Escola Bahiana de Medicina e Saúde Pública

INTRODUCTION: Academic monitoring in higher education contributes to the comprehensive development of both monitors and students. To achieve this, monitor training workshops must follow the principles of liberating and critical-reflective education, preparing the monitor beyond technical content-based approaches. OBJECTIVE: To report the experience of implementing a monitor training program, focusing on developing attitudes, knowledge, and skills essential for comprehensive training. EXPERIENCE REPORT: The attitude development workshop in monitor training begins with a reflection on the positive and negative aspects of the monitoring program, as well as possible solutions based on the monitors' experiences as students. After this stage, participants have 30 minutes to read excerpts from Paulo Freire's Pedagogia da Autonomia (Pedagogy of Autonomy), followed by a discussion circle to share their perceptions of the text and its correlation with the monitor’s educational practice. This approach integrates reflection and practice, promoting critical, collaborative, and participatory learning among future educators. FINAL CONSIDERATIONS: The workshop emphasizes a broad and critical reflection on the monitor’s role, encouraging problematization, analysis, and discussion of the competencies necessary for an active participant in the teaching-learning process. The aim is to prepare monitors who act as agents of transformation, rather than merely as content transmitters, contributing meaningfully to academic and human development.

BackgroundDuchenne muscular dystrophy is a rare, progressive neuromuscular disorder primarily affecting boys, and it follows a predictable course. Early intervention is essential for effective management, but disparities in the care of patients with rare diseases hinder access to optimal treatment.ObjectiveTo identify unmet needs and challenges in the care of patients with Duchenne muscular dystrophy within the Brazilian public health system compared with the private system.MethodsA cross-sectional observational study using the Delphi method was conducted with ten neurologists specialized in Duchenne muscular dystrophy. The specialists participated in rounds of surveys to reach consensus on key issues, including diagnosis, treatment, and care. Data was analyzed using descriptive statistics.ResultsAccording to the Delphi panel, the public health system had an average diagnostic delay of 25 months compared with 10 months in the private sector. Although genetic testing is critical, it is not funded by the public health system. Other barriers included delayed corticosteroid treatment, limited access to multidisciplinary care, and insufficient medical devices. Patients in the public health system lost ambulation earlier (11–12 years of age) than those in the private sector (13–14 years of age). Life expectancy was significantly shorter in the public system, averaging 19 to 20 years compared with 26 to 27 years of age in the private sector.ConclusionThere are significant disparities in the care of patients with Duchenne muscular dystrophy within Brazil's public health system, resulting in worse outcomes. Enhancing access to genetic testing and early multidisciplinary care is crucial to improve the quality of life and survival of these patients.

Resumo Introdução: Apesar dos avanços no manejo da doença renal crônica (DRC), o diagnóstico precoce e a estratificação de risco permanecem grandes desafios. Este estudo analisou dados nacionais derivados de uma campanha brasileira de rastreamento da DRC, voltada para indivíduos de alto risco que desconheciam sua condição, visando estimar a prevalência da doença e avaliar tendências longitudinais na taxa de filtração glomerular estimada (TFGe). Métodos: Estudo transversal observacional avaliando adultos com diabetes mellitus (DM) e/ou hipertensão arterial, sem diagnóstico prévio de DRC, que participaram de campanha de rastreamento da doença. Coletaram-se dados demográficos, clínicos e laboratoriais, incluindo creatinina sérica e relação albumina/creatinina (RAC). O estadiamento da DRC seguiu os critérios do Kidney Disease: Improving Global Outcomes (KDIGO) e calculou-se a TFGe pela equação CKD-EPI 2021. Modelos de efeitos mistos foram utilizados para avaliar as trajetórias da TFGe e regressão logística para examinar fatores de risco para DRC. Resultados: Entre 14.239 participantes de alto risco (idade média 54 anos; 84% hipertensos; 37% diabéticos), a DRC foi identificada pela primeira vez em 19,6%, com 11,3% apresentando TFGe <60 mL/min e 11,1% RAC >30 mg/g. Apesar dos resultados anormais de RAC, os testes permaneceram incomuns: <5% antes da campanha e <7% depois. O declínio da TFGe foi mais acentuado entre diabéticos (+40%), indivíduos hipertensos (+17%), aqueles com idade >65 anos (+17%) e indivíduos com índice de massa corporal (IMC) >25 kg/m2 (+60%). Modelos de regressão logística de risco projetaram ~169.000 casos de insuficiência renal em 2 anos e ~500.000 em 5 anos, excluindo o risco competitivo de mortalidade. Conclusão: Identificamos uma prevalência elevada de DRC previamente não diagnosticada nesta população de alto risco. Apesar do acesso universal a exames no Brasil, a albuminúria segue sendo significativamente subutilizada, representando uma oportunidade perdida para detecção precoce e implementação de intervenções nefroprotetoras.

Introduction: Tacrolimus remains central to liver transplantation, yet its narrow therapeutic index and pharmacokinetic variability are associated with increased risk of post-transplant diabetes mellitus (PTDM). While polymorphisms in metabolizing enzymes modulate drug exposure and diabetogenic risk, these relationships have not been systematically integrated through targeted pharmacogenomic approaches. Objective: To systematically evaluate genetic variants in tacrolimus-metabolizing genes and their associations with PTDM through integrated in silico pharmacogenomic analysis. Methods: An in silico analysis was performed, integrating data from public repositories (PharmGKB), curated literature, and functional annotations of genetic variants. Machine learning models were developed using synthetic data generated from literature/derived effect sizes to demonstrate proof-of-concept feasibility. We prioritized genes (CYP3A5, CYP3A4, ABCB1) based on PharmGKB evidence levels, functional impact, and clinical associations with tacrolimus exposure and PTDM risk, incorporating genotype information, drug dosing, and metabolic outcomes. Results: The CYP3A5*1 allele emerged as a key determinant, consistently requiring 1.5 to 2.8 fold higher tacrolimus doses and conferring a significantly elevated risk of PTDM compared to non/expressers, an effect mediated by cumulative drug exposure. In the systematic review and synthetic modeling, carriers of functional CYP3A5 alleles expresser genotypes exhibited a significantly increased PTDM risk relative to non-expressers, demonstrating a clear dose/exposure/toxicity relationship. In contrast, CYP3A4 and ABCB1 showed only suggestive but heterogeneous, evidence of association. Conclusion: This in silico pharmacogenomic study demonstrates a clinically significant association between genetic variability in tacrolimus metabolism and the development of PTDM following liver transplantation. These findings support genotype-guided strategies to optimize immunosuppressive therapy and advance precision medicine in transplant care. Keywords: Tacrolimus; Pharmacogenomics; Liver transplantation; Diabetes mellitus

Abstract Context: Chronic hepatitis C virus (HCV) infection is associated with thyroid dysfunction, historically linked to interferon-based therapies. The impact of direct-acting antivirals (DAAs) on thyroid function remains controversial. Objective: To assess the prevalence and evolution of thyroid dysfunction in HCV-infected patients treated with DAAs through a systematic review with quantitative synthesis where feasible. Methods: A comprehensive literature search was conducted in PubMed, Scopus, Web of Science, and LILACS, without language restrictions, from January 2000 through October 2025, using the following terms: ("hepatitis C" OR "HCV") AND ("thyroid disease" OR "hypothyroidism" OR "hyperthyroidism" OR "thyroiditis") AND ("direct-acting antivirals" OR "DAA" OR "sofosbuvir" OR "ledipasvir" OR "daclatasvir" OR "simeprevir" OR "velpatasvir"). A random-effects meta-analysis of baseline prevalence was performed for three studies with complete extractable data (n=13,915); one study was excluded due to methodological overlap and incomplete denominators. Results: Four studies (n = 14,016) met inclusion criteria. Baseline prevalence of thyroid dysfunction ranged from 13.3% to 24.6%. Quantitative synthesis yielded a pooled prevalence estimate of 19.0% (95% CI: 9.6–30.8%), with substantial heterogeneity (I² = 97.1%). DAA-only regimens did not induce new-onset thyroid dysfunction or autoimmunity. Following sustained virologic response (SVR), 54.5–80% of patients with pre-existing thyroid abnormalities demonstrated improvement or normalization of thyroid function. SVR rates exceeded 95%, irrespective of baseline thyroid status. Conclusion: DAAs exhibit an excellent thyroid safety profile. Despite the high baseline prevalence of thyroid dysfunction among HCV-infected individuals, there is no evidence that DAA therapy induces new thyroid abnormalities; rather, functional improvement is frequently observed after virologic cure.

