Por que e como reformar um currículo inovador? Um relato de experiência de Londrina / Why and how to reform an innovative curriculum? An experience report from Londrina

Resumo: Introdução: O curso de graduação em Medicina da Universidade Estadual de Londrina foi o segundo do Brasil a adotar currículo integrado e Aprendizagem Baseada em Problemas (PBL). Apesar de seu currículo inovador ter servido de referência a outras escolas, avaliações recentes mostraram a necessidade de reforma. Relato de experiência: As avaliações sistemáticas do curso indicaram os seguintes problemas: dificuldade de adaptação dos ingressantes à primeira série; desorganização da sequência de conteúdos ao longo do curso; falta de motivação docente para as atividades da primeira à quarta série; necessidade de incluir tópicos obrigatórios e novas tendências; e desgaste da metodologia (PBL) a partir da terceira série. Um amplo trabalho de reforma curricular foi iniciado, baseado na construção coletiva, culminando em mudanças, como: o desenho de uma primeira série mais acolhedora por meio da inclusão de nivelamento de ciências básicas e mentoria; a reorganização cronológica dos conteúdos; o redesenho dos módulos, agora organizados ao redor de grandes áreas ou especialidades afins; a adoção de metodologias ativas mais motivadoras; e a inclusão de novos conteúdos. Discussão: A adoção de novas metodologias ativas em substituição à PBL em alguns momentos apresenta vantagens estratégicas. A Aprendizagem Baseada em Equipes (TBL), mais estruturada que a PBL, pode ajudar na adaptação dos ingressantes à primeira série e facilitar a realização de metodologias ativas num contexto de escassez de docentes. A Aprendizagem Baseada em Casos (CBL) é mais motivadora e pode ser mais efetiva para desenvolver habilidades de raciocínio clínico nas séries pré-internato. Conclusão: O novo currículo, que incorpora as mudanças mencionadas, foi implantado em 2022. Novas avaliações mostrarão se as mudanças trarão melhorias ao curso em termos de adaptação, motivação e resultados de aprendizagem.

Abstract: Introduction: The undergraduate medical course of the State University of Londrina was the second in Brazil to adopt an integrated curriculum and Problem-Based Learning (PBL). Despite its innovative curriculum, which became a reference for other schools, new assessments showed the need to reform it. Experience Report: Systematic course evaluations showed some issues: difficulties in adaptation of new students attending the first year; disorganized sequence of contents throughout the course; teachers' lack of motivation for activities from first to the fourth years; need to include new contents; and deterioration of the methodology (PBL) in third and fourth years. A wide collective effort for curricular reform was initiated, which led to important changes, such as: a more welcoming first year, by including mentoring and activities for the leveling of basic knowledge; chronological reorganization of contents; redesign of modules around great areas of knowledge or related specialties; adoption of new and more motivating active learning and teaching methodologies, and the inclusion of new topics/trends. Discussion: The adoption of other active learning and teaching methodologies present strategic advantages in replacement for PBL. Team-Based Learning (TBL) is a more structured method than PBL, so it can help newcomers to adapt to the first year and make it easier to implement active methodologies in a context of teacher shortage. Case-Based Learning (CBL) generates higher motivation and can be more effective to foster the development of clinical reasoning skills in the preclinical years. Conclusion: The new curriculum, incorporating the changes described above, started in 2022. Further evaluations will show whether the changes will improve the course in terms of adaptability, motivation and learning outcomes.

InsuOnline, an Electronic Game for Medical Education on Insulin Therapy: A Randomized Controlled Trial With Primary Care Physicians.

