We introduce poly-symplectic extension of Souriau Lie groups thermodynamics based on higher-order model of statistical physics introduced by Ingarden. This extended model could be used for small data analytics and machine learning on Lie groups. Souriau geometric theory of heat is well adapted to describe density of probability (maximum entropy Gibbs density) of data living on groups or on homogeneous manifolds. For small data analytics , the density of maximum entropy should consider higher order moments constraints (Gibbs density is not only defined by first moment but fluctuations request 2nd order and higher moments) as introduced by Ingarden. We use a poly-sympletic model introduced by Christian Günther, replacing the symplectic form by a vector-valued form. The poly-symplectic approach generalizes the Noether theorem, the existence of moment mappings, the Lie algebra structure of the space of currents, the (non-)equivariant cohomology and the classification of G-homogeneous systems. The formalism is covariant, i.e., no special coordinates or coordinate systems on the parameter space are used to construct the Hamiltonian equations. We underline the contextures of these models, and the process to build these generic structures. We also introduce a more synthetic Koszul definition of Fisher Metric, based on the Souriau model, that we name Souriau-Fisher metric. This Lie groups thermodynamics is the bedrock for Lie group machine learning providing a full covariant maximum entropy Gibbs density based on representation theory (symplectic structure of coadjoint orbits for Souriau non-equivariant model associated to a class of co-homology). Inviter les savants géomètres à traiter nos problèmes avec le soucis de la commodité et de l’agrément: qu’ils écartent tout ce qui n’a rien à voir avec la pénétration de l’esprit, seule qualité dont nous faisons grand cas et que nous nous sommes proposé d’éprouver et de couronner”“—Blaise Pascal—Deuxième Lettre sur la roulette, Paris, 19 Juillet 1658 Leta vector space of finite size,a non-zero positive measure of dual space,its Laplace transform, then:-is semi-definite convex function,-is convex and semi-continuous-Letan interior point ofthen:See , for linBefore introducing Entropy, Souriau introduced the following lemma:Lemma 1.Letbe a locally compact space, Leta positive measure of, havingas support, then the following functionis convex:such that the integral is converging.Definition1. [Souriau Entropy Definition]We call “Boltzmann Law” (relative to) all measureofsuch that the set of real values:The integral is strictly positive when it converges, and then insures existence of its logarithm. The epigraph of Il est évident que l’on ne peut définir de valeurs moyennes que sur des objets appartenant à un espace vectoriel (ou affine); donc—si bourbakiste que puisse sembler cette affirmation—que l’on n’observera et ne mesurera de valeurs moyennes que sur des grandeurs appartenant à un ensemble possédant physiquement une structure affine. Il est clair que cette structure est nécessairement unique—sinon les valeurs moyennes ne seraient pas bien définies.”  space; Therefore—so this assertion may seem Bourbakist—that we will observe and measure average values only as quantity belonging to a set having physically an affine structure. It is clear that this structure is necessarily unique—if not the average values would not be well defined.) “This definition of entropy by Souriau is a general scheme that can be extended to highly abstract spaces preserving Legendre structure , if we cSee also papers of Kostant  and LeraDuhem ,112,113 Consider a Galilean Lie group:Galilean Lie algebra: Action of Lie group:Galilean transformation on position and speed is given by:J, defined on the evolution space of the particle, with value in the dual g* of the Lie algebra G, as momentum map:Souriau has proved that this action is Hamiltonian, with the map Souriau gave the demonstration for the Galilean moment map for a free particle, considering the definition of moment map:F is:Then, as General Lagrange 2 form for a force F is equal to zero, we obtain:If The main Souriau idea was to define the Gibbs states for one-parameter subgroups of the Galilean group. Souriau has proved that action of the full Galilean group on the space of motions of an isolated mechanical system is not related to any equilibrium Gibbs state . Then, if we consider the 1-parameter subgroup of the Galilean group generated by b element of Lie algebra, is the set of matrices:N point particles, indexed by i ∈ {1,2, …, N}, enclosed in a box with rigid and undeformable walls, whose motion is described by the action of the 1-parameter subgroup of the Galilean group, t ∈ R. If we consider ith particle at time t. If we assume free particle and we neglect contributions given by the collisions of the particles between themselves collisions with the walls, then we can write:Then, Gibbs state defined for a gas enclosed in a moving box could be computed by Souriau formula. If we fix the affine Euclidean reference frame The important idea is to observe that We obtain for:that can be reduded by using the properties:To obtain Souriau’s Gibbs maximum entropy density, we have to use the following change of variables:We can then write:If we consider the case of the centrifuge , the parameter of Galilean group Lie algebra are reduced to:We obtain the closed form for maximum entropy Souriau-Gibbs density:This equation describes the behaviour of a gas made of point particles of various masses in a centrifuge rotating at a constant angular velocity and explains the observation that the heavier particles concentrate farther from the rotation axis than the lighter ones. Souriau made reference to thermodynamics of butter churn see .Souriau Lie groups thermodynamics provides right results if we apply it to subgroups of Galileo group, as previous example of a cylindrical box with fluid with an invariance sub-group of size 2  providing a 2-dimensional Souriau (Planck) temperature-vector. Souriau has observed that the process, by which a refrigerated centrifuge transmits its own temperature-vector to its content, has two names: thermal conduction and viscosity, depending on the temperature-vector component that is considered. Conduction and viscosity should therefore be unified in a fundamental theory of irreversible processes (theory that remains to be constructed).In the Appendix, we develop a solution given by Roger Balian  for the erations .As observed by Souriau in Chapter IV of , the GauWe can observe in previous equations that classical multivariate Gaussian density, classically expressed by ξT] -form as the fundamental structure of the theory starts with Kijowski’s papers. The geometrical multisymplectic approach uses the generalized Legendre correspondence introduced by Lepage and Dedecker and Hamiltonian formalism developed by Hélein The map:is an affine operation ofon, and commutes for allG over This extension by Günther defines an action of Definition 3.Leta poly-momentum, element of, we can define a n-coadjoint orbitat the point, for which the canonical projectioninduces a smooth map between the n-coadjoint orbitand the coadjoint orbit:that is a surjective submersion withProposition 1.onfor which the polymoment mapverifiesandwith:and:Extending Souriau’s approach, equivariance of poly-moment is a unique action a of the Lie group is a poly-symplectic one-cocycle.Definition 4.We define a poly-symplectic two-cocyclewithFinally, we propose to define the poly-symplectic Souriau-Fisher metric.Definition 5.withis a poly-symplectic extension of Souriau-Fisher Metric.Compared to the Souriau model, heat is replaced by previous polysymplectic model:Proposition 2.The characteristic function:exists.Proof. We extrapolate Souriau’s results, who proved in ,2 that ∫ product . □Entropy is defined by the Legendre transform of the Souriau-Massieu characteristic function:Definition 6.The poly-entropy is given by Legendre transform of the poly-symplectic characteristic function:The Gibbs density could be then extended with respect to high order temperatures.Definition 7.Gibbs density is defined as the maximum entropy density of poly-Entropy:Geometry of Jean-Marie Souriau: Study of homogeneous symplectic manifolds geometry with the action of dynamical groups. Introduction of the Lie groups thermodynamics in statistical mechanics [echanics ,44.Geometry of Jean-Louis Koszul: Study of homogeneous bounded domains geometry, symmetric homogeneous spaces and sharp convex cones. Introduction of an invariant 2-form [t 2-form ,98,129.Geometry of Erich Kähler: Study of differential manifolds geometry equipped with a unitary structure satisfying a condition of integrability. The homogeneous Kähler case studied by André Lichnerowicz [nerowicz .We have introduced contextures of geometric theory of information and heat based on Souriau’s approach, but information geometry is at the interface between different geometries. First, information geometry is at the intersection between “Riemannian geometry”, “complex geometry” and “symplectic geometry”. Based on seminal work of Cartan on homogeneous domains and other works ,127,128,We have extended Souriau’s Lie groups thermodynamics by a vector-valued model based on poly-symplectic geometry, introducing higher order Souriau-Gibbs density with higher order Souriau temperatures, and elements of Lie algebra. This model preserves all contextures of Souriau’s thermodynamics with covariance of Gibbs density with respect to dynamical groups in physics. Poly-moment maps are compliant with the Noether theorem generalization in vector-valued cases.Introduction to Symplectic Geometry”, in Chinese  which is the homogeneous Galileo group ):In information geometry, the general affine group is involved A for exponential family:In the study of homogeneous bounded domains, as the simplest one given by Poincaré upper-half plane:We have seen that in geometrical mechanics, the Galileo group related to classical mechanics:http://public.weconext.eu/academie-sciences/2017-10-03_5a7/video_id_002/index.html) and by Daniel Bennequin (https://www.youtube.com/watch?v=a-ctwxBpJxE) to study the brain sense of movment. We can read in Souriau’s text the very interesting remarks on geometry and neuroscience:Je me suis dit, à force de rencontrer des groupes, il y a quelque chose de caché là-dessous. La catégorie métaphysique des groupes qui plane dans l’empyrée des mathématiques, que nous découvrons et que nous adorons, elle doit se rattacher à quelque chose de plus proche de nous. En écoutant de nombreux exposés faits par des neurophysiologistes, j’ai fini par apprendre le rôle primitif du déplacement des objets. Nous savons manipuler ces déplacements mentalement avec une très grande virtuosité. Ce qui nous permet de nous manipuler nous-même, de marcher, de courir, de sauter, de nous rattraper quand nous tombons, etc. Ce n’est pas vrai seulement pour nous, c’est vrai aussi pour les singes ; ils sont beaucoup plus adroits que nous pour anticiper les résultats d’un déplacement. Pour certaines opérations élémentaires de «lecture», ils vont même dix fois plus vite que nous. Beaucoup de neurophysiologistes pensent qu’il y a une structure spéciale génétiquement inscrite dans le cerveau, le câblage d’un groupe … Lorsque il y un tremblement de terre, nous assistons à la mort de l’Espace. … Nous vivons avec nos habitudes que nous pensons universelles. … La neuroscience s’occupe rarement de la géométrie … Pour les singes qui vivent dans les arbres, certaines propriétés du groupe d’Euclide sont mieux câblées dans leurs cerveaux.” “As illustrated in Le Hasard et la Courbure (Randomness and Curvature)” (title of Yann Ollivier HDR), that we have synthetized in Souriau-Fisher metric to “Le Hasard et la Torsion (Randomness and Torsion)” based on Elie Cartan works founded on Cosserats brothers model of elasticity [Il est une Cosmologie avec laquelle la Thermodynamique générale présente une analogie non-méconnaissable; cette Cosmologie, c’est la Physique péripatéticienne … Parmi les attributs de la substance, la Physique péripatéticienne confère une égale importance à la catégorie de la quantité et à la catégorie de la qualité; or, par ses symboles numériques, la Thermodynamique générale représente également les diverses grandeurs des quantités et les diverses intensités des qualités. Le mouvement local n’est, pour Aristote, qu’une des formes du mouvement général, tandis que les Cosmologies cartésienne, atomistique et newtonienne concordent en ceci que le seul mouvement possible est le changement de lieu dans l’espace. Et voici que la Thermodynamique générale traite, en ses formules, d’une foule de modifications telles que les variations de températures, les changements d’état électrique ou d’aimantation, sans chercher le moins du monde à réduire ces variations au mouvement local”“—Pierre Duhem—La théorie Physique: son objet, sa structure .Pour la théorie de la connaissance mais aussi pour les sciences est fondamentale la notion de perspective. Or, les expériences faites dans la géométrie algébriques, dans la théorie des nombres, et dans l’algèbre abstraite m’induisent à tenter une formulation mathématique de cette notion pour surmonter ainsi au moyen de raisonnements d’origine géométrique la géométrie. Il me semble en effet, que la tendance vers l’abstraction observée dans les mathématiques d’aujourd’hui, loin d’être l’ennemi de l’intuition ait le sens profond de quitter l’intuition pour la faire renaitre dans une alliance entre «esprit de géométrie» et «esprit de finesse», alliance rendue possible par les réserves énormes des mathématiques pures dont Pascal et Goethe ne pouvaient pas encore se douter”“—Erich Kähler—Sur la théorie des corps purement algébriques, 1952.Our new research directions will concern extension of “asticity ,127,131.


Nobel, courageous, and full of compassion, they increasingly want to save more lives, be useful; with the objective of achieving better results in care, they bravely face long working hours with no sleep, and are known as professionals that dedicate themselves constantly in work as in studies. Additionally, they have a method of working that requires physical disposition and agility in order to evaluate, diagnose, and care for their patients. Watching over the lives of others is the task of healthcare professionals.One of the major objectives of all professionals is to avoid complications, focused on safety of patients and quality of care. Nevertheless, adverse events are a reality and likely with always be a part of the system, due to the universal nature of human fallibility and the complexity in which care is inserted. Adverse events can cause severe damage to the patient or death; thus, the patient is the “first victim” of these events. However, the victims of adverse events go way beyond a given individual. When they occur, there is an indirect effect on healthcare professionals, who are considered the “second victims”.The term “second victim” was used by Albert Wu, professor of health policies and management at the Johns Hopkins Bloomberg School of Public Health, in the year 2000, to describe the impact of adverse events on healthcare professionals. Some symptoms experienced by them have been described in literature and include psychological , and cognitive  symptoms, besides physical reactions, with a negative impact on their bodies.-4It is probable that healthcare professionals directly involved in adverse events suffer emotional response reactions, which can lead to difficulty sleeping, guilt, lack of confidence, shame, anxiety, or reduced job satisfaction. If not treated, they may result in several consequences, including depression, emotional exhaustion, post-traumatic stress disorder, and suicidal ideation, according to a survey carried out by the American Society of Healthcare Risk Management, in 2015.,3An analysis of 2013 in reference to healthcare professional as “second victims”, and published in the Evaluation & the Health Professions, concluded that almost half of them experienced some impact, but few sought help. Support programs to the “second victims” should be implemented, seeking to break these barriers and aggregate all healthcare professionals, giving them the aid they need.,3A study conducted in 2017, based on professional interviews linked to the patient safety sector in intensive care hospitals in Maryland, United States, highlighted numerous barriers impeding physicians, nurses, and other healthcare professional from receiving help after the occurrence of adverse events. The primary barriers included fear of confidentiality and the negative judgment of their work colleagues.The Johns Hopkins Hospital has a multidisciplinary work group dedicated to “second victims”, which develops its activities by helping the hospital provide care and support to the healthcare professionals involved in adverse events.A survey performed with 898 physicians at the University of Missouri, also in the United States, found that the physicians, after the occurrence of an adverse event, wanted a support system that could relieve them from immediate patient care tasks for a brief time. Additionally, they desired to receive individual support and constant feedback, as well as access to specialists in patient safety and risk management, offering support and referrals to other specialists, when necessary. The healthcare system of the University of Missouri developed a support program implemented by a multiprofessional rapid response team.A glimpse of this punitive, toxic, and individual approach culture of error was made evident in Brazilian nursing, by means of a documental investigation, from 1995 to 2010, with data collected from 13 ethical-disciplinary processes received by the Regional Council of Nursing of the State of Bahia (COREN-BA). In these processes, the health organizations - represented by the nursing coordination - stood out as whistleblowers of adverse events committed by nursing professionals. This sample, in fact, still represents a major setback in human resource management in health.Unfortunately, in Brazil, support programs for this situation are unknown, studied or valued very little within the area of patient safety, perpetuating and validating a punitive culture in the management of organizations. To blame only healthcare professionals is a commonplace approach in our midst, which represents an easier act than directing it, also, to organizations.-6 Unfortunately, our culture has failed in the support to healthcare professionals involved in these cases. They declare that many organization reactions to adverse events are malicious, threatening, isolating, and fundamentally useless.It is evident that there is a risk of human error behind each undertaking/action, but each person should be responsible only for activities under their control. For the safety of the patient, healthcare professionals should have appropriate tools and environment to carry out the tasks necessary and coordinate efforts.,7Studies on adverse events affecting the patient described the main causes as lack of structural conditions in the work environment, inadequate materials and equipment, insufficient staff sizing, work overload, professional fatigue and stress, error in planning activities, process failures, and lack of effective communication. Leadership resistance is among the most significant barriers to creating an effective culture to support “second victims”. This is usually because the value and purpose of these targeted programs have not not been clearly understood. The role of leaders is extremely important, since they provide empathy and emotional support to the professional. The best strategy seems to be creating support networks at individual, organizational, or national levels. When initiating a significant accusation of adverse event, in addition to investigating the root cause, a parallel analysis should be made to determine if there are “second victims”.Recognizing the seriousness of this problem and its impact on patient care, the Joint Commission International (JCI) issued a statement, in January 2018, aimed to help healthcare organizations with recommendations and resources on how to support “second victims”. If not properly conducted, a “second victim” experience can bring physical and emotional harm to healthcare professionals who work both to treat and care for patients. Several of these victims, however, need support and care that many health organizations are not prepared to offer. This underscores the importance of establishing “second victim” programs, which play a critical role in strengthening the culture of safety and reducing stigma and prejudice. The guide briefly provides safety actions for health organizations to consider, including developing a culture for learning from health system adversities and communicating lessons learned, as well as guidance on how staff can support themselves when adverse events occur.A change of culture is needed in health care, with a transfer of the traditional one, in which shame, guilt and punishment directed at health professionals who have experienced a “second victim” phenomenon, must be quickly replaced by a movement towards a just culture, in which each one takes responsibility for the activities under their control.It is crucial that patients and families affected by adverse events receive more attention. On the other hand, care and attention should also be given to “second victims”.We emphasize the need to further recognize the nature of the “second victim” phenomenon and establish organizational support for affected healthcare professionals. An organizational environment must be built in which these sensitive issues are discussed in a clear, non-judgmental and non-punitive manner. We also emphasize the need for well-established support structures, which can meet the needs of the healthcare professionals involved. ,2Os profissionais de saúde praticam suas atividades diariamente, com ciência e dedicação, em diversas situações de cuidados excessivamente complexos. Nobres, corajosos e cheios de compaixão, querem cada vez mais salvar pessoas, serem úteis, objetivam melhores resultados na assistência, enfrentam bravamente longas jornadas de trabalho e horas sem dormir, e são conhecidos como profissionais que se dedicam constantemente, tanto no trabalho quanto nos estudos. Além disso, possuem uma forma de trabalhar que requer disposição física e agilidade para avaliar, diagnosticar e cuidar de seus pacientes. Zelar pela vida dos outros é tarefa dos profissionais de saúde.Evitar complicações é um dos principais objetivos de todos os profissionais, com foco na segurança do paciente e na qualidade da assistência. No entanto, eventos adversos são uma realidade e, provavelmente, sempre farão parte do sistema, devido à natureza universal da falibilidade humana e à complexidade na qual os cuidados se inserem. Os eventos adversos podem causar danos graves ao paciente ou óbito; assim, o paciente é a “primeira vítima” desses eventos. No entanto, as vítimas de eventos adversos vão muito além de tal indivíduo. Quando eles ocorrem, há um efeito indireto nos profissionais de saúde, considerados as “segundas vítimas”.Johns Hopkins Bloomberg School of Public Health, para descrever o impacto dos eventos adversos nos profissionais de saúde. Alguns sintomas vividos por eles foram descritos na literatura e incluem manifestações de cunhos psicológico  e cognitivo , além de reações físicas, com impacto negativo em seu organismo.O termo “segunda vítima” foi usado, em 2000, por Albert Wu, professor de política e gestão em saúde na American Society of Healthcare Risk Management, em 2015.