Great emphasis has been placed on the right hemisphere, due to its possibleselective contribution, in the processing of metaphorical statements.To describe the processing of metaphors in the case of a patient withtranscortical motor aphasia, using specific tests for patients withencephalic injuries of the right hemisphere, and to contribute to thediscussion on the inter-hemispheric relationships associated with thisfunction.A 54 year-old man with transcortical motor aphasia was evaluated three yearsafter a left hemisphere stroke. The tasks of comprehension of metaphors werebased on the subtest Metaphor Comprehension Task of the Montreal Evaluationof Communications Scale (MEC). Two metaphor comprehension tests wereapplied, in 45-minute sessions with a 48 hour interval between each. Test 1involved comprehension of the metaphors according to the options offered,and Test 2 the comprehension of metaphors measured by response time andvisual field.Although the right hemisphere was not affected by the stroke in this case,difficulties were observed in the processing of metaphors.This study suggests that the left hemisphere participates in the processingof figurative meanings. The adaptability of the brain can alsore-accommodate the uninjured areas of the brain, causing the dynamic of thebrain to be modified. As a result, deducing cerebral functions based onclinical data can be problematic. The value of this study is that it cancontribute to clinical aspects of language rehabilitation. The languagefunctions become disorganized or restricted according to the level of central nervoussystem (CNS) injury, consequently limiting social and family interactions. The injuriesthat cause this pathology are characterized as located in the dominant cerebralhemisphere, which is generally the left for language, where some correlations have beenfound between aphasic syndromes and injuries in specific cerebral areas.2The principle that underlies the development of the concept of aphasia was based on themotor and sensory system functions involved in the language acts of perception,interpretation and execution of signs to be controlled by at least two independentlyorganized cerebral systems.3 Etiology comprises injuries caused by cranium-encephalictraumas, tumors; infection processes of the CNS and most frequently, cerebral vascularaccidents.4The impaired areas that compromise language functions extend from the Broca area to theWernicke area, angular circumvolution and white matter. Capsular and putaminal injuriescan also significantly compromise communication.4 The individual cannot make use of thepropositional language that is acquired by means of elaboration of abstract acts inrelation to the situations of everyday communication.5Patients with aphasia are unable to properly convert the sequence of mentalrepresentations that constitute thinking into language signs, with similar difficultiesfor grammatical organization. These specific symptoms impact language function tovarying degrees and are caused by dysfunction in specific cerebral regions.7Aphasias can be classified by language behavior, into Boca aphasia, Wernicke aphasia,conduction aphasia, transcortical motor aphasia, transcortical sensorial aphasia,amnesic or anomic aphasia, and global aphasia.8 In this context, comprehension and processing ofmetaphors are key factors for effective interactive communication.The language alterations hamper communication rendering the individual unable to carryout professional activities, depending on his/her occupation, often making the simplestfamily contact impossible. The communication limitation creates a high level of anxietyfor the aphasics and their family. As a result of this picture, the individual can losemotivation to interact particular in severe deficit cases.8These diagnoses can be carried out by the examiner using standardized tests or otherwise.An evaluation of the language to establish the aphasic topology covers as principalaspects: oral language comprehension and expression, appointment, repetition, oralreading, written language comprehension and expression, automatic language and speechfluency.9 In transcorticalmotor aphasia although comprehension is preserved, speech is not fluent because there isimpeded initiative, latency in answers and reduced medium phrase length withsimplification of grammatical forms. The repetition is mainly of fragments of theindividual’s utterances in situations of dialogue and requests.10 Transcortical motor aphasia,therefore, can be considered part of the aphasic category that does not presentcomprehension deficits.Transcortical motor aphasia is a kind of aphasia which stems from lesions to thepre-frontal convexity (expansive injuries particularly) which can characterize certainpatient disturbances in language behavior such as: anomy, which can persistindependently for a considerable period of time, as well as problems with motorspontaneity.11 Other research suggests that bothhemispheres process language information as a network in parallel, even though the lefthemisphere dominates for direct language tasks.14 Moreover, at allprocessing levels, each hemisphere computes the input independently andcontributes toward understanding separately.11With regard to language processing, some studies suggest that the right cerebralhemisphere is predominant for processing aspects such as glyph readings, assessment ofmetaphors and other semantic functions, rejecting the notion that this hemisphere actsonly as support for the left hemisphere in language processings.coarse semantic codinghypothesis.13Metaphor processing would thus be part of the global function of this hemisphere, sincea certain distance from concrete word meanings is required in order to grasp metaphors.The possible inferences of meaning activated in this hemisphere by the relationshipbetween the topic and the metaphor vehicle would furnish the interlocutor with theproposed scope of meaning of the speaker.11We can see a relation between the speech cognitive processing and its neural base, andthe activation that occurs in the right hemisphere of wide word semantic fields mostremotely associated is called time bomb, forinstance, when used metaphorically designates two different referential categories: thecategory of bombs that explode with a programmed timer  and the categoryof things that are potentially explosive and destructive over time (metaphoricsense).15 In this way, whenthe interlocutor hears or reads the sentence “Cigarettes are time-bombs”, he performsmetaphor processing activating the vehicle’s non-literal meaning. From the interactionbetween the topic and relevant vehicle dimensions, metaphor interpretation is derived.In this theory, the metaphor is considered as a category of inclusion.11In another view, metaphors are understood as categorical assertions whereby the dualreference theory postulates that a lexical item such as 16Complementing the theory above, it is believed that the interaction between the topic andthe vehicle is also governed by combinatory types of lexical nature. Therefore, in themetaphor “my computer is temperamental”, the topic is an artifact and the vehicle is ahuman character. In this kind of combination, the relevant dimension for the topic isthe way in which the artifact is working. Identification of the nature of thecombinations between topics and vehicles in the metaphor expressions leads to specificinterpretations for each type. This allows generalizing of several metaphor combinationsbetween different words and helps explain why only certain topic-relevant dimensions areselected in the processing of a metaphor while others are discarded.11 and in turn tocontribute to the discussion on inter-hemispheric relationships for this function.The aim of this paper was to describe metaphor processing in a transcortical motoraphasic patient by applying specific tests for cerebral injuries in the righthemisphereA 54 year-old man, an electrical engineer, who had an ischemic encephalic vascularaccident on November 17, 2003, was tested for the processing of metaphors 3 yearsafter the stroke.The language assessment followed the evaluation protocol of the UNIVALI Hearing andSpeech Therapy major, evaluating both language comprehension and expression. Withregard to comprehension, it was observed that the patient was able to answer whencalled, to understand situation orders with three or more actions, requests orcommentaries, to identify verbal absurdities and to understand short historiesfollowing the therapist’s indications. However, he presented difficulties inunderstanding metaphors in situations with figurative language. But in relation toexpression, as for the language aspects the phonetic and phonologic levels, as wellas the semantic and lexical morphosyntactic were observed. No changes at phoneticand phonologic levels were observed. In contrast, at semantic and lexical levels thepresence of semantic paraphasias was identified in naming tasks, in which thepatient indicated the function of the objects instead of their names. However, asfor the vocabulary, although anomies, the lexical items denoted a formal languagelevel linked to the patient’s level of schooling. Concerning morphosyntactic aspectsthere was a predominant use of statements with three words or more, where languagewas not telegraphic and presented the correct use of conjunctions, gender andplural, showing occasional difficulties in the use of time and verbalconjugations.For discursive activities the position of the subject in the lecture and narrativeoutput was assessed. The use of personal and possessive pronouns as well as properuse of deixis was observed. In the dialogic activity there were alternating turnsand discursive dependence on the interlocutor. In the construction of the storybased on visual stimulations, the patient demonstrated ease of understanding for thetask in hand, presenting a predominantly descriptive discourse from the outset. Thesubject subsequently, with the aid of the therapist, retold the narrative once more,using the narrative operators such as “and”, “so”, and “then”. The patient talkedabout places and characters, reasonably linking situations and facts together.However, he also presented in his discourse relevance of one of the elements of thepicture in detriment to the others, and did not add new elements different to thosethat had already been presented, having needed the help of the interlocutor for thenarrative production. In the construction of narratives from sequential visualstimulations, he demonstrated to have easily understood the task to be done,performing the sequence organization with the help of the therapist; in this taskthe discourse was predominantly descriptive, linking the situation with the use ofcause and temporal nexus. For the reproduction activity of a story told beforehandby the therapist, it was observed that the patient paid attention to the therapist’sspeech, easily understood the task to be done and produced predominantly descriptivenarrative with use of operating elements of the narrative, talking about places andcharacters, repeating the presented facts while keeping to the suggested subject.All the tasks were performed with the therapist’s help, during which there was thepresence of anomies and semantic paraphasias, which with the help of the therapistwere suppressed and/or substituted. It was observed that the fluency of the dialogwas maintained despite the physiopathological symptoms present in his discourse. Thediscourse was hesitant and the patient often restarted his sentences to reformulatewhat he wanted to say.In relation to the written language, at the time of the evaluation slow reading wasnoted, but with adequate comprehension. However, writing could not be evaluatedbecause the patient was right-handed, but presented right hemiplegia and showed nowillingness or availability to write with the other hand.The CT scan revealed a hypodense lesion in the basal ganglia, internal capsule andleft periventricular white matter. Magnetic resonance imaging performed a week afterthe stroke revealed a large hypodense area compromising the left frontal, temporaland parietal regions with extension to the striatum and also internal capsule of thesame hemisphere, indicating the possibility of a large ischemic stroke in the leftmiddle and anterior cerebral artery territories.The diagnosis of transcortical motor aphasia was made and subsequently, the patientbegan to be therapeutically treated, twice a week in the clinic school of UNIVALIHearing and speech therapy. It should be emphasized that the studied case showscharacteristics closer to speech motor disturbance, given low fluency speech,preserved repetition capacity, good reading comprehension and comprehension fordaily activities and calculation.1 which investigatedsubjects with right cerebral hemisphere injured brains.All sessions were recorded and transcribed for further analysis on languagefunctioning and case evolution. Due to clinically observed discrepancies between thegeneral comprehension capacities of the language, which always remained adequate,and the perceived difficulty for comprehension of figurative meaning, it was decidedto apply tests for metaphor processing evaluation and compare them to the resultsfrom a study11 which was alsoused the subtest Metaphor Comprehension Task of Montreal Evaluation ofCommunications Scale (MEC).17 At the time this study was performed, the Brazilian versionof the MEC battery18 had not yetbeen released. The test in Portuguese followed robust criteria so it is possible toestablish equivalence between the stimuli in Portuguese used in the work and thecurrent version recently released in Brazil.The tasks of comprehension of metaphors used in this case study were based onprevious research11 The instrumentsof research were composed of two tests, namely:The tests were applied in two forty-five-minute sessions, with about 48 hours ofinterval between the sessions. The tests evaluated the accomplishment of two tasksthat involved fourteen metaphoric statements with a relative degree ofconventionality formed by four or five words. All sentences followed the criteria ofcombination of semantic types that appear in the topic position andvehicle.Test 1: metaphor comprehension through given options.Test 2: metaphor comprehension, time to answer and visual field.In test 1 of metaphor comprehension through given options, the patient was presenteda card with a metaphoric sentence and after the reading, presented a new card withthree options for answers, as possibilities of interpretation of the metaphor. Theoptions for each metaphoric sentence were composed of three explanatory sentenceswhich attributed each a different meaning for the tested metaphor. The patient hadto choose the alternative that would best explain the metaphor in the sentence.19Test 2 for metaphorical comprehension was constituted in the register of time ofanswer and visual field. For this the same metaphors from the previous test wereused, with the help of the computer as a vehicle to apply the test. The techniquesof the divided visual field was used. The technique of the divided visual field isbased on the fact that when a person fixes on a central point, each eye sees bothvisual fields, but directs the information about the right visual field to the lefthemisphere and vice-versa. This way, it is possible to send visual information toone of the side of the brain, by asking to the person to fix their gaze on aparticular point, while impulses are quickly presented to each mid visual fieldindependently.In this test, the metaphoric sentences were presented in the center of the screen andin the sequence the beginning of an explanatory sentence was presented. Theexplanatory sentence was incomplete and had to be completed with graduated and notgraduated meanings by the topic interaction and vehicle suggested, be it in theright visual field or in the left visual field. Between the presentation of theexplanatory sentence and each of the words for completing it, a cross appeared inthe center of the screen. The patient chose the metaphoric combination with itsmeaning pushing the corresponding button to the answer that was judged mostappropriate. The focus of interest was the divided visual field, reaction time andnumber of correct answers. The buttons yes and no were indicated on the mouse of thecomputer, corresponding to the green color for YES and the red color for NO. Thetest configuration was thus established:Back color: light blue;Size, type and color of letters: 55, tahoma, dark blue;Initial delay: 3300 ms;Metaphor: 2500 ms;Start of the explanatory sentence: 2000 ms;Fixation sign: 1500 ms;Answer presentation: 1000 ms;Time between answers: 2000 ms;Time between the last answer and next metaphor: 3500 ms.11 The answers obtained in the test were registered and storedon the computer.Before the test, training was performed consisting of six training-sentences alreadyused in the previous activity, repeating the training the number of times asked bythe patient (three times) until he felt ready to undergo the definitive test. Theinstructions for test 2 were presented by the researcher. Initially a sentenceappeared in the screen for about 2500 ms and soon afterwards, the beginning of theexplanation of the sentence appeared for 2000 ms, disappearing after this time.After this the words comprising the explanation appeared on the screen individually.Each word appeared randomly on the right or left side of the screen for about1000ms. The patient had a time of 2000 ms after the word had vanished to answer YESor NO. Whenever he could not answer in time, he lost the chance and a new wordappeared on the screen. Between the sentences and the words, a cross was displayedin the middle of the screen for 1500 ms.The patient was informed about the characteristics of the study having signed theterm of free and agreed consent, authorizing the publication of the data presentedhere.Test 1 previously demanded that the patient marked the answer to explain the metaphorpresented to him on the card. It was noted that the patient needed to read eachsentence in the analysis twice, while sentences 4, 6 and 9 were read three times bythe patient before indicating his answer.The answers marked by the patient were as follows .It was observed that, out of all metaphorical sentences presented to the patient intest 1, he achieved 50% correct answers. The answers given in the sentences 3, 5 and8 refer to the literal meaning of the expressions under analysis. In sentence 12,due to the need for marking one of the answers the patient said “it looks the same”and finally marked the third option.The appropriate answers to test 2 are described in 20It was noted that there were some differences in the answers for some metaphors intest 2 in relation to test 1, although the patient gave some of the suggestedanswers correctly. The 50% success rate in the answers was repeated as in test 1. Itwas also observed that he maintained literal interpretations, for instance on themetaphors 3 and 11. Moreover, it is important to mention that when he answered in anunexpected way in relation to the appropriate answer, and in an expected way inrelation to the other two options (that were the wrong ones), one cannot be surethat he has accessed the meaning of the metaphor in fact or of both senses marked asexpected. The difficulty presented by the patient may be in rejecting or otherwise,the alternative meaning of the experimental impulse, and not strictly in theunderstanding of the metaphor.In metaphor 3 it was observed that although the patient was right about themetaphorical interpretation, he also marked as a possible interpretation the optionthat refers to the literal meaning. It is relevant that in test 1 the patient hadalso answered with the literal meaning as for the interpretation of this samemetaphor.As for metaphor 4, the patient did not answer in an expected way in test 2, while intest 1 he had answered appropriately. As for metaphor 8 it was observed that thepatient did not answer in an expected way in test 2 either, and in test 1 he hadalso maintained the literal interpretation.In the interpretation of metaphors 11 and 12, although the patient had accessed themetaphorical sense answering in an expected way to these two interpretations, it wasalso observed that possible meanings were accessed in the literal relationship ofthe terms. In general, a difficulty was seen in the processing of metaphors on thepart of the patient, who in 50% of the cases accessed the metaphoricalinterpretation of the statements, but seemed to remain bound to the literal meaningof some expressions. Although the test identified the time of the answer and visualfield, these were not taken into account for this study, for they constitute subjectof future studies.21 believe thatspecific processes are distributed in wider areas of the right half of the cerebralfabric than in the left half. And, in spite of its different role, the righthemisphere carries out a vital role in human behavior and it is already quite clearthat both hemispheres contribute to the complex mental activity, although differingin their functions and organizations.For some time the right hemisphere was conceived inappropriately as the leastimportant or the passive hemisphere. Over the seventy years since Broca’sdiscoveries regarding the left hemisphere, the role of the right hemisphere hasremained unknown. It seemed that the right hemisphere was capable of toleratinggreater injuries without presenting evident damage. Small injuries in certain areasof the left hemisphere drastically affected the abilities of speech, whereas similarinjuries in the right hemisphere did not seem to cause any serious dysfunction. Thisdisparity was interpreted at first as a less important role of the right hemispherein human behavior. More recently, however, it has been proposed that this differencesimply reflects the way the processes are organized in the right hemisphere, andsome authors24 have revealed the direct involvement of the righthemisphere in the processing of metaphorical language. Patients with injuries in theright hemisphere have difficulties to interpret indirect speech,26 connotative semantic relationships,28 phrasal metaphor30 and lexical metaphorical dimension.27Specifically, as for the processing of metaphors, studies with normalsubjects11In spite of their preserved linguistic abilities, clinical observations of patientswith injuries in the right hemisphere show that they possess preferences for literalinterpretations, rejecting, therefore, metaphorical implications. As metaphoriclanguage represents a linguistic resource highly used in daily speech at formal orinformal levels, not being able to process it interferes in the understanding ofdiscursive occurrences, leading to isolation from society. This aspect turns out tobe of extreme relevance when associated to the therapeutic objectives of languagerehabilitation.29 using theparadigm of the matching between sentences and engravings. They found dissociationamong the pictorial and verbal conditions in the patients with injuries to the righthemisphere, who interpreted the metaphors in a literal way when it involved thepictorial task, but who interpreted them correctly when they were requested toexplain them verbally. The applied tests required patients with injury in the righthemisphere and the control group, to perform matching of sentences, such as“He had a heavy heart”, to an engraving, which was representedby an illustration of the literal meaning of the sentence (a man lifting a heavyheart), one of metaphorical meaning (a man crying), and for different aspects of theliteral meaning . In relation to the normal group, both patients with injuries in the righthemisphere and left hemisphere presented problems, but, when compared to oneanother, the patients with injuries in the right hemisphere presented a largernumber of mistakes for each choice, more frequently opting for the literalengraving.11The first investigation studies subjects with injured brains for metaphoricalunderstandingwealth, with theconnotative pictorial representation of an arrow pointing up or down.28 In comparison of abilities relatedto language between patient with injuries in the right and left hemispheres, goodperformance was found in both groups on the understanding of isolated words; thepatients with injuries to the right hemisphere understood new sentences better,while individuals with injuries to the left hemisphere understood familiar idiomaticsentences better.30A similar task was applied in aphasic patients with injuries to the left hemispherewho presented better performance than the patients with injuries to the righthemisphere in the crossing of words, such as 21 Patients with injury in the righthemisphere, however, also showed problems with metaphorical meanings in purelyverbal paradigms.Considering that patients with injuries in the left hemisphere tend to have moreperceptive language problems and that they have better performance than the patientswith injuries to the right hemisphere on the tasks of understanding of thefigurative language, a special role can be attributed to the right hemisphere in theunderstanding of figurative language. A possible reason for the superiority of theleft hemisphere with injuries in the accomplishment of the tasks outlined; however,it is that they involved the matching of sentences with engravings. While engravingspossibly served as additional information to the patients with left hemisphere withinjuries, they presented difficulties for the right hemisphere subjects, for most ofthem had visuospatial deficit. It is known that patients with injury in the righthemisphere would normally present worse results in non-verbal tests involvingmanipulation of geometric illustrations and tasks including forms.cold – hateful –warm, requested the participants to match words that had the samemeaning or that best went together. Semantic relationships among the words werebased on the denotative relationships (former: antonyms cold and warm), connotative(cold and foolish), metaphorical (cold– hateful) or not related (cold andwise). The performance of patients with right hemisphereinjuries was normal for the use of association of antonyms, but below normal for themetaphorical equivalence.27 Theopposite occurred in patients with left hemisphere injuries. A possible explanationfor this impairment could be the difficulty in recognizing and attributing lessfrequent meanings of ambiguous words, rather than the strict recognition ofmetaphorical meanings.11Studies using the paradigm of triads of words, for instance, 31 Such studiesindicate that injuries in the left hemisphere provoke a decrease of sensitivity forthe literal aspect of meaning and increase the dependence of connotative andmetaphorical meaning. Damage in the right hemisphere, on the contrary, seems toincrease dependence of the literal aspect of the word with loss of sensitivity forconnotative and metaphorical aspects. However, the results presented here do notseem to corroborate with this notion, since the case analyzed performed exactly inthe opposite way, suggesting evidence for dependence for literal meaning.The test of the metaphorical and non-metaphorical adjectives, although ambiguous, wasalso accomplished by means of two tests in a triad task and a dual task. In thefirst, participants had to identify which presented the most similar meaning and, inthe second, the plausibility in relation to the two words. In relation to the normalgroup, both groups with injuries presented difficulty in the accomplishment of thetask.11 presented for the same testrevealed that most of the answers of the researched group were right for themetaphorical interpretation of each sentence. Only five of the participants of thestudy opted to not to mark any of the alternatives, which can be evidence ofdifficulties in rejecting the alternative meanings. In any event, the patient-casein this study maintained a 50% rate of appropriate answers and demonstrateddifficulty in processing alternative meanings even if there are no cerebral injuriesin the right hemisphere, but rather in the left. This fact makes may suggest thatcerebral connections are dynamic and that maybe it is not plausible to attribute thefunction of processing figurative senses only to the right hemisphere.The studies previously presented refer to the difficulty of right hemisphere braininjured subjects in the processing of the metaphors; however other results20 The review ofthe research carried out by another study32 shows that the difference in the communicative performancebetween right and left hemisphere-injured patients tends to demonstrate thatseparate components of language are compromised after a right or left injury and incontrast to what is presented in most of the literature,34 do notconfirm the average of 50% of right hemisphere injured with communicative problems.In the three studies consulted on the processing of metaphors after injury to theright hemisphere, either no significant difference was found between people withinjuries in the right or left hemisphere36 or just half ofthe group presented difficulties.37Studies conclude that people with unilateral cerebral injury maintain the righthemisphere neurologically intact, process several types of figurative language,although they present damaged structural and formal aspects of the linguisticsystem.21 In most cases of cerebral injuries, some function recoveryoccurs over time and sometimes remarkable recovery is possible. Recovery can involvechanges in the intact areas and representing the contribution of brainadaptability.Consequently, deducing a cerebral function based on clinical data is problematic,given that the brain possesses a tendency for adjusting its operations in the bestpossible way after an injury; which does not mean that remaining intact areas of ainjured brain operate as they would in a normal brain. It is not as if when “lackinga piece” everything else would work as before.20Other authors criticize studies carried out with right hemisphere injured patientsbecause they consider that in most cases there seems to be no solid evaluation forperceptual deficits characteristic of these cases, or a detailed analysis of thepatients’ linguistic abilities. Besides, they emphasize that in general, the sampleis small and because they use a paradigm of forced choice the results may be relatedto the difficulty presented by the damaged right hemisphere in rejecting thealternative meaning of the experimental impulse or not, and not strictly tometaphorical understanding.The presented studies and the case study proposed in this work revealed divergencesin the results found by researchers which call in to question the specificity of theright hemisphere for the understanding of figurative language. It was noted in thesestudies that not all of the participants with injuries in the right hemisphereshowed such deficits and that, in the outlined case above there were difficultiesfor metaphorical understanding, despite being a case of left cerebral injury. Infact, the conducting of more research seems needed which could enlarge the scope ofthe subject, since the studied case suggests more complex and dynamic relationshipsbetween the cerebral hemispheres for understanding of metaphors. Specifically inthis case, as regards to transcortical motor aphasia, the patient presented deficitof 50% for both proposed tests in the metaphorical understanding and evidencedlinguistic dependence to the literal meaning for processing of figurative sense.Besides, it seems problematic to deduce cerebral functions based in clinical datasince the adaptability of the brain can also readapt in the intact areas thusmodifying the cerebral dynamics. Therefore, in spite of being a fundamental anduseful characteristic, plasticity can, as regards to rehabilitation, complicateresearchers’ efforts to deduce cerebral functions based on clinical data.


Land use change (LUC) is a main cause of global environmental change, and is an important activity to be studied. Our research aims to examine the current state of evidence on the link between LUC and human health in the Amazon region. We conducted a scoping review of literature in two research databases, resulting in 14 papers for analysis. Our analysis demonstrated a lack of clear definitions for LUC, a wide variety of negative health effects from LUC, the lack of qualitative articles, a lack of studies exploring the potential positive health effects of LUC, and the predominance of studies coming from the Brazilian Amazon. Our study validated the prevailing idea that LUC can lead to negative health consequences, if not managed properly. Considered one of the main causes of global environmental change, land use change (LUC) is generally defined as human modifications of land and the ways it is used  ,2. ChangWorldwide, agricultural expansion, a component of LUC, remains the most substantial driver of deforestation rate: about 40% of deforestation in the tropics and subtropics is for large-scale commercial agriculture . From 20Changes in ecosystems can have harmful consequences to human health. It is estimated that almost one quarter of the global burden of disease can be attributed to the environmental changes (including LUC) that contribute to air, water, and soil pollution ,13. ForeScoping reviews aim to broadly examine the existing literature on a topic in order to review concepts, report on the type of studies available regardless of their methodological quality, and identify gaps in knowledge to further inform research practice . As popuThe steps included for our review followed the framework outlined by Arksey and O’Malley , taking This review answered the following question: What is the current state of evidence on the link between LUC and human health in the Amazon region?We conducted a comprehensive scientific literature search in the electronic databases PubMed  and Web of Science (multidisciplinary). We developed and mapped key search terms with online databases prior to the article search. The research query included terms related to the Amazonian region, different aspects and activities related to LUC, and various types of diseases . We carrOur analysis for inclusion was a multi-step process . Our iniWe defined relevant publications as: any peer-reviewed article (except for reviews) published between January 1 2000 and August 31 2016; in English or Spanish; focused on or presenting data from the Amazon region ; that refer to a specific health issue; and include the topic of LUC. Our inclusion criteria for the topic of LUC was defined as either papers that refer to the existence of one or more aspects of LUC, or that partly or fully fulfilled the concept of land use change (LUC) as defined by the Intergovernmental Panel on Climate Change (IPCC): “…human activities which: (a) Change the way land is used , or (b) Affect the amount of biomass in existing biomass stocks "[We used papers that studied causative agents for health problems  for analysis, even if no health measurements were taken on humans. While it is not always true that the presence/absence of these factors will result in negative health outcomes, we felt this was a safe assumption based on existing literature . FinallyAuthors created an Excel spreadsheet  in whichThe analysis and synthesis of literature included quantitative analysis (e.g. descriptive statistics) and qualitative analysis . A narrative approach allowed reviewers to extract common themes that emerged from the findings.Of the 26 articles reviewed in full, we included 14 in the analysis after exclusion criteria were applied. These articles pertain only to two Amazonian countries, Brazil and Peru, with the former providing the most articles (11). Health data referred to in these articles came from direct and indirect measurements of a disease in humans, vectors, or animals. Only one paper addressed disease as a risk through a measurement of air pollutant exposure. Three articles were based on epidemiological data , 5 of them on data collected from vectors (e.g. relative abundance and richness of species), and one addressed local people’s perceptions of their wellbeing. Most papers did not describe specific methods for measuring changes in land use or forest cover. Five papers used mapping and satellite images to quantify forest cover; one used data on fire outbreaks related to deforestation, and one was based on governmental data on the average amount of square kilometers deforested per year. Over three quarters of reviewed articles were published from 2010 and on, reaching a peak with four publications in 2016. All were written in English.The data collection table we used is shown in Eight out of 14 papers described negative relationships between LUC and health –32, one chacras , communities, and houses. By easing access to healthcare services, roads were associated with a decrease of diarrhea and acute respiratory infections (ARI) in Brazil [Road building is considered a particularly damaging form of LUC in tropical forests  and was n Brazil . The samn Brazil .There have been mixed positive and negative results when examining highway construction and child/maternal health. Despite the construction of the Pacific Highway in Assis, Brazil, women still had low numbers of prenatal appointments. While the women in the community had access to more appointments than the rest of the state, the access was lower overall compared to the rest of Brazil. The addition of a road allowed for easier access to cesarean procedures, but there was no increase in them, suggesting that they were only used when medically necessary. There also continued to be a low number of institutionalized births , suggesting the continued use of in-house childbirth. .10 and PM2.5) levels above Brazilian and/or U.S National Ambient Air Quality standards, CO levels comparable to urban areas , and elevated benzene and HCHO levels when compared to other rural areas around the world [Multiple papers looked at lung diseases ,33,34,36he world . AnotherCenterocestus formasus, schistosomiasis, and the parasite responsible for cercarial dermatitis [Only one paper discussed LUC related to dam power plants—these were associated with abundance of potential vector species of snail . These srmatitis .When assessing papers with LUC due to livestock farming and health outcomes, one paper reported that bat bites on humans were more common where there was no livestock, suggesting that livestock could have a protective effect on bat bites on humans . Bats feTrypanosoma cruzi infection was higher in the Genipaúba locality , and the Ajuaí locality , as compared to other districts that have high human occupation, nearby secondary vegetation, and areas of only farm and pasture. There was also higher prevalence of detected antibodies among mammals and domestic mammals in Ajuaí compared to other study sites [LUC related to agriculture was associated with multiple diseases. A study of different Brazilian localities found that the prevalence of dy sites .Phlebotomine sandflies, potential carriers for leishmaniasis, were found in equal abundance across areas with different degrees of human occupations and land degradation. All sand fly species in this study were found in similar numbers through the land use categories suggesting high adaptability of sandflies, and the high adaptability could increase human-vector interactions, leading to more disease [ disease . Defores disease .The changing of land from unprotected forest to protected areas was associated with a decrease in malaria, diarrhea, and ARI . There aThe scoping review utilized a systematic approach to explore associations—both positive and negative—between health problems and LUC in the Amazon forest of Latin America. The most striking observations were the lack of clear definitions for LUC, the lack of qualitative articles, a lack of studies exploring the potential positive health effects of LUC, and the predominance of studies coming from the Brazilian Amazon. Slightly more than half of the articles examined in this study revealed that LUC can lead to negative health consequences , but other articles in our review also focused on the fact that there are often positive consequences associated with LUC. Gaps in knowledge include lack of agreed definition for LUC, a lack of representation for many different health outcomes, and the need for more research beyond the Brazilian Amazon.LUC is becoming a growing interdisciplinary field of study, receiving increasing attention from scholars within both environmental and social sciences. Academic and non-academic organizations are designating LUC as a core concern, thus potentially fostering research to better understand its causes and results.There are multitudes of ways to examine LUC, from physical observations of cover change to studies on the ways humans interact with their ever-changing world . The preAnother important task for the research community would be to work on the development of a framework—or various frameworks—that portray the complex linkages associated with LUC—whether some are causal relationships or co-emerging issues. For example, one of our difficulties was determining what articles to include in this review, since the linkages between LUC and health are sometimes direct, and at other times more indirect. Having a framework that is used by the various researchers working on this topic would allow us to contribute to building the knowledge about these linkages, modifying the frameworks based on findings if appropriate, and exploring complex topics regarding attribution and causality. Another reason to have a clear framework is that it could aid in helping direct us on issues to examine—information that would serve vulnerable populations who often have the most at stake in LUC activities. Rural populations, especially indigenous ones, are at a higher risk for exploitation by the government and corporations when it comes to LUC activities, through both the co-opting of land and through the unsafe and unhealthy conditions that can often result from LUC . These uThough most of reviewed papers address changes in land use by reference to deforestation, none of them defined, and therefore measured, LUC explicitly. Streiker & Jacob (2016) and Bauch et al. (2015) present the concept in their titles and/or abstracts, and approach LUC beyond deforestation, providing multiple examples and/or references to both causes and consequences of LUC . Other articles, ,30,31, wHealth effects related to smoke exposure and air quality were the most frequently addressed topic in the reviewed articles, especially in Brazil. This could possibly be explained by the multitude of laws regarding biomass burning that are now in effect in Brazil , and theMany of the papers we examined studied human-vector interactions. This is unsurprising, as vectors are a major cause for disease and can be relatively easily measured. There are also many examples of diseases transmitting as a result of increased contact between human population and wildlife, such as Ebola  and yellOnly one qualitative research satisfied our inclusion criteria . This shThe Amazon Basin encompasses 8 different countries  ; howeverThe differences in ecosystems across the Amazon basin make it difficult to apply one study to the entire region. While it is tempting to characterize the Amazon as one giant rainforest, it is made up of multiple ecosystem types, including mangroves, moist forest, mountain forest, and swamps . This diWhen working with any health topic, the diversity of people is important to consider. The indigenous people of the Amazon are made up of about 350 ethnic groups, some of which are still isolated . AmazoniThe drivers of LUC, and subsequent relationships with the government, also can vary. The illegal logging and mining industries of the Amazon are a looming presence. For example, in Colombia, almost all forest clearing is illegal. However, Colombia has made strides in its protection of indigenous lands, giving ownership of the majority of the remaining Amazon to its indigenous peoples . Brazil,One of our barriers was language. There were 24 papers that were written in Portuguese. Because we had no Portuguese-speakers on our team, we were unable to include these papers, limiting our results. Spanish publications were underrepresented. The addition of grey literature would have enriched our findings; however, due to limited human resources and time constraints, we were unable to search these. As described previously, another problem the researchers encountered when conducting this search was drawing specific conclusions whether an article covered a specific LUC issue, and to what extent the LUC occurred, making drawing conclusions difficult.LUC will continue to be an important research topic, both globally and locally, as human expansion continues and shifts. These changes have the potential to do great harm to humans, but with continued research and advocacy, those harms could be mitigated. Our research found that most papers lack a clear definition of LUC, demonstrate mostly negative impacts on human health, and few papers study qualitative aspects of LUC. Moving forward, the authors recommend offering clear definitions of LUC and the way it is measured, exploring the social dimensions of LUC, and performing more qualitative studies to assess these better.S1 Table(XLSX)Click here for additional data file.S1 File(DOC)Click here for additional data file.


To describe and standardize a reproducible, viable, low-cost lamb’s head model for endoscopic sinus surgery training.Otorhinolaryngology residents performed the following three endoscopic sinus surgeries using the lamb’s head model: inferior turbinectomy, bullectomy, and maxillary antrostomy. Each student dissected 10 specimens before training these procedures on human patients, and the benefit of the animal model training was evaluated.Nineteen resident physicians of comparable academic level participated in training. All participants agreed that the lamb’s head model dissections improved their skills in using surgical and videoendoscopic instruments, 90% agreed that the dissections improved their confidence with respect to training in human patients, and all stated they would recommend the same training to future residents.Lamb’s heads have been used for training in endoscopic sinus surgery. However, no standardization of this training had been performed to ensure that it is a valuable tool for learning and skill-building. The standardized method described in this study increased resident physicians’ skills and confidence before beginning their training on human patients. Moreover, our results demonstrate the feasibility of the model, considering its low cost and reproducibility.Future studies with this model should be conducted to assess whether the resulting increase in skills prevents and reduces medical errors, increases patient safety, reduces surgical costs, and improves the quality of otorhinolaryngological care. Rhinology, particularly rhinologic surgery, has undergone major transformations in recent decades since the advent of videoendoscopy. The access routes of various nasal and paranasal surgical procedures have changed to incorporate the many benefits provided by the nasal endoscope, including smaller surgical scars, decreased operative time, and fewer complications.However, this modality is a challenge for trainees and instructors. The nose is very near to the eyes, skull base, and oral cavity; an error during surgery or other iatrogenesis can cause permanent damage and may even be life-threatening , 2. TherThe acquisition of surgical skills by trainees before performing procedures in human patients has become a requirement with respect to recommendations on the development of clinical practices that ensure patient safety in health care. Furthermore, such training reduces the duration of training on live patients, and training in realistic simulators can improve outcomes and reduce the odds of error .Dissection of human cadavers, although ideal for training purposes, has become more expensive and strictly regulated on a global scale, due to ethical and legal issues . RestricConsidering the difficulties of using cadavers and the limitations of models and simulators, a search for animal models suitable for training has become necessary.The anatomy of nasal structures in the lamb is remarkably similar to that of humans. For this reason, the lamb’s head is an excellent surgical learning model and has been used successfully for otorhinolaryngology training in the past –11.The use of a lamb’s head model enables the acquisition and refinement of skills required of resident physicians before using their skills in human patients. However, such training requires standardization and systematization so that the similarities of this model with human anatomy are highlighted and result in learning and acquisition of the skills required for training of otorhinolaryngologist surgeons.The aim of this study was to describe and systematize a reproducible, feasible, and low-cost lamb’s head model for endoscopic sinus surgery training.The study was approved by the relevant Institutional Animal Care and Use Committee at School of Medicine, Universidade de Brasília with protocol number 153674/2012. The research was approved in 2012 and data collection, and data collection took place from 2013 to 2016, which means that the research was conducted only after its approval. The above committee evaluates all investigations performed in the institution, including those with human subjects. Therefore, the committee approved the use of both humans and animals in the present study. All the residents that took part in this study gave written consent after they had received detailed information about the project. All procedures were conducted in exact compliance with the approved protocol.Lamb’s heads were acquired from a regular, registered slaughterhouse in Núcleo Bandeirante, Brasília, DF, Brazil, at an approximate unit cost of USD3.00. Each specimen was provided clean and skinned and was kept frozen until use.Approximately eight hours before dissection, the specimens were removed from the freezer. Once thoroughly thawed, the specimens were washed in running water to remove any clots and the outer surfaces were wrapped in ethanol-soaked gauze. Complete thawing is important to ensure that the texture of the nasal mucosa is similar to that of the analogous human structure. Moreover, the period of use should not exceed 4 hours to avoid decomposition of the specimen, with consequent loss of quality.To facilitate handling, the lamb’s head was secured to a support fabricated specifically for this purpose. This support, designed with the aid of a machinist, was made from low-cost materials and consisted of small sheet-metal parts and three pairs of adjustable screws arranged in such a way as to allow fixation of the specimen . A commeA zero-degree rigid endoscope  was used. This endoscope was attached to a USB camera , a laptop, and a portable LED light source. Images of the training procedures were captured and stored on the laptop. The camera and light source were purchased together at an approximate cost of USD1,000.The dissections were performed in the otorhinolaryngology laboratory by resident physicians under the supervision of a single researcher. Before training, each participant watched a demonstration video of a standard dissection performed by the researchers, and the steps and surgical objectives of training were clarified.All resident physicians began training at the end of the second year of the residency program. This point in the program precedes endoscopic sinus surgery training in human patients, which is part of the third-year syllabus of our institution’s residency program.The researchers chose to train resident physicians in three procedures: inferior turbinate reduction, bullectomy, and maxillary sinus surgery. These procedures were selected because they are commonly performed in humans and are fully reproducible within the anatomical constraints of this animal model . EssentiInferior turbinate reduction was performed with the endoscope in the left hand and Heymann nasal scissors (Karl Storz). The proposed surgical model was a partial inferior turbinectomy of the head, body, and rear of the turbinate. Ethmoid bullectomy was performed after medial displacement of the middle turbinate, followed by use of through-cut, straight, Gruenwald-Henke nasal cutting forceps (Karl Storz) for complete removal of the anterior portion of the bulla. Maxillary antrostomy was performed after removal of the uncinate process