 min) and interviews (total time = 11h57min) performed with 18 last-year medical students during the first wave of COVID-19 pandemic in Brazil. The perspective of making sacrifices caused initial emotional distress in medical students, followed by a negotiation process revolving around three themes: predisposition to sacrifice, sense of competence, and sense of belonging. This negotiation process led to three response patterns: Pattern A: "No sense of duty"-the sacrifice was perceived as meaningless, and students showed intense anger and a desire to flee; Pattern B: "Sense of duty with hesitation to act"-the sacrifice was acknowledged as legitime, but students felt unprepared to contribute, leading to feelings of frustration and shame; and, Pattern C: "Sense of duty with readiness to act"-the engagement with the sacrifice was perceived as an opportunity to grow as a doctor, leading to fulfillment and proudness. Students ready to engage with the COVID-19 effort experienced identity consonance, reinforcing their professional identities. Students who felt incompetent or found the sacrifice meaningless experienced identity dissonance, which led to emotional suffering and the consideration of abandoning the course. Monitoring students' emotional reactions when facing professional challenges creates opportunities to problematize the role of sacrifice in the medical profession and scaffold professional identity development., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Background Racist interactions in clinical practice remain a pervasive reality for Black healthcare providers. We sought to develop a framework to inform supervisors' actions when confronting racism in clinical practice and protecting trainees under their oversight. Methods We conducted a qualitative study in which experienced supervisors responded to seven short, videotaped interactions between: 1) Black trainees and a simulated patient (SP) in a racist role; 2) the trainees and their respective supervisors; and 3) the trainees and their supervisors together with the SP. The clinical exchanges exemplified different types of racist (entrenching) or antiracist (uprooting) behaviors by the supervisors. After viewing each clip, participants wrote their reflections confidentially; they later joined a structured debriefing together. We used thematic analysis to identify supervisors' behavioral patterns when confronting racist interactions. Results Based on the input of 52 participants recruited into five two-hour-long sessions, we categorized the behaviors of supervisors facing anti-Black racial injuries involving learners under their oversight. We organized supervisor behaviors into five interlocking domains, each with a range of possible themes: 1) Joining : from conciliatory to confrontational in communicating with the aggressor; 2) Explicitness : from avoiding to naming racism; 3) Ownership : from individual to shared responsibility of the event and the response to it; 4) Involving: from excusing to including the aggrieved party when confronting the aggressor; and 5) Stance : from protective to paternalistic in supporting the learner's autonomy. Conclusions Our qualitative findings can provide a framework for facilitated discussion toward reflective practice among healthcare providers who may have experienced, witnessed, or intervened in anti-Black racist interactions. They can also help medical educators to inform faculty development to fight anti-Black racism in clinical practice. The video materials we developed are available for viewing and download and can be used or adapted as springboards for reflective discussion or faculty development activities., Competing Interests: No competing interests were disclosed., (Copyright: © 2023 Calhoun AJ et al.)

Environmental enrichment can increase the occurrence of natural behavior and improve leg health and other animal welfare outcomes in broiler chickens. This study aimed to assess the effects of three environmental enrichments, specifically hay bales, step platforms, and laser lights, on subclinical spondylolisthesis prevalence, productivity, behavior, and gait of broiler chickens (Gallus gallus domesticus). Twenty-four hundred day-old male Ross® AP95 chicks from a commercial hatchery were used in a completely randomized design with four treatments and four replicate pens per treatment. Pens contained either a Control (C) treatment, an environment similar to a commercial broiler chicken system without environmental enrichments, or an environment with either additional hay bales (HB), additional step platforms (SP), or additional laser lights (LL). Performance, yield, behavior (frequencies), gait score, and subclinical spondylolisthesis prevalences were assessed. When raised with SP or LL access, fewer chickens had subclinical spondylolisthesis than chickens without enrichments (C) or with HB access. Chickens with access to SP exhibited higher wing yield and less abdominal fat than animals from the C group. Chickens from the LL and HB treatments explored more and rested less frequently than animals from the C and SP treatments. As chickens aged, they became less active, exploring less and increasing resting and comfort behaviors. Treatments did not affect gait. Gait was not associated with subclinical spondylolisthesis prevalence. Environmental enrichments benefitted chicken health (subclinical spondylolisthesis) and behavior (exploration) without negative consequences for performance and yield., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lourenço da Silva et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Digital games are increasingly used to support learning across a diverse range of cognitive, affective and psychomotor domains in health professions education. Game-based learning will likely become an important competency for educators. However, educators can perceive game building as out of their reach due to a lack of expertise in digital technology. This toolbox offers advice to health professions educators who would like to build a simple game for learning known as a digital educational escape room., (© 2023 The Authors. The Clinical Teacher published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

