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MedEdPORTAL ; 17: 11106, 2021 03 02.
Artigo em Inglês | MEDLINE | ID: mdl-33768143


Introduction: During the COVID-19 pandemic, third-year medical students were temporarily unable to participate in onsite clinical activities. We identified the curricular components of an internal medicine (IM) clerkship that would be compromised if students learned solely from online didactics, case studies, and simulations (i.e., prerounding, oral presentations, diagnostic reasoning, and medical management discussions). Using these guiding principles, we created a virtual rounds (VR) curriculum to provide IM clerkship students with clinical exposure during a virtual learning period. Methods: Held three times a week for 2 weeks, VR consisted of three curricular components. First, clerkship students prerounded on an assigned hospitalized patient by remotely accessing the electronic health record and calling into hospital rounds. Second, each student prepared an oral presentation on their assigned patient. Third, using videoconferencing, students delivered these oral presentations to telemedicine VR small groups consisting of three to four students and three tele-instructors. Tele-instructors then provided feedback on oral presentations and taught clinical concepts. We assessed the effectiveness of VR by anonymously surveying students and tele-instructors. Results: Twenty-nine students and 34 volunteer tele-instructors participated in VR over four blocks. A majority of students felt VR improved their prerounding abilities (86%), oral presentation abilities (93%), and clinical reasoning skills (62%). All students found small group to be useful. Discussion: VR allowed students to practice rounding skills in a supportive team-based setting. The lessons learned from its implementation could facilitate education during future pandemics and could also supplement in-person clerkship education.

Estágio Clínico/métodos , Educação a Distância/métodos , Educação de Graduação em Medicina/métodos , Medicina Interna/educação , Visitas com Preceptor/métodos , /epidemiologia , Competência Clínica , Currículo , Medicina Hospitalar/educação , Medicina Hospitalar/tendências , Humanos , Satisfação Pessoal , Estudantes de Medicina/psicologia , Telemedicina/métodos
Cult Health Sex ; 22(3): 352-367, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31035913


Fistula-related stigma is common. The absence of a unifying conceptual framework prevents a nuanced understanding of the nature of fistula-related stigma, comparison across contexts and the ability to contrast with other stigmas. It also hinders intervention development. We conducted in-depth interviews or focus groups with 60 women who had undergone fistula surgery 6-24 months prior at Mulago Hospital in Kampala, Uganda in 2014. Transcripts were analysed for experiences and consequences of enacted, anticipated and internalised stigma. Narratives revealed experiences with enacted stigma, including gossip, verbal abuse and social exclusion. Women also anticipated and feared stigma in the future. Internalised stigma reports revealed shame and low self-esteem: self-worth reduction, feeling disgraced and envisioning no future. Consequences included social isolation, changes to normal activities, non-disclosure and poor mental health. Refining stigma theory to specific conditions has resulted in a more nuanced understanding of stigma dimensions, manifestations, mechanisms and consequences, permitting comparison across contexts and populations and the development of stigma-reduction interventions. These lessons should be applied to fistula, acknowledging unique features: concealability, the potential for treatment, lack of community awareness and the social consequences of stillbirth. Reducing fistula-related stigma requires timely surgery and supportive care, stigma-reduction interventions and addressing the complex societal structures that perpetuate fistula.

J Am Geriatr Soc ; 67(9): 1902-1906, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31112620


OBJECTIVES: Lower than recommended doses of direct-acting oral anticoagulants are often prescribed to older adults with nonvalvular atrial fibrillation (NVAF). Our goal was to determine the consequences of lower than recommended dosing on plasma apixaban concentrations during the clinical care of older adults with NVAF. DESIGN: Convenience sample of patients receiving anticoagulation during 2017. SETTING: Academic medical center. PARTICIPANTS: Stable adults older than 65 years with NVAF receiving apixaban on a chronic basis. MEASUREMENTS: Patient age, weight, creatinine, co-medications, and apixaban concentrations. RESULTS: A total of 110 older adults with NVAF (mean age = 80.4 y; range = 66-100 y with 45% women) were studied. Overall, 48 patients received recommended dosing of 5 mg twice/day, and 42 received lower than recommended dosing. One patient in each category had concentrations below the expected 5% to 95% range at time of peak concentrations. Differences in proportion of apixaban concentrations within or outside expected ranges were not significant between patients receiving lower than recommended doses and those dosed as recommended at 5 mg twice/day (P = .35). However, in patients dosed as recommended with 5 mg twice/day, four had concentrations above the 5% to 95% range for peak levels expected at 3 to 4 hours after dosing; in two, this occurred around the midpoint of the dosing interval. Twenty patients received 2.5 mg twice/day as recommended. One-third had apixaban concentrations higher than expected peak concentrations compared with the clinical trials, and more than two-thirds had levels above the reported median for peak concentrations. CONCLUSIONS: Apixaban concentrations in older adults with NVAF seen clinically were higher than expected based on clinical trial data. The findings raise questions about the optimal dosing of apixaban in older adults with NVAF encountered outside of clinical trials and suggest a role for the monitoring of apixaban concentrations during care of patients that differ from those in randomized trials or when considering dosing outside of published guidelines. J Am Geriatr Soc 67:1902-1906, 2019.

Anticoagulantes/administração & dosagem , Anticoagulantes/sangue , Fibrilação Atrial/sangue , Pirazóis/administração & dosagem , Pirazóis/sangue , Piridonas/administração & dosagem , Piridonas/sangue , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/tratamento farmacológico , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino