The Use of Clinical PBL in Primary Care in Undergraduate Medical Schools / Aplicação do PBL Clínico na Atenção Primária em Cursos de Medicina

Abstract: Introduction: Problem-based learning (PBL) is a collaborative student-centered learning method for small groups, based on the mobilization of previous knowledge and on critical reasoning for problem solving. Although it has been used predominantly in the classroom, when applied in clinical studies, PBL can increase the intrinsic motivation and long-term knowledge retention. In addition, Clinical PBL represents a more effective option to learn from practice considering the students' overload in clinical clerkships in the Unified Health System (UHS). This study aimed to assess the students' perception of a Clinical PBL model implemented in Primary Health Care (PHC) clerkships during the first four years of the Medical Course at the University of Ribeirão Preto (UNAERP) in 2017. Method: The primary outcome was assessed by the DREEM (Dundee Ready Educational Environment Measure) tool, which contains 50 items distributed in five dimensions. The questionnaire was applied to 374 medical students, corresponding to 78% of the total number of medical students from the first to the fourth year. Results: For most of the evaluated items, the students' perceptions were "positive", including the dimensions "Perception of Teachers", "Perception of Academic Results" and "Perception of the General Environment". For the dimensions "Perception of Learning" and "Perception of Social Relationships" the evaluation was "more positive than negative". The DREEM total score was 124.31, corresponding to 62.15% of the maximum score, which indicates a perception that is "more positive than negative" regarding the Clinical PBL. The internal consistency given by Cronbach's alpha was 0.92. Conclusion: The use of Clinical PBL in PHC qualifies learning from practice, is well accepted by medical students and offers a useful option to the students' overload in the clinical clerkship during the first four years of the Medical School.

Resumo: Introdução: A aprendizagem baseada em problemas (do inglês problem-based learning - PBL) é um método de aprendizagem colaborativa para pequenos grupos, centrado no estudante, fundamentado na mobilização de conhecimentos prévios e no raciocínio crítico para a solução de problemas. Embora tenha sido utilizado predominantemente em sala de aula, quando aplicado em estágios clínicos, o PBL pode aumentar a motivação intrínseca e a retenção de conhecimento em longo prazo pelos estudantes. Além disso, o PBL clínico pode representar uma opção mais efetiva de aprendizado a partir da prática ante a sobrecarga de alunos nos estágios clínicos no Sistema Único de Saúde. Este estudo teve por objetivo avaliar a percepção dos estudantes sobre um modelo de PBL clínico implementado em estágios de atenção primária à saúde (APS) no pré-internato do curso de Medicina da Universidade de Ribeirão Preto (Unaerp) em 2017. Método: O desfecho primário foi avaliado por meio do instrumento Dundee Ready Educational Environment Measure (DREEM), que contém 50 itens distribuídos em cinco dimensões. O questionário foi aplicado a 374 alunos de Medicina que correspondem a 78% do total de estudantes do pré-internato. Resultados: Para a maioria dos itens avaliados, a percepção dos foi "positiva", incluindo as dimensões "percepção dos professores", "percepção dos resultados acadêmicos" e "percepção do ambiente geral". Para as dimensões "percepção da aprendizagem" e "percepção das relações sociais", a avaliação foi "mais positiva do que negativa". O escore total das respostas foi de 124,31, correspondendo a 62,15% do escore máximo, o que indica uma percepção "mais positiva do que negativa" sobre a atividade. A consistência interna dada pelo alfa de Cronbach foi de 0,92. Conclusão: O uso do PBL clínico em APS qualifica o aprendizado a partir da prática, é bem-aceito pelos estudantes de Medicina e oferece uma opção viável à sobrecarga de alunos em estágios clínicos do pré-internato.

Students' perception of animal or virtual laboratory in physiology practical classes in PBL medical hybrid curriculum.