BACKGROUND: Most patients with diabetes mellitus (DM) are followed by primary care physicians, who often lack knowledge or confidence to prescribe insulin properly. This contributes to clinical inertia and poor glycemic control. Effectiveness of traditional continuing medical education (CME) to solve that is limited, so new approaches are required. Electronic games are a good option, as they can be very effective and easily disseminated. OBJECTIVE: The objective of our study was to assess applicability, user acceptance, and educational effectiveness of InsuOnline, an electronic serious game for medical education on insulin therapy for DM, compared with a traditional CME activity. METHODS: Primary care physicians (PCPs) from South of Brazil were invited by phone or email to participate in an unblinded randomized controlled trial and randomly allocated to play the game InsuOnline, installed as an app in their own computers, at the time of their choice, with minimal or no external guidance, or to participate in a traditional CME session, composed by onsite lectures and cases discussion. Both interventions had the same content and duration (~4 h). Applicability was assessed by the number of subjects who completed the assigned intervention in each group. Insulin-prescribing competence (factual knowledge, problem-solving skills, and attitudes) was self-assessed through a questionnaire applied before, immediately after, and 3 months after the interventions. Acceptance of the intervention (satisfaction and perceived importance for clinical practice) was also assessed immediately after and 3 months after the interventions, respectively. RESULTS: Subjects' characteristics were similar between groups (mean age 38, 51.4% [69/134] male). In the game group, 69 of 88 (78%) completed the intervention, compared with 65 of 73 (89%) in the control group, with no difference in applicability. Percentage of right answers in the competence subscale, which was 52% at the baseline in both groups, significantly improved immediately after both interventions to 92% in the game group and to 85% in control (P<.001). After 3 months, it remained significantly higher than that at the baseline in both groups (80% in game, and 76% in control; P<.001). Absolute increase in competence score was better with the game (40%) than with traditional CME (34%; P=.01). Insulin-related attitudes were improved both after the game (significant improvement in 4 of 9 items) and after control activity (3 of 9). Both interventions were very well accepted, with most subjects rating them as "fun or pleasant," "useful," and "practice-changing." CONCLUSIONS: The game InsuOnline was applicable, very well accepted, and highly effective for medical education on insulin therapy. In view of its flexibility and easy dissemination, it is a valid option for large-scale CME, potentially helping to reduce clinical inertia and to improve quality of care for DM patients. TRIAL REGISTRATION: Clinicaltrials.gov NCT001759953; https://clinicaltrials.gov/ct2/show/NCT01759953 (Archived by WebCite at http://www.webcitation.org/6oeHoTrBf).

Coproparasitological survey of intestinal parasites in the city of Londrina, Parana, Brazil: a retrospective analysis

Intestinal parasites are a major public health problem. It is important to inform and educate the public about these infections, especially where such data are scarce. This study aimed to determine the prevalence of intestinal parasites from the analysis of medical records of individuals of the city of Londrina. We analyzed 11,641 fecal reports from February 2009 to December 2012. Data were cataloged after the completion of parasitological testing of Hoffmann, Pons & Janer, Faust and Kato-Katz. From 11,641 reports, 19.1% were positive for intestinal parasites. Among those, 52.1% pertained to females and 47.9% to males, with predominance of positivity of 27.1% among children 0-10 years. For the regions studied, the northern region stood out with 35.4% of cases and prevalence of 6.8%. Among the pathogenic protozoa, reports of Giardia lamblia comprised 19.1% of positivity, while hookworms were the most frequent among helminths, comprising 7.8% of positive cases. It follows that poor conditions of basic sanitation contribute to the dissemination of these parasites. Early diagnosis is a determinant of successful treatment. Additionally, epidemiological data may be used to study the risk factors for transmission and may result in measures applicable to improving living conditions in the community

User Assessment of "InsuOnLine," a Game to Fight Clinical Inertia in Diabetes: A Pilot Study.