-4É provável que profissionais de saúde diretamente envolvidos em eventos adversos sofram reações de resposta emocional, que podem levar à dificuldade para dormir, culpa, insegurança, vergonha, ansiedade ou redução da satisfação no trabalho. Se não tratados, podem resultar em algumas consequências, incluindo depressão, desgaste, transtorno de estresse pós-traumático e ideação suicida, de acordo com pesquisa realizada pela Evaluation & the Health Professions, concluiu que quase metade deles vivencia algum impacto, mas poucos procuram ajuda.,3Uma análise de 2013 referente aos profissionais de saúde como “segundas vítimas”, publicada na  Programas de apoio às “segundas vítimas” devem ser implementados, buscando romper essas barreiras e agregar todos os profissionais de saúde, dispensando o apoio de que precisam.,3Estudo de 2017, baseado em entrevistas profissionais ligadas ao setor de segurança do paciente em hospitais de cuidados intensivos em Maryland, nos Estados Unidos, destacou inúmeras barreiras impedindo que médicos, enfermeiros e outros profissionais de saúde obtivessem ajuda após a ocorrência de eventos adversos. As principais barreiras incluíam o medo de confidencialidade e o julgamento negativo dos colegas de trabalho.University of Missouri, também nos Estados Unidos, constatou que os médicos, após a ocorrência de um evento adverso, desejavam um sistema de suporte que pudesse aliviá-los das tarefas imediatas de atendimento ao paciente por um breve período. Além disso, gostariam de receber suporte individual e feedback constante, bem como acesso a especialistas em segurança do paciente e gerenciamento de risco, oferecendo apoio e encaminhamento para outros especialistas, quando necessário. O sistema de saúde da University of Missouri desenvolveu um programa de suporte implantado por uma equipe interprofissional de resposta rápida. O Johns Hopkins Hospital possui um grupo de trabalho multidisciplinar dedicado às “segundas vítimas”, o qual desenvolve suas atividades auxiliando o hospital a prestar cuidados e apoio aos profissionais de saúde envolvidos em eventos adversos.Pesquisa realizada com 898 médicos clínicos da  Um recorte dessa cultura punitiva, tóxica e de abordagem individual do erro foi evidenciado na enfermagem brasileira, por meio de pesquisa documental, de 1995 a 2010, com dados coletados a partir de 13 processos ético-disciplinares recebidos pelo Conselho Regional de Enfermagem da Bahia (COREN-BA). Nestes, as organizações de saúde, representadas pela coordenação de enfermagem, destacaram-se como denunciantes dos eventos adversos cometidos por profissionais de enfermagem. Essa amostra, de fato, ainda representa um grande retrocesso na gestão de recursos humanos em saúde.Infelizmente, no Brasil, desconhecem-se programas de apoio a essa situação, pouco estudada ou valorizada dentro da área de segurança do paciente, perpetuando e validando uma cultura punitiva na gestão das instituições. Culpar somente os profissionais de saúde é uma abordagem corriqueira em nosso meio, o que representa um ato mais fácil do que direcioná-la, também, às instituições.-6 Infelizmente, nossa cultura tem faltado no apoio aos profissionais de saúde envolvidos nesses casos. Eles declararam que muitas reações organizacionais a eventos adversos são maliciosas, ameaçadoras, isolantes e fundamentalmente inúteis.É evidente que existe um risco de erro humano por trás de cada empreendimento/ação, mas cada pessoa deve ser responsabilizada apenas por atividades sob seu controle. Para a segurança do paciente, os profissionais de saúde devem ter ferramentas e ambiente adequados para executar as tarefas necessárias e coordenar esforços.,7Estudos sobre eventos adversos que atingem o paciente descrevem as principais causas falta de condições estruturais no ambiente de trabalho, materiais e equipamentos inadequados, dimensionamento insuficiente de pessoal, sobrecarga de trabalho, cansaço e estresse do profissional, erro de planejamento das atividades, falhas de processo e ausência de comunicação efetiva.Joint Commission International (JCI) emitiu um comunicado em janeiro de 2018 destinado a ajudar as organizações de saúde, com recomendações e recursos sobre como apoiar as “segundas vítimas”. Uma experiência de “segunda vítima”, se não conduzida adequadamente, pode trazer danos físicos e emocionais aos profissionais de saúde, que trabalham tanto para tratar como cuidar dos pacientes. Várias dessas vítimas, no entanto, precisam de apoio e cuidados que muitas organizações de saúde não estão preparadas para oferecer. Isso enfatiza a importância do estabelecimento de programas de “segundas vítimas”, que desempenham papel crítico no fortalecimento da cultura de segurança, além de reduzirem estigmas e preconceitos. O guia oferece, resumidamente, ações de segurança a serem consideradas pelas organizações de saúde, incluindo o desenvolvimento de uma cultura para aprender com as adversidades do sistema de saúde e a comunicação das lições aprendidas, além de orientações sobre como a equipe pode se apoiar na ocorrência de um eventos adversos.Reconhecendo a gravidade desse problema e seu impacto no atendimento ao paciente, a  O papel dos líderes é extremamente importante, pois eles fornecem empatia e apoio emocional ao profissional. A melhor estratégia parece ser a criação de redes de suporte em níveis individual, organizacional ou nacional. Ao iniciar uma acusação de eventos adversos significativo, além da investigação da causa raiz, deve ser iniciada uma análise paralela para determinar se existem “segundas vítimas”.A resistência da liderança está entre as barreiras mais significativas à criação de uma cultura eficaz em torno do apoio às “segundas vítimas”. Isso geralmente ocorre porque o valor e o propósito desses programas direcionados não são claramente compreendidos.É necessária uma mudança de cultura na assistência à saúde, com transferência da tradicional, em que a vergonha, a culpa e a punição voltadas para os profissionais de saúde que experimentaram um fenômeno de “segundas vítimas” devem ser rapidamente substituídas por um movimento em direção a uma cultura justa, na qual cada um se responsabilize pelas atividades sob seu controle.É crucial que pacientes e famílias prejudicados por eventos adversos recebam mais atenção. Por outro lado, devem também ser dispensados cuidados e atenção às “segundas vítimas”.Ressaltamos a necessidade de reconhecer ainda mais a natureza do fenômeno da “segundas vítima” e estabelecer apoio organizacional para os profissionais de saúde afetados. Deve ser construído um clima organizacional em que essas questões delicadas sejam discutidas de maneira clara, não julgadora e não punitiva. Enfatizamos, ainda, a necessidade de estruturas de suporte bem estabelecidas, que possam atender às necessidades dos profissionais de saúde envolvidos.


To assess longitudinally the change in quality of life in people living with HIV initiating antiretroviral therapy in three public reference services specialized in HIV care in Belo Horizonte, Brazil. Prospective cohort study among people living with HIV, aged 18 years or older, and initiating antiretroviral therapy. We obtained sociodemographic, behavioral, clinical data related to pharmacological treatment and to the service by face-to-face interviews, and supplemented these data with information from clinical records and Information Systems of the Brazilian HIV/AIDS Program. We measured the quality of life using the WHOQOL-HIV bref instrument, with a minimum interval of six months between the baseline and the follow-up interviews. We used paired t-test to assess the mean change in quality of life between the two interviewsand evaluated factors associated with this outcome using multiple linear regression. The overall quality of life, as well as the physical, psychological, level of independence, environment and spiritual quality of life domains were statistically higher in people living with HIV using antiretroviral therapy at the end of the follow-up. Factors independently associated with the increase in quality of life were having religious belief and living with other people. Having signs or symptoms of anxiety and depression and the number of adverse drug reactions reported were predictors associated with worsening quality of life. These results show an improvement in the quality of life over time in people living with HIV on antiretroviral therapy. They also highlight the need to monitor and provide health care support, especially for individuals with signs and symptoms of anxiety and depression and that report adverse reactions to medicines at the beginning of treatment. In 2015, the Protocolo Clínico e Diretrizes Terapêuticas  for the management of HIV recommended a fixed-dose combination (FDC) containing the medicines tenofovir (TDF), lamivudine (3TC) and efavirenz (EFV) as a first-line regimen. In 2017, dolutegravir (DTG), an integrase inhibitor, was recommended as the first-line regimen, replacing EFV. This medicine should be taken together with a fixed-dose combination of TDF and 3TC2 .In Brazil, in recent years, first-line antiretroviral (ARV) schemes have been modified, following the global trend and recommendations of the World Health Organization (WHO)3 . Therefore, understanding QOL is essential to analyze the physical and biopsychosocial impact that HIV can cause, enabling greater knowledge of individuals about themselves, their adaptation to the condition of living with HIV and to their treatment. Evidence on the impact of ART initiation on QOL in PLWH is also scarce.In developing countries, such as Brazil, evidence from longitudinal studies on the determinants of quality of life (QOL) in people living with HIV (PLWH) are scarce. In a literature review, gender, age, family situation, education, employment, income, viral load, TCD4+ lymphocyte count, diagnosis time, presence of symptoms of depression and anxiety, social support, health care, use of licit and illicit drugs, adherence to antiretroviral therapy (ART), lifestyle and sexual behavior were factors directly associated with PLWH QOLThe objective of our study was to evaluate longitudinally the QOL in PLWH initiating ART that attended three public reference services in Belo Horizonte, Brazil. We further evaluated the predictors of change in QOL.5 .This is a cohort study, using data from the Ecoart project, whose details were previously publishedThe sample selection was non-random, and all eligible individuals attending three public specialized HIV care services were invited to participate in the study. These servicesall together dispense ART for approximately 80% of PLWH in the municipality of Belo Horizonte, state of Minas Gerais,Brazil. Participants’ selection took place between September 2015 and October 2017.We included individuals with up to 180 days of ART usage, who attended one of the services evaluated and who were identified through their registration in the logistic control system of medicines (Siclom), a national system of ART dispensation. The inclusion criteria were the signing of the informed consent form, being 18 years of age or older, autonomy to respond to the interview and having performed the baseline interview and the second follow-up interview.8 . It also contained questions regarding sociodemographic, behavioral, clinical, laboratory information, related to pharmacological treatment and to the health care service.We obtained data by face-to-face interviews and in secondary databases, using standardized forms that contained the World Health Organization quality of life HIV instrument – in its shortened version (WHOQOLHIV – bref), the Hospital scale of anxiety and depression (HADS) and the Morisky’s therapeutic adherence scale of eight items (MMAS–8), all validated in BrazilTo minimize potential bias, researchers were properly trained and a pilot project was conducted before starting data collection.4 .We assessed QOL using the WHOQOL-HIV bref instrument in two moments: at the baseline interview and at the second follow-up interview six months after the baseline interview. The mean difference in overall QOL between these two moments was the dependent variable of our study. Therefore, we present the results only of those individuals that concluded both interviews. Data on QOL at baseline were published previously6 .The WHOQOL-HIV bref is a specific instrument for assessing QOL in PLWH, which, in 31 questions, evaluates the following domains: physical, psychological, level of independence, social relations, environment and spirituality. Each question has five-point Likert scale answer options, 1 indicating negative perceptions and 5, positive perceptions, except for seven items, in which the scale is reversed. The average of the items within each domain is used to estimate the total score for the domain. The result is multiplied by 4, and thus the scores vary between 4 and 206 .The overall QOL component and general health perception was evaluated using the first two questions of the WHOQOL-HIV bref instrument. The mean of the items was multiplied by 4; thus, the scores also ranged from 4 to 20We used sociodemographic, behavioral, clinical and laboratory variables related to pharmacological treatment and service to characterize the study population.7 . People that had 8 or more points in each of the conditions were classified with symptoms of anxiety and depression. The individuals were classified according to the presence of signs and symptoms of anxiety or depression in the baseline interview and in the follow-up interview, being categorized as: (I) never – they never presented signs and symptoms of anxiety or depression, (ii) ever – they presented these symptoms in one of the two interviews or (iii) always – they presented these symptoms in both interviews.The presence of signs or symptoms of anxiety and depression was measured using the HADS, composed of 14 items8 . Individuals that scored 8 points were considered adherents. Adverse drug reactions (ADR) were assessed by self-reporting. Individuals with less than 50 copies per ml were considered with an undetectable viral load.MMAS-8 was used to evaluate adherence to ART. The total score of MMAS-8 varies from 0 to 8, and the higher the score, the higher the adhesion9 .The variable economic class (socioeconomic status) was evaluated according to Brazilian criteria, such as high , intermediate (C) and low (D and E), in which individuals are classified by socioeconomic groups by possession of comfort items and level of education of the head of the familyFor the comorbidity variable, it was considered the self-report of any disease diagnosed by a physician, such as arterial hypertension, diabetes, hypercholesterolemia, among others.We performed adescriptive analysis by frequency distribution for categorical variables and measures of central tendency for quantitative variables.t -test to compare the mean differences in QOL scores between the two interviews.To evaluate the scores of the WHOQOL-HIV bref instrument, means and standard deviation were presented for each domain, relative to the baseline interview and the second follow-up interview. We then used paired t test (comparison of means) and the Mann-Whitney test (comparison of medians).The univariate analysis of the relationship between independent variables and the change in QOL score was evaluated by the Student We analyzed the association between change in QOL and independent variables by adjusting a multiple linear regression model. Variables with a p-value equal to or less than 0.20 were selected to enter the multivariate model. The backward stepwise method was used to obtain the final model. The results of multiple linear regression were demonstrated by regression coefficients, with their respective 95% confidence intervals (95%CI).2 and adjusted R2 were used to verify the percentage of variance related to the increase in QOL explained by the model. The Durbin-Watson statistic was used to verify the assumption that the residues are not correlated, with values between 0 and 4, and 2 means no correlation between the residues. It was also tested if there was multicolinearity in the final model, using the statistics of tolerance (acceptable > 0.10) and VIF (acceptable < 10)10 . To evaluate if the residues had normal distribution, the following graphs were performed: standardized regression residues by standardized regression predicted values, histogram of frequencies of standardized regression residues, and a quantiles-quantile graph (QQ plot).We evaluated the adequacy of the model by a set of statistics. The statistics RThe Statistical Package for the Social Sciences (SPSS) software version 22.0 was used. In all analyses, a 0.05 significance level was considered.The Ecoart research project was approved by the Research Ethics Committee (COEP) of the Universidade Federal de Minas Gerais  and the participating services. The research was conducted following the instructions of resolution 466/2012 of the National Health Council.During the entire recruitment period of the Ecoart project, 1,017 individuals served in the three services were identified. Of these, 468 performed the baseline interview, of which 323 (69.0%) performed the second follow-up interview and were included in our study   1.No statistically significant differences regarding gender, age, marital status and education were found between the group that completed the second follow-up interview with those that did not. There were also no differences regarding general QOL and QOL domains.Most of the respondents were men (83.0%), unmarried (79.9%), without children (66.9%), between 20 and 34 years old (54.5%), did not have a private health insurance (72.8%) and self-declared as non-white (76.9%). We found that 80.8% of the individuals lived with others, 38.8% had 10 to 12 years of schooling and 59.4% were employed at the time of the interview, with a predominance of Economy Class C (45.7%).Regarding behavioral characteristics and lifestyle habits, 24.5% reported current tobacco use, 65.8% reported recent alcohol use, and 47.5% reported current or prior use of illicit drugs in their lives. Most reported having some religious belief (79.4%) and 59.6% were men who have sex with other men (MSM).3, 90.1%, detectable viral load, and 26.0%, viral load greater than 100,000 copies/ml.Regarding clinical characteristics, 7.8% presented coinfection , 18.3%, one or more self-reported comorbidities, and 35.9 had signs or symptoms of anxiety and depression. Most individuals presented asymptomatic clinical classification (67.3%) and had less than or equal to six months of diagnosis of HIV infection (61.8 %). Regarding the baseline laboratory characteristics, 23.5% had an initial TCD4+ lymphocytes count less than 200 cells/mmRegarding pharmacological treatment, 63.2% used TDF/3TC/EFV, and 32.2%, TDF/3TC+DTG. Most (52.3%) had been using ART for 60 days or less, were non-adherent to ART (52.8%), reported at least one ADR (85.9%), and 53.1% reported three or less ADR   .In the second follow-up interview, regarding clinical, laboratory and ART-related characteristics, 34.3% of individuals presented signs and symptoms of anxiety and depression, 73.4% undetectable viral load, 59.5% were non-adherent to treatment, and 51.6% reported some ADR, and 79.9% reported three or less ADR   .The second follow-up interview occurred on average 9.47 months  after the baseline interview.Statistically significant improvements were observed over time in the overall QOL and in the physical, psychological, level of independence, environment and spiritual domains in individuals initiating ART. The only domain, in which the mean difference between baseline and follow-up interviews was not significant, was that of social relations.The QOL domains with the greatest mean differences were physical , spiritual  and psychological    .In the univariate analysis, individuals that reported illicit drug use throughout their lives had a higher mean difference in QOL . Individuals with no symptoms of anxiety and depression had a greater mean difference in QOL . Among the laboratory and ART-related variables, no statistically significant association was observed among VL, ARV scheme , treatment duration, adherence to treatment, ADR, number of ADR and change in Mean QOL   .In the final multiple linear regression model, individuals with religious belief  and those that lived with others  showed an increase in QOL. Whereas individuals that reported signs or symptoms of anxiety and depression in life  or always  had a reduction in QOL. With each additional ADR reported at baseline, there was a reduction in the individual’s QOL . Those individuals with higher QOL scores in the baseline interview obtained lower QOL increments at the end of the study, thus showing an inversely proportional Association    .2 statistic was equal to 0.414, that is, the model explained approximately 41.4% of the variance of the QOL increase. The Durbin-Watson statistic was equal to 2.02, indicating no correlation between the residues. In the collinearity statistics, all predictors had tolerance values above 0.56 and VIF values close to 1 (1.00 to 1.78). The distribution of standardized waste was also verified, and they approached the normal distribution. This assumption was also confirmed by the Q-Q normal residue regression graph. Finally, the dispersion graph between the standardized and predicted residues did not show that they were randomly distributed; therefore, the developed model shows good fit.Regarding the adequacy of the multiple linear regression model, the adjusted RIndividuals initiating ART in this cohort showed an increase in QOL; having a religious belief and living with other people were positively associated with QOL, whereas having signs or symptoms of anxiety and depression, anytime or always, and additional ADR reported were predictors associated with worse QOL.12 and epidemiological bulletins14 , with a predominance of male, young, self-declared non-white skin color and with high schooling.The characteristics of this population were similar to those of other studies15 . The greatest mean difference in QOL observed in the physical domain, in which aspects such as pain, discomfort, energy, sleep and rest are evaluated, may be related to the use of ART. This causes changes in the course of infection, such as slowing the progression of immunodeficiency caused by the HIV virus and restoring the immune response of individuals – consequently, it can positively affect the individual’s life18 .Our study showed that, over time, individuals in initial use of ART presented an increase in the overall QOL score, consistent with previous research15 .In the social relations domain, in which questions related to acceptance of diagnosis, family support, interpersonal relationship and sexual life were evaluated, a lower mean difference in QOL was observed. The social relationship is a complication for PLWH, since infection with the virus can be a stigmatizing health condition, which involves feelings of discrimination and, consequently, lack of social support and feelings of loneliness. Considering that these factors will hardly be influenced by the use of ART, it is important to emphasize the need to improve personal relationships and social support for these individualsWe observed a statistically significant increase in the overall perception component of QOL. The benefits of ART in the QOL can be explained by the reduction of clinical symptoms of infection. That is, this reinforces the need to link and retain individuals to the health care service and maintain adherence to treatment.15 .Some behavioral, sociodemographic, clinical and ART-related factors showed a relationship with the change in QOL in individuals initiating ART, and these findings are consistent with the scientific literature21 , which contributes to the increase in QOL and health. Faith and religious beliefs are important strategies for coping with health conditions such as HIV, when allied to ART21 .Feelings of guilt, loneliness and fear of death, commonly reported by PLWH, are related to spiritual practice and having religious beliefs22 , conducted in the Southern Brazil, individuals that lived alone presented 30% propensity to worse QOL in the social relations domain. Less emotional support during treatment could partially explain the results. Another cross-sectional study, conducted with 100 PLWH in Nepal, using the WHOQOL-bref instrument, demonstrated that good family support has a greater influence on QOL increase, being statistically associated with overall QOL23 .Our results stresses the importance of family involvement in reducing HIV-related stigma and prejudice. In another study using the same instrument, but with a cross-sectional design24 . Depression and anxiety are more frequent in PLWH than in the general population25 , which can negatively influence the individual’s behavior and contribute treatment-related difficulties and even worse adherence to ART26 . The impact of psychiatric symptoms on PLWH QOL also occurs due to a deterioration of the immune system and consequent increase in disease progression, justified by the increased level of stress and depressive symptoms27 . Although HADS is not used for diagnostic purposes, but to evaluate signs and symptoms of anxiety and depression, an association was observed between these signs and symptoms and the reduction of QOL in PLWH in follow-up interviews. These results emphasize the importance of the follow-up by a health professional  in HIV specialized services. In another cross-sectional study on QOL of the Ecoart group, conducted with 366 individuals in Belo Horizonte, being single (unmarried), having other comorbidities, lower educational level, being smoker, and having signs and symptoms of anxiety and depression was associated with lower QOL4 . In another cross-sectional study including 150PLWH conducted in Cambodia, the authors suggest a strong association between the increase in QOL assessed by the overall QOL score and the six domains of WHOQOL-HIV bref and the absence of signs or symptoms of anxiety and depression28 .Signs or symptoms of anxiety and depression can impair PLWH QOL29 . ADR can affect physically and psychologically the performance of professional and personal activities and, consequently, the QOL of individuals under treatment5 . Monitoring the use of antiretrovirals is an important tool to assess the safety of these medicines in clinical practice5 and ensure better care and satisfaction of individuals with treatment29 .In our study, we verified a greater reduction in QOL to each additional ADR reported by subjects in treatment, that is, the greater the number of ADR reported, the greater the reduction in QOL. This result is similar to that of another study conducted in Brazil, which described the lower number of ADR to ART as one of the factors associated with QOL improvementWhen comparing individuals using the TDF/3TC + DTG regimen with those using TDF/3TC/EFV or other regimens, no statistically significant differences were observed in the mean difference in overall QOL, which can be explained by the fact that part of the Ecoart study population had initiated ART even asymptomatic, due to the change of the HIV treatment guidelines by the Brazilian Ministry of Health. Therefore, these individuals may not have recognized the improvement in QOL with the use of ART, regardless of the regimen used.Our study presents as limitation the incompleteness of data from the control system of laboratory tests (Siscel), such as TCD4+ lymphocyte and VL count. To minimize this limitation, we considered the data for the three-month period before and after the second follow-up interview, resulting in a low percentage of missing data. As positive points, we cite the longitudinal design, and that data were collected with methodological rigor and in representative sites of PLWH of Belo Horizonte, the high number of the sample and the robustness of the final model obtained by multivariate analysis. Moreover, the WHOQOL-HIV bref is an instrument that evaluates QOL in the two weeks prior to the interview; thus, potential memory biases were minimized.New studies in PLWH with longer follow-up time, using the WHOQOL-HIV bref, as well as other instruments, are necessary to measure the changes in QOL of these individuals and contribute to the direction of actions and interventions of health professionals that may contribute to increasing QOL in PLWH.We concluded that, over time, PLWH initiating ART showed improvement in QOL. There is a need to monitor and provide health care support, especially for individuals with signs and symptoms of anxiety and depression and that report adverse reactions at the beginning of treatment.Our study can contribute to the planning and direction of public actions and policies, as well as to identify modifiable factors that can increase the QOL of these individuals. 1 . Em 2015, o Protocolo Clínico e Diretrizes Terapêuticas (PCDT) para o manejo do HIV passou a recomendar como esquema de primeira linha um medicamento em dose fixa combinada (DFC) contendo os fármacos tenofovir (TDF), lamivudina (3TC) e efavirenz (EFV). Em 2017, o dolutegravir (DTG), fármaco inibidor da integrase, foi inserido no esquema de primeira linha, em substituição ao EFV, juntamente com um comprimido da associação de TDF e 3TC2 .No Brasil, nos últimos anos, os esquemas antirretrovirais (ARV) de primeira linha foram modificados, seguindo a tendência mundial e recomendações da Organização Mundial da Saúde (OMS)3 . Portanto, a compreensão da QV é essencial para analisar o impacto físico e biopsicossocial que o HIV pode ocasionar nos indivíduos, possibilitando maior conhecimento acerca de si mesmo, de sua adaptação à condição de viver com HIV e de seu tratamento. Considera-se ainda que existem evidências limitadas sobre o impacto do início da TARV na QV em PVHIV.Em países em desenvolvimento, como o Brasil, existem evidências limitadas, em estudos longitudinais, sobre os fatores determinantes da qualidade de vida (QV) em pessoas que vivem com HIV (PVHIV). Em uma revisão de literatura, os fatores sexo, idade, situação familiar, escolaridade, emprego, renda, carga viral, contagem de linfócitos TCD4+, tempo de diagnóstico, presença de sintomas de depressão e ansiedade, apoio social, atenção à saúde, uso de drogas lícitas e ilícitas, adesão à terapia antirretroviral (TARV), estilo de vida e comportamento sexual foram diretamente associados à QV de PVHIVO objetivo deste estudo foi avaliar longitudinalmente a QV em PVHIV iniciando a TARV atendidas em três serviços públicos de referência em Belo Horizonte, bem como avaliar os preditores de alteração na QV.5 .Estudo de coorte, no qual foram utilizados dados do projeto Ecoart, cujos detalhes foram previamente publicadosA seleção da amostra foi não aleatória, e todos os indivíduos elegíveis e presentes em três serviços públicos de assistência especializada em HIV, que dispensam TARV para aproximadamente 80% das PVHIV no município de Belo Horizonte, foram convidados a participar do estudo. O recrutamento ocorreu entre setembro de 2015 e outubro de 2017.Foram incluídos indivíduos com até 180 dias de TARV, em acompanhamento em um dos serviços avaliados e que foram identificados por meio do registro no Sistema de Controle Logístico de Medicamentos (Siclom). Os critérios de inclusão foram assinatura do termo de consentimento livre e esclarecido (TCLE), ter 18 anos ou mais, autonomia para responder à entrevista e ter realizado a entrevista basal e a segunda entrevista de acompanhamento.World Health Organization Quality of Life HIV – em sua versão resumida (WHOQOLHIV- bref ) –, Escala Hospitalar de Ansiedade e Depressão (HADS) e Escala de Adesão Terapêutica de Morisky de Oito Itens (MMAS-8), todos validados no Brasil6 , além de perguntas relativas a informações sociodemográficas, comportamentais, clínicas, laboratoriais, relacionadas ao tratamento farmacológico e ao serviço de saúde.Os dados foram obtidos em entrevistas face a face e em bases de dados secundárias, utilizando-se formulários padronizados que continham os instrumentos Para minimizar potenciais riscos de vieses, os pesquisadores foram devidamente treinados e foi realizado projeto piloto antes de iniciar a coleta de dados.bref , em dois momentos, na entrevista basal e na segunda entrevista de acompanhamento, prevista para ocorrer seis meses após a entrevista basal. A diferença média da QV entre esses dois momentos constituiu a variável dependente deste estudo, que apresenta os resultados unicamente daqueles indivíduos que terminaram o acompanhamento. Em um artigo prévio4 foram publicados os dados relativos a QV na entrevista basal.A QV foi avaliada por meio do instrumento WHOQOLHIV- bref é um instrumento específico para avaliação da QV em PVHIV, que, por meio de 31 perguntas, avalia os domínios: físico, psicológico, nível de independência, relações sociais, meio ambiente e espiritualidade. Cada pergunta possui