The progress test as a structuring initiative for programmatic assessment.

BACKGROUND: The Progress Test is an individual assessment applied to all students at the same time and on a regular basis. The test was structured in the medical undergraduate education of a conglomerate of schools to structure a programmatic assessment integrated into teaching. This paper presents the results of four serial applications of the progress test and the feedback method to students. METHODS: This assessment comprises 120 items offered online by means of a personal password. Items are authored by faculty, peer-reviewed, and approved by a committee of experts. The items are classified by five major areas, by topics used by the National Board of Medical Examiners and by medical specialties related to a national Unified Health System. The correction uses the Item Response Theory with analysis by the "Rasch" model that considers the difficulty of the item. RESULTS: Student participation increased along the four editions of the tests, considering the number of enrollments. The median performances increased in the comparisons among the sequential years in all tests, except for test1 - the first test offered to schools. Between subsequent years of education, 2nd-1st; 4th-3rd and 5th-4th there was an increase in median scores from progress tests 2 through 4. The final year of undergraduate showed a limited increase compared to the 5th year. There is a consistent increase in the median, although with fluctuations between the observed intervals. CONCLUSION: The progress test promoted the establishment of regular feedback among students, teachers and coordinators and paved the road to engagement much needed to construct an institutional programmatic assessment.

Comparison of terbutaline and atosiban as tocolytic agents in intrauterine repair of myelomeningocele: a retrospective cohort study.

BACKGROUND: Myelomeningocele (MMC) is a neural tube defect disease. Antenatal repair of fetal MMC is an alternative to postnatal repair. Many agents can be used as tocolytics during the in utero fetal repair such as ß2-agonists and oxytocin receptor antagonists, with possible maternal and fetal repercussions. This study aims to compare maternal arterial blood gas analysis between terbutaline or atosiban, as tocolytic agents, during intrauterine MMC repair. METHODS: Retrospective cohort study. Patients were divided into two groups depending on the main tocolytic agent used during intrauterine MMC repair: atosiban (16) or terbutaline (9). Maternal arterial blood gas samples were analyzed on three moments: post induction (baseline, before the start of tocolysis), before extubation, and two hours after the end of the surgery. RESULTS: Twenty-five patients were included and assessed. Before extubation, the terbutaline group showed lower arterial pH (7.347 ± 0.05 vs. 7.396 ± 0.02 for atosiban, p = 0.006) and higher arterial lactate (28.33 ± 12.76 mg.dL-1 vs. 13.06 ± 6.35 mg.dL-1, for atosiban, p = 0.001) levels. CONCLUSIONS: Patients who received terbutaline had more acidosis and higher levels of lactate, compared to those who received atosiban, during intrauterine fetal MMC repair.

Is the Bland-Altman plot method useful without inferences for accuracy, precision, and agreement?

OBJECTIVE: This study aims to propose a comprehensive alternative to the Bland-Altman plot method, addressing its limitations and providing a statistical framework for evaluating the equivalences of measurement techniques. This involves introducing an innovative three-step approach for assessing accuracy, precision, and agreement between techniques, which enhances objectivity in equivalence assessment. Additionally, the development of an R package that is easy to use enables researchers to efficiently analyze and interpret technique equivalences. METHODS: Inferential statistics support for equivalence between measurement techniques was proposed in three nested tests. These were based on structural regressions with the goal to assess the equivalence of structural means (accuracy), the equivalence of structural variances (precision), and concordance with the structural bisector line (agreement in measurements obtained from the same subject), using analytical methods and robust approach by bootstrapping. To promote better understanding, graphical outputs following Bland and Altman's principles were also implemented. RESULTS: The performance of this method was shown and confronted by five data sets from previously published articles that used Bland and Altman's method. One case demonstrated strict equivalence, three cases showed partial equivalence, and one showed poor equivalence. The developed R package containing open codes and data are available for free and with installation instructions at Harvard Dataverse at https://doi.org/10.7910/DVN/AGJPZH. CONCLUSION: Although easy to communicate, the widely cited and applied Bland and Altman plot method is often misinterpreted, since it lacks suitable inferential statistical support. Common alternatives, such as Pearson's correlation or ordinal least-square linear regression, also fail to locate the weakness of each measurement technique. It may be possible to test whether two techniques have full equivalence by preserving graphical communication, in accordance with Bland and Altman's principles, but also adding robust and suitable inferential statistics. Decomposing equivalence into three features (accuracy, precision, and agreement) helps to locate the sources of the problem when fixing a new technique.

Ultrasound-guided pericapsular nerve group and obturator nerve phenol neurolysis for refractory inpatient hip cancer metastasis pain: a case report

Abstract Introduction: Bone cancer metastasis may produce severe and refractory pain. It is often difficult to manage with systemic analgesics. Chemical neurolysis may be an effective alternative in terminally ill patients. Case report: Female terminally ill patient with hip metastasis of gastric cancer in severe pain. Neurolytic ultrasound-guided blocks of the pericapsular nerve group and obturator nerve were performed with 5% phenol. This led to satisfactory pain relief for 10 days, until the patient's death. Discussion: This approach may be effective and safe as an analgesic option for refractory hip pain due to metastasis or pathologic fracture in terminally ill patients.