OBJECTIVE: We performed a pilot study to assess usability and playability of "InsuOnLine," a serious game for education of primary care physicians on insulin therapy for diabetes mellitus. MATERIALS AND METHODS: A multidisciplinary team has designed and developed "InsuOnLine," using Andragogy and Problem-Based Learning principles, with game elements to improve players' motivation. The prototype was tested by four medical doctors and two medical students, using the System Usability Scale (SUS) and a questionnaire to assess playability. These results were used to guide corrections, after which the beta version was retested by 14 medical students and 6 residents. RESULTS: Out of a maximum score of 100 on the SUS, the "InsuOnLine" prototype was rated 88, and some areas for improvement were identified (game instructions, controls). After corrections, the beta version was rated 92.5 on the SUS. Users have found the beta version to be fun, engaging, challenging, relevant, and realistic. Users said that the game has increased their knowledge on diabetes and insulin, that it has made them feel more confident for prescribing insulin, and that it would have impact on how they treated patients with diabetes. Most users said they have learned more from the game than they would have from a lecture. Lessons learned were the need of early piloting, preferably by users with very little or very much gaming experience, on their own computers and free patterns of use. CONCLUSIONS: "InsuOnLine" was rated by users as easy to play, fun, and useful for learning. Further studies will assess its educational effectiveness. "InsuOnLine" is a promising tool for large-scale continuing medical education on insulin, helping to fight clinical inertia in diabetes.

Gaming Habits and Opinions of Brazilian Medical School Faculty and Students: What's Next?

OBJECTIVE: This study assessed habits and opinions of medical educators and students from a Brazilian medical school about electronic games for learning or for fun. MATERIALS AND METHODS: A questionnaire was sent to Universidade Estadual de Londrina medical school faculty members and undergraduate students. RESULTS: From the 50 faculty members, 20 percent reported regular use of electronic games (at least once a week), spending 1 hour/week with games (median). Among 302 medical students, 37 percent reported regular gaming. Students spent 3 hours/week playing games (median). Male students played games 4.4 times more often than female students. About 90 percent of faculty members and students believed that games are useful for medical education, and >80 percent would like to play games for education of health professionals, but only one-third of students and one-fifth of faculty had already played one of such games. More than 80 percent of faculty would like to use a game for their educational activities. The main obstacles to incorporation of games into medical education, reported by faculty members, were associated with lack of knowledge on available options, lack of time to develop new activities, and lack of resources or institutional support. CONCLUSIONS: Playing electronic games is common among medical faculty and students, who both present very positive opinions about games for learning, but the scarcity of available options and the lack of institutional support prevent a more widespread adoption of medical education games.

[Diabetes: time to redefine goals?]. / Diabetes: hora de rever as metas?

OBJECTIVE: The aim of this study was to assess if the A1c goals from the Brazilian Diabetes Society (SBD) were compatible with their goals for blood glucose. MATERIALS AND METHODS: An online simulation (AIDA) was used to simulate a hypothetical patient with blood glucose values similar to the SBD's goals. Average glucose was calculated from generated blood glucose values, and then converted to the corresponding A1c value, using the ADA online calculator. Other glycemic profiles, using different levels of blood glucose, were also simulated in order to assess which would be the A1c value associated with each profile. RESULTS: Glycemic goals proposed by the SBD (fasting glucose < 100 mg/dL, preprandial < 110 mg/dL, and postprandial < 140 mg/dL), were associated with an A1c of 5.9%, much lower than the goal of 7% recommended by the SBD. This demonstrates incompatibility among A1c and blood glucose goals proposed by the SBD. Such A1c levels are associated with increased mortality among high-risk patients. CONCLUSIONS: Besides recommending different A1c goals for different patients, the SBD should probably review its recommendations and adopt different blood glucose goals that are compatible with the proposed A1c goals, making therapeutic targets clearer.

Diabetes: hora de rever as metas? / Diabetes: time to redefine goals?

OBJETIVO: O objetivo deste trabalho foi avaliar se a meta de A1c da Sociedade Brasileira de Diabetes (SBD) é compatível com as metas de glicemia propostas pelas mesmas diretrizes. MATERIAIS E MÉTODOS: Um simulador computadorizado online (AIDA) foi usado para simular um paciente hipotético com os valores de glicemia iguais aos alvos propostos pela SBD. A glicemia média foi calculada a partir dos valores gerados pelo simulador e convertida para o valor correspondente de A1c usando-se a calculadora online da American Diabetes Association (ADA). Outros perfis, com diferentes níveis de glicemia, também foram simulados, para avaliar qual o valor de A1c correspondente a cada um dos perfis. RESULTADOS: Os valores de glicemia de jejum < 100 mg/dL, pré-prandiais < 110 mg/dL e pós-prandiais < 140 mg/dL, recomendados pela SBD, geraram glicemia média de 123 mg/dL, que correspondeu a A1c estimada de 5,9%, muito abaixo da meta de 7% proposta pela SBD, mostrando incompatibilidade entre as metas de glicemia e A1c sugeridas nessa diretriz. Esse valor de A1c se associa a aumento do risco de morte em pacientes de alto risco. CONCLUSÕES: Além de recomendar valores diferenciados de A1c para diferentes tipos de paciente, a SBD também deveria discutir a adoção de metas diferenciadas de glicemia que fossem compatíveis com os níveis de A1c propostos, tornando mais claros os alvos de tratamento.