In this commentary, we examine how to use the recently developed educational method called Co-constructive Patient Simulation (CCPS) to improve continuous professional development in healthcare. CCPS invites learners to participate in the creation of meaningful simulated scenarios while fostering reflection-in/on/for-action and community-building. By participating in the creation of the simulated scenarios, learners guarantee that the challenges addressed by the learning activities are aligned with their developmental stages and needs. Additionally, as learners may invite supervisors to take the "hot seat" during the simulation session, the CCPS approach allows learners to witness how supervisors would handle situations perceived as challenging. This exchange of roles creates an opportunity for camaraderie, as supervisors expose themselves and assume a vulnerable position. This camaraderie facilitates educational bonding and community building. As a result, in this participatory and co-creative approach to simulation, experts become the facilitators of a learner-centred activity, which increases motivation and allows tailored and contextualised learning. This co-constructive approach to simulation adds to the repertoire of more traditional CPD strategies by fostering spontaneity and authenticity. It integrates learning opportunities in clinical practice, amplifies learner's critical reflection and autonomy, and harnesses real-life challenges to offer meaningful solutions to lifelong learning. The democratic environment optimised by experts joining the activity and sharing their vulnerabilities with trainees further catalyzes the creation of a community for teaching, learning, and shared development., Competing Interests: No potential conflict of interest was reported by the authors., (© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Introduction: Medical professionals meet many transitions during their careers, and must learn to adjust rapidly to unfamiliar workplaces and teams. This study investigated the use of a digital educational escape room (DEER) in facilitating medical students' learning around managing uncertainty in transitioning from classroom to clinical placement., Methods: We used design-based research to explore the design, build, and test of a DEER, as well as gain insight into how these novel learning environments work, using Community of Inquiry (CoI) as a guiding conceptual framework. This study represented a mixed methods pilot test of a prototype DEER. Twenty-two medical students agreed to participate, and data were collected through qualitative (i.e., focus groups, game-play observations) and quantitative (i.e., questionnaires) methods., Results: Eighty-two per cent of participants agreed or strongly agreed that the DEER supported their learning around uncertainty. Participants offered diverse examples of how the game had facilitated new insights on, and approaches to, uncertainty. With respect to the learning environment, multiple indicators and examples of the three domains of CoI - cognitive, teaching and social presence - were observed., Discussion: Our findings suggested that DEERs offer a valuable online learning environment for students to engage with complex and emotion-provoking challenges, such as those experienced at transitions. The study also suggested that CoI can be applied to the design, implementation, and evaluation of DEER learning environments, and we have proposed a set of design principles that may offer guidance here., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2023 The Author(s).)

Objective: To calculate the positive likelihood ratio to determine whether telemedicine is able to optimize referral to the emergency department., Methods: Unicenter study with 182 consecutive patients admitted to Hospital Israelita Albert Einstein due to respiratory symptoms. All patients were submitted to oxygen saturation measurement using the standard method Welch Allyn finger device vital sign monitor and a 2-minute evaluation (Binah.ai mobile application). The reproducibility of oxygen saturation measurements made with both methods was investigated using interclass correlation coefficients and analysis of dispersion. Bland-Altman plots were constructed and kappa concordance coefficients used to examine data normality. Accuracy was also estimated., Results: Oxygen saturation measurement differences between methods were ≤2% in more than 85% of cases. The mean difference (bias) between methods was near zero (0.835; Bland-Altman analysis). Oxygen saturation measurements made using the Binah.ai mobile application had an average ability to detect patients with altered oxygen saturation levels compared to the conventional method (ROC analysis). The positive likelihood ratio of the mobile application was 6.23., Conclusion: Mobile applications for oxygen saturation measurement are accessible user-friendly tools with moderate impact on clinical telemedicine evaluation of patients with respiratory symptoms, and may optimize referral to the emergency department.

Background: Although low-middle income countries have been disproportionately affected by the COVID-19 pandemic, there is scarce information about the impact of long COVID on their population. This study aimed to evaluate long COVID symptomatology, complications (hospital readmission and metabolic disorders), and main clinical features that impact Quality of Life (QoL)., Methods: This cross-sectional study provides a detailed clinical and laboratory picture of individuals who presented residual symptoms after mild to severe acute COVID-19. Between Aug-2020 to Sep-2021, long COVID patients were evaluated in a reference center for long COVID in Bahia State, Brazil. The EQ-5D-5L questionnaire accessed QoL., Results: A total of 1164 (52 ±13.4 years, 57% female, 88% black/mixed-race) were evaluated 2.3 [IQR = 1.6-3.7] months after mild (n = 351, 30.2%), moderate (338, 29.0%) or severe (475, 40.8%) acute illness. Dyspnea (790, 67.9%), fatigue (738, 63.5%), and chest pain (525, 42.9%) were the most frequent residual symptoms regardless of acute severity, affecting the QoL of 88.9% of patients (n/N-826/925), mainly the domains of anxiety/depression and pain/discomfort. High levels of HbA1c were detected for 175 out of 664 patients (26.6%), 40% of them without a previous diagnosis of diabetes mellitus. Of note, hospital admission one-to-three months after the acute phase of disease was required for 51 (4.4%) patients., Conclusion: In this majority-black/mixed-race population, long COVID was associated with post-acute hospitalization, newly diagnosed diabetes mellitus, and decreased QoL, particularly in women and regardless of disease severity of acute infection, suggesting important implications for health care system., Competing Interests: The authors have declared that no competing interests exist.

