Management of diabetes mellitus and associated cardiovascular risk factors in Brazil – the Brazilian study on the practice of diabetes care

Abstract Background The Brazilian Study on the Practice of Diabetes Care main objective was to provide an epidemiological profile of individuals with type 1 and 2 diabetes mellitus (DM) in Brazil, concerning therapy and adherence to international guidelines in the medical practice. Methods This observational, cross-sectional, multicenter study collected and analyzed data from individuals with type 1 and 2 DM attending public or private clinics in Brazil. Each investigator included the first 10 patients with type 2 DM who visited his/her office, and the first 5 patients with type 1 DM. Results A total of 1,358 patients were analyzed; 375 (27.6%) had type 1 and 983 (72.4%) had type 2 DM. Most individuals were women, Caucasian, and private health care users. High prevalence rates of hypertension, dyslipidemia and central obesity were observed, particularly in type 2 DM. Only 7.3% and 5.1% of the individuals with types 1 and 2 DM, respectively, had optimal control of blood pressure, plasma glucose and lipids. The absence of hypertension and female sex were associated with better control of type 1 DM and other cardiovascular risk factors. In type 2 DM, older age was also associated with better control. Conclusions Female sex, older age, and absence of hypertension were associated with better metabolic control. An optimal control of plasma glucose and other cardiovascular risk factors are obtained only in a minority of individuals with diabetes. Local numbers, compared to those from other countries are worse.

Ensino de anestesiologia durante a graduação por meio de uma liga acadêmica: qual o impacto no aprendizado dos alunos?

JUSTIFICATIVA E OBJETIVOS: As ligas acadêmicas vêm se firmando como instrumentos de ensino médico e inserção dos estudantes de medicina na prática das especialidades, inclusive na anestesiologia. Como o papel das ligas no processo de desenvolvimento de competências e aprendizado de seus alunos não é bem conhecido, avaliou-se o aprendizado dos integrantes de uma liga acadêmica de anestesiologia após um ano de participação nas suas atividades. MÉTODO: Os alunos de uma liga acadêmica de anestesiologia foram acompanhados de março a dezembro de 2010 e avaliados por meio de testes cognitivos objetivos de múltipla escolha aplicados antes do início das atividades e após sua conclusão. A frequência nas atividades e o perfil epidemiológico dos alunos foram correlacionados aos resultados dos testes. RESULTADOS: Foram analisados 20 acadêmicos do 3º ao 6º ano, com média de idade de 22,8 (21-26) anos. A frequência média nas atividades propostas foi 10,4/13 (80%). A média de acertos no primeiro teste foi 8,1/17 (47,6%), sendo que os alunos do 3º ano apresentam notas menores (p < 0,02) em relação aos demais. No teste pós-liga, a média de acertos foi 11,9/17 (70%), mostrando melhora no desempenho dos alunos (p < 0,05), e não houve diferença entre as notas dos diferentes anos da graduação. Foi encontrada relação forte entre frequência nas atividades e melhora nas notas (r = 0,719; p < 0,001). CONCLUSÕES: Os alunos que participaram da liga apresentaram melhora nos testes de avaliação de conhecimento, sugerindo que a liga é útil instrumento de ensino e promove ganho de aprendizado em anestesiologia. As atividades desenvolvidas nas ligas podem ter papel positivo na formação acadêmica dos graduandos, destacando-se, neste artigo, a anestesiologia

Reconfigurando a interação entre ensino, serviço e comunidade

O Conselho Municipal da Saúde (CMS) de Ribeirão Preto (SP) conduziu discussões sobre os fundamentos da reconfiguração da interação entre a gestão local do Sistema Único de Saúde (SUS) e as instituições de ensino superior (IES), para promover a reorientação da formação profissional em saúde. Essa iniciativa local foi ao encontro das políticas indutoras nacionais, tais como o Promed, o Pró-Saúde e o PET-Saúde. O relato da experiência desse município expôs os interesses corporativos, políticos e econômicos dos agentes envolvidos. Ainda mostrou que o controle social e a cogestão foram potentes instrumentos para consolidar as instâncias democráticas de decisão, apontando o desafio de regular e avaliar o impacto dessa interação por meio de indicadores de saúde, ensino, pesquisa e deíndices de satisfação dos usuários.

