Brazilian Guidelines for In-office and Out-of-office Blood Pressure Measurement ­ 2023 / Diretrizes Brasileiras de Medidas da Pressão Arterial Dentro e Fora do Consultório ­ 2023

Hypertension is one of the primary modifiable risk factors for morbidity and mortality worldwide, being a major risk factor for coronary artery disease, stroke, and kidney failure. Furthermore, it is highly prevalent, affecting more than one-third of the global population. Blood pressure measurement is a MANDATORY procedure in any medical care setting and is carried out by various healthcare professionals. However, it is still commonly performed without the necessary technical care. Since the diagnosis relies on blood pressure measurement, it is clear how important it is to handle the techniques, methods, and equipment used in its execution with care. It should be emphasized that once the diagnosis is made, all short-term, medium-term, and long-term investigations and treatments are based on the results of blood pressure measurement. Therefore, improper techniques and/or equipment can lead to incorrect diagnoses, either underestimating or overestimating values, resulting in inappropriate actions and significant health and economic losses for individuals and nations. Once the correct diagnosis is made, as knowledge of the importance of proper treatment advances, with the adoption of more detailed normal values and careful treatment objectives towards achieving stricter blood pressure goals, the importance of precision in blood pressure measurement is also reinforced. Blood pressure measurement (described below) is usually performed using the traditional method, the so-called casual or office measurement. Over time, alternatives have been added to it, through the use of semi-automatic or automatic devices by the patients themselves, in waiting rooms or outside the office, in their own homes, or in public spaces. A step further was taken with the use of semi-automatic devices equipped with memory that allow sequential measurements outside the office (ABPM; or HBPM) and other automatic devices that allow programmed measurements over longer periods (HBPM). Some aspects of blood pressure measurement can interfere with obtaining reliable results and, consequently, cause harm in decision-making. These include the importance of using average values, the variation in blood pressure during the day, and short-term variability. These aspects have encouraged the performance of a greater number of measurements in various situations, and different guidelines have advocated the use of equipment that promotes these actions. Devices that perform HBPM or ABPM, which, in addition to allowing greater precision, when used together, detect white coat hypertension (WCH), masked hypertension (MH), sleep blood pressure alterations, and resistant hypertension (RHT) (defined in Chapter 2 of this guideline), are gaining more and more importance. Taking these details into account, we must emphasize that information related to diagnosis, classification, and goal setting is still based on office blood pressure measurement, and for this reason, all attention must be given to the proper execution of this procedure.

La hipertensión arterial (HTA) es uno de los principales factores de riesgo modificables para la morbilidad y mortalidad en todo el mundo, siendo uno de los mayores factores de riesgo para la enfermedad de las arterias coronarias, el accidente cerebrovascular (ACV) y la insuficiencia renal. Además, es altamente prevalente y afecta a más de un tercio de la población mundial. La medición de la presión arterial (PA) es un procedimiento OBLIGATORIO en cualquier atención médica o realizado por diferentes profesionales de la salud. Sin embargo, todavía se realiza comúnmente sin los cuidados técnicos necesarios. Dado que el diagnóstico se basa en la medición de la PA, es claro el cuidado que debe haber con las técnicas, los métodos y los equipos utilizados en su realización. Debemos enfatizar que una vez realizado el diagnóstico, todas las investigaciones y tratamientos a corto, mediano y largo plazo se basan en los resultados de la medición de la PA. Por lo tanto, las técnicas y/o equipos inadecuados pueden llevar a diagnósticos incorrectos, subestimando o sobreestimando valores y resultando en conductas inadecuadas y pérdidas significativas para la salud y la economía de las personas y las naciones. Una vez realizado el diagnóstico correcto, a medida que avanza el conocimiento sobre la importancia del tratamiento adecuado, con la adopción de valores de normalidad más detallados y objetivos de tratamiento más cuidadosos hacia metas de PA más estrictas, también se refuerza la importancia de la precisión en la medición de la PA. La medición de la PA (descrita a continuación) generalmente se realiza mediante el método tradicional, la llamada medición casual o de consultorio. Con el tiempo, se han agregado alternativas a través del uso de dispositivos semiautomáticos o automáticos por parte del propio paciente, en salas de espera o fuera del consultorio, en su propia residencia o en espacios públicos. Se dio un paso más con el uso de dispositivos semiautomáticos equipados con memoria que permiten mediciones secuenciales fuera del consultorio (AMPA; o MRPA) y otros automáticos que permiten mediciones programadas durante períodos más largos (MAPA). Algunos aspectos en la medición de la PA pueden interferir en la obtención de resultados confiables y, en consecuencia, causar daños en las decisiones a tomar. Estos incluyen la importancia de usar valores promedio, la variación de la PA durante el día y la variabilidad a corto plazo. Estos aspectos han alentado la realización de un mayor número de mediciones en diversas situaciones, y diferentes pautas han abogado por el uso de equipos que promuevan estas acciones. Los dispositivos que realizan MRPA o MAPA, que además de permitir una mayor precisión, cuando se usan juntos, detectan la hipertensión de bata blanca (HBB), la hipertensión enmascarada (HM), las alteraciones de la PA durante el sueño y la hipertensión resistente (HR) (definida en el Capítulo 2 de esta guía), están ganando cada vez más importancia. Teniendo en cuenta estos detalles, debemos enfatizar que la información relacionada con el diagnóstico, la clasificación y el establecimiento de objetivos todavía se basa en la medición de la presión arterial en el consultorio, y por esta razón, se debe prestar toda la atención a la ejecución adecuada de este procedimiento.

