Exploring mechanisms underlying learning from deliberate reflection: An experimental study.

INTRODUCTION: Previous research suggests that, relative to generating a differential diagnosis, deliberate reflection during practice with clinical cases fosters learning from a subsequently studied scientific text and promotes interest in the subject matter. The present experiment aimed to replicate these findings and to examine whether motivational or cognitive mechanisms, or both, underlie the positive effects of reflection. METHODS: A total of 101 5th-year medical students participated in an experiment containing four phases: Students (a) diagnosed two clinical cases of jaundice-related diseases either through deliberate reflection or differential diagnosis; (b) reported their situational interest and awareness of knowledge gaps; (c) studied a text about jaundice, either under free or restricted time; and (d) recalled the text. Outcome measures were text-recall, situational interest and awareness of knowledge gaps. RESULTS: A main effect of diagnostic approach on recall of the text was found, with the reflection group recalling more studied material than the differential diagnosis group (means: 72.56 vs 58.80; P = .01). No interaction between diagnostic approach and study time (free or restricted) emerged, nor was there a main effect of the latter. Relative to the differential diagnosis group, students who reflected upon the cases scored significantly higher on both situational interest (means: 4.45 vs 3.99, P < .001) and awareness of knowledge gaps (means: 4.13 vs 3.85, P < .01). DISCUSSION: Relative to generating differential diagnoses, reflection upon clinical cases increased learning outcomes on a subsequent study task, an effect that was independent of study time, suggesting that cognitive mechanisms underlie this effect, rather than increases in motivation to study. However, higher scores on situational interest and awareness of knowledge gaps and a tendency towards larger gains when time was free suggest that higher motivation may also contribute to learning from reflection.

Effects of deliberate reflection on students' engagement in learning and learning outcomes.

CONTEXT: Reflection in practice is assumed to enhance interest in knowing more about a topic, increasing engagement in learning and learning outcomes. However, this claim lacks empirical evidence, particularly in medical education. The authors investigated the effects of deliberate reflection upon clinical cases on medical students' engagement in a learning activity and learning outcomes. METHODS: A three-task (diagnostic task; learning activity; test) experiment was conducted in August 2017. Seventy-two fourth-year students from UNIFENAS-BH Medical School, Brazil, diagnosed two clinical cases with jaundice as the chief complaint, either by following a deliberate reflection procedure or making differential diagnosis. Subsequently, all participants received the same study material on the diagnosis of jaundice. Finally, they took a recall test on the study material. Outcome measurements were study time and test scores. RESULTS: There was a significant effect of experimental condition on students' engagement in the learning activity and on learning outcomes. Students who deliberately reflected upon the cases invested more time in studying the material than those who made a differential diagnosis (respectively, mean = 254.97, standard deviation = 115.45 versus mean = 194.96, standard deviation = 111.68; p = 0.02; d = 0.53). Deliberate reflection was also related to higher scores in the test relative to differential diagnosis (respectively, mean = 22.08, standard deviation = 14.94 versus mean = 15.75, standard deviation = 9.24; p = 0.03; d = 0.51). Medium effect sizes (Cohen's d) were observed in both measurements. CONCLUSIONS: Relative to making differential diagnosis, deliberate reflection while diagnosing cases fostered medical students' engagement in learning and increased learning outcomes. Teachers can employ this relatively easy procedure, possibly both with simulated and real scenarios, to motivate their students and help them expand their knowledge, an important requirement for their professional development.

The effect of self-explanation of pathophysiological mechanisms of diseases on medical students' diagnostic performance.

Self-explanation while diagnosing clinical cases fosters medical students' diagnostic performance. In previous studies on self-explanation, students were free to self-explain any aspect of the case, and mostly clinical knowledge was used. Elaboration on knowledge of pathophysiological mechanisms of diseases has been largely unexplored in studies of strategies for teaching clinical reasoning. The purpose of this two-phase experiment was to investigate the effect of self-explanation of pathophysiology during practice with clinical cases on students' diagnostic performance. In the training phase, 39 4th-year medical students were randomly assigned to solve 6 criterion cases (3 of jaundice; 3 of chest pain), either self-explaining the pathophysiological mechanisms of the findings (n = 20) or without self-explaining (n = 19). One-week later, in the assessment phase, all students solved 6 new cases of the same syndromes. A repeated-measures analysis of variance on the mean diagnostic accuracy scores showed no significant main effects of study phase (p = 0.34) and experimental condition (p = 0.10) and no interaction effect (p = 0.42). A post hoc analysis found a significant interaction (p = 0.022) between study phase and syndrome type. Despite equal familiarity with jaundice and chest pain, the performance of the self-explanation group (but not of the non-self-explanation group) on jaundice cases significantly improved between training and assessment phases (p = 0.035) whereas no differences between phases emerged on chest pain cases. Self-explanation of pathophysiology did not improve students' diagnostic performance for all diseases. Apparently, the positive effect of this form of self-explanation on performance depends on the studied diseases sharing similar pathophysiological mechanisms, such as in the jaundice cases.