Comparison of terbutaline and atosiban as tocolytic agents in intrauterine repair of myelomeningocele: a retrospective cohort study

Abstract Background: Myelomeningocele (MMC) is a neural tube defect disease. Antenatal repair of fetal MMC is an alternative to postnatal repair. Many agents can be used as tocolytics during the in utero fetal repair such as β2-agonists and oxytocin receptor antagonists, with possible maternal and fetal repercussions. This study aims to compare maternal arterial blood gas analysis between terbutaline or atosiban, as tocolytic agents, during intrauterine MMC repair. Methods: Retrospective cohort study. Patients were divided into two groups depending on the main tocolytic agent used during intrauterine MMC repair: atosiban (16) or terbutaline (9). Maternal arterial blood gas samples were analyzed on three moments: post induction (baseline, before the start of tocolysis), before extubation, and two hours after the end of the surgery. Results: Twenty-five patients were included and assessed. Before extubation, the terbutaline group showed lower arterial pH (7.347 ± 0.05 vs. 7.396 ± 0.02 for atosiban, p = 0.006) and higher arterial lactate (28.33 ± 12.76 mg.dL-1 vs. 13.06 ± 6.35 mg.dL-1, for atosiban, p = 0.001) levels. Conclusions: Patients who received terbutaline had more acidosis and higher levels of lactate, compared to those who received atosiban, during intrauterine fetal MMC repair.

Decreasing inconsistent alarms notifications: a pragmatic clinical trial in a post-anesthesia care unit

Abstract Background: Alarms alert healthcare professionals of deviations from normal/physiologic status. However, alarm fatigue may occur when their high pitch and diversity overwhelm clinicians, possibly leading to alarms being disabled, paused, and/or ignored. We aimed to determine whether a staff educational program on customizing alarm settings of bedside monitors may decrease inconsistent alarms in the Post-Anesthesia Care Unit (PACU). Methods: This is a prospective, analytic, quantitative, pragmatic, open-label, single-arm study. The outcome was evaluated on PACU admission before (P1) and after (P2) the implementation of the educational program. The heart rate, blood pressure, and oxygen saturation alarms were selected for clinical consistency. Results: A total of 260 patients were included and 344 clinical alarms collected, with 270 (78.4%) before (P1), and 74 (21.6%) after (P2) the intervention. Among the 270 alarms in P1, 45.2% were inconsistent (i.e., false alarms), compared to 9.4% of the 74 in P2. Patients with consistent alarms occurred in 30% in the P1 and 27% in the P2 (p = 0.08). Patients with inconsistent alarms occurred in 25.4% in the P1 and in 3.8% in the P2. Ignored consistent alarms were reduced from 21.5% to 2.6% (p = 0.004) in the P2 group. The educational program was a protective factor for the inconsistent clinical alarm (OR = 0.11 [95% CI 0.04-0.3]; p < 0.001) after adjustments for age, gender, and ASA physical status. Conclusion: Customizing alarm settings on PACU admission proved to be a protective factor against inconsistent alarm notifications of multiparametric monitors.

Is the Bland-Altman plot method useful without inferences for accuracy, precision, and agreement?

ABSTRACT OBJECTIVE This study aims to propose a comprehensive alternative to the Bland-Altman plot method, addressing its limitations and providing a statistical framework for evaluating the equivalences of measurement techniques. This involves introducing an innovative three-step approach for assessing accuracy, precision, and agreement between techniques, which enhances objectivity in equivalence assessment. Additionally, the development of an R package that is easy to use enables researchers to efficiently analyze and interpret technique equivalences. METHODS Inferential statistics support for equivalence between measurement techniques was proposed in three nested tests. These were based on structural regressions with the goal to assess the equivalence of structural means (accuracy), the equivalence of structural variances (precision), and concordance with the structural bisector line (agreement in measurements obtained from the same subject), using analytical methods and robust approach by bootstrapping. To promote better understanding, graphical outputs following Bland and Altman's principles were also implemented. RESULTS The performance of this method was shown and confronted by five data sets from previously published articles that used Bland and Altman's method. One case demonstrated strict equivalence, three cases showed partial equivalence, and one showed poor equivalence. The developed R package containing open codes and data are available for free and with installation instructions at Harvard Dataverse at https://doi.org/10.7910/DVN/AGJPZH. CONCLUSION Although easy to communicate, the widely cited and applied Bland and Altman plot method is often misinterpreted, since it lacks suitable inferential statistical support. Common alternatives, such as Pearson's correlation or ordinal least-square linear regression, also fail to locate the weakness of each measurement technique. It may be possible to test whether two techniques have full equivalence by preserving graphical communication, in accordance with Bland and Altman's principles, but also adding robust and suitable inferential statistics. Decomposing equivalence into three features (accuracy, precision, and agreement) helps to locate the sources of the problem when fixing a new technique.