Monitoramento do desenvolvimento infantil realizado no Brasil

OBJETIVO: Revisar a literatura científica para verificar como a vigilância do desenvolvimento infantil vem sendo realizada no Brasil. FONTES DE DADOS: Pesquisa em bases de dados (PubMed, Medline, SciELO e Banco de Teses da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) sobre estudos das práticas médicas em relação à vigilância e ao monitoramento do desenvolvimento infantil no Brasil, de 2000 a 2011. Os termos usados para pesquisa foram: vigilância de desenvolvimento infantil, intervenção precoce, triagem de desenvolvimento e testes de triagem de desenvolvimento. Foram encontrados dez textos referentes ao tema em estudo. Artigos originais, de revisão e teses foram revisados, bem como as listas de referências das publicações sobre o assunto. SÍNTESE DOS DADOS: Os estudos sobre a prática do monitoramento do desenvolvimento infantil no Brasil apontam uma importante falha, desde a formação do médico pediatra até a prática clínica, em relação a este tema. CONCLUSÕES: Há necessidade urgente, principalmente frente a uma população emergente de prematuros, que os pediatras façam uma reciclagem do conhecimento sobre o desenvolvimento infantil.

Swiss residents' speciality choices--impact of gender, personality traits, career motivation and life goals

BACKGROUND: The medical specialties chosen by doctors for their careers play an important part in the development of health-care services. This study aimed to investigate the influence of gender, personality traits, career motivation and life goal aspirations on the choice of medical specialty. METHODS: As part of a prospective cohort study of Swiss medical school graduates on career development, 522 fourth-year residents were asked in what specialty they wanted to qualify. They also assessed their career motivation and life goal aspirations. Data concerning personality traits such as sense of coherence, self-esteem, and gender role orientation were collected at the first assessment, four years earlier, in their final year of medical school. Data analyses were conducted by univariate and multivariate analyses of variance and covariance. RESULTS: In their fourth year of residency 439 (84.1%) participants had made their specialty choice. Of these, 45 (8.6%) subjects aspired to primary care, 126 (24.1%) to internal medicine, 68 (13.0%) to surgical specialties, 31 (5.9%) to gynaecology & obstetrics (G&O), 40 (7.7%) to anaesthesiology/intensive care, 44 (8.4%) to paediatrics, 25 (4.8%) to psychiatry and 60 (11.5%) to other specialties. Female residents tended to choose G&O, paediatrics, and anaesthesiology, males more often surgical specialties; the other specialties did not show gender-relevant differences of frequency distribution. Gender had the strongest significant influence on specialty choice, followed by career motivation, personality traits, and life goals. Multivariate analyses of covariance indicated that career motivation and life goals mediated the influence of personality on career choice. Personality traits were no longer significant after controlling for career motivation and life goals as covariates. The effect of gender remained significant after controlling for personality traits, career motivation and life goals. CONCLUSION: Gender had the greatest impact on specialty and career choice, but there were also two other relevant influencing factors, namely career motivation and life goals. Senior physicians mentoring junior physicians should pay special attention to these aspects. Motivational guidance throughout medical training should not only focus on the professional career but also consider the personal life goals of those being mentored.

The use of learning management systems: A Longitudinal Case Study

In this article the use of Learning Management Systems (LMS) at the School of Engineering, University of Borås, in the year 2004 and the academic year 2009-2010 is investigated. The tools in the LMS were classified into four groups (tools for distribution, tools for communication, tools for interaction and tools for course administration) and the pattern of use was analyzed. The preliminary interpretation of the results was discussed with a group of teachers from the School of Engineering with long experience of using LMS. High expectations about LMS as a tool to facilitate flexible education, student centered methods and the creation of an effective learning environment is abundant in the literature. This study, however, shows that in most of the surveyed courses the available LMS is predominantly used to distribute documents to students. The authors argue that a more elaborate use of LMS and a transformation of pedagogical practices towards social constructivist, learner centered procedures should be treated as an integrated process of professional development.