Described here is the implementation of a lung ultrasound course for physiotherapists focused on the acquisition and retention of knowledge and skills. Initially, we provided online lectures in a virtual learning environment (VLE), in which we taught the semiquantification of edema through a lung ultrasound score (LUS). Afterward, the physiotherapists participated in face-to-face lectures (which resumed the online lectures), followed by hands-on training and simulation with ultrasound. We assessed knowledge acquisition through a multiple-choice test with 30 questions (totaling 10 points). The test was applied before accessing the VLE (pre-VLE), before the face-to-face course and at its end (pre- and post-course). Physiotherapists collected actual patients' ultrasound scans, which were uploaded to the VLE and assessed by three supervisors, who performed a consensus LUS calculation and gave virtual written feedback. Thirteen physiotherapists collected 59 exams. The test results were 3.60 ± 1.58 (pre-VLE), 5.94 ± 1.45 (pre-course) and 8.50 ± 0.71 (post-course), with p &lt; 0.001 for all. The intraclass correlation coefficient for LUS between physiotherapists and supervisors was 0.814 (p &lt; 0.001), with moderate-to-weak agreement for LUS of the lung apical, median and basal zones, with κ = 0.455.334, and 0.417 (p &lt; 0.001 for all). Trainees were found to have increased short-term acquisition and retention of knowledge and skills, with a good intraclass correlation coefficient between them and the consensus of supervisors for the LUS of actual patients., Competing Interests: Conflict of interest disclosure —The authors declare there are no conflicts of interest. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors., (Copyright © 2022 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Background: The management of acute myocardial infarction (AMI) presents several challenges in patients with diabetes, among them the higher rate of recurrent thrombotic events, hyperglycemia and risk of subsequent heart failure (HF). The objective of our study was to evaluate effects of DPP-4 inhibitors (DPP-4i) on platelet reactivity (main objective) and cardiac risk markers., Methods: We performed a single-center double-blind randomized trial. A total of 70 patients with type 2 diabetes (T2DM) with AMI Killip ≤2 on dual-antiplatelet therapy (aspirin plus clopidogrel) were randomized to receive sitagliptin 100 mg or saxagliptin 5 mg daily or matching placebo. Platelet reactivity was assessed at baseline, 4 days (primary endpoint) and 30 days (secondary endpoint) after randomization, using VerifyNow Aspirin™ assay, expressed as aspirin reaction units (ARUs); B-type natriuretic peptide (BNP) in pg/mL was assessed at baseline and 30 days after (secondary endpoint)., Results: Mean age was 62.6 ± 8.8 years, 45 (64.3%) male, and 52 (74.3%) of patients presented with ST-segment elevation MI. For primary endpoint, there were no differences in mean platelet reactivity ( p = 0.51) between the DPP-4i (8.00 {-65.00; 63.00}) and placebo (-14.00 {-77.00; 52.00}) groups, as well in mean BNP levels ( p = 0.14) between DPP-4i (-36.00 {-110.00; 15.00}) and placebo (-13.00 {-50.00; 27.00}). There was no difference between groups in cardiac adverse events., Conclusions: DPP4 inhibitor did not reduce platelet aggregation among patients with type 2 diabetes hospitalized with AMI. Moreover, the use of DPP-4i did not show an increase in BNP levels or in the incidence of cardiac adverse events. These findings suggests that DPP-4i could be an option for management of T2DM patients with acute MI.

Acute crises of decompensation of a chronic disease are, in most cases, handled in an Emergency Room setting. In these services, emergency care professionals face several challenges, such as incomplete information on the patient's disease, scarce resources, and the pressure of having to make decisions in a short time. In this context, what can be done to provide patient-centered care that is at the same time technically appropriate and aligned with their values? Understanding the patient's situation in relation to their disease; talking to the patient about their clinical condition, comprehending their values and feelings; and understanding time as Kairos - that is, the time of the consultation as an opportunity to understand the patient's needs and build a shared therapeutic plan - are possible solutions to this challenge. Proper handling of patients with severe diseases requires that all links of health care systems are functional and coordinated from primary health care to hospital and home care, starting with the education of health care professionals and the strengthening of work settings that foster the expression of Kairos. This is a long and fundamental path for health care systems such as the Brazilian Unified National Health System (SUS) and that health managers and professionals should not afford to ignore.