Over the years, much criticism against animal use for physiology teaching has been made. Hence, replacement by suitable alternatives has increased in several pedagogical approaches. This study examined students' perceptions of animal versus virtual (video/computer) laboratory classes in physiological sciences associated with the effectiveness of the problem-based learning (PBL) hybrid curriculum. Three cohorts of medical students from the University of Ribeirão Preto, who participated in animal or virtual physiology classes or both, were asked to fill out a 5-point Likert questionnaire about knowledge acquisition/motivation, importance to PBL learning goals, skills acquired, need for animal use, academic formation, learning impairment, and alternative methods. We also assessed their grades in the final exam. A total of 350 students were included, in which 108 participated only in virtual classes, 120 only in practical animal laboratory classes, and 122 in both approaches. The majority agreed that the two methods improved their knowledge acquisition/motivation and helped to reinforce tutorial goals and to acquire skills. However, the cohort who experienced both approaches favored animal laboratory. Students believe animal use is needed and did not impair their learning. Conversely, their opinion about academic formation without animal laboratory classes was divided, as was whether this approach inspired them to seek alternative methods. Despite the different perceptions, there was no difference among the groups' final grades (7.3 ± 1 vs. 7.2 ± 1 vs. 7.2 ± 2 for virtual or practical animal laboratory classes or both, respectively). Therefore, virtual activities are not as effective as animal use in the opinions of the students, but they are successful strategies in physiology learning that can be used in practical classes in a hybrid PBL curriculum.

Curcumin Analog CH-5 Suppresses the Proliferation, Migration, and Invasion of the Human Gastric Cancer Cell Line HGC-27.

Gastric cancer is one of the most frequent malignant tumors in the world. The majority of patients are diagnosed with metastatic gastric cancer, which has a low survival rate. These data reinforce the importance of studying the anticancer activity of new molecules with the potential to suppress gastric cancer metastasis. Curcumin is a well-studied compound that has demonstrated anti-metastatic effects. Here we investigated if CH-5, a curcumin derivative compound, has anti-metastatic properties in the human gastric cancer cell line HGC-27. Firstly, we found that CH-5 decreased viability and induced apoptosis in HGC-27 cells in a dose-dependent manner. Additionally, CH-5 suppressed the migration and invasion of HGC-27 cells by downregulating the expression and collagenase activity of matrix metalloproteinase 2 in a dose-dependent manner. In conclusion, CH-5 showed anticancer activities, including the induction of apoptosis, and the suppression of migration and invasion in HGC-27 cells, suggesting that CH-5 can be a lead molecule for the development of anti-metastatic drugs for gastric cancer therapy.

Contextual considerations in implementing problem-based learning approaches in a Brazilian medical curriculum: the UNAERP experience.

BACKGROUND: Despite being a well-established pedagogical approach in medical education, the implementation of problem-based learning (PBL) approaches hinges not only on educational aspects of the medical curriculum but also on the characteristics and necessities of the health system and the medical labor market within which it is situated. AIM: To report our experiences implementing a PBL-based approach in a region of Brazil where: 1) all pre-university education and the vast majority of medical courses are based on traditional, lecture-based instructions; and 2) students' career interests in primary care, arguably the prototypical PBL trainee, are heavily disfavored because of economics. RESULTS: Brazilian guidelines require that clinical training take place during the last 2 years of the medical program and include intensive, supervised, inpatient and outpatient rotations in pediatrics, family medicine, obstetrics and gynecology, internal medicine, and surgery. Throughout the pre-clinical curriculum, then, students learn to deal with progressively more difficult and complex cases--typically through the use of PBL tutors in a primary care context. However, because of curricular time constraints in the clerkships, and students' general preoccupation with specialty practice, the continuation of PBL-based approaches in the pre-clinical years--and the expansion of PBL into the clerkships--has become exceedingly difficult. DISCUSSION AND CONCLUSION: Our experience illustrates the importance of context (both cultural and structural) in implementing certain pedagogies within one Brazilian training program. We plan to address these barriers by: 1) integrating units, whenever possible, within a spiral curriculum; 2) introducing real patients earlier in students' pre-clinical coursework (primarily in a primary care setting); and 3) using subject experts as PBL tutors to better motivate students.