Ensino da anatomia: dissecção em associação com a tecnologia no curso de Medicina / Teaching anatomy: dissection in association with technology in the Medical course

Resumo: Introdução: Um estudo de 2010 apontou as necessidades futuras da educação médica, com conteúdos e práticas integrados, fomentada pela tecnologia educacional virtual e pela prioridade na competência, não no tempo. A anatomia, indistinta de outros fundamentos da medicina, enfrenta restrições à dissecção de cadáveres. Objetivo: Ensaio sobre o ensino da anatomia em contextos clínicos e com emprego de tecnologias. Método: Utilizaram-se a plataforma PubMed da National Library of Medicine e os descritores ((anatomy [MeSH Terms]) AND (method, teaching [MeSH Terms])) AND (surgery [MeSH Terms]). Resultado: Há indicação de 316 artigos no período 2000-2022 (junho de 2022). A principal pergunta sobre o ensino de anatomia refere-se à substituição da técnica de dissecção e, por consequência, do uso do cadáver. Estudos sugerem a manutenção do uso da dissecção, da prossecção e de maior uso de meios digitais e modelares. Conclusão: O material cadavérico deve ser garantido com maior uso da prossecção, com a dissecção sendo dirigida ou eletiva. Realidade virtual e material de prossecção devem ser assimilados como instrumentais e supervisionados por anatomistas qualificados e enriquecidos pela interpretação e aplicabilidade clínica.

Abstract: Introduction: A 2010 study pointed out the future needs of medical education, with integrated contents and practices, fostered by virtual educational technology and by prioritizing competence, not time. Anatomy, indistinguishable from other fundamentals of medicine, faces restrictions on cadaver dissection. Objective: Essay on the teaching of anatomy in clinical contexts and the use of technologies Method: The "pubmed" platform of the National Library of Medicine and descriptors ((anatomy[MeSH Terms]) AND (method, teaching[MeSH Terms])) AND (surgery[MeSH Terms]) were used. Result: There are indications of 316 articles in the period 2000-2022 (June 2022). The main question about the teaching of Anatomy is the replacement of the dissection technique and, consequently, the use of the cadaver. Studies suggest maintaining the use of dissection, prosection and greater use of digital and model means. Conclusion: Cadaveric material should be secured with greater use of prosection and dissection being directed or elective. Virtual reality and permanent material must be assimilated as instrumental and supervised by qualified anatomists and enriched by interpretation and clinical applicability.

Ultrasound-guided peripheral abdominal wall blocks

The practice of regional anesthesia is in a state of progressive evolution, mainly due to the advent of ultrasound as an anesthesiologist's instrument. Alternative techniques for postoperative analgesia of abdominal surgeries, such as transversus abdominis plane block, oblique subcostal transversus abdominis plane block, rectus abdominis muscle sheath block, ilioinguinal and iliohypogastric nerve block, and quadratus lumborum plane block, have proven useful, with good analgesic efficacy, especially when neuroaxial techniques (spinal anesthesia or epidural anesthesia) are not possible. This review discusses such blockades in detail, including the anatomical principles, indications, techniques, and potential complications.

Aprepitant plus palonosetron for the prevention of postoperative nausea and vomiting after breast cancer surgery: a double blind, randomized trial

OBJECTIVES: To evaluate the addition of a fourth antiemetic intervention in patients at high risk for postoperative nausea and vomiting (PONV). METHODS: High-risk patients (Apfel score 3 or 4) scheduled for unilateral mastectomy were randomly allocated in one of two groups, oral aprepitant (oral aprepitant 80 mg, intravenous dexamethasone 8 mg, and palonosetron 0.075 mg) and oral placebo (oral placebo, intravenous dexamethasone 4 mg, and palonosetron 0.075 mg). Patients and caregivers were blinded to the group assignments. The primary efficacy endpoints included the incidence of nausea and vomiting, and the secondary endpoints included use of rescue antiemetics during a 48-hour postoperative period. ClinicalTrials.gov: NCT02431286. RESULTS: One hundred patients were enrolled in this study and 91 were analyzed, 48 in group A and 43 in group P. No patient presented with nausea or vomiting in the first 2 hours after surgery. From the 2nd to the 6th hour, the incidence of PONV was 8.33% in group A and 9.30% in group P. In the first 24 hours, the incidence of PONV was 27.08% in the group A and 20.93% in group P. From the 24th to the 48th hour, the incidence of PONV was 8.33% in group A and 13.95% in group P. There were no statistically significant differences in PONV between groups. CONCLUSION: The addition of aprepitant as a third antiemetic resulted in no significant reduction in the incidence of PONV in this population. However, the incidence of PONV was reduced in relation to the general population.