Background: Physicians may receive diagnostic information in different orders, and there is a lack of empirical evidence that the order of presentation may influence clinical reasoning., Objective: We investigated whether diagnostic accuracy of chest pain cases is influenced by the order of presentation of the history and electrocardiogram (EKG) to cardiology residents., Methods: We conducted an experimental study during a resident training in 2019. Twelve clinical cases were presented in 2 diagnostic rounds. Residents were randomly allocated to seeing the EKG first (EKGF) or the history first (HF). The mean diagnostic accuracy scores (range 0-1) and confidence level (0-100) in each diagnostic round and time needed to make the diagnosis were evaluated., Results: The final diagnostic accuracy was higher than the initial in both groups. After the first round, diagnostic accuracy was higher in HF (n=24) than in EKGF (n=28). Time taken to judge the history was comparable in both groups. Time taken to judge the EKG was shorter in HF (40±11 vs 64±13 seconds; P <.01). Time invested in the second round was significantly correlated with changing the initial diagnosis. A significant difference was observed in confidence ratings after the initial diagnosis, with EKGF reporting less confidence relative to HF., Conclusions: The order in which history and EKG are presented influences the clinical reasoning process., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Introduction: Medical schools worldwide are creating inclusion policies to increase the admission of students from vulnerable social groups. This study explores how medical students from vulnerable social groups experience belongingness as they join the medical community., Methods: This qualitative study applied thematic analysis to 10 interviews with medical students admitted to one medical school through an affirmative policy. The interviews followed the drawing of a rich picture, in which the students represented a challenging situation experienced in their training, considering their socio-economic and racial background. The analysis was guided by the modes of belonging (engagement, imagination, and alignment) described by the Communities of Practice framework., Results: Participants struggled to imagine themselves as future doctors because they lack identification with the medical environment, suffer from low self-esteem, aside from experiencing racial and social discrimination. Participants also find it troublesome to engage in social and professional activities because of financial disadvantages and insufficient support from the university. However, participants strongly align with the values of the public health system and show deep empathy for the patients., Discussion: Including students with different socio-economic and racial backgrounds offers an opportunity to reform the medical culture. Medical educators need to devise strategies to support students' socialization through activities that increase their self-esteem and make explicit the contributions they bring to the medical community., (© 2022. The Author(s).)

Objective: COVID-19 pandemic required optimization of hospital institutional flow, especially regarding the use of intensive care unit (ICU) beds. The aim of this study was to assess whether the individualization of the indication for postoperative recovery from pulmonary surgery in ICU beds was associated with more perioperative complications., Method: retrospective analysis of medical records of patients undergoing anatomic lung resections for cancer in a tertiary hospital. The sample was divided into: Group-I, composed of surgeries performed between March/2019 and February/2020, pre-pandemic, and Group-II, composed of surgeries performed between March/2020 and February/2021, pandemic period in Brazil. We analyzed demographic data, surgical risks, surgeries performed, postoperative complications, length of stay in the ICU and hospital stay. Preventive measures of COVID-19 were adopted in group-II., Results: 43 patients were included, 20 in group-I and 23 in group-II. The groups did not show statistical differences regarding baseline demographic variables. In group-I, 80% of the patients underwent a postoperative period in the ICU, compared to 21% in group-II. There was a significant difference when comparing the average length of stay in an ICU bed (46 hours in group-I versus 14 hours in group-II - p<0.001). There was no statistical difference regarding postoperative complications (p=0.44)., Conclusions: the individualization of the need for ICU use in the immediate postoperative period resulted in an improvement in the institutional care flow during the COVID-19 pandemic, in a safe way, without an increase in surgical morbidity and mortality, favoring the maintenance of essential cancer treatment.

The present study aimed to evaluate the effect of alkaline treatments with urea, NaOH and Ca(OH)2 on chemical composition and in situ ruminal degradability of dry matter, crud protein and neutral detergent fiber of sugarcane tip hay. Samples were incubated in the rumen of three cannulated cattle for up to 72 hours in a split plot randomized block design. Ammoniation with 6% urea increased (p<0.05) the crude protein content by 13% and reduced the neutral detergent fiber and insoluble nitrogen content of the hay. When treated with the highest doses of the compounds, there was a high potential degradability of dry matter, crude protein and neutral detergent fiber, and a shorter neutral detergent fiber lag time. Ammoniation with urea promotes a reduction in the content of NDF, hemicellulose and insoluble nitrogen, with an increase in the content of CP in the hay, with emphasis for the level of 6% urea. The ruminal degradation of sugarcane tip hay increases with alkaline treatments using 6% urea or 3% NaOH, however, ammoniation with urea is indicated for the treatment of hay, as this is low cost and can be easily adopted by farmers in the semiarid region.