Percutaneous closure of patent foramen ovale in cryptogenic embolism

BACKGROUND The options for secondary prevention of cryptogenic embolism in patients with patent foramen ovale are administration of antithrombotic medications or percutaneous closure of the patent foramen ovale. We investigated whether closure is superior to medical therapy. METHODS We performed a multicenter, superiority trial in 29 centers in Europe, Canada, Brazil, and Australia in which the assessors of end points were unaware of the study-group assignments. Patients with a patent foramen ovale and ischemic stroke, transient ischemic attack (TIA), or a peripheral thromboembolic event were randomly assigned to undergo closure of the patent foramen ovale with the Amplatzer PFO Occluder or to receive medical therapy. The primary end point was a composite of death, nonfatal stroke, TIA, or peripheral embolism. Analysis was performed on data for the intention-to-treat population. RESULTS The mean duration of follow-up was 4.1 years in the closure group and 4.0 years in the medical-therapy group. The primary end point occurred in 7 of the 204 patients (3.4%) in the closure group and in 11 of the 210 patients (5.2%) in the medical-therapy group (hazard ratio for closure vs. medical therapy, 0.63; 95% confidence interval [CI], 0.24 to 1.62; P=0.34). Nonfatal stroke occurred in 1 patient (0.5%) in the closure group and 5 patients (2.4%) in the medical-therapy group (hazard ratio, 0.20; 95% CI, 0.02 to 1.72; P=0.14), and TIA occurred in 5 patients (2.5%) and 7 patients (3.3%), respectively (hazard ratio, 0.71; 95% CI, 0.23 to 2.24; P=0.56). CONCLUSIONS Closure of a patent foramen ovale for secondary prevention of cryptogenic embolism did not result in a significant reduction in the risk of recurrent embolic events or death as compared with medical therapy. (Funded by St. Jude Medical; ClinicalTrials.gov number, NCT00166257.).

Communication Across Cultures - Use of Video to Promote Culturally Competent Patient Management

Diverse belief systems exist among dental and medical patients related to health, healing and wellness. Culturally competent health care may be defined as the ability to provide care to patients with diverse values, beliefs and behaviors, including modifying delivery of care to meet patients’ social and cultural needs. [See PDF for complete abstract]

Fractional Flow Reserve–Guided PCI for Stable Coronary Artery Disease

Background We hypothesized that in patients with stable coronary artery disease and stenosis, percutaneous coronary intervention (PCI) performed on the basis of the fractional flow reserve (FFR) would be superior to medical therapy. Methods In 1220 patients with stable coronary artery disease, we assessed the FFR in all stenoses that were visible on angiography. Patients who had at least one stenosis with an FFR of 0.80 or less were randomly assigned to undergo FFR-guided PCI plus medical therapy or to receive medical therapy alone. Patients in whom all stenoses had an FFR of more than 0.80 received medical therapy alone and were included in a registry. The primary end point was a composite of death from any cause, nonfatal myocardial infarction, or urgent revascularization within 2 years. Results The rate of the primary end point was significantly lower in the PCI group than in the medical-therapy group (8.1% vs. 19.5%; hazard ratio, 0.39; 95% confidence interval [CI], 0.26 to 0.57; P<0.001). This reduction was driven by a lower rate of urgent revascularization in the PCI group (4.0% vs. 16.3%; hazard ratio, 0.23; 95% CI, 0.14 to 0.38; P<0.001), with no significant between-group differences in the rates of death and myocardial infarction. Urgent revascularizations that were triggered by myocardial infarction or ischemic changes on electrocardiography were less frequent in the PCI group (3.4% vs. 7.0%, P=0.01). In a landmark analysis, the rate of death or myocardial infection from 8 days to 2 years was lower in the PCI group than in the medical-therapy group (4.6% vs. 8.0%, P=0.04). Among registry patients, the rate of the primary end point was 9.0% at 2 years. Conclusions In patients with stable coronary artery disease, FFR-guided PCI, as compared with medical therapy alone, improved the outcome. Patients without ischemia had a favorable outcome with medical therapy alone. (Funded by St. Jude Medical; FAME 2 ClinicalTrials.gov number, NCT01132495 .).

