The resident-as-teacher educational challenge: a needs assessment survey at the National Autonomous University of Mexico Faculty of Medicine

<p>Abstract</p> <p>Background</p> <p>The role of residents as educators is increasingly recognized, since it impacts residents, interns, medical students and other healthcare professionals. A widespread implementation of resident-as-teacher courses in developed countries' medical schools has occurred, with variable results. There is a dearth of information about this theme in developing countries. The National Autonomous University of Mexico (UNAM) Faculty of Medicine has more than 50% of the residency programs' physician population in Mexico. This report describes a needs assessment survey for a resident as teacher program at our institution.</p> <p>Methods</p> <p>A cross-sectional descriptive survey was developed based on a review of the available literature and discussion by an expert multidisciplinary committee. The goal was to identify the residents' attitudes, academic needs and preferred educational strategies regarding resident-as-teacher activities throughout the residency. The survey was piloted and modified accordingly. The paper anonymous survey was sent to 7,685 residents, the total population of medical residents in UNAM programs in the country.</p> <p>Results</p> <p>There was a 65.7% return rate (5,186 questionnaires), a broad and representative sample of the student population. The residents felt they had knowledge and were competent in medical education, but the majority felt a need to improve their knowledge and skills in this discipline. Most residents (92.5%) felt that their role as educators of medical students, interns and other residents was important/very important. They estimated that 45.5% of their learning came from other residents. Ninety percent stated that it was necessary to be trained in teaching skills. The themes identified to include in the educational intervention were mostly clinically oriented. The educational strategies in order of preference were interactive lectures with a professor, small groups with a moderator, material available in a website for self-learning, printed material for self-study and homework, and small group web-based learning.</p> <p>Conclusions</p> <p>There is a large unmet need to implement educational interventions to improve residents' educational skills in postgraduate educational programs in developing countries. Most perceived needs of residents are practical and clinically oriented, and they prefer traditional educational strategies. Resident as teachers educational interventions need to be designed taking into account local needs and resources.</p

Algoritmo de Tratamiento Multimodal para Preescolares Latinoamericanos con Trastorno por Déficit de Atención con Hiperactividad (TDAH)

