[Implementation of the Choosing Wisely Program in the General Surgery Residency]. / Implementação do Programa Choosing Wisely no Internato de Cirurgia Geral.

INTRODUCTION: The practice of unnecessary conduct and waste in Health is an important topic, not often addressed during undergraduate training. Medical education has a fundamental role in student and doctors' training concerning cost-conscious attitudes for good health care. The aim of this study was to describe and assess the implementation of the Choosing Wisely campaign within a General Surgery residency program. MATERIAL AND METHODS: This was an interventional study involving residency advisors and specialty residents. Recommendations based on three procedures frequently used in clinical practice, with no benefits and involving unnecessary risks for patients were identified by residency advisors with the use of the Delphi method and were grouped by frequency and by nature according to the Choosing Wisely layout. Educational actions such as workshops and banner advertising in addition to training activities regarding cost-conscious healthcare were carried out. This subject was also included in the theoretical evaluation of the residency program. RESULTS: The leading five recommendations were related to (i) computed tomography overuse (versus ultrasound imaging) in patients with suspected acute appendicitis, (ii) multithreaded computed tomography overuse in patients with low-risk trauma, (iii) longer than recommended antibiotic prophylaxis in surgical patients, (iv) longer than recommended preoperative fasting period and (v) upper gastrointestinal endoscopy overuse in surgical patients without an adequate clinical evidence or without the presence of warning signs. Awareness and reflection among participants were improved, leading to high grades in final evaluation. DISCUSSION: Changes in training regarding quality of care and cost awareness should start throughout undergraduate training, within a learning environment focused on a reflective and evidence-based practice. All the benefits and harms to patients were taken into account in the recommendations that emerged from this study. CONCLUSION: The inclusion of this initiative in the General Surgery residency, involving reflective discussions on campaign recommendations regarding procedures frequently used in clinical practice, with no benefits and involving unnecessary risks for patients may lead to more cost-conscious procedures.

Introdução: A prática de condutas desnecessárias e os desperdícios na saúde são temas importantes e ainda pouco abordados no curso de Medicina. A educação médica tem um papel fundamental na formação de estudantes e médicos com atitudes custo-conscientes para uma boa atenção à saúde. O objectivo deste estudo foi descrever e avaliar a implementação do programa Choosing Wisely - Escolhas Criteriosas em Saúde, no internato de Cirurgia Geral.Material e Métodos: Estudo de intervenção envolvendo orientadores de formação e internos. Utilizando a técnica Delphi, os orientadores de formação identificaram três intervenções frequentemente observadas na prática clínica sem benefício e com potenciais riscos desnecessários para o doente, que geraram recomendações, agrupadas e adaptadas ao formato do programa Choosing Wisely. O tema foi incluido na avaliação do internato, tendo sido desenvolvidas ações de formação e de divulgação em banners personalizados, a par de atividades de aprendizagem reflexiva sobre o programa e da integração da temática na avaliação teórica do internato.Resultados: As cinco principais recomendações referem-se (i) à utilização excessiva de tomografia axial computorizada na abordagem da suspeita de apendicite aguda e (ii) de tomografia axial computorizada de vários segmentos do corpo em traumatismos de baixo grau de gravidade, (iii) profilaxia antibiótica mais prolongada do que o recomendado no doente cirúrgico, (iv) jejum mais prolongado do que o recomendado no pré-operatório de todas as cirurgias e (v) utilização excessiva da endoscopia digestiva alta em doentes cirúrgicos sem sinais clínicos de alarme. As ações de formação geraram um incremento da sensibilização e reflexão, traduzido globalmente por um elevado aproveitamento na avaliação final.Discussão: A formação em escolhas criteriosas em saúde, promovendo uma utilização de cuidados de saúde consciente e de qualidade, sugere que as mudanças devem ocorrer ao longo do curso de Medicina, num ambiente de aprendizagem centrado numa prática reflexiva e baseada na evidência. As recomendações produzidas no estudo tiveram em consideração a totalidade dos benefícios e riscos para o doente.Conclusão: A integração da iniciativa Choosing Wisely no programa de formação em Cirurgia Geral deu origem a um conhecimento e discussão mais reflexivos sobre as recomendações relativas à utilização racional e criteriosa de cuidados de saúde, podendo resultar numa prática médica mais sustentável e sensível aos custos que gera.

Latin American and Caribbean consensus on noninvasive central nervous system neuromodulation for chronic pain management (LAC2-NIN-CP).

INTRODUCTION: Chronic pain (CP) is highly prevalent and generally undertreated health condition. Noninvasive brain stimulation may contribute to decrease pain intensity and influence other aspects related to CP. OBJECTIVE: To provide consensus-based recommendations for the use of noninvasive brain stimulation in clinical practice. METHODS: Systematic review of the literature searching for randomized clinical trials followed by consensus panel. Recommendations also involved a cost-estimation study. RESULTS: The systematic review wielded 24 transcranial direct current stimulation (tDCS) and 22 repetitive transcranial magnetic stimulation (rTMS) studies. The following recommendations were provided: (1) Level A for anodal tDCS over the primary motor cortex (M1) in fibromyalgia, and level B for peripheral neuropathic pain, abdominal pain, and migraine; bifrontal (F3/F4) tDCS and M1 high-definition (HD)-tDCS for fibromyalgia; Oz/Cz tDCS for migraine and for secondary benefits such as improvement in quality of life, decrease in anxiety, and increase in pressure pain threshold; (2) level A recommendation for high-frequency (HF) rTMS over M1 for fibromyalgia and neuropathic pain, and level B for myofascial or musculoskeletal pain, complex regional pain syndrome, and migraine; (3) level A recommendation against the use of anodal M1 tDCS for low back pain; and (4) level B recommendation against the use of HF rTMS over the left dorsolateral prefrontal cortex in the control of pain. CONCLUSION: Transcranial DCS and rTMS are recommended techniques to be used in the control of CP conditions, with low to moderate analgesic effects, and no severe adverse events. These recommendations are based on a systematic review of the literature and a consensus made by experts in the field. Readers should use it as part of the resources available to decision-making.

Lack of association between serum syndecan-4, myocardial fibrosis and ventricular dysfunction in subjects with chronic Chagas disease.

BACKGROUND: Syndecan-4 is a transmembrane glycoprotein associated with inflammation and fibrosis. Increased syndecan-4 levels were previously detected after acute myocardial infarction and in subjects with heart failure. However, the levels of syndecan-4 in subjects with Chagas disease have not so far been investigated. The aim of this study was to investigate the potential role of serum sydencan-4 as a novel biomarker for myocardial fibrosis and cardiac dysfunction in subjects with Chagas disease. METHODS: This study comprised subjects with Chagas disease (n = 56), being 14 (25%) with the indeterminate form, 16 (29%) with the cardiac form without ventricular dysfunction, and 26 (46%) with the cardiac form with ventricular dysfunction. RESULTS: Syndecan-4 serum concentrations did not correlate with presence or absence of myocardial fibrosis (P = 0.386) nor disease severity in subjects with Chagas disease (P = 0.918). Additionally, no correlation was found either between the degree of myocardial fibrosis and serum syndecan-4 [r = 0.08; P = 0.567] or between left ventricular ejection fraction and syndecan-4 [r = 0.02; P = 0.864]. In contrast, NT-proBNP levels correlated with ejection fraction and myocardial fibrosis. CONCLUSIONS: Our results demonstrate the lack of correlations between serum syndecan-4, myocardial fibrosis and cardiac dysfunction in subjects with Chagas disease. Further studies are required to show if syndecan-4 concentrations can be marker for prognosis assessment or disease progression.