Assessment of the Implementation of a Chatbot-Based Screening for Burnout and COVID-19 Symptoms Among Residents During the Pandemic.

Background: Early identification of COVID-19 symptoms and burnout among residents is essential for proper management. Digital assistants might help in the large-scale screening of residents. Objective: To assess the implementation of a chatbot for tele-screening emotional exhaustion and COVID-19 among residents at a hospital in Brazil. Methods: From August to October 2020, a chatbot sent participants' phones a daily question about COVID-19 symptoms and a weekly question about emotional exhaustion. After 8 weeks, the residents answered the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). The primary outcome was the reliability of the chatbot in identifying suspect cases of COVID-19 and burnout. Results: Among the 489 eligible residents, 174 (35.6%) agreed to participate. The chatbot identified 61 positive responses for COVID-19 symptoms, and clinical suspicion was confirmed in 9 residents. User error in the first weeks was the leading cause (57.7%, 30 of 52) of nonconfirmed suspicion. The chatbot failed to identify 3 participants with COVID-19 due to nonresponse. Twelve of 118 (10.2%) participants who answered the MBI-HSS were characterized as having burnout by the MBI-HHS. Two of them were identified as at risk by the chatbot and 8 never answered the emotional exhaustion screening question. Conversely, among the 19 participants identified as at risk for emotional exhaustion by the chatbot, 2 (10.5%) were classified with burnout, and 5 (26.3%) as overextended based on MBI-HHS scores. Conclusions: The chatbot was able to identify residents suspected of having COVID-19 and those at risk for burnout. Nonresponse was the leading cause of failure in identifying those at risk.

Late Diagnosis of Disseminated Sporothrix brasiliensis Infection with Bone Marrow Involvement in an HIV-Negative Patient.

Sporotrichosis is a fungal disease that causes symptoms similar to those of other infectious and non-infectious diseases, making diagnosis difficult and challenging. Here, we report a case of an HIV-negative patient presenting disseminated sporotrichosis with widespread cutaneous lesions mimicking pyoderma gangrenosum, with bone marrow infection, pancytopenia, and hemophagocytic syndrome. However, all the clinical manifestations and a bacterial coinfection delayed the request for a fungal diagnosis. Therefore, sporotrichosis should always be investigated in patients from endemic areas presenting with widespread cutaneous lesions associated with pancytopenia.

Soluble inflammatory markers as predictors of virological response in patients with chronic hepatitis C virus infection treated with interferon-α plus ribavirin.

The host immune response plays an important role in viral clearance in patients who are chronically infected with hepatitis C virus (HCV) and are treated with interferon and ribavirin. Activation of the immune system involves the release of pro and anti-inflammatory molecules that can be measured in plasma samples. The present study aimed to evaluate the association between pretreatment plasma levels of chemokines and soluble tumor necrosis factor receptors (sTNF-R) and the virological response in treated patients with chronic hepatitis C infection. Forty-one chronically-infected HCV patients that were being treated with interferon-α (IFN-α) plus ribavirin were included in the study. Socio-demographic, clinical and laboratory data were collected and pretreatment plasma levels of chemokine CCL2, CCL3, CCL11, CCL24, chemokine CXCL9, CXCL10, sTNF-R1 and sTNF-R2 were measured. The virological response was assessed at treatment week 12, at the end of treatment and 24 weeks after treatment. Pretreatment CXCL10 levels were significantly higher in patients without an early virological response (EVR) or sustained virological response (SVR) compared to responders [512.9 pg/mL vs. 179.1 pg/mL (p = 0.011) and 289.9 pg/mL vs. 142.7 pg/mL (p = 0.045), respectively]. The accuracy of CXCL10 as a predictor of the absence of EVR and SVR was 0.79 [confidence interval (CI) 95%: 0.59-0.99] and 0.69 (CI 95%: 0.51-0.87), respectively. Pretreatment plasma levels of the other soluble inflammatory markers evaluated were not associated with a treatment response. Pretreatment CXCL10 levels were predictive of both EVR and SVR to IFN-α and ribavirin and may be useful in the evaluation of candidates for therapy.

Simulation-based Training for Pelvic and Breast Physical Examination: Effect on the Anxiety and Self-confidence of Medical Students.

OBJECTIVE: To evaluate factors associated with anxiety and the effect of simulation-based training (SBT) on student anxiety, self-confidence and learning satisfaction in relation to pelvic and breast examination. METHODS: A longitudinal study was conducted with 4th year medical students at the Universidade José do Rosário Vellano. A 12-item, self-report questionnaire on student anxiety at performing gynecological examinations was applied before and after SBT, with answers being given on a Likert-type scale. After training, the self-confidence levels and satisfaction of the students related to the learning process were also evaluated. RESULTS: Eighty students with a mean age of 24.1 ± 4.2 years were included in the study. Of these, 62.5% were women. Pre-SBT evaluation showed that students were more anxious at performing a pelvic examination than a breast examination (2.4 ± 1.0 versus 1.7 ± 0.8, respectively; p < 0.001). The primary reason for anxiety regarding both pelvic and breast examination was fear of hurting the patient. SBT significantly reduced student anxiety (2.0 ± 0.8 versus 1.5 ± 0.5, respectively; p < 0.001). The satisfaction and self-confidence of the students were found to be high (6.8 ± 0.3 and 6.0 ± 0.9, respectively), with no difference between genders. CONCLUSION: The use of SBT in teaching students to perform pelvic and breast examinations resulted in reduced anxiety and increased self-confidence in a group of medical students of both genders, with high levels of satisfaction in relation to the training.

