Detection of nosocomial malnutrition is improved in Amazon region by a standard clinical nutrition education program

Background: In Brazil hospital malnutrition is highly prevalent. physician awareness of malnutrition is low, and nutrition therapy is underprescribed. One alternative to approach this problem is to educate health care providers in clinical nutrition. The present study aims to evaluate the effect of an intensive education course given to health care professionals and students on the diagnosis ability concerning to hospital malnutrition. Materials and methods: An intervention study based on a clinical nutrition educational program, offered to medical and nursing students and professionals, was held in a hospital of the Amazon region. Participants were evaluated through improvement of diagnostic ability, according to agreement of malnutrition diagnosis using Subjective Global Assessment before and after the workshop, as compared to independent evaluations (Kappa Index, k). To evaluate the impact of the educational intervention on the hospital malnutrition diagnosis, medical records were reviewed for documentation of parameters associated with nutritional status of in-patients. The SPSS statistical software package was used for data analysis. Results: A total of 165 participants concluded the program. The majority (76.4%) were medical and nursing students. Malnutrition diagnosis improved after the course (before k = 0.5; after k = 0.64; p < 0.05). A reduction of false negatives from 50% to 33.3% was observed. During the course, concern of nutritional diagnosis was increased W = 17.57; p < 0.001) and even after the course, improvement on the height measurement was detected chi(2) 12.87;p < 0.001). Conclusions: Clinical nutrition education improved the ability of diagnosing malnutrition; however the primary impact was on medical and nursing students. To sustain diagnostic capacity a clinical nutrition program should be part of health professional curricula and be coupled with continuing education for health care providers.

The characteristics of depressive symptoms in medical students during medical education and training: a cross-sectional study

Background: Medical education and training can contribute to the development of depressive symptoms that might lead to possible academic and professional consequences. We aimed to investigate the characteristics of depressive symptoms among 481 medical students (79.8% of the total who matriculated). Methods: The Beck Depression Inventory (BDI) and cluster analyses were used in order to better describe the characteristics of depressive symptoms. Medical education and training in Brazil is divided into basic (1(st) and 2(nd) years), intermediate (3(rd) and 4(th) years), and internship (5(th) and 6(th) years) periods. The study organized each item from the BDI into the following three clusters: affective, cognitive, and somatic. Statistical analyses were performed using analysis of variance (ANOVA) with post-hoc Tukey corrected for multiple comparisons. Results: There were 184 (38.2%) students with depressive symptoms (BDI > 9). The internship period resulted in the highest BDI scores in comparison to both the basic (p < .001) and intermediate (p < .001) periods. Affective, cognitive, and somatic clusters were significantly higher in the internship period. An exploratory analysis of possible risk factors showed that females (p = .020) not having a parent who practiced medicine (p = .016), and the internship period (p = .001) were factors for the development of depressive symptoms. Conclusion: There is a high prevalence towards depressive symptoms among medical students, particularly females, in the internship level, mainly involving the somatic and affective clusters, and not having a parent who practiced medicine. The active assessment of these students in evaluating their depressive symptoms is important in order to prevent the development of co-morbidities and suicide risk.

Oral Health Promotion Through an Online Training Program for Medical Students

The objective of this study was to compare the impact on knowledge and counseling skills of face-to-face and Internet-based oral health training programs on medical students. Participants consisted of 148 (82 percent) of the 180 invited students attending their fifth academic year at the Faculty of Medicine, University of Sao Paulo, Brasil, in 2007. The interventions took place during a three-month training period in the clinical Center for Health Promotion, which comprised part of a clerkship in Internal Medicine. The students were divided into four groups: 1) Control Group (Control), with basic intervention; 2) Brochure Group (Br), with basic intervention plus complete brochure with oral health themes; 3) Cybertutor Group (Cy), with basic intervention plus access to an Internet-based training program about oral health themes; and 4) Cybertutor + Contact Group (Cy+C), the same as Cy plus brief proactive contact with a tutor. The impact of these interventions on student knowledge was measured with pre- and post assessments, and student skills in asking and counseling about oral health were assessed with an objective structured clinical examination (OSCE). Multivariate logistic regression models were applied to identify the odds ratios of scoring above Control's medians on the final assessment and the OSCE. In the results, Cy+C performed significantly better than Control on both the final assessment (OR 9.4; 95% CI 2.7-32.8) and the OSCE (OR 5.6; 95% CI 1.9-16.3) and outperformed all the other groups. The Cy+C group showed the most significant increase in knowledge and the best skills in asking and counseling about oral health.