A hipertensão arterial (HA) é um dos principais fatores de risco modificáveis para morbidade e mortalidade em todo o mundo, sendo um dos maiores fatores de risco para doença arterial coronária, acidente vascular cerebral (AVC) e insuficiência renal. Além disso, é altamente prevalente e atinge mais de um terço da população mundial. A medida da PA é procedimento OBRIGATÓRIO em qualquer atendimento médico ou realizado por diferentes profissionais de saúde. Contudo, ainda é comumente realizada sem os cuidados técnicos necessários. Como o diagnóstico se baseia na medida da PA, fica claro o cuidado que deve haver com as técnicas, os métodos e os equipamentos utilizados na sua realização. Deve-se reforçar que, feito o diagnóstico, toda a investigação e os tratamentos de curto, médio e longo prazos são feitos com base nos resultados da medida da PA. Assim, técnicas e/ou equipamentos inadequados podem levar a diagnósticos incorretos, tanto subestimando quanto superestimando valores e levando a condutas inadequadas e grandes prejuízos à saúde e à economia das pessoas e das nações. Uma vez feito o diagnóstico correto, na medida em que avança o conhecimento da importância do tratamento adequado, com a adoção de valores de normalidade mais detalhados e com objetivos de tratamento mais cuidadosos no sentido do alcance de metas de PA mais rigorosas, fica também reforçada a importância da precisão na medida da PA. A medida da PA (descrita a seguir) é habitualmente feita pelo método tradicional, a assim chamada medida casual ou de consultório. Ao longo do tempo, foram agregadas alternativas a ela, mediante o uso de equipamentos semiautomáticos ou automáticos pelo próprio paciente, nas salas de espera ou fora do consultório, em sua própria residência ou em espaços públicos. Um passo adiante foi dado com o uso de equipamentos semiautomáticos providos de memória que permitem medidas sequenciais fora do consultório (AMPA; ou MRPA) e outros automáticos que permitem medidas programadas por períodos mais prolongados (MAPA). Alguns aspectos na medida da PA podem interferir na obtenção de resultados fidedignos e, consequentemente, causar prejuízo nas condutas a serem tomadas. Entre eles, estão: a importância de serem utilizados valores médios, a variação da PA durante o dia e a variabilidade a curto prazo. Esses aspectos têm estimulado a realização de maior número de medidas em diversas situações, e as diferentes diretrizes têm preconizado o uso de equipamentos que favoreçam essas ações. Ganham cada vez mais espaço os equipamentos que realizam MRPA ou MAPA, que, além de permitirem maior precisão, se empregados em conjunto, detectam a HA do avental branco (HAB), HA mascarada (HM), alterações da PA no sono e HA resistente (HAR) (definidos no Capítulo 2 desta diretriz). Resguardados esses detalhes, devemos ressaltar que as informações relacionadas a diagnóstico, classificação e estabelecimento de metas ainda são baseadas na medida da PA de consultório e, por esse motivo, toda a atenção deve ser dada à realização desse procedimento.

Translation, cross-cultural adaptation and validation of the EPOCH-RRT questionnaire "Empowering Patients On Choices For Renal Replacement Therapy" for the Brazilian context / Tradução, adaptação transcultural e validação do questionário EPOCH-RRT "Empowering Patients On Choices For Renal Replacement Therapy" para o contexto brasileiro

Abstract Introduction: Chronic kidney disease (CKD) is a global public health problem. In Brazil, the incidence and prevalence rates of dialysis CKD progressively increase, but the transition process is a challenge for patients and caregivers in coping with the disease. Dialysis urgency, lack of planned access or prior knowledge of treatment is a reality for most. Guidelines recommend that treatment options should include the conscious preference of a fully informed patient. However, pre-dialysis educational information is an exception, leading to a large number of unplanned initial dialysis. The original study "Empowering Patients on Choices for Renal Replacement Therapy" (EPOCH-RRT) aimed to identify patient priorities and gaps in shared decision-making about dialysis, using structured interviews with questions about demographics, clinical history and patients' perception of their health. The goal of this study was to carry out the translation, cross-cultural adaptation and validation of the questionnaires used in the EPOCH-RRT Study for the Brazilian context. Method: This is a methodological study that consisted of the initial translation, synthesis of the translations, back translation, review by a committee of experts, pre-test and evaluation of the psychometric properties of the instrument. All ethical precepts were followed. Results: The questionnaires were translated, adapted and validated for the Brazilian context. Additionally, it was applied to 84 chronic renal patients on hemodialysis, peritoneal dialysis and outpatients. Discussion: There is a lack of an educational-therapeutic approach aimed at patients with CKD, and the EPOCH-RRT questionnaire can be a tool for Brazilian dialysis services to change this paradigm.

Resumo Introdução: A doença renal crônica (DRC) é um problema de saúde pública mundial. No Brasil, as taxas de incidência e prevalência da DRC dialítica aumentam progressivamente, mas o processo de transição apresenta-se como desafio para pacientes e cuidadores no enfrentamento da doença. Urgência dialítica, ausência de acesso planejado ou conhecimento prévio do tratamento é uma realidade para a maioria. Diretrizes recomendam que opções de tratamento devam incluir a preferência consciente de um paciente totalmente informado. No entanto, informação educacional pré-diálise é exceção, acarretando grande número de diálises iniciais não planejadas. O estudo original "Empowering Patients on Choices for Renal Replacement Therapy" (EPOCH-RRT) teve por objetivo identificar as prioridades do paciente e as lacunas na tomada de decisões compartilhadas sobre a diálise, utilizando entrevistas estruturadas, com questões sobre dados demográficos, história clínica e percepção dos pacientes sobre sua saúde. O objetivo desta pesquisa foi realizar a tradução, adaptação transcultural e validação dos questionários utilizados no Estudo EPOCH-RRT para o contexto brasileiro. Método: Trata-se de estudo metodológico que consistiu na tradução inicial, síntese das traduções, retro tradução, revisão por um comitê de especialistas, pré-teste e avaliação das propriedades psicométricas do instrumento. Todos os preceitos éticos foram seguidos. Resultados: Os questionários foram traduzidos, adaptados e validados para o contexto brasileiro. Adicionalmente, foi aplicado em 84 pacientes renais crônicos em hemodiálise, diálise peritoneal e ambulatoriais. Discussão: Há carência de enfoque educativo-terapêutico dirigido aos pacientes com DRC, e o questionário EPOCH-RRT pode ser uma ferramenta para serviços de diálise brasileiros mudarem esse paradigma.

Translation, cross-cultural adaptation and validation of the EPOCH-RRT questionnaire "Empowering Patients On Choices For Renal Replacement Therapy" for the Brazilian context.