OBJECTIVE: The aim of this study was to assess if the A1c goals from the Brazilian Diabetes Society (SBD) were compatible with their goals for blood glucose. MATERIALS AND METHODS: An online simulation (AIDA) was used to simulate a hypothetical patient with blood glucose values similar to the SBD's goals. Average glucose was calculated from generated blood glucose values, and then converted to the corresponding A1c value, using the ADA online calculator. Other glycemic profiles, using different levels of blood glucose, were also simulated in order to assess which would be the A1c value associated with each profile. RESULTS: Glycemic goals proposed by the SBD (fasting glucose < 100 mg/dL, preprandial < 110 mg/dL, and postprandial < 140 mg/dL), were associated with an A1c of 5.9%, much lower than the goal of 7% recommended by the SBD. This demonstrates incompatibility among A1c and blood glucose goals proposed by the SBD. Such A1c levels are associated with increased mortality among high-risk patients. CONCLUSIONS: Besides recommending different A1c goals for different patients, the SBD should probably review its recommendations and adopt different blood glucose goals that are compatible with the proposed A1c goals, making therapeutic targets clearer.

InsuOnline, a Serious Game to Teach Insulin Therapy to Primary Care Physicians: Design of the Game and a Randomized Controlled Trial for Educational Validation.

BACKGROUND: Physicians´ lack of knowledge contributes to underuse of insulin and poor glycemic control in adults with diabetes mellitus (DM). Traditional continuing medical education have limited efficacy, and new approaches are required. OBJECTIVE: We report the design of a trial to assess the educational efficacy of InsuOnline, a game for education of primary care physicians (PCPs). The goal of InsuOnline was to improve appropriate initiation and adjustment of insulin for the treatment of DM. InsuOnline was designed to be educationally adequate, self-motivating, and attractive. METHODS: A multidisciplinary team of endocrinologists, experts in medical education, and programmers, was assembled for the design and development of InsuOnline. Currently, we are conducting usability and playability tests, with PCPs and medical students playing the game on a desktop computer. Adjustments will be made based on these results. An unblinded randomized controlled trial with PCPs who work in the city of Londrina, Brazil, will be conducted to assess the educational validity of InsuOnline on the Web. In this trial, 64 PCPs will play InsuOnline, and 64 PCPs will undergo traditional instructional activities (lecture and group discussion). Knowledge on how to initiate and adjust insulin will be assessed by a Web-based multiple choice questionnaire, and attitudes regarding diabetes/insulin will be assessed by Diabetes Attitude Scale 3 at 3 time points-before, immediately after, and 6 months after the intervention. Subjects´ general impressions on the interventions will be assessed by a questionnaire. Software logs will be reviewed. RESULTS: To our knowledge, this is the first research with the aim of assessing the educational efficacy of a computer game for teaching PCPs about insulin therapy in DM. We describe the development criteria used for creating InsuOnline. Evaluation of the game using a randomized controlled trial design will be done in future studies. CONCLUSIONS: We demonstrated that the design and development of a game for PCPs education on insulin is possible with a multidisciplinary team. InsuOnline can be an attractive option for large-scale continuous medical education to help improving PCPs´ knowledge on insulin therapy and potentially improving DM patients´ care. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01759953; http://clinicaltrials.gov/show/NCT01759953 (Archived by WebCite at http://www.webcitation.org/6Dq8Vc7a6).