Percutaneous closure of patent foramen ovale in patients with cryptogenic embolism: a network meta-analysis

BACKGROUND Up to 40% of ischaemic strokes are cryptogenic. A strong association between cryptogenic stroke and the prevalence of patent foramen ovale (PFO) suggests paradoxical embolism via PFO as a potential cause. Randomized trials failed to demonstrate superiority of PFO closure over medical therapy. METHODS AND RESULTS Randomized trials comparing percutaneous PFO closure against medical therapy or devices head-to-head published or presented by March 2013 were identified through a systematic search. We performed a network meta-analysis to determine the effectiveness and safety of PFO closure with different devices when compared with medical therapy. We included four randomized trials (2963 patients with 9309 patient-years). Investigated devices were Amplatzer (AMP), STARFlex (STF), and HELEX (HLX). Patients allocated to PFO closure with AMP were less likely to experience a stroke than patients allocated to medical therapy [rate ratio (RR) 0.39; 95% CI: 0.17-0.84]. No significant differences were found for STF (RR 1.01; 95% CI: 0.44-2.41), and HLX (RR, 0.71; 95% CI: 0.17-2.78) when compared with medical therapy. The probability to be best in preventing strokes was 77.1% for AMP, 20.9% for HLX, 1.7% for STF, and 0.4% for medical therapy. No significant differences were found for transient ischaemic attack and death. The risk of new-onset atrial fibrillation was more pronounced for STF (RR 7.67; 95% CI: 3.25-19.63), than AMP (RR 2.14; 95% CI: 1.00-4.62) and HLX (RR 1.33; 95%-CI 0.33-4.50), when compared with medical therapy. CONCLUSIONS The effectiveness of PFO closure depends on the device used. PFO closure with AMP appears superior to medical therapy in preventing strokes in patients with cryptogenic embolism.

Derivation and validation of multimarker prognostication for normotensive patients with acute symptomatic pulmonary embolism.

RATIONALE Not all patients with acute pulmonary embolism (PE) have a high risk of an adverse short-term outcome. OBJECTIVES This prospective cohort study aimed to develop a multimarker prognostic model that accurately classifies normotensive patients with PE into low and high categories of risk of adverse medical outcomes. METHODS The study enrolled 848 outpatients from the PROTECT (PROgnosTic valuE of Computed Tomography) study (derivation cohort) and 529 patients from the Prognostic Factors for Pulmonary Embolism (PREP) study (validation cohort). Investigators assessed study participants for a 30-day complicated course, defined as death from any cause, hemodynamic collapse, and/or adjudicated recurrent PE. MEASUREMENTS AND MAIN RESULTS A complicated course occurred in 63 (7.4%) of the 848 normotensive patients with acute symptomatic PE in the derivation cohort and in 24 patients (4.5%) in the validation cohort. The final model included the simplified Pulmonary Embolism Severity Index, cardiac troponin I, brain natriuretic peptide, and lower limb ultrasound testing. The model performed similarly in the derivation (c-index of 0.75) and validation (c-index of 0.85) cohorts. The combination of the simplified Pulmonary Embolism Severity Index and brain natriuretic peptide testing showed a negative predictive value for a complicated course of 99.1 and 100% in the derivation and validation cohorts, respectively. The combination of all modalities had a positive predictive value for the prediction of a complicated course of 25.8% in the derivation cohort and 21.2% in the validation cohort. CONCLUSIONS For normotensive patients who have acute PE, we derived and validated a multimarker model that predicts all-cause mortality, hemodynamic collapse, and/or recurrent PE within the following 30 days.

Outcome discrepancies and selective reporting: impacting the leading journals?

BACKGROUND Selective outcome reporting of either interesting or positive research findings is problematic, running the risk of poorly-informed treatment decisions. We aimed to assess the extent of outcome and other discrepancies and possible selective reporting between registry entries and published reports among leading medical journals. METHODS Randomized controlled trials published over a 6-month period from July to December 31st, 2013, were identified in five high impact medical journals: The Lancet, British Medical Journal, New England Journal of Medicine, Annals of Internal Medicine and Journal of American Medical Association were obtained. Discrepancies between published studies and registry entries were identified and related to factors including registration timing, source of funding and presence of statistically significant results. RESULTS Over the 6-month period, 137 RCTs were found. Of these, 18% (n = 25) had discrepancies related to primary outcomes with the primary outcome changed in 15% (n = 20). Moreover, differences relating to non-primary outcomes were found in 64% (n = 87) with both omission of pre-specified non-primary outcomes (39%) and introduction of new non-primary outcomes (44%) common. No relationship between primary or non-primary outcome change and registration timing (prospective or retrospective; P = 0.11), source of funding (P = 0.92) and presence of statistically significant results (P = 0.92) was found. CONCLUSIONS Discrepancies between registry entries and published articles for primary and non-primary outcomes were common among trials published in leading medical journals. Novel approaches are required to address this problem.