INTRODUCTION: Chronic kidney disease (CKD) is a global public health problem. In Brazil, the incidence and prevalence rates of dialysis CKD progressively increase, but the transition process is a challenge for patients and caregivers in coping with the disease. Dialysis urgency, lack of planned access or prior knowledge of treatment is a reality for most. Guidelines recommend that treatment options should include the conscious preference of a fully informed patient. However, pre-dialysis educational information is an exception, leading to a large number of unplanned initial dialysis. The original study "Empowering Patients on Choices for Renal Replacement Therapy" (EPOCH-RRT) aimed to identify patient priorities and gaps in shared decision-making about dialysis, using structured interviews with questions about demographics, clinical history and patients' perception of their health. The goal of this study was to carry out the translation, cross-cultural adaptation and validation of the questionnaires used in the EPOCH-RRT Study for the Brazilian context. METHOD: This is a methodological study that consisted of the initial translation, synthesis of the translations, back translation, review by a committee of experts, pre-test and evaluation of the psychometric properties of the instrument. All ethical precepts were followed. RESULTS: The questionnaires were translated, adapted and validated for the Brazilian context. Additionally, it was applied to 84 chronic renal patients on hemodialysis, peritoneal dialysis and outpatients. DISCUSSION: There is a lack of an educational-therapeutic approach aimed at patients with CKD, and the EPOCH-RRT questionnaire can be a tool for Brazilian dialysis services to change this paradigm.

Hypertension from the patient's perspective: contributions to the care offered by health professionals and self-care - a qualitative study

ABSTRACT BACKGROUND: Hypertension is the most common disease in primary care settings. Only 30% of cases were adequately controlled. OBJECTIVES: To analyze the knowledge and understanding of patients with hypertension regarding the factors that facilitate and limit adherence to treatment and, based on the results, build specific guidelines on hypertension self-care and control. DESIGN AND SETTING: This qualitative study was conducted in a primary healthcare setting. METHODS: Patients with hypertension who were followed at a primary healthcare unit were interviewed through focus groups, and a qualitative interpretation of their statements according to Bardin's content analysis was performed. RESULTS: Three focus groups were formed (21 participants), from whose analysis emerged 74 core ideas related to the concept of hypertension, causes of increase in blood pressure, clinical consequences of hypertension, and possible patients' contributions to help control blood pressure, arising from eating habits, psychosocial conditions, and lifestyle. Patients tend to accept the concept of "high blood pressure" as an inherent condition of the disease in their lives. Eating habits are strongly related to life history and self-perception of health. The association between high blood pressure and nervousness or stress appears to be strong. CONCLUSION: The experience of having "pressure problem" is unique for each person. It is necessary to optimize listening, recognizing that, for the patient to understand what hypertension is and its management, there must be understanding and convergence of proposals, adjustments, and changes in a positive and personalized way. As a result of this study, we implemented educational actions in primary healthcare units.

Hypertension from the patient's perspective: contributions to the care offered by health professionals and self-care - a qualitative study.

BACKGROUND: Hypertension is the most common disease in primary care settings. Only 30% of cases were adequately controlled. OBJECTIVES: To analyze the knowledge and understanding of patients with hypertension regarding the factors that facilitate and limit adherence to treatment and, based on the results, build specific guidelines on hypertension self-care and control. DESIGN AND SETTING: This qualitative study was conducted in a primary healthcare setting. METHODS: Patients with hypertension who were followed at a primary healthcare unit were interviewed through focus groups, and a qualitative interpretation of their statements according to Bardin's content analysis was performed. RESULTS: Three focus groups were formed (21 participants), from whose analysis emerged 74 core ideas related to the concept of hypertension, causes of increase in blood pressure, clinical consequences of hypertension, and possible patients' contributions to help control blood pressure, arising from eating habits, psychosocial conditions, and lifestyle. Patients tend to accept the concept of "high blood pressure" as an inherent condition of the disease in their lives. Eating habits are strongly related to life history and self-perception of health. The association between high blood pressure and nervousness or stress appears to be strong. CONCLUSION: The experience of having "pressure problem" is unique for each person. It is necessary to optimize listening, recognizing that, for the patient to understand what hypertension is and its management, there must be understanding and convergence of proposals, adjustments, and changes in a positive and personalized way. As a result of this study, we implemented educational actions in primary healthcare units.

Use of prescribed psychotropic drugs among medical students and associated factors: a cross-sectional study

Abstract BACKGROUND: The worldwide prevalences of anxiety and depressive disorders are 3.6% and 4.4%, respectively. Among medical students, many studies have indicated that the prevalences of these mental disorders vary between 19.7% and 47.1%, but there is a lack of information on psychotropic drug usage in this group of students. OBJECTIVE: To evaluate the prevalence of psychotropic drug use, adherence to therapy and main clinical and diagnostic indications relating to psychotropic drug use among medical students. DESIGN AND SETTING: Cross-sectional study at a Brazilian private university in the city of Sorocaba, state of São Paulo. METHODS: Observational analytical cross-sectional study, conducted during the second semester of 2019, through a semi-structured online questionnaire, answered by first to sixth-year medical students. RESULTS: Among the 263 participants (41.7% of the 630 enrolled students), the current prevalence of psychotropic drug usage was 30.4%. This prevalence increased over the course and 90.7% of the drugs were prescribed at regular medical consultations (85.5% by psychiatrists). The main indications for psychotropic drug usage were anxiety (30.0%), depression (22.8%), insomnia (7.2%), panic (5.3%) and attention deficit hyperactivity disorder (3.8%). Women were more likely to present diagnoses of depression and panic. Most of the participants used antidepressants and had good adherence to medications. Adequate sleep and regular physical activity were identified as protective factors against mental disorders. CONCLUSION: The prevalence of mental disorders among medical students is high, which justifies the use of psychotropic drugs. This study provides valuable information and recommendations for institutional educational actions to improve students' mental health.

Use of prescribed psychotropic drugs among medical students and associated factors: a cross-sectional study.

BACKGROUND: The worldwide prevalences of anxiety and depressive disorders are 3.6% and 4.4%, respectively. Among medical students, many studies have indicated that the prevalences of these mental disorders vary between 19.7% and 47.1%, but there is a lack of information on psychotropic drug usage in this group of students. OBJECTIVE: To evaluate the prevalence of psychotropic drug use, adherence to therapy and main clinical and diagnostic indications relating to psychotropic drug use among medical students. DESIGN AND SETTING: Cross-sectional study at a Brazilian private university in the city of Sorocaba, state of São Paulo. METHODS: Observational analytical cross-sectional study, conducted during the second semester of 2019, through a semi-structured online questionnaire, answered by first to sixth-year medical students. RESULTS: Among the 263 participants (41.7% of the 630 enrolled students), the current prevalence of psychotropic drug usage was 30.4%. This prevalence increased over the course and 90.7% of the drugs were prescribed at regular medical consultations (85.5% by psychiatrists). The main indications for psychotropic drug usage were anxiety (30.0%), depression (22.8%), insomnia (7.2%), panic (5.3%) and attention deficit hyperactivity disorder (3.8%). Women were more likely to present diagnoses of depression and panic. Most of the participants used antidepressants and had good adherence to medications. Adequate sleep and regular physical activity were identified as protective factors against mental disorders. CONCLUSION: The prevalence of mental disorders among medical students is high, which justifies the use of psychotropic drugs. This study provides valuable information and recommendations for institutional educational actions to improve students' mental health.