Mentors, students, and the undergraduate medical course: a virtuous circle

BACKGROUND: Mentoring Programs have been developed in several medical schools, but few studies have investigated the mentors'perspective. PURPOSES: To explore mentors'perceptions regarding their experience. METHODS: Mentors at a medical school were invited to participate in an in-depth interview including questions on satisfaction, difficulties, and perception of changes resulting from the program. RESULTS: Mentors' satisfaction and difficulties are strongly associated with students'involvement in the activity. Mentors believe changes observed in students were more related to life issues; for some mentors, there is no recognition or awareness of the program. However, most of the mentors acknowledged important changes in relation to themselves: as teachers, faculty members, and individuals. CONCLUSION: Attendance is crucial for both the mentoring relationship and strengthening of the program. Students involved in the activity motivate mentors in teaching and curriculum development, thereby creating a virtuous circle and benefiting undergraduate medical education as a whole.

Surgical Outcomes after Preceptored Laparoscopic Colorectal Surgery: Results of a Brazilian Preceptorship Program

Background/Aims: Safety of laparoscopic colectomy education methods remains unknown. This study aimed at comparing the outcomes of patients undergoing preceptored laparoscopic colectomy with patients operated on by the same preceptor. Methodology: A prospective analysis of 30 preceptored operations performed by nine surgeons (PD group) between 2006 and 2008 was conducted. Data of 30 operations matched for diagnosis and surgery type conducted by the same preceptor (P group) were evaluated. Results: Median age was 56.2 (26-80) and 55.2 (22-81) respectively in P and PD group (p=0.804). Eleven (36.7%) were male in P group, 16 (53.3%) in PD group (p=0.194). Preceptored operations were not significantly longer than operations performed by the preceptor (198 vs. 156 min) - p=0.072. Length of hospital stay did not differ [4 days (3-12) in P group, and 5 (3-15) in PD group, p=0.296]. Conversion occurred in 4 cases in PD and in 2 in P group (p=0.389). Morbidity was similar (23.3% in P and 26.7% in PD group). One patient from P and two from PD group needed re-operation. No deaths occurred. Conclusions: Laparoscopic colorectal surgery preceptorship programs in surgeon learner`s place are safe. Surgeons` introduction through basic and hands-on courses is required for skills acquisition needed to minimize adverse outcomes.

Como implementar uma diretriz - da teoria à prática: exemplo da profilaxia para Tromboembolismo Venoso

The objective of this manuscript is to discuss the existing barriers for the dissemination of medical guidelines, and to present strategies that facilitate the adaptation of the recommendations into clinical practice. The literature shows that it usually takes several years until new scientific evidence is adopted in current practice, even when there is obvious impact in patients' morbidity and mortality. There are some examples where more than thirty years have elapsed since the first case reports about the use of a effective therapy were published until its utilization became routine. That is the case of fibrinolysis for the treatment of acute myocardial infarction. Some of the main barriers for the implementation of new recommendations are: the lack of knowledge of a new guideline, personal resistance to changes, uncertainty about the efficacy of the proposed recommendation, fear of potential side-effects, difficulties in remembering the recommendations, inexistence of institutional policies reinforcing the recommendation and even economical restrains. In order to overcome these barriers a strategy that involves a program with multiple tools is always the best. That must include the implementation of easy-to-use algorithms, continuous medical education materials and lectures, electronic or paper alerts, tools to facilitate evaluation and prescription, and periodic audits to show results to the practitioners involved in the process. It is also fundamental that the medical societies involved with the specific medical issue support the program for its scientific and ethical soundness. The creation of multidisciplinary committees in each institution and the inclusion of opinion leaders that have pro-active and lasting attitudes are the key-points for the program's success. In this manuscript we use as an example the implementation of a guideline for venous thromboembolism prophylaxis, but the concepts described here can be easily applied to any other guideline. Therefore, these concepts could be very useful for institutions and services that aim at quality improvement of patient care. Changes in current medical practice recommended by guidelines may take some time. However, if there is a broader participation of opinion leaders and the use of several tools listed here, they surely have a greater probability of reaching the main objectives: improvement in provided medical care and patient safety.