Introduction During the first Latin American ADHD consensus held in Mexico in 2007 a treatment algorithm for attention-deficit/hyperactivity disorder (ADHD) in preschoolers was proposed. Since then, some studies have emerged regarding not only pharmacological treatment but also psychosocial managing strategies for this population that require a review. The main objective was to review the recent literature on preschool ADHD clinical management in order to update the treatment algorithm and to include together both psychopharmacological treatment and psychosocial management strategies into the decision tree. Method A task force with six experts from five Latinamerican countries was constituted. The task force included different health specialties: child and adolescent psychiatry, neuropaediatrics, psychology and neuropsychology. Literature in the field of preschool ADHD, published between 2006 and 2008, was reviewed, and the evidence level of studies was assessed, to develop the Multimodal Treatment Algorithm for Preschool ADHD in accordance with the Latin American population needs. From the gathered information, the experts elaborated the main recommendations for the assessment and management of ADHD Latin American preschoolers, and constructed the decision tree according to the evidence level of each treatment intervention. Results ADHD is among the most common neuropsychiatric consultations in preschool-aged children. There are five studies in Latin America showing a preschool ADHD prevalence between 3.24% and 11.2%. The main clinical manifestations are mostly related with poor impulse control, difficulty to follow simple instructions, overactivity and, in some cases, aggression and rejection by peers. Many studies show high comorbidity with oppositional defiant disorder and other neuropsychiatric disorders, such as language, learning and motor disorder and anxiety and depression as well. The ADHD clinical presentation in preschoolers has the same severity level and comorbidity as in school-age children, and it requires comprehensive treatment. There are some helpful scales to assess ADHD preschool children, such as the Parent and Teacher versions of the Conners Rating Scale, the IDC-PRE Scale, and the Early Childhood Inventory4. A diagnosis of preschool ADHD requires patient fulfilling DSM-IVTR criteria. Special recommendations made by the Latin American Multimodal Treatment Algorithm for Preschool ADHD group were: 1. to guarantee a minimum duration of ADHD symptoms of nine months; 2. to verify the report of symptoms directly with teachers; 3. to obtain clear-cut impact and repercussion criteria for «clear evidence of clinically significant impairment in social, academic, or family functioning»; severity is more important than the number of symptoms, and finally; 4. to rule out a list of different disorders mimicking ADHD, and also to detect factors and psychosocial situations influencing the ADHD presentation. There are several alternatives for the preschool ADHD treatment, population, which were inserted in the decision tree according to their evidence level. The Latin American Multimodal Treatment Algorithm for Preschool ADHD group recommends the integrated and rational use of both pharmacological and psychosocial treatments. Psychosocial treatments for the ADHD preschooler with good clinical evidence are: psychoeducation, parental management training (PMT), parentchild interaction therapy (PCIT) and behavioral school-based intervention. After parental assessment on ADHD knowledge, parent’s psychoeductation promotes good information about ADHD, and also gives parents guidance and support. There are some published studies about the efficacy of PMT and PCIT in Latin American preschool population. These therapeutic interventions help families to learn how to manage their children difficulties and improve family functioning. PCIT was designed for 2-7 year old children; it has a clinical orientation and involves the child, parents, and other family members in the treatment. Recent studies show a robust response to the PCIT reducing the ADHD symptomatology. Finally, behavioral school-based intervention has some evidence, and its implementation includes teacher training in contingency management plans in order to promote children self-regulation. Methylphenidate (MPD) is the most studied psychopharmacological agent in this young population. Due to its robust clinical evidence, it is the first-line agent for the treatment of preschool children with ADHD. The group for the development of the Multimodal Treatment Algorithm for Latin American Preschool ADHD recommends to start with low doses of MPD, 1.25–2.5 mg/day, and gradually increase them every 2-3 weeks, until the maximum dose of 2.5-7.5 mg/day is reached. There are only two open-studies showing atomoxetine efficacy in this population. Atomoxetine has a medium evidence level and further studies are needed for more conclusions. The group recommends the use of atomoxetine with a maximum dose of 1.25 mg/kg/day. Other agents have a low level of evidence. Ampehtamines (available only in Chile and Puerto Rico), with only one study, and the alpha-agonists (clonidine and guanfacine) have been used based on clinical experience only. Further research is needed, especially head to head studies, comparing these agents with the MPD gold standard in both short and long-term follow-up studies. Any treatment decision should be closely monitored in order to make efficacy accurate in clinical response and to provide security for the young patient. While a child is using psychopharmacological treatment, it is important to monitor weight and size monthly. The main modifications to the former version of the Multimodal Treatment Algorithm for Latin American Preschool ADHD are: 1. the specific recommendation of psychosocial treatment such as psychoeducation, PMT, PCIT, and behavioral school-based intervention; 2. the recommendation of methylphenidate (available in all Latin American countries) as first pharmacological agent, followed by atomoxetine or amphetamines, and, in last instance, to consider the use of clonidine, and; 3. psychosocial treatment continuation is recommended for the maintenance jointly with the medication showing the best response. Conclusions There are two main pillars for the adequate treatment of preschool ADHD. On the one hand, there are psychosocial interventions such as psychoeducation, PMT, PCIT and behavioral school-based interventions; on the other hand, pharmacological treatment, especially with methylphenidate. Other pharmacological agents have a lack of scientific evidence. As the Multimodal Treatment Algorithm for Latin American Preschoolers with ADHD group, we recommend to start with the psychosocial treatment intervention, and then to follow the pharmacological options. New proposals should be developed according to the special needs and contexts of Latin America. - Introducción: En el Primer Consenso Latinoamericano de TDAH, celebrado en México en 2007 se propuso un algoritmo de tratamiento farmacológico para preescolares con Trastorno por Déficit de Atención con Hiperactividad (TDAH). Desde entonces han surgido algunos estudios no solo sobre tratamiento farmacológico, sino también sobre estrategias de manejo psicosociales en esta población que ameritan una revisión. El objetivo fue integrar la literatura reciente sobre el manejo clínico del TDAH en preescolares con el fin de actualizar el algoritmo latinoamericano de tratamiento e incorporar al árbol de decisiones las medidas psicosociales. Metodología: Se integró un panel de expertos con seis especialistas de diferentes áreas: psiquiatría infantil y de la adolescencia, neuropediatría, psicología y neuropsicología de cinco países latinoamericanos. Se revisó la literatura de entre 2006 y 2008; se evaluó el nivel de evidencia científica de los estudios, y se desarrolló el algoritmo de tratamiento de preescolares con TDAH, de acuerdo con las necesidades de la población latinoamericana. A partir de la información obtenida los especialistas propusieron las principales recomendaciones para evaluar y manejar a los preescolares latinoamericanos con TDAH y construyeron un árbol de decisiones según el nivel de evidencia científica de cada propuesta de tratamiento. Resultados: El algoritmo multimodal para el tratamiento de preescolares latinoamericanos con TDAH plantea como primer recurso el manejo psicosocial y luego el tratamiento farmacológico. Los principales cambios en el algoritmo son: la recomendación específica de los tratamientos psicosociales como la psicoeducación, el Entrenamiento en Manejo Parental (EMP) y la Terapia Interaccional Padre-Hijo (TIPH). La recomendación del metilfenidato como primera etapa farmacológica (disponible en todos los países de Latinoamérica), seguido de la atomoxetina o las anfetaminas; en el último término se puede considerar el uso de clonidina. Finalmente, se recomienda continuar con los tratamientos psicosociales para el mantenimiento en conjunto con la medicación con la que se mostró la mejor respuesta. Conclusiones: Existen diversas alternativas de tratamiento para esta población; éstas se distribuyeron en el árbol de decisiones de acuerdo con el nivel de evidencia. El algoritmo para preescolares latinoamericanos con TDAH recomienda el uso conjunto y racional de tratamientos farmacológicos y psicosociales