Impact of a radiological protection campaign in emergency paediatric radiology: a multicentric observational study in Brazil.

PURPOSE: To evaluate the impact of a paediatric radiological protection campaign, implemented in the emergency units of a healthcare provider network in Brazil. This campaign aimed to promote awareness among emergency department physicians, regarding justification of paediatric X-ray referrals for paranasal sinus, chest and CT exams, as a strategy to reduce exposure to ionising radiation. METHOD: Frequency analysis of common paediatric imaging referrals from 19 emergency departments was performed for a 3-year period (2015-2018) to coincide with before, during and after the implementation of the radiation protection campaign. The campaign was multifaceted and involved dissemination of educational materials and imaging referral guidelines along with quarterly meetings with participating centres' leaderships. Additionally, patient dose cards were distributed to patients/carers. The Chi-Square test was used to examine the association between the type of examination and the patient's age group. Exact-Fisher test was performed to check for an association between participant engagement and the existence of the radiation protection committee. RESULTS: Referrals reduced by 25% following the campaign with no reports of misdiagnosis. Many referrals in the youngest age groups. In 15 units, a radiological protection committee was created to raise awareness and to create a multi professional team to communicate the risks and benefits of radiological procedure in children. CONCLUSION: The campaign resulted in a substantial reduction in radiological referrals while promoting a radiation protection culture. Simple education initiatives can contribute to savings in both finances and radiation doses, particularly important in radiosensitive cohorts.

A inserção da mentoria na matriz curricular de um curso de Medicina: relato de experiência / The inclusion of mentoring in the medical course curriculum: an experience report

Resumo: Introdução: Em 2018, foi implantado no curso de Medicina da Faculdade de Ciências Médicas e da Saúde da Pontifícia Universidade Católica de São Paulo um novo projeto pedagógico do curso (PPC). Nessa construção, surgiu a oportunidade de incluir um módulo para a prática da mentoria, pois havia várias questões relacionadas à vida no câmpus que vinham preocupando a comunidade, tais como a necessidade de os alunos e professores apropriarem-se do PPC, o fato de os discentes ainda muito jovens serem afastados da família, estudantes oriundos de escolas tradicionais pouco afeitas às metodologias ativas de ensino-aprendizagem que constituem a base do curso, a avaliação somativa e a recuperação do desempenho insatisfatório, o trote, o convívio com a diversidade, a autonomia do aluno e o processo de formação e identidade do profissional médico. Relato de experiência: No novo PPC, o módulo de Estudos Orientados garantiu o espaço para a mentoria dentro da grade curricular do primeiro ao terceiro ano, em pequenos grupos protegidos. Ao fim do primeiro ano, a avaliação regular da docência revelou dificuldades que foram superadas com a capacitação dos docentes para a atividade da mentoria, viabilizada com o auxílio de profissionais externos e experientes que ajudaram a dar identidade à mentoria, ajustada às características do curso e do PPC. A avaliação seguinte revelou melhora evidente da percepção dos alunos e professores. Nesse momento, a consulta feita com a maioria dos envolvidos trouxe novas informações que permitiram estabelecer diretrizes norteadoras para a atividade em cada ano do curso. Discussão: Todo o processo de implantação do módulo, dividido em três etapas, foi muito rico e exigiu a participação de todos os envolvidos. Conclusão: Nossa experiência permite inferir que, por suas características complexas e mutáveis, a mentoria deve ser construída em estreita relação com a comunidade e ajustada às necessidades de cada curso e do seu projeto pedagógico.

Abstract: Introduction: In 2018, a new pedagogical project (PP) was implemented in the medical course of the Faculty of Medical and Health Sciences of the Pontifical Catholic University of São Paulo. In this framework the opportunity arose to include a module for the practice of mentoring. At that time there were several issues related to life on campus that had been worrying the community, such as the need for students and teachers to take part in the PP, very young students living away from their families, students from traditional schools unfamiliar with the active teaching-learning methodologies that form the basis of the course, summative assessment and recovery from unsatisfactory performance, hazing, living with diversity, student autonomy and the construction process of the identity of the medical professional. Experience report: In the new PP, the Guided Studies module guaranteed a space for mentoring within the curriculum from the first to the third year, in small, protected groups. At the end of the first year, the regular teachers' assessment revealed difficulties that were overcome through teacher training in mentoring, supported by experienced teachers who helped to give identity to the mentoring, shaped to the characteristics of the course and the PP. The following evaluation revealed an evident improvement in the perception of students and teachers. A survey was conducted at that time among the majority of those involved, bringing to light new information that allowed for mentoring guidelines for each year of the course to be established. Discussion: The entire three stages implementation process of the module was very rich and required the participation of all those involved. Conclusion: This experience allows us to infer that, due to its complex and changeable characteristics, mentoring must be built in close relationship with the community and adjusted to the needs of each course and its pedagogical project.

The Fellows Project: Education Skills for Health Profession Students / Projeto Fellows: Habilidades de Educação para Estudantes das Profissões da Saúde

Abstract: New information technologies have produced profound changes in education and society. All knowledge areas have been constantly reinvented, readjusted and recreated to fit the changing demands of professional practice. Education in the health professions has also followed this trend. It is now clear how students, the future educators, are involved in this transformation and have been vectors of these changes. In parallel, the new curricula for health professions courses presuppose the active participation of students in their own training and in the training of their peers. This new way of teaching, which privileges teamwork, peer learning, interdisciplinarity, and autonomy, stimulates and demands this leadership role from students. Active student participation in undergraduate educational activities has several benefits: it favors learning; interpersonal relationships; acquiring skills in communication, mentoring, leadership, research, and management and develops social accountability. Undergraduate students in the health professions, even at the earliest stages of their education, make their choices and direct their interest to the area of knowledge they desire in professional life. When this choice falls on a specific area of health, they find, at the undergraduate level, ways to begin to develop their knowledge and skills in clinical practice, surgery, pediatrics, laboratory research, public health and other areas, but find no support for training when they intend to be future teachers. In this context, the FELLOWS Project emerged, proposed and carried out by medical students, a blended learning teaching development project that aims to train and improve education skills for students of the health professions, herein presented as an experience report. In 2017 the project took place from April to October, in monthly nighttime meetings, and eventually on Saturdays. It was conducted by four medical students (coordinators), two supervising local teachers and had collaborators from other medical education institutions. In 2018 the educational activities were held exclusively by students/resident coordinators and supervising teachers through two immersion sessions (Friday, Saturday and Sunday), separated by a 4 month-period, during which an education project was prepared, created in groups of six students accompanied by a tutor and a coordinator. The activities of the FELLOWS Project follow the National Curriculum Guidelines for the Undergraduate Medical Course of 2001 and 2014, meet the demands of health education in Brazil and respect the desired profile of the professional graduate, with social accountability. It offers contact with and progressive skills of communication and competencies for teaching, using active teaching-learning methodologies, teamwork, the use of digital technologies, exercising oral and written communication and creativity for innovation. The FELLOWS Project implementation process has brought direct benefits to the organizers and participants and indirect benefits to the educational institutions to which they belong, as it involved knowledge production, student engagement and social accountability.

Resumo: As novas tecnologias da informação produziram profundas transformações na educação e na sociedade. Todas as áreas do conhecimento têm sido constantemente reinventadas, readaptadas e recriadas para se ajustarem às novas exigências da prática profissional. A educação nas profissões da saúde também tem seguido esses passos. É nítido como os estudantes, futuros educadores, estão envolvidos nessa transformação e têm sido vetores dessas mudanças. Paralelamente, a concepção dos novos currículos para os cursos da área da saúde pressupõe a participação ativa dos estudantes na própria formação e na de seus pares. Essa nova forma de ensinar, que privilegia o trabalho em equipe, a aprendizagem por pares, a interdisciplinaridade e a autonomia, estimula e exige esse protagonismo dos estudantes. A participação ativa do estudante nas atividades educativas da graduação traz inúmeros benefícios: favorece o aprendizado, as relações interpessoais e a aquisição de habilidades de comunicação, de orientação, de liderança, de pesquisa e de gestão, e desenvolve a responsabilidade social. Os estudantes das profissões da saúde, mesmo nas fases mais precoces de formação, fazem suas escolhas e direcionam sua formação para o que desejam na vida profissional. Quando essa escolha recai sobre uma área específica da saúde, eles encontram, desde a graduação, maneiras de começar a desenvolver seus conhecimentos e habilidades em clínica médica, cirurgia, pediatria, pesquisa em laboratório, saúde pública e outras áreas, mas não encontram apoio à formação quando pretendem ser futuros professores. Nesse contexto, surgiu o Projeto FELLOWS, um projeto de desenvolvimento docente, proposto e conduzido por estudantes de Medicina, em blended learning (presencial e a distância) que tem como objetivos a formação e o aperfeiçoamento em habilidades de educação para estudantes das profissões da saúde, aqui apresentado como um relato de experiência. Em 2017, o projeto estendeu-se de abril a outubro em encontros mensais no horário noturno e, eventualmente, aos sábados. Foi conduzido por quatro estudantes de Medicina (coordenadores) e dois professores supervisores e contou com colaboradores de outras instituições de educação médica. Em 2018, as atividades educativas foram realizadas exclusivamente pelos estudantes/residentes coordenadores e os professores supervisores, por meio de duas sessões de imersão (sexta, sábado e domingo), separadas por um período de quatro meses em que foi elaborado um projeto de educação, construído em grupos de seis estudantes acompanhados por um tutor e um coordenador. As atividades do Projeto FELLOWS seguem as Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina de 2001 e 2014, atendem às demandas da educação nas áreas da saúde no Brasil e respeitam o perfil desejado do profissional egresso, com responsabilidade social. Oferecem o contato e progressivo domínio de habilidades de comunicação e de competências para o trabalho docente, o uso de metodologias ativas de ensino-aprendizagem, o trabalho em equipe, o uso de tecnologias digitais, o exercício da comunicação oral e escrita e a criatividade para a inovação. O processo de execução do Projeto FELLOWS trouxe benefícios diretos para os organizadores e para os participantes, e benefícios indiretos para as instituições de ensino a que pertencem, pois envolveu produção de conhecimento, engajamento estudantil e responsabilidade social.

Radiological protection in the perspective of health professionals exposed to radiation.

OBJECTIVE: To evaluate the knowledge of health professionals about radiological protection and to implement educational actions to promote a safe working environment for professionals, patients and companions. METHOD: An exploratory cross-sectional study, applying a questionnaire to 59 participants from different sectors of a teaching hospital. Open-ended questions were analyzed through the discourse of the collective subject and closed-ended questions were analyzed through quantitative analysis. RESULTS: In the opinion of the participants, their professional training did not offer radioprotection class or the training was insufficient for the practice. In addition, the work environment does not provide regulatory norms and training on radioprotection. Most participants do not have solid knowledge and do not present safe behavior in radioprotection. In the internal week for the prevention of work accidents, a lecture and a theatricalisation about the topic of radioprotection were conducted and a booklet was distributed. CONCLUSION: Radiation protection education is necessary in the curricula of the training courses for health professionals and in the work environment.

Radiological protection in the perspective of health professionals exposed to radiation / Protección radiológica en la perspectiva de los profesionales de la salud expuestos a la radiación / Proteção radiológica na perspectiva dos profissionais de saúde expostos à radiação

ABSTRACT Objective: To evaluate the knowledge of health professionals about radiological protection and to implement educational actions to promote a safe working environment for professionals, patients and companions. Method: An exploratory cross-sectional study, applying a questionnaire to 59 participants from different sectors of a teaching hospital. Open-ended questions were analyzed through the discourse of the collective subject and closed-ended questions were analyzed through quantitative analysis. Results: In the opinion of the participants, their professional training did not offer radioprotection class or the training was insufficient for the practice. In addition, the work environment does not provide regulatory norms and training on radioprotection. Most participants do not have solid knowledge and do not present safe behavior in radioprotection. In the internal week for the prevention of work accidents, a lecture and a theatricalisation about the topic of radioprotection were conducted and a booklet was distributed. Conclusion: Radiation protection education is necessary in the curricula of the training courses for health professionals and in the work environment.

