Adding guidance to deliberate reflection improves medical student's diagnostic accuracy.

CONTEXT: Diagnostic competence in students is a major medical education goal. Adding instructional guidelines to prompt deliberate reflection fosters medical students' diagnostic proficiency. This study investigates the effects of this teaching strategy on diagnostic accuracy in solving clinical cases of different complexity levels by novice and senior students. METHOD: Eighty third-year and 62 sixth-year medical students participated in this three-phase experimental study. First, participants were randomly assigned to one of three experimental conditions (free reflection, cued reflection and worked example) to diagnose 12 clinical text-based cases, following different levels of deliberate reflection. In an immediate test and a delayed test, the participants diagnosed varied sets of 12 cases, six involving the same diseases (four routine and two rare). The main outcomes were the diagnostic accuracy scores achieved for the cases assessed by repeated measures of analysis of variance for each category. RESULTS: There was a significant primary effect of experimental condition (P < .001), year of training (P < .001) and study phase (P < .001) on the diagnostic accuracy achieved. The use of deliberate reflection in addition to instructional guidelines resulted in improved results in the immediate test for all cases evaluated (P < .001), regardless of participants' seniority. In the delayed test, this benefit was maintained for simple cases (P < .001). For complex cases, the benefit was maintained only for senior students (P < .001). The cued reflection and worked example groups did not differ in performance (P > .05), but both groups surpassed the free reflection group (P < .001), regardless of the students' learning stage and case complexity.

O ensino de cuidados de saúde no Brasil entre os séculos XVI e XIX / The teaching health care in Brazil between the 16 th and 19 th centuries

Resumo Introdução: Entre os anos de 1500 e 1822, o Brasil esteve sob o domínio colonial de Portugal, e apenas em 1808 as duas primeiras escolas oficiais de Medicina foram abertas em seu território. Por mais de três séculos após o descobrimento, a falta de instituições locais para formar profissionais de saúde foi um problema diante de uma população vulnerável tanto às doenças tropicais quanto às enfermidades importadas. Nesse contexto, predominava a disseminação de conhecimentos, crenças e práticas dos padres jesuítas, pajés indígenas e africanos escravizados, frequentemente com perspectivas conflitantes. Desenvolvimento: Este ensaio tem como objetivos abordar o ensino dos cuidados de saúde no Brasil colonial e refletir sobre esse período histórico e suas influências para a formação de médicos no país. Conclusão: A educação médica tem enfrentado atualmente muitos desafios, e entendemos que os avanços pedagógicos, científicos e tecnológicos devem ser adotados, sem desconsiderar os contextos histórico e cultural, e a pluralidade da população e do sistema de saúde nacional. Mais de 500 anos se passaram desde a chegada dos portugueses, e ainda hoje o Brasil continua sendo um país com complexidades territorial, étnica, cultural, econômica e religiosa ímpares.

Abstract Introduction: Between 1500 and 1822, Brazil was under the colonial rule of Portugal, and it was only in 1808 that the first two official medical schools were opened in its territory. For more than three centuries after the European discovery of Brazil, the lack of local institutions to train health professionals was a problem for a population vulnerable to both tropical and imported diseases. In this context, the knowledge, beliefs and practices of Jesuit priests, indigenous shamans and enslaved Africans predominated, often with conflicting perspectives. Development: This essay aims to address the teaching of health care in colonial Brazil and reflect on this historical period and its influences on the training of doctors in the country. Conclusion: Medical education is currently facing many challenges, and we understand that pedagogical, scientific and technological advances must be adopted, but without disregarding the historical and cultural context and the plurality of the population and the national health system. More than five hundred years have passed since the arrival of the Portuguese, and to this day Brazil remains a country with unique territorial, ethnic, cultural, economic and religious complexity.

Clinical course of 63 children with hereditary spherocytosis: a retrospective study.

BACKGROUND: Hereditary spherocytosis (HS) is an inherited hemolytic anemia that is caused by deficiency or dysfunction of erythrocyte cytoskeletal proteins. AIM: The aim of this study was to describe the clinical course of hereditary spherocytosis in patients treated in the Pediatric Hematology Unit, Hospital das Clínicas, Universidade Federal de Minas Gerais. METHODS: Sixty-three under 16-year-old patients with hereditary spherocytosis were retrospectively evaluated between January 1988 and December 2007. Hereditary spherocytosis was diagnosed based on clinical history, physical examination and on a positive osmotic fragility curve. Patients underwent screening for cholelithiasis by ultrasonography. They were classified into three groups: mild, moderate and severe. The events of interest were need for blood transfusion, cholelithiasis, splenic sequestration, aplastic crisis, and splenectomy. Differences between subgroups were evaluated by the two-sided log-rank test. RESULTS: The mean age at diagnosis was 5.2 years and most patients were classified as moderate (54%). Patients with the severe form of the disease were younger (p-value = 0.001) and needed more blood transfusions (p-value = 0.004). Seventeen patients (27%) developed cholelithiasis, 14 (22.2%) splenic sequestration and three (4.8%) aplastic crises. Twenty-two patients (34.9%) were splenectomized with the main indication being splenic sequestration in nine patients (41%). CONCLUSION: The clinical course of patients with hereditary spherocytosis in this study was relatively benign however cholelithiasis was a common complication.

Lesão de Morel-Lavallée: relato de caso / Morel LavalléeLesion: case report

A lesão de Morel-Lavallée, descrita inicialmente no século XIX pelo cirurgião francês Victor Auguste François Morel-Lavallée, constitui lesão de partes moles, sobretudo nas áreas que revestem as protuberâncias ósseas. Sua fisiopatologia consiste no deslocamento da pele e do tecido celular subcutâneo sobre a fáscia muscular, provocado por forças tangenciais súbitas e intensas, secundárias a traumatismos. No espaço criado pela avulsão dos tecidos, acumulam-se sangue, linfa e debris gordurosos. O diagnóstico é baseado na história clínica, no exame físico e nos exames de imagem. O tratamento geralmente é conservador e o prognóstico é bom, nas lesões menores. Em casos de lesões extensas podem ocorrer graves complicações. O diagnóstico diferencial inclui bursite, hematoma, abscesso, tumores benignos e neoplasias malignas. O presente relato visa alertar o pediatra sobre a possibilidade diagnóstica de lesão de Morel-Lavallée, garantindo-se sua abordagem precoce e adequada, especialmente quando se considera a prática de esportes cada vez mais comum entre crianças e adolescentes, além do risco da sua ocorrência por traumas associados às atividades lúdicas próprias da faixa etária pediátrica.(AU)

The injury of Morel-Lavallée, first described in the nineteenth century by the French surgeon Victor Auguste François Morel-Lavallée, is a soft tissue injury, particularly in the linimg areas of the bony prominences. The patophysiology consists in the displacement of the skin and the fascia subcutaneous tissue caused by sudden and intense shear forces, secondary to trauma. In the space created by tissue avulsions acumulates blood, lymph and fatty debris. Diagnosis is based on clinical history, physical examination and imaging studies. Treatment is usually conservative and the prognosis is good, in the minor injuries. In cases of extensive lesions the result can be serious complications. The differential diagnosis includes bursitis, hematoma, abscess, benign and malignant neoplasms. This report aims to alert the pediatrician about the diagnostic possibility of Morel-Lavallée lesion nsuring their early and appropriate approach, especially when we consider the practice of sports, increasingly common among children and adolescents, and the risk of their occurrence of traumas associated with own play activities of pediatric patients.(AU)

Clinical course of 63 children with hereditary spherocytosis: a retrospective study

BACKGROUND: Hereditary spherocytosis (HS) is an inherited hemolytic anemia that is caused by deficiency or dysfunction of erythrocyte cytoskeletal proteins. AIM: The aim of this study was to describe the clinical course of hereditary spherocytosis in patients treated in the Pediatric Hematology Unit, Hospital das Clínicas, Universidade Federal de Minas Gerais. METHODS: Sixty-three under 16-year-old patients with hereditary spherocytosis were retrospectively evaluated between January 1988 and December 2007. Hereditary spherocytosis was diagnosed based on clinical history, physical examination and on a positive osmotic fragility curve. Patients underwent screening for cholelithiasis by ultrasonography. They were classified into three groups: mild, moderate and severe. The events of interest were need for blood transfusion, cholelithiasis, splenic sequestration, aplastic crisis, and splenectomy. Differences between subgroups were evaluated by the two-sided log-rank test. RESULTS: The mean age at diagnosis was 5.2 years and most patients were classified as moderate (54 percent). Patients with the severe form of the disease were younger (p-value = 0.001) and needed more blood transfusions (p-value = 0.004). Seventeen patients (27 percent) developed cholelithiasis, 14 (22.2 percent) splenic sequestration and three (4.8 percent) aplastic crises. Twenty-two patients (34.9 percent) were splenectomized with the main indication being splenic sequestration in nine patients (41 percent). CONCLUSIONS: The clinical course of patients with hereditary spherocytosis in this study was relatively benign however cholelithiasis was a common complication.