Sugammadex ED90 dose to reverse the rocuronium neuromuscular blockade in obese patients / Dose ED90 de Sugamadex para reverter o bloqueio neuromuscular com rocurônio em pacientes obesos

ABSTRACT Objective: to determine the ED90 (minimum effective dose in 90% of patients) of sugammadex for the reversal of rocuronium-induced moderate neuromuscular blockade (NMB) in patients with grade III obesity undergoing bariatric surgery. Methods: we conducted a prospective study with the biased coin up-and-down sequential design. We chosen the following doses: 2.0mg/Kg, 2.2mg/Kg, 2.4mg/Kg, 2.6mg/Kg, 2.8mg/Kg. The complete reversal of rocuronium-induced NMB considered a T4/T1 ratio ≥0.9 as measured by TOF. After induction of general anesthesia and calibration of the peripheral nerve stimulator and accelerometer, we injected rocuronium 0.6mg/kg. We administered propofol and remifentanil by continuous infusion, and intermittent boluses of rocuronium throughout the procedure. Results: we evaluated 31 patients, of whom 26 had displayed successful reversal of the NMB with sugammadex, and failure in five. The mean time to complete moderate NMB reversal was 213 seconds (172-300, median 25-75%). The ED90 of sugammadex calculated by regression was 2.39mg/kg, with a 95% confidence interval of 2.27-2.46 mg/kg. Conclusion: the ED90 of sugammadex in patients with grade III obesity or higher was 2.39mg/kg.

RESUMO Objetivos: determinar a ED90 (dose mínima eficaz em 90% dos pacientes) de sugamadex para a reversão de bloqueio neuromuscular (BNM) moderado induzido pelo rocurônio em pacientes com obesidade grau III submetidos à cirurgia bariátrica. Métodos: estudo prospectivo com o método de projeção sequencial para cima e para baixo da moeda enviesada. As seguintes doses foram escolhidas: 2,0mg/kg-1, 2,2mg/kg-1, 2,4mg/kg-1, 2,6mg/kg-1, 2,8mg/kg-1. A reversão completa de BNM induzido por rocurônio considerou uma relação T4/T1 ≥0,9 na medida do TOF. Após a indução da anestesia geral e calibração do estimulador de nervo periférico e acelerômetro, rocurônio 0,6mg/kg-1 foi injetado. Infusão contínua de propofol e remifentanil, e bolus intermitente de rocurônio foram injetados durante todo o procedimento. Resultados: trinta e um pacientes foram avaliados, 26 dos quais bem-sucedidos e cinco sem reversão completa do BNM moderado promovido pelo sugamadex. O tempo médio para completar reversão de BNM foi 213 segundos (172 a 300 segundos; mediana, 25-75%). O ED90 de sugamadex calculado pela regressão foi de 2,39mg/kg-1 com um intervalo de confiança de 95% (2,27 a 2,46mg/kg-1). Conclusão: o ED90 de sugamadex em pacientes com obesidade grau III ou superior foi 2,39mg/kg-1.

Factor structure and psychometric properties of the Dispositional Resilience Scale among Brazilian adult patients / Estrutura fatorial e propriedades psicométricas da Escala de Resiliência Disposicional para pacientes brasileiros adultos

ABSTRACT Objective Verifying the psychometrics of a Brazilian version of the Dispositional Resilience Scale (DRS-15). Methods Cross-cultural adaptation was done interviewing 65 adult patients. Validation was evaluated by application of the Lipp Brazilian Stress Symptoms Inventory (ISSL), Self-Report Questionnaire (SRQ), and other measures to 575 participants from the psychiatric ambulatories (for borderline personality, anxiety or post-traumatic stress disorders) and non-psychiatric ambulatories (chronic pain, pre-anesthetic consultation and companions for the latter). Temporal stability was verified with 123 participants. Results Exploratory factor analysis yielded a three-factor solution. Psychometrics were acceptable (alpha coefficient, 0.71; intraclass correlation coefficient, 0.81). Correlations with the ISSL, SRQ and other measures were noted except for factor 3. In the psychiatric sample, hardiness scores of borderline patients were lower than those of patients with anxiety disorders. Conclusion This version of the DRS-15 exhibited good reliability in a sample of Brazilian patients; validity was confirmed in two of the scale factors.

RESUMO Objetivo Verificar as propriedades psicométricas da versão brasileira da Escala de Resiliência Disposicional (DRS-15). Métodos A adaptação transcultural foi feita com 65 pacientes. A validação foi estudada pela aplicação do Inventário de Sintomas de Stress para Adultos de Lipp (ISSL), Self-Report Questionnaire (SRQ) e outros instrumentos a 575 participantes de ambulatórios psiquiátricos (transtorno borderline de personalidade, ansiedade ou transtorno de estresse pós-traumático) e não-psiquiátricos (dor crônica, avaliação pré-anestésica ou acompanhantes). A estabilidade foi verificada com 123 participantes. Resultados A análise exploratória revelou três fatores, com propriedades aceitáveis (alfa de 0,71; coeficiente de correlação intraclasse de 0,81). Notaram-se correlações com o ISSL, SRQ e demais instrumentos, exceto para o fator 3. Na amostra psiquiátrica, a resiliência disposicional dos pacientes borderlines foi menor que a dos pacientes com transtornos de ansiedade. Conclusão Esta versão da DRS-15 apresentou boa confiabilidade numa amostra de adultos; a validade foi confirmada para dois fatores da escala.