OBJETIVO: Avaliar os fatores relacionados à ansiedade e ao efeito do treinamento baseado em simulação (TBS) na ansiedade, autoconfiança e satisfação do estudante em relação ao aprendizado do exame pélvico e de mamas. MéTODOS: Estudo longitudinal com alunos do quarto ano de medicina da Universidade José do Rosário Vellano, utilizando questionário autorrespondido com 12 itens em escala tipo Likert sobre a ansiedade em relação ao exame ginecológico, pré e pós-TBS. Após o treinamento, avaliou-se também o grau de autoconfiança e satisfação com o processo de aprendizado. RESULTADOS: Foram incluídoS: 80 alunos com média etária de 24,1 ± 4,2 anos, dos quais 62,5% eram mulheres. Na avaliação pré-treinamento, a ansiedade dos alunos em relação ao exame pélvico foi maior do que a ansiedade em relação ao exame das mamas (2,4 ± 1,0 versus 1,7 ± 0,8, respectivamente; p < 0,001). O principal motivo de ansiedade em relação tanto ao exame pélvico quanto ao de mamas foi o receio de machucar a paciente. O TBS reduziu significativamente a ansiedade dos alunos (2,0 ± 0,8 versus 1,5 ± 0,5, respectivamente; p < 0,001). A satisfação e autoconfiança dos estudantes foram elevadas (6,8 ± 0,3 e 6,0 ± 0,9, respectivamente), sem diferença entre gêneros. CONCLUSãO: O uso de TBS no ensino de exame pélvico e mamário resultou em uma diminuição na ansiedade e elevada autoconfiança em um grupo de estudantes de medicina, de ambos os gêneros, e bons níveis de satisfação em relação ao treinamento.

COVID-19 in long-term care facilities for the elderly: laboratory screening and disease dissemination prevention strategies. / COVID-19 nas instituições de longa permanência para idosos: estratégias de rastreamento laboratorial e prevenção da propagação da doença.

An infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the 2019 Novel Coronavirus Disease (COVID-19) pandemic has unveiled a hitherto hidden reality: the vulnerability of the population living in long-term care facilities for the elderly (LTCF). To date, several scientific publications have revealed a concentration of up to 60% of deaths attributed to COVID-19 in such institutions. Most LTFC residents share the primary risk factors currently associated with increased morbimortality due to the COVID-19 infection. It is crucial to define actions to prevent SARS-CoV-2 spread in this environment, besides the usual measures of social distancing and isolation of the carriers of this disease. This paper proposes strategies for the investigation of this infection in LTCF residents and workers using laboratory tests available in Brazil. The early identification of individuals with SARS-CoV-2, who may actively and continuously spread the virus, allows adopting measures aimed at interrupting the local transmission cycle of this infection.

Fatores associados à saúde mental de alunos do internato interprofissional de enfrentamento à COVID-19: um estudo transversal / Factors associated with the mental health of students participating in an interprofessional COVID-19 internship: a cross-sectional study

Objetivo: analisar os fatores associados a sintomas ansiosos e depressivos de alunos do internato interprofissional da Santa Casa de Belo Horizonte. Analisou-se também a autopercepção de aprendizagem e satisfação. Método: estudo transversal no qual analisou-se os fatores associados a sintomas ansiosos e depressivos estimados pelo Transtorno de Ansiedade Generalizada (GAD-7) e pelo Questionário de Saúde do Paciente (PHQ-9) em alunos de um internato interprofissional de enfrentamento à COVID-19. Ao final do internato, analisou-se a percepção do alcance dos objetivos de aprendizagem e a experiência do aluno utilizando Net Promoter Score (NPS). Resultado: entre os 92 alunos analisados, 22 (23,9%) apresentaram escores elevados para sintomas ansiosos e 26 (28,3%) para sintomas depressivos. A frequência de sintomas ansiosos foi maior entre alunos de farmácia quando comparados aos de medicina ou enfermagem (42,9%, 28,9%, 9,7%, respectivamente, p=0,035). Sintomas ansiosos foram menos frequentes entre alunos que sempre tiveram acesso a equipamento de proteção individual (EPI) quando comparados aos demais (17,7% vs. 36,7%; p=0,046). Alunos que tiveram sintomas de COVID-19, quando comparados aos demais, apresentaram maior frequência de sintomas ansiosos (44,1% vs. 12,1%; p=0,001) e depressivos (41,2% vs. 20,7%; p=0,035). O atendimento a pacientes com COVID-19 não esteve associado a sintomas depressivos nem ansiosos. Observou-se alto nível de percepção do alcance dos objetivos de aprendizagem, maior entre estudantes de enfermagem. O escore geral do NPS foi de 70, com maior frequência de promotores entre alunos de enfermagem (90%), quando comparados aos de farmácia (67%) e medicina (62%). Conclusão: sintomas ansiosos estiveram associados à categoria profissional, acesso a EPI e história prévia de sintomas de COVID-19.A percepção do alcance de objetivos propostos foi elevada e o escore NPS foi satisfatório, com maior proporção de promotores na enfermagem