Influences of sex and age on biological rhythms of serum lipids and lipoproteins

Background: Few studies have evaluated seasonal variations of biochemical parameters routinely analyzed in clinical laboratories. Rhythmic patterns for lipids and lipoproteins have been demonstrated and have been the object of research, mainly because of their demonstrated association with coronary artery disease. This study evaluated the occurrence of biological rhythms on serum lipids and lipoproteins and the effects of sex and age on the rhythms in a Brazilian hospital outpatient population. Methods: Retrospective laboratory study was carried out to evaluate the results of total cholesterol (TC), HDL-cholesterol (HDL-C), LDL-cholesterol (LDL-C) and triglycerides (TG), from individuals registered at a university referral hospital over 8years. The studied population was composed of individuals of both sexes and all ages totaling 38,579 participants and 301,934 measurements. Statistical analyses were carried out using the SAS program and the temporal analysis used the Cosinor method. Results: TG rhythm was present only in females. All other parameters were equally rhythmic in both sexes. Regarding age, HDL-C presented rhythms in all age groups, but TC and LDL-C showed seasonality only for those > 13years, TG did not present rhythms in all age groups. Conclusion: Effects of sex and age on biological rhythms detected in TC, LDL-C and HDL-C should be considered a significant cause of pre-analytical variation in these laboratory tests. (C) 2009 Elsevier B.V. All rights reserved.

Distance Education in Another Register: Uses and Appropriation of Technologies in Teacher Education

The article explores the relationships between distance education, information and communication technologies and teacher education. Its focus is on the interactive media and its uses in an in-service teacher education program, in Brazil, and on the ways the teachers used the technologies doing their own appropriateness. It departs from the presuppositions of the society of knowledge, that is, the close relationships between new technologies, continuing professional development and social inclusion, arguing that this paradigm is an ideological discourse. The article shows how the teachers have used the technologies in creative ways, calling the attention to the importance of this teachers` abilities as a basic skill to facing the challenges of the society of knowledge itself.

Lipid goals among patients with diabetes or metabolic syndrome: Lipid Treatment Assessment Project (L-TAP) 2

Objective: This analysis of the Lipid Treatment Assessment Project 2 population compared lipid goal attainment by diabetes and metabolic syndrome status. Research design and methods: Dyslipidaemic patients aged >= 20 years on stable lipid lowering therapy had their lipid levels determined once during enrolment at investigation sites in nine countries between September 2006 and April 2007. Achievement of low-density lipoprotein (LDL) cholesterol success, triglycerides < 150 mg/dl (1.7 mmol/l), and high-density lipoprotein (HDL) cholesterol success (> 40 mg/dl [1.0 mmol/l] in men or > 50 mg/dl [1.3 mmol/l] in women) was compared using logistic regression. Results: A total of 9955 patients were evaluated. Patients with diabetes, compared with those without diabetes, had lower achievement of LDL cholesterol goals (according to National Cholesterol Education Program Adult Treatment Panel [NCEP ATP] III guidelines; 67% vs. 75%), triglycerides < 150 mg/dl (55% vs. 64%), and HDL cholesterol success (61% vs. 74%; p < 0.0001 for all comparisons). The significantly lower lipid goal attainment in patients with diabetes was consistent across participating world regions. Patients with metabolic syndrome, compared with those without metabolic syndrome, had lower achievement of NCEP ATP III LDL cholesterol goals (69% vs. 76%), triglycerides < 150 mg/dl (36% vs. 83%), and HDL cholesterol success (49% vs. 89%; p < 0.0001 for all comparisons). As the number of metabolic syndrome components increased, lipid success rates progressively decreased (p < 0.0001 for LDL cholesterol success, triglycerides < 150 mg/dl, and HDL cholesterol success). Conclusions: This analysis indicates that despite their increased cardiovascular risk, patients with diabetes or metabolic syndrome remain undertreated.

