Experiences of disabled students in undergraduate medical education.

PURPOSE: Since people with disabilities (PwD) are underrepresented in medical education, the authors of this article conducted a qualitative research in the form of an in-depth interview with students with disabilities from a medical school in Brazil, to characterize their experiences in medical education and identify barriers and facilitators to inclusion. MATERIALS AND METHODS: Participants were recruited by snowball sampling, signed an informed consent form, and completed a socioeconomic questionnaire. They were interviewed individually with open-ended questions so that they could develop narratives. RESULTS: The students identified some barriers to inclusion - teachers' lack of knowledge about students' special needs, students' own lack of knowledge about their needs during the medical course, underestimation of the disability by teachers and classmates, difficult access to college buildings - and facilitators, such as acceptance of the disability by professors and colleagues, proactivity of professors and colleagues in adapting practical learning scenarios. CONCLUSION: Students identified peer and teacher acceptance as an important determinant of inclusion, which is in line with the biopsychosocial view of disability. They also reported doubts about their ability to practice medicine, which dialogues with literature research that points to a medical culture that expects nothing less than perfection from students.

Education is an important factor in end-of-life care: results from a survey of Brazilian physicians' attitudes and knowledge in end-of-life medicine.

BACKGROUND: According to the Latin America Association for palliative care, Brazil offers only 0.48 palliative care services per 1 million inhabitants. In 2012, no accredited physicians were working in palliative care, while only 1.1% of medical schools included palliative care education in their undergraduate curricula. As a reflection of the current scenario, little research about end-of-life care has been published so that studies addressing this subject in the Brazilian setting are crucial. METHODS: A cross-sectional study study conducted with students applying for the medical residency of the Federal University of São Paulo were invited to voluntarily participate in an anonymous and self-administered questionnaire survey. The latter included demographic information, attitudes, prior training in end-of-life care, prior end-of-life care experience, the 20-item Palliative Care Knowledge Test (PCKT) and a consent term. RESULTS: Of the 3086 subjects applying for residency, 2349 (76%) answered the survey, 2225 were eligible for analysis while 124 were excluded due to incomplete data. Although the majority (99,2%) thought it was important to have palliative care education in the medical curriculum, less than half of them (46,2%) reported having received no education on palliative care. The overall performance in the PCKT was poor, with a mean score of 10,79 (± 3). While philosophical questions were correctly answered (81,8% of correct answers), most participants lacked knowledge in symptom control (50,7% for pain, 57,3% for dyspnea, 52,2% for psychiatric problems and 43,4% for gastrointestinal problems). Doctors that had already concluded a prior residency program and the ones that had prior experience with terminal patients performed better in the PCKT (p < 0,001). The high-performance group (more than 50% of correct answers) had received more training in end-of-life care, showed more interest in learning more about the subject, had a better sense of preparedness, as well as a higher percentage of experience in caring for terminal patients (p < 0,001). CONCLUSIONS: Our study showed that Brazilian physicians lack not only the knowledge, but also training in end-of-life medicine. Important factors to better knowledge in end-of-life care were prior training, previous contact with dying patients and prior medical residency. Corroborating the literature, for this group, training showed to be a key factor in overall in this area of knowledge. Therefore, Brazilian medical schools and residency programs should focus on improving palliative training, especially those involving contact with dying patients.

Evidências de revisões sistemáticas Cochrane sobre o tratamento da fibrilação atrial / Evidence from Cochrane systematic reviews on the treatment of atrial fibrillation

Contexto: A fibrilação atrial é uma taquiarritmia supraventricular prevalente, associada a um risco elevado de fenômenos tromboembólicos complicações cardiovasculares. Muitas intervenções são propostas para o tratamento da fibrilação atrial e para a prevenção de suas principais complicações. Objetivo: Avaliar evidências de revisões sistemáticas Cochrane sobre efetividade e segurança de intervenções para fibrilação atrial. Métodos: Revisão de revisões sistemáticas com busca sistematizada na Biblioteca Cochrane. Dois autores avaliaram os critérios de elegibilidade das revisões encontradas e sumarizaram de modo qualitativo seus resultados. Resultados: Foram incluídas 11 revisões sistemáticas Cochrane, que forneceram evidências de qualidade desconhecida a moderada para intervenções em pacientes com fibrilação atrial. Conclusão: Nenhuma evidência de alta qualidade foi relatada pelas revisões sistemáticas incluídas. Desta forma, qualquer conclusão sólida para a prática clínica em fibrilação atrial dependerá de novos estudos primários e de atualizações das revisões existentes.