Factor structure and psychometric properties of the Connor-Davidson resilience scale among Brazilian adult patients / Estrutura fatorial e propriedades psicométricas da Escala de Resiliência de Connor-Davidson para pacientes brasileiros adultos

ABSTRACT: CONTEXT AND OBJECTIVE: Personal resilience is associated with several mental health outcomes. The Connor-Davidson resilience scale (CD-RISC) is a widely used self-report measurement of resilience. This study aimed to investigate the reliability and validity of a Brazilian Portuguese version of the CD-RISC. DESIGN AND SETTING: Cross-sectional validation study carried out in the outpatient clinics of a public university hospital. METHODS: The cross-cultural adaptation followed established guidelines and involved interviews with 65 adults in psychiatric and non-psychiatric outpatient clinics at a teaching hospital. Validation was assessed through concurrent application of the Lipp Brazilian Stress Symptom Inventory (ISSL), Self-Report Questionnaire (SRQ), Sheehan Disability Scales (SDS) and Chronic Pain Grade (CPG) to 575 patients at the same setting. Temporal stability was verified through a second application to 123 participants. RESULTS: Factor analysis identified four factors, named tenacity, adaptability-tolerance, reliance on support from outside and intuition. The alpha coefficient of 0.93 and intraclass correlation coefficient of 0.84 indicated good internal consistency and temporal stability. Significant correlations between this version of the CD-RISC and the ISSL, SRQ, SDS and CPG were noted. The patients at the outpatient clinic for borderline personality had resilience scores that were significantly lower than those of the patients at the general anxiety or post-traumatic stress outpatient clinics. CONCLUSION: This Brazilian Portuguese version of the Connor-Davidson resilience scale exhibited adequate reliability and validity among a sample of Brazilian adult patients.

RESUMO: CONTEXTO E OBJETIVO: A resiliência pessoal está associada a diversos desfechos em saúde mental. A escala de resiliência de Connor-Davidson (CD-RISC) vem sendo amplamente empregada como uma medida autorrelatada de resiliência. Este estudo teve por objetivo verificar a confiabilidade e a validade de uma versão da CD-RISC para o português no contexto cultural brasileiro. DESENHO E LOCAL: Estudo transversal de validação conduzido nos ambulatórios de hospital público universitário. MÉTODOS: De acordo com diretrizes bem conhecidas, a adaptação cultural foi feita com 65 adultos entrevistados em ambulatórios psiquiátricos e não psiquiátricos de um hospital de ensino. A validação se deu pela aplicação concorrente do Inventário de Stress para Adultos de Lipp (ISSL), Questionário de Autorrelato de Sintomas (SRQ), Escalas de Incapacidade de Sheehan (SDS) e Escala Graduada de Dor Crônica (CPG) a 575 pacientes do mesmo hospital. A estabilidade temporal foi verificada numa segunda aplicação a 123 participantes. RESULTADOS: A análise fatorial identificou quatro fatores, nomeados como tenacidade, adaptabilidade-tolerância, amparo e intuição. Um coeficiente alfa de 0,93 e um coeficiente de correlação intraclasse de 0,84 indicaram adequadas consistência interna e estabilidade temporal. Correlações significativas entre esta versão da CD-RISC e o ISSL, SRQ, SDS e CPG foram identificadas. Os pacientes do ambulatório para personalidade borderline tiveram escores de resiliência significativamente mais baixos que os pacientes dos ambulatórios geral de ansiedade ou de estresse pós-traumático. CONCLUSÃO: A presente versão em português da escala de resiliência de Connor-Davidson apresentou confiabilidade e validade adequadas numa amostra de pacientes brasileiros adultos.

Perioperative warming with a thermal gown prevents maternal temperature loss during elective cesarean section. A randomized clinical trial / O aquecimento no perioperatório com avental cirúrgico térmico impede a perda de temperatura materna durante a cesariana eletiva. Estudo clínico randômico

Abstract Background and objectives: Decrease in body temperature is common during general and regional anesthesia. Forced-air warming intraoperative during cesarean section under spinal anesthesia seems not able to prevent it. The hypothesis considers that active warming before the intraoperative period avoids temperature loss during cesarean. Methods: Forty healthy pregnant patients undergoing elective cesarean section with spinal anesthesia received active warming from a thermal gown in the preoperative care unit 30 min before spinal anesthesia and during surgery (Go, n = 20), or no active warming at any time (Ct, n = 20). After induction of spinal anesthesia, the thermal gown was replaced over the chest and upper limbs and maintained throughout study. Room temperature, hemoglobin saturation, heart rate, arterial pressure, and tympanic body temperature were registered 30 min before (baseline) spinal anesthesia, right after it (time zero) and every 15 min thereafter. Results: There was no difference for temperature at baseline, but they were significant throughout the study (p < 0.0001; repeated measure ANCOVA). Tympanic temperature baseline was 36.6 ± 0.3 °C, measured 36.5 ± 0.3 °C at time zero and reached 36.1 ± 0.2 °C for gown group, while control group had baseline temperature of 36.4 ± 0.4 °C, measured 36.3 ± 0.3 °C at time zero and reached 35.4 ± 0.4 °C (F = 32.53; 95% CI 0.45-0.86; p < 0.001). Hemodynamics did not differ throughout the study for both groups of patients. Conclusion: Active warming 30 min before spinal anesthesia and during surgery prevented a fall in body temperature in full-term pregnant women during elective cesarean delivery.