Educação à distância em nefrologia na Amazônia: processos e resultados / Distance education in nephrology in the Amazon region: processes and results

A carência de docentes qualificados na Região Amazônica levou à adoção de tecnologias de Educação à Distância para organizar a disciplina de Nefrologia do quarto ano do curso de graduação em Medicina da Faculdade São Lucas (FSL), localizada em Porto Velho (RO). Neste trabalho, descrevemos a construção do curso na plataforma Moodle, usando uma estrutura de módulos para discutir os principais tópicos de Nefrologia em fóruns de discussão assíncronos online com base em problemas clínicos ilustrativos, e mostramos os resultados do curso, que já foi realizado com três turmas de alunos, bem como as avaliações da metodologia, realizadas pelos alunos e pela instituição.

The relative lack of qualified teachers in the Amazon Region led to the adoption of Distance Education technologies in order to implement Nephrology classes in the fourth year of the medical course in São Lucas College (Faculdade de São Lucas), located in Porto Velho, Rondonia. In this paper, we describe the construction of the course on the Moodle platform, using a modular structure to discuss the main topics of Nephrology in online asynchronous forums based on illustrative clinical problems, and we also show the results of the classes, which has already been completed with 3 groups of medical students, and the evaluation of the methodology by the students and by the institution.

Increased levothyroxine requirement in a woman with previously well-controlled hypothyroidism and intestinal giardiasis.

The most common cause of apparent inefficiency or resistance to oral therapy with levothyroxine for hypothyroidism is nonadhesion. However, in some subjects in whom the control of hypothyroidism is extremely difficult, levothyroxine bioavailability defects should be considered. We report here the case of a 57-year-old woman with hypothyroidism that was well-controlled for the previous 6 years but suddenly presented with poor hormonal control and abdominal symptoms, despite repeatedly reporting good compliance to therapy. Adequate control of thyroid function was only obtained after intestinal giardiasis was diagnosed and treated.

Increased levothyroxine requirement in a woman with previously well-controlled hypothyroidism and intestinal giardiasis / Aumento da necessidade de levotiroxina em uma paciente com hipotireoidismo previamente bem-controlado e giardíase intestinal

The most common cause of apparent inefficiency or resistance to oral therapy with levothyroxine for hypothyroidism is nonadhesion. However, in some subjects in whom the control of hypothyroidism is extremely difficult, levothyroxine bioavailability defects should be considered. We report here the case of a 57-year-old woman with hypothyroidism that was well-controlled for the previous 6 years but suddenly presented with poor hormonal control and abdominal symptoms, despite repeatedly reporting good compliance to therapy. Adequate control of thyroid function was only obtained after intestinal giardiasis was diagnosed and treated.

A causa mais comum de aparente ineficácia ou resistência ao tratamento do hipotireoidismo com levotiroxina oral é a má adesão. No entanto, em alguns pacientes nos quais o controle do hipotireoidismo é extremamente difícil, defeitos na biodisponibilidade da levotiroxina devem ser considerados. Relatamos aqui o caso de uma mulher de 57 anos de idade com hipotireoidismo que vinha previamente bem controlado durante 6 anos, mas que, abruptamente, começou a apresentar mau controle hormonal, apesar de insistentemente relatar boa adesão ao tratamento. O controle adequado da função tireoidiana só foi possível depois que uma giardíase intestinal foi diagnosticada e tratada.

Management of amiodarone-induced thyrotoxicosis in Latin America: an electronic survey.