Alcoholic hepatitis is a form of acute liver injury with significant morbidity and mortality. Several scoring systems have been developed and used to predict mortality, including Maddrey's discriminant function (MDF), model for end-stage liver disease (MELD), and modified MELD including sodium (MELD-Na). We conducted a systematic review of Pubmed, Embase, and Cochrane Library to compare the accuracy of these scores in alcoholic hepatitis mortality prediction. The pooled sensitivity and specificity of MDF for mortality prediction in 28 days were 0.898 [95% confidence interval (CI) 0.777-0.957, I2 = 0%] and 0.370 (95% CI: 0.271-0.482, I2 = 78%), respectively; in 90 days, they were 0.898 (95% CI: 0.799-0.951, I2=21%) and 0.346 (95% CI: 0.246-0.463, I2 = 88%), respectively. The pooled sensitivity and specificity of MELD for mortality prediction in 28 days were 0.862 (95% CI: 0.755-0.926, I2 = 0%) and 0.697 (95% CI: 0.552-0.812, I2 = 82%), respectively; in 90 days, they were 0.884 (95% CI: 0.802-0.935, I2 = 21%) and 0.557 (95% CI: 0.300-0.787, I2 = 96%), respectively. The pooled sensitivity and specificity of MELD-Na for mortality prediction in 28 days were 0.652 (95% CI: 0.429-0.823, I2 = 79%) and 0.757 (95% CI: 0.666-0.830, I2 = 91%), respectively; in 90 days, they were 0.701 (95% CI: 0.661-0.737, I2 = 53%) and 0.816 (95% CI: 0.711-0.888, I2 = 94%), respectively. No significant statistical difference was observed when comparing area under the curve of these scores.

Bilateral complex nephrolithiasis presents a significant surgical challenge. The standard treatment, percutaneous nephrolithotomy (PCNL), can be performed in a traditional staged approach (staged bilateral PCNL [sPCNL]) or as a bilateral same-session procedure (same-session bilateral PCNL [ssPCNL]). Although the staged method has been favored for safety, ssPCNL has emerged as a viable alternative. This meta-analysis aims to systematically compare the efficacy, safety, and efficiency of ssPCNL vs sPCNL to provide comprehensive, evidence-based insights for clinical decision-making. A systematic review and meta-analysis was conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed, Scopus, and Cochrane databases for comparative studies. Primary outcomes analyzed were stone-free rate (SFR), minor complications (Clavien-Dindo I-II), and hospital stay. Secondary outcomes included operative time, hemoglobin decrease, and transfusion need. Data from studies were pooled using a random-effects model for all analyses. Risk of bias was assessed with risk of bias in randomized trials and Risk of Bias in Nonrandomized Studies of Interventions. Five studies met the inclusion criterion, comprising a total of 749 patients (308 ssPCNL, 441 sPCNL). The pooled analysis revealed no statistically significant difference between the groups in SFRs (odds ratio [OR]: 0.80 [0.47; 1.36]) or minor complications (OR: 0.88 [0.44; 1.73]). However, the ssPCNL group demonstrated a significantly shorter hospital stay (mean difference [MD] = -2.92 days; [-3.60; -2.24]; I2 = 84.7%). After sensitivity analysis, ssPCNL was also associated with a reduced operative time (MD: -45.18 minutes). Transfusion needs were comparable. ssPCNL is a safe, effective, and efficient alternative to the staged approach for managing bilateral renal stones. It offers comparable clinical outcomes while reducing patient morbidity and health care burdens associated with multiple procedures and longer hospitalizations. Thus, ssPCNL should be considered a valuable treatment option for appropriately selected patients in experienced centers.