Effects of the serjania erecta and zeyheria montana ethanol extracts inexperimental pulpitis in rats: A histological study

Objectives: The aim of this study was to evaluate, by the semi-quantitative histological analysis, the anti-inflammatory activity of the ethanolic extracts of Serjania erecta e Zeyheria Montana, in experimental pulpits in rats. Study Design: In order to induce pulp inflammation, cavities were performed on the occlusal surface of the mandibular first molars of 45 male rats, without pulp exposure. The animals were distributed into 4 groups: GI, teeth without cavities; GII, single dose of saline solution via intraperitoneal (IP); GIII, single dose (IP) of 300mg/Kg ofethanolic extract of Zeyheria montana; GIV, single dose (IP) of 300mg/Kg of ethanolic extract of Serjania erecta. After 6, 12 and 24 hours, 5 animals of each group were killed by anesthetic overdose. The histological analyses of the pulp tissue were performed and the data analyzed by Dunn´s multiple test, at significance of 5%.Results: After 12 h, the GIII presented score statistically lower (p<0.05) than positive control group. After 24 h, GIII presented inflammatory index statistically lower than the positive control (p<0.01) and Serjania erecta (p<0.05) groups. Conclusion: The Zeyheria montana extract presented better anti-inflammatory activity than positive control group and Serjania erecta extract, which did not show anti-inflammatory effect in the analyzed periods (AU)

Effects of the serjania erecta and zeyheria montana ethanol extracts in experimental pulpitis in rats: a histological study.

OBJECTIVES: The aim of this study was to evaluate, by the semi-quantitative histological analysis, the anti-inflammatory activity of the ethanolic extracts of Serjania erecta e Zeyheria Montana, in experimental pulpits in rats. STUDY DESIGN: In order to induce pulp inflammation, cavities were performed on the occlusal surface of the mandibular first molars of 45 male rats, without pulp exposure. The animals were distributed into 4 groups: GI, teeth without cavities; GII, single dose of saline solution via intraperitoneal (IP); GIII, single dose (IP) of 300 mg/Kg of ethanolic extract of Zeyheria montana; GIV, single dose (IP) of 300 mg/Kg of ethanolic extract of Serjania erecta. After 6, 12 and 24 hours, 5 animals of each group were killed by anesthetic overdose. The histological analyses of the pulp tissue were performed and the data analyzed by Dunn's multiple test, at significance of 5%. RESULTS: After 12 h, the GIII presented score statistically lower (p<0.05) than positive control group. After 24 h, GIII presented inflammatory index statistically lower than the positive control (p<0.01) and Serjania erecta (p<0.05) groups. CONCLUSION: The Zeyheria montana extract presented better anti-inflammatory activity than positive control group and Serjania erecta extract, which did not show anti-inflammatory effect in the analyzed periods.

Avaliação da atividade antiinflamatória de AINES em tecido pulpar de ratos / Anti-inflamatory evaluation of AINES in rat´s pulps

O presente estudo avaliou a atividade antiinflamatória de antiinflamatórios não-esteroidais (AINEs)em tecido pulpar de ratos, por meio de microscopia óptica. Preparos cavitários foram realizados nos incisivossuperiores de 40 ratos para a indução de processo inflamatório pulpar. Os animais foram distribuídos aleatoriamenteem 5 grupos segundo a medicação administrada: G1 - celecoxib; G2 - rofecoxib; G3 - diclofenacode sódio; G4 - ibuprofeno e G5 - solução fisiológica (controle). A terapia com AINEs foi iniciada apo?s 24 horasda realização da exposição pulpar. Nos períodos de 1, 3, 5 e 7 dias após o início da terapia medicamentosa,2 animais de cada grupo foram sacrificados e tiveram seus dentes extraídos para a análise histológica dotecido pulpar. Os índices utilizados para avaliação qualitativa variaram de 1 (tecido quase regenerado) até6 (inflamação severa). Os dados foram analisados por meio de Análise de Variância e teste de Tukey. Verificou-se que todos os medicamentos testados foram capazes de reduzir a inflamação quando comparadosao grupo controle. O grupo tratado com celecoxib apresentou os melhores resultados na redução do quadroinflamatório (p<0,01), seguido pelo rofecoxib e ibuprofeno, que se comportaram de maneira estatisticamentesemelhantes entre si (p>0,01) e superiores ao diclofenaco de sódio (p<0,01).