opções de resposta em escala Likert de cinco pontos, onde 1 indica percepções negativas e 5, percepções positivas, exceto para sete itens em que a escala é invertida. A média dos itens dentro de cada domínio é usada para calcular a pontuação total do domínio. O resultado é multiplicado por 4, e, assim, os escores variam entre 4 e 206 .O WHOQOLHIV- bref . Fez-se a média dos itens, e o resultado foi multiplicado por 4; dessa forma, os escores também variaram de 4 a 206 .O componente QV global e percepção geral da saúde foi construído utilizando as duas primeiras perguntas do instrumento WHOQOLHIV- Para caracterizar a população do estudo, foram analisadas variáveis sociodemográficas, comportamentais, clínicas e laboratoriais, relacionadas ao tratamento farmacológico e ao serviço.7 . Pessoas que tiveram 8 ou mais pontos em cada um dos agravos foram classificadas com sintomas de ansiedade e depressão. Os indivíduos foram classificados segundo a presença de sinais e sintomas de ansiedade ou depressão na entrevista basal e na entrevista de acompanhamento, sendo categorizados em: (i) nunca apresentaram sinais e sintomas de ansiedade ou depressão, (ii) apresentaram esses sintomas em alguma das duas entrevistas ou (iii) apresentaram sintomas em ambas as entrevistas.A presença de sinais ou sintomas de ansiedade e depressão foi mensurada por meio da HADS, composta por 14 itens8 . Foram considerados aderentes os indivíduos que obtiveram escore de 8 pontos. As reações adversas a medicamentos (RAM) foram avaliadas por meio de autorrelato. Foram considerados indivíduos com carga viral (CV) indetectável aqueles que apresentaram valor inferior a 50 cópias por ml.A MMAS-8 foi utilizada para avaliar a adesão a TARV. O escore total da MMAS-8 varia de 0 a 8, sendo que, quanto maior for a pontuação, maior é a adesãostatus socioeconômico) foi avaliada de acordo com critérios brasileiros, como alta , intermediária (C) e baixa (D e E), na qual os indivíduos são classificados por meio de grupos socioeconômicos por posse de itens de conforto e nível de escolaridade do chefe familiar9 .A variável classe econômica  e o teste Mann-Whitney (comparação de medianas).A análise univariável da relação entre variáveis independentes e a alteração no escore de QV foi avaliada pelo teste p igual ou inferior a 0,20.A associação foi analisada pelo ajuste de um modelo de regressão linear múltipla. Foram selecionadas para entrar no modelo multivariável as variáveis que apresentaram valor backward stepwise foi utilizado para obtenção do modelo final. Os resultados da regressão linear múltipla foram demonstrados por meio de coeficientes da regressão, com seus respectivos intervalos de confiança a 95% (IC95%).O método 2e R2ajustado foram utilizadas para verificar a porcentagem da variância relacionada ao incremento na QV explicada pelo modelo. A estatística de Durbin- Watson foi utilizada para verificar o pressuposto de que os resíduos não estão correlacionados, com valores entre 0 e 4, sendo que 2 significa ausência de correlação entre os resíduos. Foi testado também se havia multicolinearidade no modelo final, utilizando as estatísticas de tolerância  e VIF (aceitável < 10)10 . Para avaliar se os resíduos tinham distribuição normal, foram realizados os seguintes gráficos: resíduos padronizados da regressão por valores previstos da regressão padronizados, histograma de frequências dos resíduos padronizados da regressão, e um gráfico percentil-percentil (P.P. plot).A adequação do modelo foi avaliada por um conjunto de estatísticas. As estatísticas Rsoftware Statistical Package for the Social Sciences (SPSS) versão 22.0. Em todas as análises considerou-se o nível de significância de 0,05.Foi utilizado o O projeto de pesquisa Ecoart foi aprovado pelo Comitê de Ética em Pesquisa (COEP) da Universidade Federal de Minas Gerais  e dos serviços participantes. A pesquisa foi realizada seguindo instruções da Resolução 466/2012 do Conselho Nacional de Saúde.Durante todo o período de recrutamento do projeto Ecoart, foram identificados 1.017 indivíduos atendidos nos três serviços. Desses, 468 realizaram a entrevista basal, e 323  realizaram a segunda entrevista de acompanhamento e foram incluídos nesse estudo   1 .Ao comparar o grupo que completou a segunda entrevista de acompanhamento com aqueles que não a realizaram, não houve diferenças estatisticamente significantes em relação a sexo, idade, estado civil e escolaridade. Também não houve diferenças entre os indivíduos na entrevista basal quanto à QV geral e nos domínios de QV.%, uma ou mais comorbidades autorrelatadas, e 35,9%, sinais ou sintomas de ansiedade e depressão. A maioria dos indivíduos apresentou classificação clínica assintomática  e tinha tempo de diagnóstico de infecção pelo HIV menor ou igual a seis meses . No que diz respeito às características laboratoriais basais, 23,5% apresentaram contagem inicial de linfócitos TCD4+inferior a 200 células/mm3, 90,1%, CV detectável, e 26,0%, CV superior a 100.000 cópias/ml. Em relação ao tratamento farmacológico, 63,2% utilizaram TDF/3TC/EFV, e 32,2%, TDF/3TC + DTG. A maioria  estava em uso de TARV há 60 dias ou menos, eram não aderentes a TARV , apresentaram RAM , com três ou menos RAM  , sem cônjuge , sem filhos , entre 20 e 34 anos , não possuía plano privado de saúde  e se autodeclarou como não branco . Verificou-se que 80,8% dos indivíduos residiam com outras pessoas, 38,8% possuíam de 10 a 12 anos de escolaridade e 59,4% estavam empregados no momento da entrevista, havendo predomínio da classe econômica C . Em relação às características comportamentais e hábitos de vida, 24,5% relataram uso atual de tabaco, 65,8%, uso de álcool recente, e 47,5% declararam já ter utilizado ou utilizar drogas ilícitas na vida. A maioria declarou ter alguma crença religiosa . Verificou-se que 59,6% eram homens que fazem sexo com outros homens (HSH). Quanto às características clínicas, 7,8% apresentaram coinfecção , 18,3   .Na segunda entrevista de acompanhamento, em relação às características clínicas, laboratoriais e relacionadas a TARV, 34,3% dos indivíduos apresentaram sinais e sintomas de ansiedade e depressão, 73,4%, CV indetectável , 59,5% relataram não adesão tratamento, e 51,6% relataram alguma RAM, sendo que 79,9% relataram três ou menos RAM   .Os dados de QV foram obtidos na entrevista basal e na segunda entrevista de acompanhamento, que ocorreu em média 9,47 meses  após a entrevista basal.Foram observadas, ao longo do tempo, melhorias estatisticamente significantes na QV global e nos domínios, físico, psicológico, nível de independência, ambiente e espiritual em indivíduos iniciando TARV. O único domínio em que a diferença média entre as entrevistas basal e de acompanhamento não foi significante foi o das relações sociais.Os domínios de QV com maiores diferenças médias foram o físico , espiritual  e psicológico    .Na análise univariável, indivíduos que relataram uso de drogas ilícitas durante toda a vida apresentaram diferença média na QV mais elevada . Indivíduos com ausência de sintomas de ansiedade e depressão apresentaram maior diferença média na QV . Dentre as variáveis laboratoriais e relacionadas a TARV, não foi observada associação estatisticamente significativa entre CV, esquema ARV , tempo de tratamento, adesão ao tratamento, RAM, número de RAM e alteração da QV média   .No modelo final de regressão linear múltipla, apresentaram aumento na QV indivíduos que possuíam alguma crença religiosa  e os que residiam com outras pessoas . Enquanto indivíduos que reportaram sinais ou sintomas de ansiedade e depressão alguma vez  ou sempre  apresentaram redução na QV. A cada RAM adicional relatada na entrevista basal houve redução na QV do indivíduo . Aqueles indivíduos que apresentaram maiores escores de QV na entrevista basal obtiveram menores incrementos de QV ao final do estudo, mostrando assim uma associação inversamente proporcional    .2ajustado foi igual a 0,414, ou seja, o modelo explicou aproximadamente 41% da variância do incremento da QV. A estatística de Durbin-Watson foi igual a 2,02, indicando que não houve correlação entre os resíduos. Nas estatísticas de colinearidade, todos os preditores tiveram valores de tolerância acima de 0,56 e valores de VIF próximos de 1 . Foi verificada também a distribuição dos resíduos padronizados, sendo que se aproximaram da distribuição normal. Essa suposição foi também confirmada pelo gráfico P-P normal de regressão dos resíduos. Finalmente, o gráfico de dispersão entre os resíduos padronizados e previstos não mostrou que eles estavam aleatoriamente distribuídos; portanto, o modelo desenvolvido apresenta bom ajuste.Com relação à adequação do modelo de regressão linear múltipla, a estatística de ROs indivíduos em início de TARV desta coorte apresentaram incremento na QV, sendo que possuir crença e morar com outras pessoas associaram-se positivamente à QV, enquanto possuir sinais ou sintomas de ansiedade e depressão, alguma vez ou sempre, e RAM adicional reportada foram preditores associados a pior QV.12 e boletins epidemiológicos14 , com predominância de indivíduos do sexo masculino, jovens, cor de pele autodeclarada não branca e com alta escolaridade.As características dessa população foram semelhantes às de outros estudos15 .O presente estudo mostrou que, ao longo do tempo, indivíduos em uso inicial de TARV apresentaram aumento no escore global de QV, consonante com pesquisas anteriores18 .A maior diferença média de QV observada no domínio físico, no qual são avaliados aspectos como dor, desconforto, energia, sono e repouso, pode estar relacionada ao uso de TARV. Esta provoca alterações no curso da infecção, como desaceleração da progressão da imunodeficiência provocada pelo vírus HIV e restauração da resposta imunológica dos indivíduos – consequentemente, pode impactar positivamente na vida das pessoas15 .No domínio relações sociais, em que foram avaliadas questões relacionadas a aceitação do diagnóstico, apoio familiar, relacionamento interpessoal e vida sexual, foi observada menor diferença média de QV. A relação social é um complicador para as PVHIV, uma vez que a infecção pelo vírus pode ser uma condição de saúde estigmatizante, que envolve sentimentos de discriminação e, consequentemente, falta de apoio social e sentimentos de solidão. Considerando que esses fatores dificilmente serão influenciados pelo uso da TARV, é importante ressaltar a necessidade de melhorar as relações pessoais e o suporte social para esses indivíduosFoi demonstrado aumento estatisticamente significante no componente de percepção global da QV. Os benefícios dos medicamentos na QV podem ser explicados pela redução dos sintomas clínicos da infecção. Ou seja, isso reforça a necessidade de vinculação e retenção dos indivíduos ao serviço de saúde e adesão ao tratamento.15 .Alguns fatores comportamentais, sociodemográficos, clínicos e relacionados a TARV mostraram relação com a alteração na QV em indivíduos no início da TARV, sendo esses achados condizentes com a literatura científica21 , o que contribui para o aumento da QV e da saúde do indivíduo. Fé e crenças religiosas são importantes estratégias de enfrentamento de condições de saúde como o HIV, quando aliadas a TARV21 .Sentimentos de culpa, solidão e receio da morte, comumente reportados por PVHIV, estão relacionados ao exercício da espiritualidade e crenças religiosas22 , realizado na região Sul do Brasil, foi demonstrado que os indivíduos que moravam sozinhos apresentaram 30% de propensão a pior QV no domínio relações sociais. Um menor suporte emocional durante o tratamento poderia explicar parcialmente os resultados encontrados. Outro estudo transversal, realizado com 100 PVHIV no Nepal, utilizando o instrumento WHOQOL- bref , demonstrou que um bom apoio familiar tem maior impacto no incremento de QV, sendo estatisticamente associado à QV geral23 .Nossos resultados destacam a importância do envolvimento familiar para a redução do estigma e do preconceito relacionados ao HIV. Em outro estudo utilizando o mesmo instrumento, porém com delineamento transversal24 . Existem evidências de que depressão e ansiedade são mais frequentes em PVHIV do que na população em geral25 , o que pode exercer influência negativa no comportamento do indivíduo e contribuir para dificuldades em relação ao tratamento e ainda para pior adesão a TARV26 . O impacto de sintomas psiquiátricos na QV de PVHIV também acontece devido a uma deterioração do sistema imunológico e consequente aumento da progressão da doença, justificados pelo nível aumentado de estresse e sintomas depressivos27 . Apesar de a HADS não ser utilizada com fins diagnósticos, e sim para avaliar sinais e sintomas de ansiedade e depressão, foi observada associação entre esses sinais e sintomas e a redução da QV nas PVHIV nas entrevistas de acompanhamento, o que evidencia a importância do acompanhamento por um profissional de saúde  nos serviços onde esses indivíduos estão sendo acompanhados. Em outro estudo sobre QV do grupo Ecoart, de delineamento transversal, realizado com 366 indivíduos em Belo Horizonte, estiveram associados a menor QV indivíduos solteiros, com outras comorbidades, com menor nível educacional, tabagistas, com sinais e sintomas de ansiedade e depressão4 . Em outro estudo, com delineamento transversal com PVHIV, realizado em Camboja, onde foram avaliadas 150 pessoas, os autores sugerem forte associação entre o incremento da QV avaliado pelo escore global de QV e pelos seis domínios do WHOQOLHIV- bref e a ausência de sinais ou sintomas de ansiedade e depressão28 .Sinais ou sintomas de ansiedade e depressão são fatores que podem limitar a QV de PVHIV29 . A ocorrência de RAM pode afetar física e psicologicamente a realização de atividades profissionais e pessoais e, consequentemente, a QV de indivíduos em tratamento5 . A monitorização do uso de antirretrovirais é importante ferramenta para avaliar a segurança desses medicamentos na prática clínica5 e garantir melhor assistência e satisfação dos indivíduos com o tratamento29 .Neste estudo, observou-se que a cada RAM adicional relatada por indivíduos em tratamento houve maior redução na QV, ou seja, quanto maior é o número de RAM relatadas, maior é a redução na QV. Este resultado é similar ao de outro estudo realizado no Brasil, que descreveu o menor número de RAM a TARV como um dos fatores associados à melhora da QVAo compararmos os indivíduos em uso do esquema TDF/3TC + DTG com aqueles em uso de TDF/3TC/EFV ou outros esquemas, não foram observadas diferenças estatisticamente significantes na diferença média de QV geral, o que pode ser explicado por parte da população do estudo Ecoart ter iniciado o uso dos ARV mesmo assintomático, em função da mudança do protocolo de tratamento de HIV pelo MS. Portanto, esses indivíduos podem não ter reconhecido a melhora na QV com o uso da TARV, independentemente do esquema utilizado. Este estudo apresenta como limitação a incompletude dos dados do Sistema de Controle de Exames Laboratoriais (Siscel), como contagem de linfócitos TCD4+ e CV. Para minimizar essa limitação, consideramos os dados do período de três meses anteriores e posteriores à segunda entrevista de acompanhamento, resultando em baixo percentual de dados faltantes.bref é um instrumento que avalia a QV nas duas semanas anteriores à entrevista; assim, potenciais vieses de memória foram minimizados.Como pontos positivos, deve-se ressaltar que o estudo é longitudinal, que a coleta de dados foi realizada com rigor metodológico e em locais representativos da PVHIV de Belo Horizonte, o número elevado da amostra e a robustez do modelo final obtido por meio de análise multivariável. Além disso, o WHOQOLHIV- bref , bem como outros instrumentos, são necessários para mensurar as alterações na QV desses indivíduos e contribuir para o direcionamento de ações e intervenções dos profissionais de saúde que podem contribuir para aumentar a QV em PVHIV.Novos estudos em PVHIV com maior tempo de seguimento, utilizando o WHOQOLHIV- Conclui-se que, ao longo do tempo, PVHIV iniciando a TARV apresentaram melhora na QV. Há necessidade de acompanhar e prover cuidados de saúde, em especial para indivíduos com sinais e sintomas de ansiedade e depressão e que relatam reações adversas no início do tratamento.Este estudo pode contribuir para o planejamento e o direcionamento de ações e políticas públicas, bem como para identificar fatores modificáveis que possam aumentar a QV desses indivíduos.


We describe a peer-led mental health (MH) workshop that was held at the Michael G. DeGroote School of Medicine  in collaboration with Student Affairs. Workshop aims included facilitating discussions among peers and engaging in case-based learning about MH experiences in medical school. Post-workshop, attendees reported increased comfort in talking to classmates about personal MH, recognizing MH crises, and asking for help from peers. We believe that engaging medical learners in MH discussions early on in medical education is critical, and that peer-led workshops may aid in decreasing future MH difficulties and burnout. Due to the low-cost of holding peer-led workshops, this event could be easily replicated at other training sites.Nous décrivons un atelier sur la santé mentale dirigé par des pairs qui s’est tenu à l’école de médecine Michael G. DeGroote  en collaboration avec le service des affaires étudiantes. Les objectifs de l’atelier étaient de faciliter les discussions entre pairs et de d’encourager l’engagement dans une expérience d’apprentissage par discussion de cas utilisant l’apprentissage expérientiel en santé mentale durant le cours de médecine. À l’issue de l’atelier, les participants ont déclaré se sentir plus à l’aise pour parler de leur santé mentale avec leurs pairs, reconnaître les crises de santé mentale et demander l’aide de leurs pairs. On croit qu’il est essentiel que les étudiants en médecine prennent part aux discussions sur la santé mentale dès le début du programme d’études en médecine et que les ateliers dirigés par des pairs peuvent contribuer à réduire leurs potentiels problèmes de santé mentale et d’épuisement. En raison du faible coût des ateliers dirigés par des pairs, cet événement pourrait facilement être reproduit dans d’autres sites de formation.1 In Canada, 39.4.% of first-year students disclosed some degree of psychological distress.1 Moreover, the prevalence of burnout during medical school has been reported as high as 44.2%.2 Promoting prevention, recognizing symptoms, and destigmatizing psychological distress are crucial actions that encourage MS to seek help.2 We investigated the effectiveness of a peer-led workshop on improving first-year MS’ comfort discussing MH.Researchers have reported that medical students (MS) are a high-risk group for mental health (MH) challenges. Compared to other postsecondary graduates, MS experience higher levels of psychological distress, mood/anxiety disorders, and suicidal ideation.We held an optional, two-hour, peer-led MH workshop on-campus for all 28 first-year MS at Michael G. DeGroote School of Medicine’s Niagara Regional Campus (NRC), halfway through the year. Students were in pre-clerkship, which consists of lectures and small group learning . Four second-year NRC students hosted the workshop, presented an introduction to MH in medical school, and shared personal narratives. The hosts also developed case scenarios about coping strategies and recognizing peers in need, based on personal experiences and situations MS may encounter during their training. The hosts facilitated small group discussions about the scenarios. Due to the sensitive nature of the workshop, the NRC Student Affairs Director was present during the workshop and accessible via email post-workshop for student support.3, a validated 40-item self-report survey designed to identify sources of stress in MS across six domains . Additionally, students completed a novel wellness questionnaire (NWQ) pre- and post-workshop. Created by the workshop hosts, the NWQ was designed to evaluate the efficacy of the workshop. Because the NWQ has not been validated, a retrospective face validity assessment regarding the clarity of the NWQ was performed via anonymous peer-review by eight second-year MS and was deemed to be clear and understandable. This project was identified as quality improvement by the Hamilton Integrated Research Ethics Board, and was thus exempt from ethics review.Pre-workshop, attendees completed the Medical Student Stressor Questionnaire (MSSQ)p < 0.05) students’ comfort levels talking to classmates about personal MH, recognizing MH crises, and asking for help from friends for personal MH . In the future, we hope to evaluate NWQ validity and to assess for longitudinal effects of the workshop.


Scientific Reports 10.1038/s41598-020-59070-8, published online 10 February 2020Correction to: The Acknowledgements section in this Article is incomplete.“This study was supported by the Brazilian Council for Scientific and Technological Development/CNPq (grant number: 165696/2014-1). The authors thank the Pro Reitoria de Pós Graduação, Univ. Estadual Paulista (UNESP), from São Paulo state, Brazil for the financial support.”should read:“This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001. The authors gratefully acknowledge financial support from the Brazilian Council for Scientific and Technological Development/CNPq (grant number: 165696/2014-1), and the Universidade Federal de Mato Grosso do Sul.”


Uma crítica ao modelo é que, embora países não europeus tenham sido incluídos, a grande maioria dos pacientes era da Espanha, França, Itália e Reino Unido, que contribuíram com 19, 16, 15 e 12 centros, respectivamente.3Quanto à América Latina, o Brasil contribuiu com dados de 4 centros, Argentina 1 e Uruguai 1. Além disso, o modelo não analisou separadamente a cirurgia valvar. De fato, apenas 2,2% dos pacientes (497 em números absolutos) com EI ativa foram incluídos.4 Uma limitação descrita no estudo foi que todos os centros participaram voluntariamente, o que introduz um viés de seleção para os dados.3A curva ROC , com escore de 3 pontos e disfunção ventricular esquerda pelo menos moderada, com escore de 1 ponto, ou seja, o Euroscore dele seria de 6 pontos e a mortalidade prevista seria superior a 11%. Não raramente, esse paciente foi submetido a cirurgia cardíaca anterior , o que acrescenta 3 pontos ao escore.Society of Thoracic Surgeons–Infective Endocarditis(STS-IE), publicado em 2011,8 tem suas variáveis mostradas esquematicamente na8 A mortalidade geral foi de 8,2%, embora a cirurgia valvar múltipla tivesse uma mortalidade operatória de 13%. As complicações pós-operatórias estavam presentes em mais da metade dos pacientes, sendo as mais comuns a ventilação prolongada em mais de um quarto.O escore da8 Embora apenas pacientes com EI tenham sido estudados, esse foi um registro voluntário exclusivamente de hospitais americanos. Características importantes da EI, como microbiologia, discriminação entre válvulas nativas e próteses e presença de complicações intracardíacas  não foram analisadas. Surpreendentemente, 43% dos pacientes foram operados de maneira “eletiva”, o que é um cenário diferente das outras séries.No escore STS-IE, os números variam de 0 a 110 pontos e, de acordo com esse modelo, um paciente com 35 pontos teria um risco operatório de pelo menos 10% de mortalidade.13 mostradas na1 As características específicas da EI são: EI de válvula protética, grande destruição intracardíaca,Staphylococcus spp., patógeno isolado na cultura de amostras de sangue , presença de abscesso, complicações perivalvares, microrganismo virulento; além destes, há bloqueio atrioventricular e microrganismos Gram-negativos não-HACEK (os últimos 2 para o modelo INC-Rio4) e envolvimento perivalvar .13 Quando agrupados, além do envolvimento da prótese, essencialmente o tipo de microrganismo e a destruição da válvula  são as características distintivas desses “escores de EI”  abordaram o desempenho dos escores na EI, ambos com pequeno número. No primeiro, os autores concluíram que, apesar da disponibilidade de escores específicos, o EuroSCORE logístico era o melhor para prever a mortalidade em sua coorte e nenhum escore foi proposto; no segundo, os escores de EI mencionados não foram avaliados (a maioria deles publicada após 2016), mas a sensibilidade e especificidade do Euroscore I foram de 81,5% e 63%; para Euroscore II, 29,6% e 97,6%, e para o STS-IE 7,4% e 98,4%, respectivamente. Os valores da AUC foram de 0,86 (Euroscore I), 0,90 (Euroscore II) e 0,85 (STS-IE). Na análise multivariada, as variáveis consideradas estatisticamente significantes para óbito foram bloqueio AV, choque cardiogênico, diabetes mellitus insulinodependente, microrganismos Gram-negativos não-HACEK e uso de inotrópicos. Estes foram incluídos em um modelo, o INC-Rio,4 com sensibilidade calculada de 88,9% e especificidade de 91,8%; a AUC foi de 0,97. Casalino et al.14 estudaram todos os tipos de cirurgia valvar em 440 pacientes, nos quais a taxa de mortalidade foi de 16,0%  e constataram que a AUC foi de 0,76 para o EuroSCORE aditivo e logístico e 0,81 para o EuroSCORE II. Eles concluíram que os modelos de EuroSCORE tinham boa capacidade discriminatória, embora a calibração estivesse comprometida devido à subestimação da mortalidade.Em conclusão, vários grupos estão em busca de um escore adequado para prever a mortalidade em pacientes operados por EI. O Euroscore I e II, amplamente utilizados, e o STS-IE, foram estudados comparativamente aos novos escores propostos, alguns dos quais  incluíram partes do Euroscore. No Brasil, apenas 2 estudos .1The management of left- sided IE often involves surgery during the index admission, and the main challenge is to rapidly and correctly identify patients at high risk and to transfer them to institutions with a surgical team with expertise in endocarditis surgery.The article by Pivatto F Jr et al.2For operative mortality to remain a valid measure of quality of care, it must be related to the risk profile of the patients receiving surgery.2Prognostic scores are important for several reasons: a reasonable estimate of the risk of death is important in clinical decision-making regarding surgical indication; the estimate is necessary to inform patients and their families of the surgical risk; risk stratification permits a fair comparison of cardiac surgery results, so that surgeons and hospitals treating high-risk patients will not appear to have worse results than others.2These variables are presented in2Euroscore I, published in 1999, evaluated 19,030 patients submitted to cardiac surgery in 8 countries in Europe, studying 97 risk factors for death, and among those, the ones that significantly affected surgical prognosis were selected.3had the goal of updating the first model by evaluating 22,381 patients from 43 countries in the world, including sites outside Europe, so as to create a more reliable score, incorporating new variables and adjusting others  and some continuous variables, such as number of previous cardiac surgeries and pulmonary artery systolic pressures were treated as a dichotomic variable.3Euroscore II, published in 2012, others . At thi3As for Latin America, Brazil contributed with data from 4 centers, Argentina 1 and Uruguay 1. Also, the model did not analyze valve surgery separately. In fact, only 2.2% of patients (497 in absolute numbers) with active IE had been included.4A limitation outlined in the study was that all centers participated voluntarily, what introduces selection bias to the data.3The receiving operator curve (ROC) of the scores showed an area under the curve (AUC) of 0.78 for the logistic and additive Euroscore and of 0.80 for Euroscore II. A criticism to the model is, that although non-European countries were included, the vast majority of patients were from Spain, France, Italy and the United Kingdom, who contributed with 19, 16, 15 and 12 sites respectively.6Therefore, Euroscore I does not discriminate well this subset of patients, as most will probably fall into the 6+ score. Patrat-Delon et al.,7studying 149 patients operated for IE in France, between 2002 and 2013, of which in-hospital mortality was 21%, came to a similar conclusion regarding EuroSCORE II: it underestimated mortality in patients with predicted mortality over 10%.7Patients with IE must be thoroughly assessed. If we consider the usual profile of a patient with IE who is operated at Instituto Nacional de Cardiologia, for example, he or she will have a serum creatinine above normal, scoring 2 points; active disease (under antibiotic treatment for IE at the time of surgery), scoring 3 points, and at least moderate left ventricular dysfunction, scoring 1, that is, with a total Euroscore of 6 and anticipated mortality of over 11%. Not infrequently, this patient previously had cardiac surgery , which adds 3 points to the total score.8has its variables shown schematically in8Overall mortality was 8.2%, although multiple valve surgery had an operative mortality of 13%. Postoperative complications were present in more than half the patients, most common of which were prolonged ventilation in over a quarter.The Society of Thoracic Surgeons–Infective Endocarditis (STS-IE) score, published in 2011,8Although only patients with IE were studied, this was a voluntary registry of American hospitals only. Important features of IE, such as microbiology, the discrimination between native and prosthetic valves and the presence of intracardiac complications  were not analyzed. Surprisingly, 43% of the patients were operated on “electively”, which is a different scenario from other series.In the STS-IE score, numbers vary from 0-110 points and, according to this model, a patient with 35 points would have an operative risk of at least 10% mortality.13shown in1Features specific to IE are prosthetic valve IE, large intracardiac destruction,Staphylococcusspp., pathogen isolated from a blood specimen culture , presence of abscess, perivalvar complications, virulent microorganism; besides these, there is atrioventricular block and non-HACEK Gram negatives (the last 2 for INC-Rio model4) and perivalvular involvement (ex. annular abscess or aortocavitary fistula).13When grouped, in addition to prosthesis involvement, essentially type of microorganism and valve destruction  are the distinctive features in these “IE scores”  have addressed the performance of scores in IE, both with small numbers. In the first, the authors concluded that, despite the availability of specific scores, the logistic EuroSCORE was the best to predict mortality in their cohort and no score was proposed; in the second, the mentioned IE scores were not evaluated (most of them published after 2016), but the sensitivity and specificity of Euroscore I was 81.5% and 63%; for Euroscore II , 29.6% and 97.6%, and for STS-IE 7.4% and 98.4%, respectively. AUC values were 0.86 (Euroscore I), 0.90 (Euroscore II) and 0.85 (STS-IE). In the multivariate analysis, the variables found to be statistically significant for death were AV block, cardiogenic shock, insulin-dependent diabetes mellitus, non-HACEK Gram negative microorganisms and inotropic use. These were included in a model, INC-Rio4with a calculated sensitivity of 88.9% and specificity of 91.8%; AUC was 0.97. Casalino et al.14have studied all-type valvular surgery in 440 patients, in which mortality rate was 16.0% (6.0% in elective surgery and 34.0% in emergency/urgency surgery), and found the AUC was 0.76 for additive and logistic EuroSCORE and 0.81 for EuroSCORE II. They concluded that the EuroSCORE models showed good discriminatory capacity, although calibration was compromised due to mortality underestimation.In conclusion, several groups are in search of an adequate score to predict mortality in patients operated for IE. The widely used Euroscore I and II, and the STS-IE have been studied comparatively to the new proposed scores, some of which  have included parts of Euroscore to them. In Brazil, only 2 studies (the present one, with 107 patients, and the one by Martins et al.viridansstreptococcal IE, longer delay time to diagnosis, and younger age.We believe a multinational study in Brazil would be of paramount importance, with a greater number of patients, to propose and validate a score, since patients with IE in our country dramatically differ from those in North American or European countries, especially due to the high proportion of rheumatic valvopathy, group


Dr. Marcela Mansur was erroneously included as consortium author and should be removed from the section below:Carolina da Paz Zampier, Thayana da Conceição Barbosa, Paulo Chagas Neto, Gisele Dallapicola Brisson, Filipe Vicente dos Santos Bueno, Ingrid Cezar Sardou, Bruno Gonçalves Aguiar, Anna Carolina Silva Dias, Patrícia Carneiro de Brito, Geraldo Pedral Sampaio, Raimundo Antônio Gomes Oliveira, Claudia Teresa de Oliveira, César Casagranda, Geni Ramos Vera, Gustavo Ribeiro Neves, Isis Maria Quezado Magalhães, José Carlos Córdoba, Juliana Teixeira Costa, Rebeca Ferreira Marques, Renata Pereira de Souza Barros, Renata Sarkis Alves, Renato Guedes, Sidnei Epelman.MATERIAL AND METHODS, T-ALL Molecular Characterization, paragraph no. 1:In the original article, previously published data from this author was not correctly acknowledged. A correction has been made to “Partial clinical, molecular and prognostic data on Brazilian samples diagnosed from 2005-2012 have been previously published , 20.”Acknowledgements. The correct names of the funders partially supporting this work are 1) TUCCA-Associação para Crianças e Adolescentes com Câncer, São Paulo, Brazil; 2) SwissBridge Fundation- Fundação do Câncer, Rio de Janeiro, Brazil (# L0J SWB 2014 SUB-PROJECT 1.A).There is also an error in the The authors apologize for these errors and state that they do not change the scientific conclusions of the article in any way. The original article has been updated.