RESUMEN Objetivo: Evaluar los conocimientos de los profesionales de la salud sobre la protección radiológica con el intuito de implementar acciones educativas para promover un ambiente de trabajo seguro para los profesionales, pacientes y acompañantes Método: Se trata de un estudio transversal exploratorio, desarrollado por medio de un cuestionario aplicado a 59 participantes de diferentes sectores de un hospital de enseñanza. Se analizaron las cuestiones abiertas mediante el discurso del sujeto colectivo, y las cerradas, mediante análisis cuantitativo. Resultados: Según la opinión de los participantes, el curso no sumó conocimiento sobre la radioprotección o fue insuficiente para la práctica. El ambiente de trabajo tampoco pone a disposición normas reguladoras y formación sobre el tema. La mayoría de los participantes no poseen conocimiento sólido y comportamiento seguro en radioprotección. Durante la semana interna de prevención de accidentes de trabajo, se realizaron conferencias y teatralización sobre el tema radioprotección y se distribuyeron cartillas. Conclusión: Es necesario la inclusión educativa sobre radioprotección en los planes de estudio de los cursos formadores de profesionales de la salud y en el ambiente de trabajo.

RESUMO Objetivo: Avaliar o conhecimento que os profissionais de saúde têm sobre proteção radiológica e implementar ações educativas para promover um ambiente de trabalho seguro aos profissionais, pacientes e acompanhantes. Método: Estudo transversal exploratório, aplicando-se um questionário a 59 participantes de diferentes setores de um hospital de ensino. Questões abertas foram analisadas pelo discurso do sujeito coletivo. Questões fechadas tiveram análise quantitativa. Resultados: Na opinião dos participantes, o curso que fizeram não ofereceu formação sobre radioproteção ou foi insuficiente para a prática. O ambiente de trabalho também não disponibiliza normas regulatórias e formação sobre radioproteção. A maioria dos participantes não tem conhecimento sólido e comportamento seguro em radioproteção. Na semana interna de prevenção de acidentes de trabalho, foram feitas palestra e teatralização sobre o tema radioproteção e distribuída cartilha. Conclusões: São necessárias inserções educativas em radioproteção nas grades curriculares dos cursos formadores de profissionais de saúde e no ambiente de trabalho.

Health Professionals' Perceptions on the Integration of Medical Students' Training in Family Health Care Units / Percepção dos Profissionais de Saúde em relação à Integração do Ensino de Estudantes de Medicina nas Unidades de Saúde da Família

ABSTRACT Introduction The Centro Universitário de Votuporanga (UNIFEV) medicine course was implemented in 2012 according to the 2001 National Curricular Guidelines for Undergraduate Medical Courses. The practical module of Community Service Education Integration is the curricular unit that places students into Primary Health Care (PHC) scenarios from the first period of the course until the internship period, breaking with the traditional model of hospital-centered training, which is segmented into specialties. The module of medical skills and attitudes training also leads the student, in some cases, to PHC services, but with focus on the basic clinical procedures in controlled scenarios, which may be those from typical clinical practice, simulations or even those performed in laboratories. During internship, the student continues in PHC as an intern in general, family and community medicine. In this context, the integration of community-education-service plays a major role in the transformations undergone in undergraduate training in health, which are also aimed at modifying the current healthcare model. Objectives To understand the perception of professionals from the Family Health Care Units regarding medical student work placement and to interpret the results of this integration as far as the service, the community and the medical training are concerned. Methodology Qualitative research carried out with health professionals who work in three Family Health Care Units of Votuporanga, São Paulo, Brazil. They were invited to participate in focus groups to express their opinions about thought-provoking questions. The recorded material was transcribed, organized and analyzed according to Bardin's content analysis, which allowed categories of analysis to emerge based on what the participants said. Results and discussion: The opinions that have emerged allow to identify the following aspects: teaching-service-community integration contributes to medical education; student presence promotes team integration and self-learning and promotes the work process; student integration has impact on the community. Among the student's contributions, participants highlighted the academic and health care reflective practices, health education actions and complementary activities that support the health team in solving local problems. Participants also identified some situations of difficulty, such as: students in the early periods of the course need to acquire affective domains for an adequate professional posture at PHC units; the embarrassment of patients in the medical consultation with the presence of students; and the short length of stay of the students for the necessary bond building. Conclusion For PHC professionals, the inclusion of students in these scenarios contributes to the development of the service, medical training and community support. Due to the solidary relations existing between the educational institution and the PHC management, this research may contribute to promote the necessary adaptations and prepare the community and professionals for the presence of students in PHC.

RESUMO Introdução O curso de Medicina do Centro Universitário de Votuporanga (UNIFEV), implantado em 2012 em acordo com as Diretrizes Curriculares Nacionais para os Cursos de Graduação em Medicina (DCN) de 2001, insere os discentes nos cenários da atenção primária à saúde (APS) desde o primeiro período do curso até o final do internato, rompendo com o modelo tradicional de formação, centrado no hospital e segmentado em especialidades. Nesse contexto, a integração ensino-serviço-comunidade exerce um papel importante na transformação dos cursos de graduação em saúde, visando também à modificação do modelo assistencial vigente. Objetivos Compreender a percepção dos profissionais das Unidades de Saúde da Família (USF) quanto à inserção dos estudantes de Medicina nesses serviços e interpretar os reflexos desta integração para o serviço, a comunidade e a formação médica. Métodos Pesquisa qualitativa, realizada com profissionais de saúde de três USF de Votuporanga (SP), frequentadas pelos discentes da UNIFEV. Eles foram convidados a participar de grupos focais em que expressaram suas opiniões de acordo com perguntas disparadoras de discussão. O material gravado foi transcrito, organizado e submetido à análise de conteúdo de Bardin. Resultados e discussão Emergiram opiniões que permitem identificar o que segue: a integração ensino-serviço-comunidade contribui com a formação médica; a presença do aluno promove a integração e o autoaprendizado da equipe e promove o processo de trabalho; a integração do aluno tem impacto na comunidade. Entre as contribuições do aluno, os participantes destacaram as práticas reflexivas assistenciais e acadêmicas, as ações de educação em saúde e as atividades complementares que apoiam a equipe na resolução de problemas locais. Os participantes identificaram algumas situações de dificuldade, tais como: os estudantes dos períodos iniciais do curso necessitam adquirir domínios afetivos para uma adequada postura profissional na USF; o constrangimento de pacientes na consulta médica com a presença dos estudantes; e o curto tempo de permanência dos discentes para a necessária construção de vínculo. Conclusão Para os profissionais das USF, a inserção dos estudantes nestes cenários contribui para o desenvolvimento do serviço, a formação médica e o apoio à comunidade. Devido às relações solidárias existentes entre a instituição de ensino e a gestão do SUS, esta pesquisa pode contribuir para promover as adaptações necessárias e preparar a comunidade e os profissionais para a presença dos estudantes na APS.