Characterization of cardiac arrest in the emergency department of a Brazilian University Reference Hospital: A prospective study.

BACKGROUND & OBJECTIVES: Sudden cardiac arrest (CA) represents one of the greatest challenges for medicine due to the vast number of cases and its social and economic impact. Despite advances in cardiopulmonary resuscitation (CPR) techniques, mortality rates have not significantly decreased over decades. This study was undertaken to characterize patients that have suffered CA and to identify factors related to mortality. METHODS: This prospective study was conducted at Emergency Department of São Paulo Hospital, Brazil. Two hundred and eighty five patients were followed for one year after treatment for CA. The mean age was 66.3±17.2 yr, and they were predominantly male (55.8%) and Caucasian (71.9%). Mortality rate and factors associated with mortality were the primary and secondary outcome measures. Data were collected using an in-hospital Utstein-style report. A logistic regression analysis was used to determine which variables were related to mortality. RESULTS: Regarding the characteristics of CPR, 76.5 per cent occurred in hospital, respiratory failure was the most common presumed immediate cause of CA (30.8%) and pulseless electrical activity was the most frequent initial rhythm (58.7%). All attempts at CPR utilized chest compressions and ventilation and the most utilized interventions were epinephrine (97.2%) and intubation (68.5%). Of all patients treated, 95.4 per cent died. Patients with pulseless electrical activity had a higher risk of death than those patients with ventricular fibrillation. INTERPRETATION & CONCLUSIONS: The findings of the study highlighted that the mortality rate among CA patients was high. The variable that best explained mortality was the initial CA rhythm.

Statins for progression of aortic valve stenosis and the best evidence for making decisions in health care.

In the Western world, calcified aortic valve stenosis is the most common form of valvular heart disease, affecting up to 3% of adults over the age of 75 years. It is a gradually progressive disease, characterized by a long asymptomatic phase that may last for several decades, followed by a short symptomatic phase associated with severe restriction of the valve orifice. Investigations on treatments for aortic valve stenosis are still in progress. Thus, it is believed that calcification of aortic valve stenosis is similar to the process of atherosclerosis that occurs in coronary artery disease. Recent studies have suggested that cholesterol lowering through the use of statins may have a salutary effect on the progression of aortic valve stenosis.

Quality of life after surgical myocardial revascularization, angioplasty or medical treatment.

BACKGROUND: Although the clinical benefits of coronary interventions seem to be confirmed, their effects on quality of life (QoL) are still scarcely studied. OBJECTIVE: To assess the QoL in multivessel coronary disease in patients randomly undergoing surgery, angioplasty or medical treatment. METHODS: The Short-Form Health Survey (SF-36) questionnaire was answered by 483 patients. Of these, 161 underwent surgical revascularization, 166 underwent angioplasty, and 153 were medically treated. RESULTS: At baseline, 86% of the patients referred angina, 34% referred infarction, and 32% were smokers. Medical Treatment: 12 patients (7.7%) had AMI, 24 (15.3%) underwent surgery, and 19 (12.1%) died. In addition, 5 (3.2%) had stroke, and 40 (25.6%) had angina. As regards the mental component, 64.1% and 30.8% had their condition improved and worsened, respectively. As regards the physical component, 70.5% and 27.6% had their condition improved and worsened, respectively. SURGERY: 13 patients (8.1%) had AMI, 2 (1.2%) underwent surgery, and 12(7.4%) died. Also, 9 (5.6%) had stroke and 30 (18.6%) had angina. As regards the mental component, 72.7 % and 25.5% had their condition improved and worsened, respectively. As regards the physical component, 82.6% and 16.1% had their condition improved and worsened, respectively. Angioplasty: 18 patients (10.9%) had AMI, 51 (30.7%) underwent interventions, and 18 (19.9%) died. Additionally, six (3.6%) presented stroke and 35 (21%) reported angina. As regards the mental component, 66.9% and 26.5% had their condition improved and worsened, respectively. As regards the physical component, 77.1% and 20.5% had their condition improved and worsened, respectively. CONCLUSION: Improvement was observed in all domains and in the three therapeutic modalities. Comparatively, surgery had provided a better quality of life after a four-year follow-up.