Resumo Justificativa e objetivos: A redução da temperatura corporal é comum durante a anestesia tanto geral quanto regional. O sistema de ar forçado aquecido no intraoperatório durante a cesariana sob anestesia peridural não parece conseguir impedi-la. A hipótese considera que o aquecimento ativo antes do período intraoperatório evita a perda de temperatura durante a cesariana. Métodos: Quarenta pacientes grávidas, saudáveis, submetidas à cesariana eletiva com anestesia espinal receberam aquecimento ativo de um avental térmico na unidade de cuidados pré-operatórios 30 minutos antes da anestesia e durante a cirurgia (Go, n = 20) ou nenhum aquecimento ativo a qualquer momento (Ct, n = 20). Após a indução da anestesia espinhal, o avental térmico foi colocado sobre o tórax e os membros superiores e mantido durante o estudo. Temperatura ambiente, saturação de hemoglobina, frequência cardíaca, pressão arterial e temperatura corporal timpânica foram registradas 30 minutos antes (fase basal) da anestesia espinhal, logo após a anestesia (tempo zero) e a cada 15 minutos subsequentemente. Resultados: Não houve diferença de temperatura na fase basal, mas as diferenças foram significativas ao longo do estudo (p < 0,0001; Ancova de medida repetida). A temperatura timpânica na fase basal foi de 36,6 ± 0,3 °C, mediu 36,5 ± 0,3 °C no tempo zero e atingiu 36,1 ± 0,2 °C no grupo avental, enquanto a temperatura basal do grupo controle foi de 36,4 ± 0,4 °C, mediu 36,3 ± 0,3 °C no tempo zero e atingiu 35,4 ± 0,4 °C (F = 32,53; IC de 95% 0,45-0,86, p < 0,001). A hemodinâmica não diferiu ao longo do estudo em ambos os grupos de pacientes. Conclusão: O aquecimento ativo 30 minutos antes da anestesia espinhal e durante a cirurgia evitou a queda da temperatura corporal em mulheres grávidas a termo durante a cesariana eletiva.

Anesthesiology Journal club assessment by means of semantic changes / Avaliação do clube de revista de anestesiologia por meio de mudanças semânticas / Evaluación del club de la revista de anestesiología por medio de cambios semánticos

BACKGROUND AND OBJECTIVES: the interactive approach of a journal club has been described in the medical education literature. The aim of this investigation is to present an assessment of journal club as a tool to address the question whether residents read more and critically. METHODS: this study reports the performance of medical residents in anesthesiology from the Clinics Hospital - University of São Paulo Medical School. All medical residents were invited to answer five questions derived from discussed papers. The answer sheet consisted of an affirmative statement with a Likert type scale (totally disagree-disagree-not sure-agree-totally agree), each related to one of the chosen articles. The results were evaluated by means of item analysis - difficulty index and discrimination power. RESULTS: residents filled one hundred and seventy three evaluations in the months of December 2011 (n = 51), July 2012 (n = 66) and December 2012 (n = 56). The first exam presented all items with straight statement, second and third exams presented mixed items. Separating "totally agree" from "agree" increased the difficulty indices, but did not improve the discrimination power. CONCLUSIONS: the use of a journal club assessment with straight and inverted statements and by means of five points scale for agreement has been shown to increase its item difficulty and discrimination power. This may reflect involvement either with the reading or the discussion during the journal meeting. .

JUSTIFICATIVA E OBJETIVOS: a abordagem interativa de um clube de revista foi descrita na literatura de ensino médico. O objetivo desta investigação é apresentar uma avaliação do clube de revista como uma ferramenta para discutir a questão da leitura crítica entre os residentes. MÉTODOS: este estudo relata o desempenho dos médicos residentes de anestesiologia do Hospital das Clínicas - Faculdade de Medicina da Universidade de São Paulo. Todos os médicos residentes foram convidados a responder a cinco perguntas derivadas de artigos discutidos. A folha de resposta consistia em uma declaração afirmativa com uma escala do tipo Likert (discordo totalmente, discordo, não tenho certeza, concordo, concordo totalmente), cada declaração relacionada a um dos artigos escolhidos. Os resultados foram avaliados por meio da análise de itens - índice de dificuldade e poder de discriminação. RESULTADOS: os residentes completaram 173 avaliações nos meses de dezembro de 2011 (n = 51), julho de 2012 (n = 66) e dezembro de 2012 (n = 56). O primeiro teste apresentou todos os itens com declaração direta e o segundo e terceiro testes apresentaram itens mistos. Separar "concordo totalmente" de "concordo" aumentou os índices de dificuldade, mas não melhorou o poder de discriminação. CONCLUSÕES: o uso de uma avaliação do clube revista com declarações diretas e inversas e com o uso de uma escala de cinco pontos para acordo mostrou aumentar a dificuldade do item e o poder de discriminação. Isso pode refletir o envolvimento com a leitura ou com a discussão durante as reuniões do clube. .