Objective: to analyze the factors associated with symptoms of anxiety and depression among interprofessional students at Santa Casa de Belo Horizonte. Self-perception of learning and satisfaction were also analyzed. Methods: cross-sectional study that analyzed the factors associated with symptoms of anxiety and depression estimated by the Generalized Anxiety Disorder 7-item (GAD-7) and Patient Health Questionnaire-9 (PHQ-9). At the end of the internship, the perception of achievement of learning objectives and the student's experience were analyzed using the Net Promoter Score (NPS). Results: among the 92 students analyzed, 22 (23,9%) had high scores for anxiety symptoms and 26 (28,3%) for depressive symptoms. The frequency of anxious symptoms was higher among pharmacy students when compared to medicine or nursing students (42.9%, 28.9%, 9.7%, respectively, p=0.035). Anxiety symptoms were less frequent among students who always had access to personal protective equipment (PPE) when compared to the others (17.7% vs. 36.7%; p=0.046). Students who had symptoms of Covid-19, when compared to the others, had a higher frequency of anxiety (44.1% vs. 12.1%; p=0.001) and depressive symptoms (41.2% vs. 20.7%; p =0.035). Caring for Covid-19 patients was not associated with depression or anxiety. There was a high level of perception of achievement of learning objectives, higher among nursing students. Overall NPS score was 70, with a higher frequency of promoters among nursing students (90%), when compared to those in pharmacy (67%) or medicine (62%). Conclusion: anxiety symptoms were associated with the professional category, access to PPE, and previous history of Covid-19. The perception of achievement of learning objectives was high and the NPS score was satisfactory, with more promoters among nursing students

Associação entre o uso não prescrito de nootrópicos e qualidade do sono em estudantes de medicina / Association between nonprescription use of nootropics and sleep quality in medical students

Objetivos: analisar a qualidade do sono de estudantes de medicina em uma universidade privada brasileira e sua associação com o uso não prescrito de nootrópicos (metilfenidato, lisdexanfetamina e modafinil). Métodos: a qualidade do sono foi analisada utilizando-se o questionário de Pittsburgh (PSQI). Considerou-se um questionário sociodemográfico para identificação psicossocial dos participantes e uso de nootrópicos. Os resultados foram representados como média e desvio-padrão (para as variáveis quantitativas) ou frequência (para as qualitativas), e as associações foram analisadas pelo teste de qui-quadrado. Resultados: responderam ao questionário 362 alunos. Os níveis médios de PSQI global em estudantes com uso recente não prescrito de nootrópicos foi semelhante ao observado para estudantes que nunca usaram nootrópicos (7,76 vs. 7,73; p=0,96). A análise do PSQI por domínio específico também não mostrou diferença estatisticamente significativa. Observou-se que 23,6% das mulheres e 33,9% dos homens tiveram boa qualidade do sono, sendo essa diferença estatisticamente significativa (p=0,04). O uso de seis doses ou mais de bebida alcoólica esteve relacionado com níveis mais altos do PSQI (7,47 vs. 8,19; p=0,047). Alunos com qualidade do sono ruim apresentaram menor satisfação com a escolha profissional (OR = 1.84; IC95%= 1.09 - 3.11), menor percepção de aquisição de habilidades (OR = 1.96; IC95% = 1.16 - 3.31) e maior proporção de pensamentos relacionados a abandonar o curso (OR = 0,46; IC95% = 0,27 - 0,77). O uso recente e não prescrito de nootrópicos esteve associado ao uso de maconha e ao desejo de abandonar o curso. Conclusões: a qualidade do sono foi pior no sexo feminino e naqueles com maior ingestão de álcool; esteve associada à menor satisfação com escolha profissional e desejo de abandono do curso

Aims: analysing the quality of sleep of the medical students at a private university and its association with the non-prescription use of nootropics (methylphenidate, lisdexamfetamine and modafinil). Methods: the sleep quality was analyzed by using the Pittsburgh Sleep Quality Index. A sociodemographic questionnaire was considered to identify the psychosocial characteristics of the participants and the use of nootropics. Results were represented as mean and standard deviation (for quantitative variables) or frequency (for qualitative variables), and associations were analyzed using the chisquare test. Results: 362 students answered the questionnaire. The medium levels of global PSQI in students with recent unprescribed use of nootropics was like that observed for students who had never used nootropics (7.76 vs.7.73; p=0.96). The PSQI analysis by specific domain also showed no statistically significant difference for any domain. It was observed that 23.6% of women and 33,9% of men had good sleep quality, with this difference being statistically significant (p=0.04). The use of six doses or more of alcoholic beverages was related to higher levels of PSQI (7.47 vs. 8.19; p=0.047). Students with poor sleep quality had less satisfaction with their professional choice (OR = 1.84; 95% CI= 1.09 - 3.11), lower perception of skills acquisition (OR= 1.96; 95%CI = 1.16 - 3.31) and a higher proportion of thoughts related to dropping out of the course (OR = 0.46; 95%CI = 0.27 - 0.77). Recent and non-prescription use of nootropics was associated with marijuana use and the desire to drop out of the course. Conclusions: sleep quality was worse in females and in those with higher alcohol intake, and was associated with lower satisfaction with professional choice and desire to drop out of the course. No association was found between non-prescription use of nootropics and sleep quality in medical students

Clinical and radiographic features of HIV-related pulmonary tuberculosis according to the level of immunosuppression.

