Experience with the first Internet-based course at the Faculty of Medicine, University of São Paulo

PURPOSE: The Internet expands the range and flexibility of teaching options and enhances the ability to process the ever-increasing volume of medical knowledge. The aim of this study is to describe and discuss our experience with transforming a traditional medical training course into an Internet-based course. METHOD: Sixty-nine students were enrolled for a one-month course. They answered pre- and post-course questionnaires and took a multiple-choice test to evaluate the acquired knowledge. RESULTS: Students reported that the primary value for them of this Internet-based course was that they could choose the time of their class attendance (67%). The vast majority (94%) had a private computer and were used to visiting the Internet (75%) before the course. During the course, visits were mainly during the weekends (35%) and on the last week before the test (29%). Thirty-one percent reported that they could learn by reading only from the computer screen, without the necessity of printed material. Students were satisfied with this teaching method as evidenced by the 89% who reported enjoying the experience and the 88% who said they would enroll for another course via the Internet. The most positive aspect was freedom of scheduling, and the most negative was the lack of personal contact with the teacher. From the 80 multiple-choice questions, the mean of correct answers was 45.5, and of incorrect, 34.5. CONCLUSIONS: This study demonstrates that students can successfully learn with distance learning. It provides useful information for developing other Internet-based courses. The importance of this new tool for education in a large country like Brazil seems clear.

A critical review of the possible benefits associated with homeopathic medicine

OBJECTIVE: To evaluate the recent scientific research progress on homeopathy. METHODOLOGY: Homeopathy was evaluated in terms of its clinical research; in vitro research, and physical foundations. The Medline database was the main reference source for the present research, concerning data of approximately the last 10 years. Secondary references (not available in this database) were obtained by means of direct requests to authors listed in the primary references. RESULTS: Clinical studies and in vitro research indicate the inefficacy of homeopathy. Some few studies with positive results are questionable because of problems with the quality and lack of appropriate experimental controls in these studies. The most recent meta-analyses on the topic yielded negative results. One of the few previous meta-analyses with positive results had serious publication bias problems, and its results were later substantially reconsidered by the main authors. The sparse in vitro homeopathic research with positive results has not been replicated by independent researchers, had serious methodological flaws, or when replicated, did not confirm the initial positive results. A plausible mechanism for homeopathic action is still nonexistent, and its formulation, by now, seems highly unlikely. CONCLUSIONS: As a result of the recent scientific research on homeopathy, it can be concluded that ample evidence exists to show that the homeopathic therapy is not scientifically justifiable.

Prescription and adherence to statins of patients with coronary artery disease and hypercholesterolemia

OBJECTIVE: Statins have proved to be safe and effective in the secondary prevention of coronary artery disease, but the level of prescription and the reasons for nonadherence to treatment in many coronariopathy treatment centers has not been determined. The purpose of this study was to identify reasons for nonadherence to statin therapy. METHODS: We analyzed 207 consecutive patients with coronary artery disease and hypercholesterolemia (total cholesterol > or = 200mg/dL or LDL - cholesterol > or = 130mg/dL). Patients' average age was 61.7±10 year; 111 (53.6%) male were and 94 (46.6%) were female. We analyzed the level of prescription and adherence to treatment with statins. RESULTS: Statins were prescribed for 139 (67%) patients, but only 85 (41%) used the drug. In spite of being indicated, statins were not prescribed in 68 (33%) patients. Of 54 (26%) patients, nonadherent to statins, 67% did not use the drug due to its high cost, 31% due to the lack of instruction, and only 2% due to side effects. Total cholesterol (260.3±42.2 vs 226.4±51.9; p<0.0001) and LDL cholesterol (174.6±38.1 vs 149.6±36.1; p<0.0001) were lower in patients on medication. HDL-cholesterol increased from 37.6±9.6 to 41.5±12.9mg/dL (p=0.02), and triglycerides were not modified in patients using statins. CONCLUSION: The prescription of statins in patients with coronary artery disease and dyslipidemia is high; however, its adherence is far from satisfactory, due to the high cost of the medication. Reduction in total cholesterol and LDL cholesterol levels did not reach the targets recommended by the Brazilian Consensus on Dyslipidemia.