This study evaluated the anti-inflammatory effect of non-steroids anti-inflammatory (AINEs) in rat´s pulps,behind optic microscopy. Cavities were done in maxillary incisors of 40 rats to induce pulp inflammatory.The animals were divided in 5 groups according to medication: G1 - celecoxib; G2 - rofecoxib; G3 - diclofenacode sódio; G4 - ibuprofeno and G5 - saline (control). The therapy was initialized 24 hours after the pulpexposition. In the periods of 1, 3, 5 and 7 days after the therapy, 2 animals of each group were sacrificedand had their teeth extracted to histological analysis of pulp tissue. The scores were 1 (healed tissue) to 6(severe inflammation). The data were evaluated by Variance analysis and Tukey´s test. It was verified thatall medicaments were capable to reduce inflammation compared to control group. The celecoxib group presentedthe best results in reduction of inflammation (p<0,01), followed by rofecoxib and ibuprofeno, whichwere statistically equal (p>0,01) and better than diclofenaco de sódio (p<0,01).

Descriptive and functional neuroanatomy of locus coeruleus-noradrenaline-containing neurons involvement in bradykinin-induced antinociception on principal sensory trigeminal nucleus.

The present study was carried out in Wistar rats, using the jaw-opening reflex and dental pulp stimulation, to investigate noradrenaline- and serotonin-mediated antinociceptive circuits. The effects of microinjections of bradykinin into the principal sensory trigeminal nucleus (PSTN) before and after neurochemical lesions of the locus coeruleus noradrenergic neurons were studied. Neuroanatomical experiments showed evidence for reciprocal neuronal pathways connecting the locus coeruleus (LC) to trigeminal sensory nuclei and linking monoaminergic nuclei of the pain inhibitory system to spinal trigeminal nucleus (STN). Fast blue (FB) injections in the locus coeruleus/subcoeruleus region retrogradely labeled neurons in the contralateral PSTN and LC. Microinjections of FB into the STN showed neurons labeled in both ipsilateral and contralateral LC, as well as in the ipsilateral Barrington's nucleus and subcoeruleus area. Retrograde tract-tracing with FB also showed that the mesencephalic trigeminal nucleus sends neural pathways towards the ipsilateral PSTN, with outputs from cranial and caudal aspects of the brainstem. In addition, neurons from the lateral and dorsolateral columns of periaqueductal gray matter also send outputs to the ipsilateral PSTN. Microinjections of FB in the interpolar and caudal divisions of the STN labeled neurons in the caudal subdivision of STN. Microinjections in the STN interpolar and caudal divisions also retrogradely labeled serotonin- and noradrenaline-containing nucleus of the brainstem pain inhibitory system. Finally, the gigantocellularis complex (nucleus reticularis gigantocellularis/paragigantocellularis), nucleus raphe magnus and nucleus raphe pallidus also projected to the caudal divisions of the STN. Microinjections of bradykinin in the PSTN caused a statistically significant long-lasting antinociception, antagonized by the damage of locus coeruleus-noradrenergic neuronal fibres with (N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine) (DSP4), a neurotoxin that specifically depleted noradrenaline from locus coeruleus terminal fields. These data suggest that serotonin- and noradrenaline-containing nuclei of the endogenous pain inhibitory system exert a key-role in the antinociceptive mechanisms of bradykinin and the locus coeruleus is crucially involved in this effect.

Localização de áreas cerebrais envolvidas na atividade antinociceptiva da bradicinina

A bradicinina microinjetada em regiões ventriculares do cérebro de ratos e no loco ceruleo, núcleos trigeminois principal, oral e interpolar e raiz sensorial do nervo trigeminal elevou o limiar doloroso quando utilizado o teste algesimétrico de estimulação elétrica da polpa dental (AU)