OBJECTIVE: To assess diagnostic and therapeutic approaches to amiodarone-induced thyrotoxicosis (AIT) among members of the Latin American Thyroid Society (LATS). METHODS: LATS members responded to an online questionnaire that presented an index case (a 62-year-old man on amiodarone, with thyrotoxic symptoms and a nodular goitre) and a variant (same patient, no goitre). RESULTS: About 25% of invited members responded to the questionnaire. Most respondents lived in iodine-sufficient areas and observed that amiodarone-induced hypothyroidism (AIH) is more common than AIT. Nearly all assessed TSH, and the most used combination of tests was TSH and free T4 (37%). Thyroid autoimmunity was assessed by about 90%. Interleukin-6 (IL-6) was useful to 80%. Additional tests ordered for the index case were: radioactive iodine uptake (RAIU; 57%), echo-colour Doppler sonography (ECDS; about 50%) and fine-needle aspiration biopsy (FNAB; 44%). For the variant, ECDS and RAIU were judged unhelpful by 16%. Most defined the index case as type I AIT and the variant as type II AIT, but 16% in LATS suggested a mixed form in the index case. As initial treatment, nearly all used thionamides in the index case [with potassium perchlorate (KClO(4)) in one-third], while glucocorticoids were indicated to the variant by 66%. Only about 5% considered amiodarone withdrawal unnecessary. If initial strategy is ineffective in type I AIT, KClO(4) (half) or glucocorticoids (a third) are added; in type II, glucocorticoids are indicated by most. Once euthyroidism is restored, ablative therapy is prescribed by a third of respondents for type I AIT. CONCLUSIONS: There are several points of disagreement among thyroidologists regarding AIT management, mainly in the radiological evaluation and the approach to the already stabilized patient if amiodarone needs to be restarted.

[Prevalence of thyroid autoimmunity in a group of patients with type 1 diabetes mellitus in Londrina, PR]. / Prevalência de auto-imunidade tireoidiana em um grupo de pacientes com diabetes mellitus tipo 1 em Londrina, PR.

UNLABELLED: Thyroid autoimmunity is a frequent comorbid condition subjects with in type 1 diabetes mellitus (DM1). We evaluated the prevalence of antithyroid autoantibodies (antimicrosomal, antithyroglobulin and antithyroid peroxidase), in addition to clinical (gender, age, DM duration) and laboratory (TSH, HbA1) characteristics of 101 patients (mean age 20 +/- 9.6 years; 62 female) followed at the HC/UEL. RESULTS: Autoantibodies were found in 31 subjects (30.7%). In the age group <12 years, 15% had thyroid antibodies; from 12 to 18 years, 32%, and >18 years, 35.7% (p= 0.22). Among the patients with positive antibodies, 40% had some thyroid dysfunction vs only 4.4% of those without antibodies (p<0.001). The average TSH was higher in the positive than in negative group (3.75 and 2.32microU/mL, respectively; p= 0.01). CONCLUSIONS: The prevalence of thyroid antibodies was 30.7%, in accordance to the literature.

Prevalência de auto-imunidade tireoidiana em um grupo de pacientes com diabetes mellitus tipo 1 em Londrina, PR / Prevalence of thyroid autoimmunity in a group of patients with type 1 diabetes mellitus from Londrina, PR

A auto-imunidade tireoidiana é uma co-morbidade freqüente entre pacientes com diabetes mellitus tipo 1 (DM1). Neste estudo, avaliamos a prevalência da positividade para auto-anticorpos anti-tireoidianos (anti-microssomal, anti-Tg e anti-TPO), bem como características clínicas (idade, sexo, duracão do DM) e laboratoriais (funcão tireoidiana, HbA1) de 101 pacientes (idade média de 20 n 9,6 anos; 62 do sexo feminino) com DM atendidos no HC/UEL. RESULTADOS: A presenca de auto-anticorpos foi detectada em 31 pacientes (30,7 por cento). No grupo com idade <12 anos, a prevalência de anticorpos foi de 15 por cento; entre 12-18 anos, 32 por cento, e >18 anos, 35,7 por cento (p= 0,22). Entre os 31 pacientes com anticorpos positivos, 40 por cento apresentava alguma disfuncão tireoidiana, comparados a apenas 4,4 por cento daqueles sem anticorpos (p<0,001). O TSH médio foi maior no grupo com anticorpos presentes (3,75 vs. 2,32æU/mL; p= 0,01). CONCLUSAO: A prevalência da positividade para anticorpos marcadores de tireoidite auto-imune foi de em 30,7 por cento, compatível com a literatura.