Percepção dos Internos e Recém-Egressos do Curso de Medicina da PUC-SP sobre Sua Formação para Atuar na Atenção Primária à Saúde / Perception of Interns and Doctors Recently Graduated from the Medicine Course of PUC-SP on Their Training to Work in Primary Health Care

RESUMO Introdução A Faculdade de Ciências Médicas e da Saúde (FCMS) da PUC/SP campus Sorocaba (SP) iniciou, em 2006, uma reforma curricular do curso de Medicina e um novo projeto pedagógico baseado nas Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina de 2001 (DCN). Nesta organização curricular, a Prática em Atenção à Saúde é um módulo horizontal com seus eixos desenvolvidos do primeiro ao sexto ano, realizado em vários cenários de prática, mas priorizando a atenção primária à saúde do Sistema Único de Saúde (SUS) e tendo a aprendizagem baseada na prática e a problematização como estratégias centrais de ensino-aprendizagem. Objetivo Avaliar se o aluno de Medicina no final do curso e o recém-egresso se julgam preparados para atuar na atenção primária à saúde, identificando os pontos positivos e negativos da sua formação de modo a propor os ajustes necessários no sentido de contribuir para o aprimoramento do curso de Medicina e da formação dos egressos da FCMS da PUC/SP. Métodos Questionário com quatro questões abertas e cinco de múltipla escolha em escala Likert, respondido por 66 internos e oito recém-formados. Resultados Mais de 70% dos participantes se sentem bem preparados ou muito bem preparados para atuar na atenção primária como generalistas, de maneira humanista, crítica e reflexiva, com competências para desenvolver ações de prevenção, promoção e reabilitação de saúde, de acordo com as DCN e a hierarquização do SUS e valorizando o trabalho multiprofissional. Foram considerados pontos positivos: a inserção do aluno na atenção primária desde o início do curso, favorecendo a humanização da relação médico-paciente, e o conhecimento e manejo das doenças mais prevalentes. Os pontos mais negativos relatados foram: pouco atendimento médico ao longo do módulo, visitas domiciliares sem a presença dos preceptores e desvalorização da atenção primária à saúde na vida profissional. Conclusões Os internos ao final do curso e recém-egressos do curso de Medicina da FCMS da PUC/SP se sentem preparados e seguros para atuar na atenção primária à saúde do SUS da forma preconizada nas DCN e oferecem sugestões críticas para melhorar o ensino/aprendizagem neste cenário.

ABSTRACT Background The School of Medical Sciences and Health (FCMS - Faculdade de Ciências Médicas e da Saúde) at the Sorocaba campus of the Pontifical Catholic University of São Paulo (PUC/SP - Pontifícia Universidade Católica de São Paulo) began to reform the curriculum of the Medical course in 2006, introducing a new educational project based on the 2001 Brazilian National Curricular Directives (DCN - Diretrizes Curriculares Nacionais) for Medical Degree Courses. In this curriculum, Health Care Practice is a horizontal module with its six disciplines studied from the first to the sixth year, in various practical scenarios, but with a focus on primary health care in the Unified Health System (SUS - Sistema Único de Saúde), with learning based on practice and problem solving as central educational strategies. Objective To assess whether medical students and new graduates consider themselves prepared to work in primary health care, identifying the strengths and weaknesses of their training in order to propose the adjustments required to improve the Medical course and training of graduates from the FCMS of PUC/SP. Methods A questionnaire with four open questions and five multiple choice questions using the Likert scale was answered by 66 interns and 8 new graduates. Results More than 70% of the participants consider that they are well prepared or very well prepared to work in primary health care as general practitioners, in a person-centred, critical and reflective manner, with the skills to perform activities in health prevention, promotion and rehabilitation in accordance with the DCN and the priorities of the SUS, while valuing multiprofessional work. Participants consider as curriculum strengths: involving the student in primary health care from the beginning of the course, favouring a person-centred approach in the doctor/patient relationship, and the understanding and management of the most prevalent diseases. The weakest points reported were: little medical care was provided to patients during the course, home visits were conducted without the tutor, and Primary Health Care is undervalued in professional life. Conclusions Interns at the end of the course and new graduates from the Medical course of FCMS at PUC/SP feel themselves prepared and confident to work in primary health care as general practitioners in the SUS in the way specified in the DCN and offer critical suggestions to improve teaching/learning in this scenario.

RADIOPROTECTION CAMPAIGN AND CARD: EDUCATIONAL STRATEGIES THAT REDUCE CHILDREN'S EXCESSIVE EXPOSURE TO RADIOLOGICAL EXAMS. / CAMPANHA E CARTEIRA DE RADIOPROTEÇÃO: ESTRATÉGIAS EDUCATIVAS QUE REDUZEM A EXPOSIÇÃO EXCESSIVA DE CRIANÇAS A EXAMES RADIOLÓGICOS.

OBJECTIVES: To analyze the results of an initiative aimed at improving the reasonable use of radiological examinations, ensuring their technical quality, implementing a radioprotection campaign that includes training of the professional team, and introducing the radioprotection card for children under 12 years old as a tool for parents and doctors to control children's exposure to radiation. METHODS: The study was held in a health care insurance system covering 140,000 people. A radioprotection campaign was implemented according to Image Gently • protocols, ensuring the lowest dose of radiation and the quality of examinations, and the radioprotection card was implemented. To assess the effectiveness of these actions, the number of radiological examinations performed at the pediatric emergency room in a period of one year preceding the campaign was compared with the number of radiological examinations performed one year after the campaign. RESULTS: The campaign was well accepted by all professionals, families, and patients involved. In the year following the implementation of radioprotection strategies, there was a 22% reduction of radiological examinations performed at the pediatric emergency room. There was also a 29% reduction in the request of two or more radiological examinations for the same child or examinations with two or more incidences. CONCLUSIONS: The campaign and the radioprotection card for children under 12 years old proved to be feasible strategies and correlated with a reduction in radiological examinations requested and performed at the pediatric emergency room.