Deficiência de ferro: ainda a principal etiologia entre crianças encaminhadas por motivo de anemia para serviço especializado de hematologia / Iron deficiency: still the main cause of referral of children to hematology services for reason of anemia

OBJETIVOS: determinar os motivos de encaminhamento e diagnósticos de crianças com anemia para serviço especializado. MÉTODOS: coorte histórico e concorrente de crianças com anemia encaminhadas ao Serviço de Hematologia do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil, entre maio de 1999 e dezembro de 2001. RESULTADOS: foram avaliadas 153 crianças menores de 16 anos, sendo 83 por cento procedentes de Centros de Saúde. Aproximadamente um terço das crianças não recebeu qualquer terapêutica no serviço de origem. Cento e onze (71,3 por cento) tiveram diagnóstico de anemia ferropriva. Treze crianças (8,6 por cento) tiveram diagnóstico de talassemia minor; outras treze crianças apresentaram outros diagnósticos de anemias e 11,5 por cento das crianças não apresentavam anemia. Os valores médios de hemoglobina na abordagem pelo hematologista foram significativamente maiores que os dos serviços de origem (9,7±1,9 vs. 8,9±2,0); p=0,001. Somente 16,2 por cento crianças não responderam ao primeiro tratamento com sais de ferro oral, sendo o sulfato ferroso o principal medicamento prescrito (79,3 por cento). CONCLUSÕES: A deficiência de ferro foi a principal etiologia das crianças encaminhadas por motivo de anemia para serviço especializado. Encaminhamentos desnecessários de indivíduos com anemia ferropriva para serviços especializados representam prejuízo aos pacientes e ônus excedente para o sistema de saúde.

OBJECTIVES: to determine the reasons for diagnosis of anemia among children and referral to specialized services. METHODS: an historical and concurrent cohort study was carried out among anemic children referred to the Hematology Service of the Federal University of Minas Gerais's Clinical Hospital, Belo Horizonte, in the State of Minas Gerais, Brazil, between May 1999 and December 2001. RESULTS: 153 children aged under 16 were evalua-ted, 83 percent of whom had been referred by Health Centers. Approximately one third of the children did not receive any treatment at the referring service. One hundred and eleven (71.3 percent) were diagnosed as having iron-deficiency anemia. Thirteen children (8.6 percent) received a diagnosis of thalassemia minor; and a further thirteen other anemia-related diagnoses. 11.5 percent had no kind of anemia. The mean hemoglobin levels were significantly higher when tested by a hematologist than at the referring services (9.7±1.9 vs. 8.9±2.0); p=0.001. Only 16.2 percent of children did not respond to initial treatment with oral iron salts, with iron (II) sulfate being the medication usually prescribed (79.3 percent). CONCLUSIONS: iron deficiency was the main cause of children being referred to a specialized service for reason of anemia. Unnecessary referral of individuals with iron-deficiency anemia is potentially harmful to patients and puts an excessive burden on the health system.

Anemia hemolítica auto-imune como sintoma inicial de linfoma de hodgkin / Autoimmune hemolytic anemia as an initial symptom in Hodgkin's disease

Objetivo: relatar um caso de linfoma de Hodgkin precedido por anemia hemolítica auto-imune (AHAI). Descrição: relata-se o caso de um paciente de 10 anos de idade com quadro clínico e laboratorial típico de AHAI por anticorpo de reação fria. Após quatro anos de evolução, com resposta inicial ao uso de corticóide e imunoglobulina, o paciente apresentou anemia refratária, hepatoesplenomegalia, febre e perda de peso, sendo diagnosticado linfoma de Hodgkin (LH) estádio IIB. Após 23 meses de encerramento da quimioterapia, o paciente encontra-se em remissão clínica, tanto da AHAI quanto do linfoma. Comentários: a AHAI consiste de um grupo de doenças cuja característica comum é a presença de auto-anticorpos que diminuem o tempo de sobre vida dos eritrócitos. A maioria dos casos de AHAI crônica é secundária a uma doença de base grave, assim, esses pacientes demandam seguimento clínico rigoroso e prolongado. O presente relato de caso mostra que o LH deve ser considerado no diagnóstico diferencial de uma criança com AHAI crônica.