Impact of Endovascular Technique in Vascular Surgery Training at a Large University Hospital in Brazil

OBJECTIVES: The aim of this study was to determine the impact of endovascular surgery versus open vascular technique training in a Brazilian teaching service. DESIGN: Cross-sectional study. SETTING: Hospital das Clinicas-Faculty of Medicine University of Sao Paulo, a tertiary institutional hospital Brazil. PARTICIPANTS: We reviewed 1,040 arterial operations performed during 2 distinct time periods: January 1995 to December 1996, and January 2006 to December 2007. Based on the disease treated, the procedures were classified into the following 5 groups: abdominal aortic aneurysms (AAA), aorto-iliac obstructive disease (Al), obstructive disease of the femoropoplitealtibial segment (FP), carotid disease (C), and others (0). The operations were also divided into an endovascular surgery (ES) group and an open surgery (OS) group. We compared the number of open and endovascular procedures for each arterial disease group during both periods. RESULTS: During the 2006-2007 period, 654 patients were treated surgically, whereas over the 1995-1996 period, 386 arterial operations were performed. A. significant increase in endovascular procedures (p < 0.001) was found from the 1995-1996 period to the 2006-201)7 period (35 vs 351, respectively) in all groups, whereas open surgery showed a slight increase in the number of procedures in the AAA and 0 groups only. In the 1995-1996 period, OS was the primary surgical method for all groups, but in the 2006-2007 time frame, OS was performed more frequently than ES only in the AAA and 0 groups. Considering all vascular disease groups, OS was the technique used in 90.9% (351 of 386) of the operations during 1995-1996, whereas in 2006-2007, OS was performed in only 46.3% (303 of 654) of the procedures. CONCLUSIONS: The increase in the number of ES observed over the past decade has had little impact on OS procedures performed at our medical center, not bringing harm to open surgical training. (J Surg 68:19-23. (C) 2011 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Physicians` attitudes and adherence to use of risk scores for primary prevention of cardiovascular disease: cross-sectional survey in three world regions

Objective: To evaluate physicians` attitudes and adherence to the use of risk scores in the primary prevention of cardiovascular disease (CVD). Design and methods: A cross-sectional survey of 2056 physicians involved in the primary prevention of CVD. Participants included cardiologists (47%), general practitioners (42%), and endocrinologists (11%) from several geographical regions: Brazil (n=968), USA (n=381), Greece (n=275), Chile (n=157), Venezuela (n=128), Portugal (n=42), The Netherlands (n=41), and Central America (Costa Rica, Panama, El Salvador and Guatemala; n=64). Results: The main outcome measure was the percentage of responses on a multiple-choice questionnaire describing a hypothetical asymptomatic patient at intermediate risk for CVD according to the Framingham Risk Score. Only 48% of respondents reported regular use of CVD risk scores to tailor preventive treatment in the case scenario. Of non-users, nearly three-quarters indicated that `It takes up too much of my time` (52%) or `I don`t believe they add value to the clinical evaluation` (21%). Only 56% of respondents indicated that they would prescribe lipid-lowering therapy for the hypothetical intermediate-risk patient. A significantly greater proportion of regular users than non-users of CVD risk scores identified the need for lipid-lowering therapy in the hypothetical patient (59 vs. 41%; p<0.0001).

Cardiovascular prevention in HIV patients: Results from a successful intervention program