Medical charts and radiographs from 38 HIV-infected patients with positive cultures for Mycobacterium tuberculosis from sputum or bronchoalveolar lavage were reviewed in order to compare the clinical, radiographic, and sputum bacilloscopy characteristics of HIV-infected patients with pulmonary tuberculosis according to CD4+ lymphocyte count (CD4). The mean age of the patients was 32 years and 76% were male. The median CD4 was 106 cells/mm(3) and 71% had CD4 < 200 cells/mm(3). Sputum bacilloscopy was positive in 45% of the patients. Patients with CD4 < 200 cells/mm(3) showed significantly less post-primary pattern (7% vs. 63%; p = 0.02) and more frequently reported weight loss (p = 0.04). Although not statistically significant, patients with lower CD4 showed lower positivity of sputum bacilloscopy (37% vs. 64%; p = 0.18). HIV-infected patients with culture-confirmed pulmonary tuberculosis had a high proportion of non-post-primary pattern in thoracic radiographs. Patients with CD4 lower than 200 cells/mm(3) showed post-primary patterns less frequently and reported weight loss more frequently.

The use of deliberate reflection to reduce confirmation bias among orthopedic surgery residents / O uso da reflexão deliberada para reduzir o viés de confirmação em residentes de ortopedia

Introduction: cognitive biases might affect decision-making processes such as clinical reasoning and confirmation bias is among the most important ones. The use of strategies that stimulate deliberate reflection during the diagnostic process seems to reduce availability bias, but its effect in reducing confirmation bias needs to be evaluated. Aims: to examine whether deliberate reflection reduces confirmation bias and increases the diagnostic accuracy of orthopedic residents solving written clinical cases. Methods: experimental study comparing the diagnostic accuracy of orthopedic residents in the resolution of eight written clinical cases containing a referral diagnosis. Half of the written cases had a wrong referral diagnosis. One group of residents used deliberate reflection (RG), which stimulates comparison and contrast of clinical hypotheses in a systematic manner, and a control group (CG), was asked to provide differential diagnoses with no further instruction. The study included 55 third-year orthopedic residents, 27 allocated to the RG and 28 to the CG. Results: residents on the RG had higher diagnostic scores than the CG for clinical cases with a correct referral diagnosis (62.0±20.1 vs. 49.1±21.0 respectively; p = 0.021). For clinical cases with incorrect referral diagnosis, diagnostic accuracy was similar between residents on the RG and those on the CG (39.8±24.3 vs. 44.6±26.7 respectively; p = 0.662). We observed an overall confirmation bias in 26.3% of initial diagnoses (non-analytic phase) and 19.5% of final diagnoses (analytic phase) when solving clinical cases with incorrect referral diagnosis. Residents from RG showed a reduction in confirmation of incorrect referral diagnosis when comparing the initial diagnosis given in the non-analytic phase with the one provided as the final diagnosis (25.9±17.7 vs. 17.6±18.1, respectively; Cohen d: 0.46; p = 0.003). In the CG, the reduction in the confirmation of incorrect diagnosis was not statistically significant. Conclusions:confirmation bias was present when residents solved written clinical cases with incorrect referral diagnoses, and deliberate reflection reduced such bias. Despite the reduction in confirmation bias, diagnostic accuracy of residents from the RG was similar to those from the CG when solving the set of clinical cases with a wrong referral diagnosis.

Introdução: os vieses cognitivos podem afetar tanto os processos de tomada de decisão como o raciocínio clínico e o viés de confirmação está entre os mais importantes. O uso de estratégias que estimulem a reflexão deliberada durante o processo diagnóstico parece reduzir o viés de disponibilidade, mas seu efeito na redução do viés de confirmação precisa ser avaliado. Objetivos: examinar se a reflexão deliberada reduz o viés de confirmação e aumenta a acurácia do diagnóstico de residentes de ortopedia ao resolverem casos clínicos escritos. Métodos: estudo experimental comparando a acurácia diagnóstica de residentes de ortopedia na resolução de oito casos clínicos escritos contendo um diagnóstico de encaminhamento. Metade dos casos escritos tinha um diagnóstico de encaminhamento errado. Um grupo de residentes utilizou a reflexão deliberada (GR), que estimula a comparação e o contraste de hipóteses clínicas de maneira sistemática, e um grupo controle (GC) foi solicitado a fornecer diagnósticos diferenciais sem maiores instruções. O estudo incluiu 55 residentes de ortopedia do terceiro ano, 27 alocados no GR e 28 no GC. Resultados: residentes no GR tiveram escores diagnósticos mais altos do que o GC para casos clínicos com um diagnóstico de encaminhamento correto (62,0±20,1 vs. 49,1±21,0 respectivamente; p = 0,021). Para os casos clínicos com diagnóstico de encaminhamento incorreto, a acurácia diagnóstica foi semelhante entre os residentes do GR e os do GC (39,8±24,3 vs. 44,6±26,7 respectivamente; p = 0,662). Observamos viés geral de confirmação em 26,3% dos diagnósticos iniciais (fase não analítica) e 19,5% dos diagnósticos finais (fase analítica) na resolução de casos clínicos com diagnóstico de encaminhamento incorreto. Os residentes do GR mostraram uma redução na confirmação do diagnóstico de encaminhamento incorreto ao comparar o diagnóstico inicial dado na fase não analítica com aquele fornecido como diagnóstico final (25,9±17,7 vs. 17,6±18,1, respectivamente; Cohen d: 0,46; p = 0,003). No GC, a redução na confirmação do diagnóstico incorreto não foi estatisticamente significativa. Conclusões: o viés de confirmação esteve presente quando os residentes resolveram casos clínicos escritos com diagnósticos de encaminhamento incorretos e a reflexão deliberada reduziu esse viés. Apesar da redução do viés de confirmação, a acurácia diagnóstica dos residentes do GR foi semelhante à do GC na solução do conjunto de casos clínicos com diagnóstico de encaminhamento incorreto.

Risk factors for neurocognitive impairment in HIV-infected patients and comparison of different screening tools.

HIV-associated neurocognitive disorder (HAND) is relatively frequent among HIV-infected patients and is often underdiagnosed. Assessment of HAND in daily clinical practice is challenging and different tools have been proposed. OBJECTIVE: To evaluate risk factors and compare different screening tools for neurocognitive impairment in HIV-infected patients. METHODS: HIV-infected patients were evaluated using the International HIV-Dementia Scale (IHDS), Mini-Mental State Examination (MMSE) and a neurocognitive self-perception questionnaire recommended by the European AIDS Clinical Society. Sociodemographic, clinical and laboratory data were obtained through chart review and patient interview. RESULTS: Among the 63 patients included, low performance on the IHDS was observed in 54.0% and IHDS score was inversely associated with age (OR 0.13; 95%CI [0.02-0.67]). Regarding cognitive self-perception, 63.5% of patients reported no impairment on the three domains covered by the questionnaire. Among those patients self-reporting no problems, 42.1% had low performance on the IHDS. None of the patients scored below the education-adjusted cut-off on the MMSE. CONCLUSION: IHDS scores suggestive of HAND were observed in more than half of the patients and lower scores were found among older patients. There was low agreement between the different tools, suggesting that the MMSE may be inadequate for assessing HAND. The self-assessment questionnaire had low sensitivity and might not be useful as a screening tool.

As alterações neurocognitivas associadas ao HIV (HAND) são relativamente frequentes entre pacientes infectados pelo HIV, porém são subdiagnosticadas. Avaliação de HAND na prática clínica diária é desafiador e diferentes ferramentas têm sido propostas. OBJETIVO: Avaliar fatores de risco e comparar diferentes ferramentas de rastreamento de alterações neurocognitivas em pacientes infectados pelo HIV. MÉTODOS: Pacientes infectados pelo HIV foram avaliados usando a Escala Internacional de Demência pelo HIV (IHDS), Mini Exame do Estado Mental (MEEM) e um questionário de autopercepção neurocognitiva recomendado pela Sociedade Clínica Europeia de AIDS. Dados sociodemográficos, clínicos e laboratoriais foram obtidos por revisão de prontuário e entrevista com o paciente. RESULTADOS: Entre os 63 pacientes incluídos no estudo, um baixo desempenho no IHDS foi observado em 54,0% e o escore no IHDS esteve inversamente associado à idade (OR 0,13; IC95% [0,02-0,67]). Em relação à autopercepção cognitiva, 63,5% dos pacientes não relataram nenhum prejuízo nos três domínios avaliados pelo instrumento. Nenhum paciente apresentou escore no MEEM abaixo do ponto de corte ajustado para escolaridade. CONCLUSÃO: Escores no IHDS sugestivos de HAND foram observados em mais da metade dos pacientes e valores mais baixos foram encontrados entre pacientes mais velhos. Houve pouca concordância entre os diferentes métodos de avaliação, sugerindo que o MEEM é inadequado para avaliação de HAND e o questionário de auto-avaliação tem uma baixa sensibilidade, não parecendo ser útil como ferramenta de triagem.