JUSTIFICACIÓN Y OBJETIVOS: El abordaje interactivo de un club de revista ha sido descrito en la literatura de enseñanza médica. El objetivo de esta investigación es presentar una evaluación del club de revista como una herramienta para discutir la cuestión de la lectura crítica entre los residentes. MÉTODOS: Este estudio relata el desempeño de los médicos residentes de anestesiología del Hospital das Clínicas de la Facultad de Medicina de la Universidad de São Paulo. Todos los médicos residentes fueron invitados a responder a 5 preguntas derivadas de artículos discutidos. La hoja de respuesta consistía en una declaración afirmativa con una escala del tipo Likert ("estoy totalmente en desacuerdo", "en desacuerdo", "no estoy seguro", "estoy de acuerdo", "estoy totalmente de acuerdo"), cada declaración relacionada con uno de los artículos escogidos. Los resultados se evaluaron por medio del análisis de los ítems: índice de dificultad y poder de discriminación. RESULTADOS: Los residentes completaron 173 evaluaciones en los meses de diciembre de 2011 (n = 51), julio de 2012 (n = 66) y diciembre de 2012 (n = 56). El primer test incluyó todos los títulos con declaración directa y el segundo y el tercero tuvieron títulos mezclados. Separar "estoy totalmente de acuerdo" de "estoy de acuerdo" aumentó los índices de dificultad pero no mejoró el poder de discriminación. CONCLUSIONES: El uso de una evaluación del club de revista con declaraciones directas e inversas y con el uso de una escala de 5 puntos para "estoy de acuerdo", mostró el aumento de la dificultad del ítem y del poder de discriminación. Eso puede reflejar el nivel de implicación en la lectura o en la discusión durante las reuniones del club. .

Incidence of postoperative dyspepsia is not associated with prophylactic use of drugs / Incidência de dispepsia pós-operatória não está associada com uso profilático de medicamentos

CONTEXT AND OBJECTIVE: Preoperative fasting guidelines do not recommend H2 receptor antagonists or proton pump inhibitors. This study investigated prophylactic use of gastric protection and the incidence of dyspeptic symptoms in the immediate postoperative period. DESIGN AND SETTING: Non-randomized observational investigation in a post-anesthesia care unit. METHODS: American Society of Anesthesiologists risk classification ASAP1 and ASAP2 patients over 18 years of age were evaluated to identify dyspeptic symptoms during post-anesthesia care for up to 48 hours, after receiving or not receiving prophylactic gastric protection during anesthesia. History of dyspeptic symptoms and previous use of such medications were exclusion criteria. The odds ratio for incidence of dyspeptic symptoms with use of these medications was obtained. RESULTS: This investigation studied 188 patients: 71% women; 50.5% ASAP1 patients. Most patients received general anesthesia (68%). Gastric protection was widely used (n = 164; 87.2%), comprising omeprazole (n = 126; 76.8%) or ranitidine (n = 38; 23.2%). Only a few patients did not receive any prophylaxis (n = 24; 12.8%). During the observation, 24 patients (12.8%) reported some dyspeptic symptoms but without any relationship with prophylaxis (relative risk, RR = 0.56; 95% confidence interval, CI: 0.23-1.35; P = 0.17; number needed to treat, NNT = 11). Omeprazole, compared with ranitidine, did not reduce the chance of having symptoms (RR = 0.65; 95% CI: 0.27-1.60; P = 0.26; NNT = 19). CONCLUSION: This study suggests that prophylactic use of proton pump inhibitors or H2 receptor antagonists was routine for asymptomatic patients and was not associated with postoperative protection against dyspeptic symptoms. .

CONTEXTO E OBJETIVO: Diretrizes para jejum pré-operatório não recomendam antagonistas dos receptores H2 ou inibidores da bomba de prótons. Este estudo investigou o uso profilático de proteção gástrica e a incidência de sintomas dispépticos no período pós-operatório imediato. TIPO DE ESTUDO E LOCAL: Estudo observacional não aleatorizado em unidade de recuperação pós-anestésica. MÉTODOS: Pacientes ASAP1 e ASAP2, classificação de risco da American Society of Anesthesiologists, com mais de 18 anos de idade, foram avaliados para identificar sintomas dispépticos durante a recuperação pós-anestésica em até 48 horas, tendo ou não recebido proteção gástrica profilática durante a anestesia. História de sintomas dispépticos e uso prévio de tais medicamentos foram critérios de exclusão. A razão de chances para incidência de sintomas dispépticos com uso desses medicamentos foi obtida. RESULTADOS: Foram estudados 188 pacientes, 71% mulheres, 50,5% dos pacientes ASAP1. A maioria dos pacientes recebeu anestesia geral (68%). Proteção gástrica foi amplamente usada (n = 164; 87,2%), consistindo de omeprazol (n = 126; 76,8%) ou ranitidina (n = 38; 23,2%). Poucos pacientes não receberam qualquer profilaxia (n = 24; 12,8%). Durante a observação, 24 pacientes (12,8%) relataram alguns sintomas dispépticos, porém sem relação com profilaxia (risco relativo, RR = 0,56; intervalo de confiança, IC 95% 0,23-1,35, P = 0,17; número necessário para tratar, NNT = 11). Omeprazol, comparado à ranitidina, não reduziu a chance de ter sintomas (RR = 0,65; IC 95% 0,27-1,60; P = 0,26; NNT = 19). CONCLUSÃO: Este estudo sugere que o uso profilático de inibidores da bomba de prótons ...