Objectives: To analyze the effect of a prevention program oil the estimated cardiovascular risk calculated by three risk scores. Methods: We prospectively evaluated 87 HIV+ patients with elevated cardiovascular risk estimation. Framirigham (FIRS), PROCAM and National Cholesterol Education Program (ATP-III) were applied. Cardiovascular risk was defined as elevated if >10%. All patients received non-pharmacological (diet, exercise, smoking cessation) and, when appropriate, pharmacological therapy. Results: Mean age was 52 years, 92% were male, 39.1% were smokers, 70.1% had hypertension, 18.4% had diabetes. All patients were under HAART, 56.3% were receiving protease inhibitors (131). After 6 months, intervention was associated to significant changes oil triglycerides (298 242 and 206 +/- 135 mg/dL, p<0.05), total-cholesterol (224 +/- 47 and 189 +/- 38 mg/dL, p<0.001). LDL-cholesterol (129 +/- 44 and 109 +/- 30 mg/dL,p<0.001). Frequencies of patients with elevated cardiac risk before and 6 months after intervention were 92% x 27.6% (p < 0.0001), 80.5% x 50.6% (p < 0.0002), and 25.3% x 14.9% (p = 0.12), for FIRS, ATP III and PROCAM, respectively. Conclusions: An intervention Program focused on reduction of traditional risk factors was able to decrease the frequency of patients with HIV infection and elevated cardiovascular risk estimation. FIRS showed greater sensitivity than the other scores. (C) 2008 Elsevier Ireland Ltd. All rights reserved.

Whole-Genome Characterization of Human and Simian Immunodeficiency Virus Intrahost Diversity by Ultradeep Pyrosequencing

Rapid evolution and high intrahost sequence diversity are hallmarks of human and simian immunodeficiency virus (HIV/SIV) infection. Minor viral variants have important implications for drug resistance, receptor tropism, and immune evasion. Here, we used ultradeep pyrosequencing to sequence complete HIV/SIV genomes, detecting variants present at a frequency as low as 1%. This approach provides a more complete characterization of the viral population than is possible with conventional methods, revealing low-level drug resistance and detecting previously hidden changes in the viral population. While this work applies pyrosequencing to immunodeficiency viruses, this approach could be applied to virtually any viral pathogen.

Validity and applicability of the Mini International Neuropsychiatric Interview administered by family medicine residents in primary health care in Brazil

Objective: To evaluate the validity and applicability of the Mini International Neuropsychiatric Interview (MINI) used by family medicine residents in primary health care (PHC) in Brazil. Methods: Training for administrating the MINI was given as part of a broad psychiatry education program. Interviews were held with 120 PHC patients who were at least 15 years old. MINI was administered by 25 resident physicians, while the Structured Clinical Interview for Diagnosis (SCID) was administered by a psychiatrist blind to patients` results on the MINI, and the diagnoses on both interviews were compared. The resident physicians answered questions on the applicability of the MINI. Results: Concordance levels for any mental disorder, the broader current diagnostic categories and the most common specific diagnoses were analyzed. Kappa coefficients ranged between 0.65 and 0.85; sensitivity, between 0.75 and 0.92; specificity, between 0.90 and 0.99; positive predictive values (PPV), between 0.60 and 0.86; negative predictive values (NPV), between 0.92 and 0.99; and accuracy, between 0.88 and 0.98. The resident physicians considered MINI comprehensibility and clinical relevance satisfactory. Conclusions: These good psychometric results in a real-world setting may be related to a special training program, which is more frequent, intensive and diversified. In these conditions, the MINI is a useful tool for general practitioners. (c) 2008 Elsevier Inc. All rights reserved.

Avaliação da consulta médica realizada por ingressantes na residência de Pediatria

Diversos autores relatam que a consulta médica se associa a melhores resultados quando se adota como referencial o modelo centrado no paciente. OBJETIVO: Avaliar se os médicos ingressantes na residência de Pediatria realizam consultas ambulatoriais segundo pressupostos do modelo centrado no paciente. MÉTODO: Em 2007, no início de seu estágio de ambulatório, dez residentes foram selecionados aleatoriamente para serem filmados durante a realização de uma consulta. Adotando-se como referencial teórico pressupostos do modelo centrado no paciente, os dados foram analisados por meio de metodologia qualitativa, por meio da técnica exploratória, com três juízes independentes. RESULTADOS: A maioria dos residentes explora precocemente a primeira queixa referida pelos pais, assumindo-a como principal; não explora outras queixas; decide e faz orientações terapêuticas de modo não compartilhado; conversa pouco com as crianças; cria longos momentos de silêncio durante a consulta; não explica o exame físico e às vezes utiliza o prontuário como a principal fonte de informação. CONCLUSÃO: Os residentes realizam consultas sem a inclusão da perspectiva dos pais e, portanto, não atendem segundo pressupostos do modelo centrado no paciente.