Simulation-based training for pelvic and breast physical examination: Effect on the anxiety and self-confidence of medical students / Treinamento baseado em simulação para exame físico pélvico e de mamas: Efeito na ansiedade e autoconfiança dos estudantes de medicina

Abstract Objective: To evaluate factors associated with anxiety and the effect of simulation-based training (SBT) on student anxiety, self-confidence and learning satisfaction in relation to pelvic and breast examination. Methods: A longitudinal study was conducted with 4th year medical students at the Universidade José do Rosário Vellano. A 12-item, self-report questionnaire on student anxiety at performing gynecological examinations was applied before and after SBT, with answers being given on a Likert-type scale. After training, the self-confidence levels and satisfaction of the students related to the learning process were also evaluated. Results: Eighty students with a mean age of 24.1 ± 4.2 years were included in the study. Of these, 62.5% were women. Pre-SBT evaluation showed that students were more anxious at performing a pelvic examination than a breast examination (2.4 ± 1.0 versus 1.7 ± 0.8, respectively; p < 0.001). The primary reason for anxiety regarding both pelvic and breast examination was fear of hurting the patient. SBT significantly reduced student anxiety (2.0 ± 0.8 versus 1.5 ± 0.5, respectively; p < 0.001). The satisfaction and self-confidence of the students were found to be high (6.8 ± 0.3 and 6.0 ± 0.9, respectively), with no difference between genders. Conclusion: The use of SBT in teaching students to perform pelvic and breast examinations resulted in reduced anxiety and increased self-confidence in a group of medical students of both genders, with high levels of satisfaction in relation to the training.

Resumo Objetivo: Avaliar os fatores relacionados à ansiedade e ao efeito do treinamento baseado em simulação (TBS) na ansiedade, autoconfiança e satisfação do estudante em relação ao aprendizado do exame pélvico e de mamas. Métodos: Estudo longitudinal com alunos do quarto ano de medicina da Universidade José do Rosário Vellano, utilizando questionário autorrespondido com 12 itens em escala tipo Likert sobre a ansiedade em relação ao exame ginecológico, pré e pós-TBS. Após o treinamento, avaliou-se também o grau de autoconfiança e satisfação com o processo de aprendizado. Resultados: Foram incluídos 80 alunos com média etária de 24,1 ± 4,2 anos, dos quais 62,5% eram mulheres. Na avaliação pré-treinamento, a ansiedade dos alunos em relação ao exame pélvico foi maior do que a ansiedade em relação ao exame das mamas (2,4 ± 1,0 versus 1,7 ± 0,8, respectivamente; p < 0,001). O principal motivo de ansiedade em relação tanto ao exame pélvico quanto ao de mamas foi o receio de machucar a paciente. O TBS reduziu significativamente a ansiedade dos alunos (2,0 ± 0,8 versus 1,5 ± 0,5, respectivamente; p < 0,001). A satisfação e autoconfiança dos estudantes foram elevadas (6,8 ± 0,3 e 6,0 ± 0,9, respectivamente), sem diferença entre gêneros. Conclusão: O uso de TBS no ensino de exame pélvico e mamário resultou em uma diminuição na ansiedade e elevada autoconfiança em um grupo de estudantes de medicina, de ambos os gêneros, e bons níveis de satisfação em relação ao treinamento.

COVID-19 nas instituições de longa permanência para idosos: estratégias de rastreamento laboratorial e prevenção da propagação da doença / COVID-19 in long-term care facilities for the elderly: laboratory screening and disease dissemination prevention strategies

Resumo A pandemia da "novel coronavirus disease" 2019 (COVID-19), infecção causada pelo coronavírus 2 da síndrome respiratória aguda grave (SARS-CoV-2), tem descortinado uma realidade até então oculta: a vulnerabilidade da população residente em instituições de longa permanência para idosos (ILPI). Diversas publicações científicas têm revelado a concentração de até 60% dos óbitos atribuídos à COVID-19 em tais instituições. A maioria dos residentes em ILPI reúnem os principais fatores de risco para morbimortalidade pela COVID-19, o que torna imprescindível a definição de ações voltadas à prevenção da transmissibilidade do SARS-CoV-2 neste ambiente, além das medidas usuais de distanciamento social e isolamento dos portadores da doença. Propõem-se, no presente artigo, estratégias de rastreamento da infecção em residentes e trabalhadores de ILPI por meio de testes laboratoriais disponíveis no Brasil. A identificação precoce de indivíduos portadores do SARS-CoV-2 com possibilidades de transmissão ativa e continuada do vírus permite a adoção de medidas que interrompam o ciclo de transmissão local da infecção.

Abstract An infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the 2019 Novel Coronavirus Disease (COVID-19) pandemic has unveiled a hitherto hidden reality: the vulnerability of the population living in long-term care facilities for the elderly (LTCF). To date, several scientific publications have revealed a concentration of up to 60% of deaths attributed to COVID-19 in such institutions. Most LTFC residents share the primary risk factors currently associated with increased morbimortality due to the COVID-19 infection. It is crucial to define actions to prevent SARS-CoV-2 spread in this environment, besides the usual measures of social distancing and isolation of the carriers of this disease. This paper proposes strategies for the investigation of this infection in LTCF residents and workers using laboratory tests available in Brazil. The early identification of individuals with SARS-CoV-2, who may actively and continuously spread the virus, allows adopting measures aimed at interrupting the local transmission cycle of this infection.

Sexual dysfunction and dissatisfaction in chronic hepatitis C patients.