Application of receptive music therapy in internal medicine and cardiology

OBJECTIVE: To investigate the effects of receptive music therapy in clinical practice. METHODS: Receptive music therapy was individually applied via musical auditions, including five stages: musical stimulation, sensation, situation, reflection, and behavioral alteration. Following anamnesis and obtainment of consent, patients answered a first questionnaire on health risk evaluation (Q1), and after participating in 16 weekly music therapy sessions, answered a second one (Q2). RESULTS: Two men and 8 women, aged above 18 years, referred to us due to symptoms of stress, emotional suffering, and the need to change lifestyles (health risk behavior) were studied between August 1998 and December 1999. Comparison between answers to Q1 and Q2, showed a trend (P=0.059) for reduction of ingestion of cholesterol-rich foods and for increased prospects in life with a tendency towards improvement, and also of increased intake of fiber-rich food (55.6%), increased levels of personal satisfaction (44.5%), and decreased levels of stress (66.7%). CONCLUSION: The study demonstrated decreased stress levels and increased personal satisfaction, higher consumption of fiber-rich food, lower cholesterol intake, and a better perspective on life, suggesting that receptive music therapy may be applied in clinical practice as an auxiliary therapeutic intervention for the treatment of behavioral health risks.

A new proposal to guide velocity and inclination in the ramp protocol for the treadmill ergometer

OBJECTIVE: To suggest criteria to guide protocol prescription in ramp treadmill testing, according to sex and age, based on velocity, inclination, and max VO2 reached by the population studied. METHODS: Prospective study describing heart rate (HR), time, velocity, inclination, and VO2 estimated at maximum effort of 1840 individuals from 4 to 79 years old, who performed a treadmill test (TT) according to the ramp protocol. A paired Student t test was used to assess the difference between predicted and reached max VO2, calculated according to the formulas of the "American College of Sports Medicine". RESULTS: Submaximal HR was surpassed in 90.1% of the examinations, with a mean time of 10.0±2.0 minute. Initial and peak inclination velocity of the exercise and max VO2 were inversely proportional to age and were greater in male patients. Predicted Max VO2 was significantly lower than that reached in all patients, except for female children and adolescents (age < 20 years old). CONCLUSION: Use of velocity, inclination, and maximum VO2 actually reached, as a criterion in prescribing the ramp protocol may help in the performance of exercise in treadmill testing. The ramp protocol was well accepted in all age groups and sexes with exercise time within the programmed 8 to 12 minutes.

The influence of patient's consciousness regarding high blood pressure and patient's attitude in face of disease controlling medicine intake

OBJECTIVE: To assess the relation between blood pressure control and the following: the Morisky-Green test, the patient's consciousness regarding high blood pressure, the patient's attitude in face of medicine intake, the patient's attendance at medical consultations, and the subjective physician's judgment. METHODS: We studied 130 hypertensive patients with the following characteristics: 73% females, 60±11 years, 58% married, 70% white, 45% retired, 45% with incomplete elementary schooling, 64% had a familial income of 1 to 3 minimum wages, body mass index of 30±7 kg/m², consciousness regarding the disease for a mean period of 11±9.5 years, and mean treatment duration of 8 ±7 years. RESULTS: Only 35% of the hypertensive individuals had blood pressure under control and a longer duration of treatment (10±7 vs 7±6.5 years; P<0.05). The retiree predominated. The result of the Morisky-Green test did not relate to blood pressure control. In evaluating the attitude in face of medicine intake, the controlled patients achieved significantly higher scores than did the noncontrolled patients (8±1.9 vs 7 ±2, P<0.05). The hypertensive patients had higher levels of consciousness regarding their disease and its treatment, and most (70%) patients attended 3 or 4 medical consultations, which did not influence blood pressure control. The physicians attributed significantly higher scores regarding adherence to treatment to controlled patients (6±0.8 vs 5±1.2; P<0.05). CONCLUSION: Consciousness regarding the disease, the Morisky-Green test, and attendance to medical consultations did not influence blood pressure control.

Reverse Auction: A Potential Strategy for Reduction of Pharmacological Therapy Cost

Background:Polypharmacy is a significant economic burden.Objective:We tested whether using reverse auction (RA) as compared with commercial pharmacy (CP) to purchase medicine results in lower pharmaceutical costs for heart failure (HF) and heart transplantation (HT) outpatients.Methods:We compared the costs via RA versus CP in 808 HF and 147 HT patients followed from 2009 through 2011, and evaluated the influence of clinical and demographic variables on cost.Results:The monthly cost per patient for HF drugs acquired via RA was $10.15 (IQ 3.51-40.22) versus $161.76 (IQ 86.05‑340.15) via CP; for HT, those costs were $393.08 (IQ 124.74-774.76) and $1,207.70 (IQ 604.48-2,499.97), respectively.Conclusion:RA may reduce the cost of prescription drugs for HF and HT, potentially making HF treatment more accessible. Clinical characteristics can influence the cost and benefits of RA. RA may be a new health policy strategy to reduce costs of prescribed medications for HF and HT patients, reducing the economic burden of treatment.