with a sickle knife (Karl Storz), and the procedure was considered complete after exposure of the maxillary fontanelle.All dissections were recorded using the image capture system of the camera installed on the computer. Each resident physician performed dissection 10 times, five in each nostril, in a total of 5 heads, always alternating sides, and always starting on the left side.At the end of the dissections, the recorded videos were collected for later evaluation of the residents’ learning process. Several previously validated learning assessment tools could be used for this analysis.Upon completion of the 10 dissections and after starting training of these procedures on human patients, the residents completed a questionnaire to rate their satisfaction and progress during training, as well as the personal perceptions of their skills, using a five-point Likert scale. The questionnaire is shown in The completed questionnaires were then analyzed to formulate conclusions about residents’ expectations and assess their learning. The answers to each statement were converted to percentages and added.A total of 19 residents (6 men and 13 women) from the same academic year and residency period performed the three surgeries proposed for each endoscopic dissection. Each resident performed 10 dissections in 5 lamb’s heads over an average period of 5 to 8 weeks. There were four cohorts of residents over 4 years.A total of 190 videos were recorded in mp4 format. On average, each dissection lasted 33 minutes. The average duration was 31 minutes on the left side and 35 minutes on the right side.Inferior turbinectomy, bullectomy, and maxillary antrostomy in the lamb’s head model were considered similar to the procedures performed in humans by 90%, 100%, and 95% of the residents, respectively.All participants agreed that the dissections in the lamb model increased their skills with surgical and videoendoscopic instruments, 90% agreed that the dissections improved their confidence to begin training on human patients, and all stated they would recommend the same training to future residents.Use of the lamb’s head model helped overcome the difficulties of using human cadavers and the limitations of alternative methods. This model complies with the principles of ethical animal use; because the study specimens do not have commercial value, this material is usually discarded after slaughter. Therefore, this training model is low-cost and complies with legal requirements.The lamb’s head has been widely used in endoscopic sinus surgery, and its similarity to human anatomy has been well documented –11. HoweSimilarities between our work and this previous study are the use of the lamb’s head and the use of video recording dissections. In fact, our study builds on the experience of Awad et al. (2015), but focusing only on the resident training scenario and on the use of the lamb’s head as an additional educational tool to offer safer environmental training for junior doctors.Compared to the previous study, we sought to provide a thorough description of use of the established lamb’s head model for sinonasal surgery training. Detailed explanations of how the specimens were prepared, how the head support was fabricated, and of the tools and instruments employed were provided, as one of our intentions was to facilitate reproducibility anywhere with this low-cost, readily available model.Another objective of our manuscript was to standardize training with the lamb’s head model specifically for surgical skill acquisition, focusing on individual skill-building and improvement; hence, each participant repeated the same step 10 times. In their validation of this model, Awad et al. did not measure individual learning because their sample was composed of distinct groups with very different levels of knowledge, and participants practiced only once on the model .The primary objective of the standardization described in this study was to facilitate the acquisition of basic surgical skills and foster proper handling of surgical instruments. Dissection training using the animal model proposed herein will not teach residents how to treat a human disease; however, after having learned surgical skills during dissection, students will be better able to initiate training on humans under the supervision of an expert.To avoid selection bias, we evaluated a sample composed exclusively of second-year residents, in contrast to other studies that evaluated resident physicians of different academic levels, senior otolaryngologists, fellows, and even undergraduate students –17. For The lamb’s head model enabled the acquisition of skills using surgical and videoendoscopic instruments and improved the confidence of the resident physicians who were beginning endoscopic sinus surgery training, as demonstrated by the fact that all participants stated they would recommend the same training to future residents.The proposed model is low-cost, requires little equipment, is portable, and can be replicated and used anywhere. Moreover, the recording of the dissections allows the evaluation of performance and learning at any time, thus obviating the need for supervision from teachers or advisors during the dissection itself; this increases trainee autonomy and saves valuable time.Our study was innovative in that it standardized the training of resident physicians with the established lamb’s head model and explicitly described how to construct a low-cost version of this model.Although human cadaver dissection is the best strategy to train for endoscopic sinus surgery, the high cost of obtaining these anatomical specimens and, particularly, limitations on its use owing to ethical and legal concerns have prompted a search for alternatives .Several human head models have been developed from synthetic materials. These models have precise anatomical characteristics, and are portable and hygienic. However, their texture is poor compared with real human tissues , 6. AnotThe disadvantages of the lamb’s head model include the need for storage, the thawing period required before use, and the unavailability of lamb meat or slaughterhouses in some regions, although both are common in most countries.The standardization proposed herein and the responses obtained demonstrate the relevance of using the lamb’s head model in the initial stages of surgical training, which will benefit patients. Furthermore, this study highlights the economic feasibility of the model, because the overall cost of both equipment and specimens is low. For these reasons, we recommend that the lamb’s head model be adopted for training of physicians who do not have access to human cadavers.It is important to note that this study did not aim to compare resident physicians among one another but, rather, to compare the dissections made by each resident physician. Therefore, we assessed the progress of each trainee, respecting individual characteristics and skills.However, further studies are necessary to evaluate the actual acquisition of skills by residents using the lamb’s head model. This can be achieved by assessing surgical learning using tools previously validated for this purpose .Nasal dissection using the lamb’s head model proposed in this study is a viable, low-cost alternative to the use of human cadavers. Future studies with this model would help demonstrate whether the resulting acquisition of skills can prevent and reduce medical errors, increase patient safety, decrease surgical costs, and improve the quality of otorhinolaryngological care.