Oxygen concentrators performance with nitrous oxide at 50:50 volume / Desempenho de concentradores de oxigênio com óxido nitroso em volume de 50:50 / Rendimiento de los concentradores de oxígeno con óxido nitroso a un volumen de 50:50

Background and objectives: Few investigations have addressed the safety of oxygen from concentrators for use in anesthesia in association with nitrous oxide. This study evaluated the percent of oxygen from a concentrator in association with nitrous oxide in a semi-closed rebreathing circuit. Methods: Adult patients undergoing low risk surgery were randomly allocated into two groups, receiving a fresh gas flow of oxygen from concentrators (O293) or of oxygen from concentrators and nitrous oxide (O293N2O). The fraction of inspired oxygen and the percentage of oxygen from fresh gas flow were measured every 10 min. The ratio of FiO2/oxygen concentration delivered was compared at various time intervals and between the groups. Results: Thirty patients were studied in each group. There was no difference in oxygen from concentrators over time for both groups, but there was a significant improvement in the FiO2 (p < 0.001) for O293 group while a significant decline (p < 0.001) for O293N2O. The FiO2/oxygen ratio varied in both groups, reaching a plateau in the O293 group. Pulse oximetry did not fall below 98.5% in either group. Conclusion: The FiO2 in the mixture of O293 and nitrous oxide fell during the observation period although oxygen saturation was higher than 98.5% throughout the study. Concentrators can be considered a stable source of oxygen for use during short anesthetic procedures, either pure or in association with nitrous oxide at 50:50 volume. .

Justificativa e objetivos: poucas pesquisas abordaram a segurança do oxigênio a partir de concentradores para uso em anestesia em associação com óxido nitroso. Este estudo avaliou a porcentagem de oxigênio a partir de um concentrador em associação com óxido nitroso em um circuito de reinalação semifechado. Métodos: pacientes adultos submetidos à cirurgia de baixo risco foram alocados aleatoriamente em dois grupos e receberam um fluxo de gases frescos de concentradores de oxigênio (O293) ou de concentradores de oxigênio e óxido nitroso (O293N2O). A fração inspirada de oxigênio e a porcentagem do fluxo de gases frescos de oxigênio foram medidas a cada 10 minutos. O razão da concentração liberada de FiO2/oxigênio foi comparada em diferentes intervalos de tempo e entre os grupos. Resultados: foram avaliados em cada grupo 30 pacientes. Não houve diferença em oxigênio a partir dos concentradores ao longo do tempo para ambos os grupos, mas houve uma melhora significativa da FiO2 (p < 0,001) no grupo O293, enquanto houve uma queda significativa (p < 0,001) no grupo O293N2O. A razão FiO2/oxigênio variou em ambos os grupos e atingiu um patamar no grupo O293. A oximetria de pulso não caiu abaixo de 98,5% em ambos os grupos. Conclusão: a FiO2 na mistura de O293 e óxido nitroso caiu durante o período de observação, embora a saturação de oxigênio tenha ficado acima de 98,5% durante todo o estudo. Os concentradores podem ser considerados uma fonte estável de oxigênio para uso durante procedimentos anestésicos de curta duração, tanto puro quanto em associação com óxido nitroso em volume de 50:50. .

Justificación y objetivos: pocas investigaciones han abordado la seguridad del oxígeno a partir de concentradores para su uso en anestesia en asociación con el óxido nitroso. Este estudio evaluó el porcentaje de oxígeno de un concentrador en asociación con el óxido nitroso en un circuito de reinhalación semicerrado. Métodos: pacientes adultos sometidos a cirugía de bajo riesgo fueron asignados aleatoriamente en 2 grupos, para recibir un flujo de gases frescos de concentradores de oxígeno (O293) o de concentradores de oxígeno y óxido nitroso (O293NO). La fracción inspirada de oxígeno y el porcentaje del flujo de gases frescos de oxígeno fueron medidos cada 10 min. La relación concentración liberada de FiO2/oxígeno fue comparada en diferentes intervalos de tiempo y entre los grupos. Resultados: treinta pacientes fueron evaluados en cada grupo. No hubo diferencia en el oxígeno de los concentradores a lo largo del tiempo para ambos grupos, pero sí hubo una mejoría significativa en la FiO2 (p < 0,001) en el grupo O293, mientras que hubo una caída significativa (p < 0,001) en el grupo O293NO. La relación FiO2/oxígeno varió en ambos grupos, alcanzando una meseta en el grupo O293. La oximetría de pulso no descendió por debajo del 98,5% en ningún grupo. Conclusión: la FiO2 en la mezcla de O293 y óxido nitroso cayó durante el período de observación, aunque la saturación de oxígeno quedó por encima de un 98,5% durante todo el estudio. Los concentradores pueden ser considerados una fuente estable de oxígeno para uso durante procedimientos anestésicos de corta duración, tanto puro como en asociación con el óxido nitroso en volumen de 50:50. .