OBJETIVOS: Analisar resultados de iniciativa para racionalizar o uso de exames radiológicos, garantindo sua qualidade técnica, e implantar uma campanha de radioproteção que inclua a capacitação da equipe profissional e a Carteira de Radioproteção para crianças de até 12 anos como instrumento para que os pais e médicos controlem a exposição das crianças à radiação. MÉTODOS: Em um sistema de saúde suplementar com cobertura de 140 mil pessoas, foi implantada a campanha de radioproteção com base nos protocolos Image Gently •, garantindo a menor dose possível de exposição à radiação, com qualidade técnica, e implantando a Carteira de Radioproteção. Para aferir a eficácia dessas ações, comparou-se o número de exames radiológicos realizados no setor de urgência e emergência pediátrica no período de um ano anterior à campanha com o número de exames radiológicos realizados no período de um ano posterior à campanha. RESULTADOS: As ações foram bem-aceitas por todos os grupos envolvidos. No ano seguinte à implantação das estratégias de radioproteção, observou-se redução de 22% no número de exames radiológicos realizados no setor pediátrico de urgência e emergência. Houve ainda diminuição de 29% da solicitação de dois ou mais exames para a mesma criança ou de exames com duas ou mais incidências. CONCLUSÕES: A campanha de radioproteção e a implantação da Carteira de Radioproteção para crianças até 12 anos revelaram-se estratégias factíveis e associaram-se à redução dos exames radiológicos solicitados e realizados no setor de urgência e emergência pediátrica.

Campanha e carteira de radioproteção: estratégias educativas que reduzem a exposição excessiva de crianças a exames radiológicos / Radioprotection campaign and card: educational strategies that reduce children's excessive exposure to radiological exams

RESUMO Objetivos: Analisar resultados de iniciativa para racionalizar o uso de exames radiológicos, garantindo sua qualidade técnica, e implantar uma campanha de radioproteção que inclua a capacitação da equipe profissional e a Carteira de Radioproteção para crianças de até 12 anos como instrumento para que os pais e médicos controlem a exposição das crianças à radiação. Métodos: Em um sistema de saúde suplementar com cobertura de 140 mil pessoas, foi implantada a campanha de radioproteção com base nos protocolos Image Gently •, garantindo a menor dose possível de exposição à radiação, com qualidade técnica, e implantando a Carteira de Radioproteção. Para aferir a eficácia dessas ações, comparou-se o número de exames radiológicos realizados no setor de urgência e emergência pediátrica no período de um ano anterior à campanha com o número de exames radiológicos realizados no período de um ano posterior à campanha. Resultados: As ações foram bem-aceitas por todos os grupos envolvidos. No ano seguinte à implantação das estratégias de radioproteção, observou-se redução de 22% no número de exames radiológicos realizados no setor pediátrico de urgência e emergência. Houve ainda diminuição de 29% da solicitação de dois ou mais exames para a mesma criança ou de exames com duas ou mais incidências. Conclusões: A campanha de radioproteção e a implantação da Carteira de Radioproteção para crianças até 12 anos revelaram-se estratégias factíveis e associaram-se à redução dos exames radiológicos solicitados e realizados no setor de urgência e emergência pediátrica.

ABSTRACT Objectives: To analyze the results of an initiative aimed at improving the reasonable use of radiological examinations, ensuring their technical quality, implementing a radioprotection campaign that includes training of the professional team, and introducing the radioprotection card for children under 12 years old as a tool for parents and doctors to control children's exposure to radiation. Methods: The study was held in a health care insurance system covering 140,000 people. A radioprotection campaign was implemented according to Image Gently • protocols, ensuring the lowest dose of radiation and the quality of examinations, and the radioprotection card was implemented. To assess the effectiveness of these actions, the number of radiological examinations performed at the pediatric emergency room in a period of one year preceding the campaign was compared with the number of radiological examinations performed one year after the campaign. Results: The campaign was well accepted by all professionals, families, and patients involved. In the year following the implementation of radioprotection strategies, there was a 22% reduction of radiological examinations performed at the pediatric emergency room. There was also a 29% reduction in the request of two or more radiological examinations for the same child or examinations with two or more incidences. Conclusions: The campaign and the radioprotection card for children under 12 years old proved to be feasible strategies and correlated with a reduction in radiological examinations requested and performed at the pediatric emergency room.

Maternal and fetal outcome in women with hypertensive disorders of pregnancy: the impact of prenatal care.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are the most important cause of maternal and fetal death and pregnancy complications in Latin America and the Caribbean. OBJECTIVES: The objective of this study was to characterize the epidemiological profile of women with HDP admitted to a Brazilian tertiary reference hospital, and to evaluate maternal and fetal outcome in each HDP and the impact of prenatal care on the maternal and fetal outcome. METHODS: HDP in 1501 women were classified according to usual definitions as chronic hypertension (n = 564), pre-eclampsia (n = 579), eclampsia (n = 74) and pre-eclampsia/eclampsia superimposed on chronic hypertension (n = 284). Adverse maternal and fetal outcomes registered as maternal death and near miss and fetal outcomes documented as stillbirth, neonatal death and newborn respiratory complications were compiled. Prenatal care was classified as complete (⩾ 6 visits), incomplete (< 6 visits) or not done. RESULTS: Women with eclampsia were younger (15 years), 68% were on their first pregnancy, had higher blood pressure, higher mortality and greater number of near miss cases and their children had lower birth weight, higher intra-uterus and neonatal mortality, and more respiratory distress. Women with pre-eclampsia/eclampsia superimposed on chronic hypertension and their fetuses had intermediate outcome and those with chronic hypertension and pre-eclampsia the better outcome among those with HDP. Women who had incomplete prenatal care or prenatal not done had progressive higher mortality rates and greater frequency of near miss cases, and their children had higher mortality rates. CONCLUSION: In a tertiary reference hospital, eclampsia and chronic hypertension superimposed on pre-eclampsia are associated with a worst outcome for mothers and fetuses, whereas complete prenatal care is associated with a better maternal and fetal outcome in HDP.