INTRODUCTION: The prevalence of sexual dysfunction (SD) and dissatisfaction with sexual life (DSL) in patients with chronic hepatitis C virus infection (CHC) was jointly investigated via a thorough psychopathological analysis, which included dimensions such as fatigue, impulsiveness, psychiatric comorbidity, health-related quality of life (HRQL) and sociodemographic and clinical characteristics. METHODS: Male and female CHC patients from an outpatient referral center were assessed using the Brief Fatigue Inventory, the Barrat Impulsiveness Scale, the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale, the Hamilton Anxiety Scale (HAM-A), and the World Health Organization Quality of Life Scale-Brief Version (WHOQOL-BREF). Structured psychiatric interviews were performed according to the Mini-International Neuropsychiatric Interview. SD was assessed based on specific items in the BDI (item 21) and the HAM-A (item 12). DSL was assessed based on a specific question in the WHOQOL-BREF (item 21). Multivariate analysis was performed according to an ordinal linear regression model in which SD and DSL were considered as outcome variables. RESULTS: SD was reported by 60 (57.1%) of the patients according to the results of the BDI and by 54 (51.4%) of the patients according to the results of the HAM-A. SD was associated with older age, female gender, viral genotype 2 or 3, interferon-α use, impulsiveness, depressive symptoms, antidepressant and benzodiazepine use, and lower HRQL. DSL was reported by 34 (32.4%) of the patients and was associated with depressive symptoms, anxiety symptoms, antidepressant use, and lower HRQL. CONCLUSIONS: The prevalence of SD and DSL in CHC patients was high and was associated with factors, such as depressive symptoms and antidepressant use. Screening and managing these conditions represent significant steps toward improving medical assistance and the HRQL of CHC patients.

Impulsiveness in chronic hepatitis C patients.

OBJECTIVE: The objective was to investigate impulsiveness among chronic hepatitis C (CHC) patients and its association with sociodemographic, clinical and psychopathological factors. METHOD: Ninety-one CHC individuals were enrolled in a cross-sectional study at a Brazilian public university-based outpatient's service for infectious diseases. They were assessed using the Barrat Impulsiveness Scale, Brief Fatigue Inventory, Beck Depression Inventory and Hamilton Anxiety Scale. Structured psychiatric interview was performed according to the Mini International Neuropsychiatric Interview. Multivariate analysis was performed according to linear stepwise forward regression. RESULTS: The total score of impulsiveness according to BIS in studied population was 64.6±9.8. The scores for the nonplanning, cognitive-attentional and motor domains were 23.8±5, 19.4±2.9 and 21.4±5, respectively. Impulsiveness was associated with lower educational level, current interferon-α (IFN) use, attention-deficit/hyperactivity disorder, alcohol use disorder, mixed anxiety and depressive disorder, specific phobia, bipolar spectrum disorders and anxiety symptoms. During IFN treatment, impulsiveness was also associated with suicide risk. CONCLUSION: Impulsiveness was frequent in CHC patients and was associated with several psychopathological alterations. Impulsiveness management should be considered when attending CHC patients.

Health related quality of life among patients with chronic hepatitis C: a cross-sectional study of sociodemographic, psychopathological and psychiatric determinants.

INTRODUCTION: Chronic hepatitis C virus infection patients have higher rates of psychiatric disorders than the general population. Chronic hepatitis C virus infection is known to be associated with impaired health related quality of life. To our knowledge, there is no previous research of health related quality of life in chronic hepatitis C patients that combined structured psychiatric interview and careful psychopathological evaluation, including depression, anxiety and fatigue instruments. The aim of this study was to evaluate health related quality of life of chronic hepatitis C patients and to investigate the association with sociodemographic, psychopathological and psychiatric factors. MATERIALS AND METHODS: Eighty-one individuals with chronic hepatitis C virus infection receiving care at a Brazilian public university-based outpatient service for infectious diseases were enrolled in the study. The World Health Organization Quality of Life Scale Brief Version was used to assess health related quality of life. Standard psychiatric interview (Mini International Neuropsychiatric Interview-Plus) was conducted to establish Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I psychiatric diagnosis. Further instruments completed psychopathological investigation: Beck Depression Inventory, Hospital Anxiety and Depression Scale, Brief Fatigue Inventory, Hamilton Depression Scale and Hamilton Anxiety Scale. Pearson Chi-Square and Kruskal-Wallis were performed for categorical and continuous univariate analysis, respectively. Correlation between psychopathological and health related quality of life scores was performed according to Spearman's correlation. Multivariate analysis was performed according to stepwise forward ordinal logistic regression. The significance threshold was fixed at α=0.05. RESULTS: Depressive disorders were associated with worse scores in overall health related quality of life and in all domains. Fatigue was associated with lower scores in physical and psychological domains, and married status with higher scores in psychological health related quality of life. We found strong correlation among scores of depression, fatigue and health related quality of life. CONCLUSION: Depression and fatigue must be properly investigated and managed in HCV patients in order to improve HRQL. WHOQOL-BREF proved to be a useful instrument to assess HRQL in HCV patients.