Neonate Human Remains: A Window of Opportunity to the Molecular Study of Ancient Syphilis

Ancient DNA (aDNA) analysis can be a useful tool in bacterial disease diagnosis in human remains. However, while the recovery of Mycobacterium spp. has been widely successful, several authors report unsuccessful results regarding ancient treponemal DNA, casting doubts on the usefulness of this technique for the diagnosis of ancient syphilis. Here, we present results from an analysis of four newborn specimens recovered from the crypt of “La Ermita de la Soledad” (XVI–XVII centuries), located in the province of Huelva in the southwest of Spain. We extracted and analyzed aDNA in three independent laboratories, following specific procedures generally practiced in the aDNA field, including cloning of the amplified DNA fragments and sequencing of several clones. This is the most ancient case, reported to date, from which detection of DNA from T. pallidum subspecies pallidum has been successful in more than one individual, and we put forward a hypothesis to explain this result, taking into account the course of the disease in neonate individuals

ACE2-binding exposes the SARS-CoV-2 fusion peptide to broadly neutralizing coronavirus antibodies

The coronavirus spike glycoprotein attaches to host receptors and mediates viral fusion. Using a broad screening approach, we isolated seven monoclonal antibodies (mAbs) that bind to all human-infecting coronavirus spike proteins from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immune donors. These mAbs recognize the fusion peptide and acquire affinity and breadth through somatic mutations. Despite targeting a conserved motif, only some mAbs show broad neutralizing activity in vitro against alpha- and betacoronaviruses, including animal coronaviruses WIV-1 and PDF-2180. Two selected mAbs also neutralize Omicron BA.1 and BA.2 authentic viruses and reduce viral burden and pathology in vivo. Structural and functional analyses showed that the fusion peptide–specific mAbs bound with different modalities to a cryptic epitope hidden in prefusion stabilized spike, which became exposed upon binding of angiotensin-converting enzyme 2 (ACE2) or ACE2-mimicking mAbs

Study protocol of effectiveness of a biopsychosocial multidisciplinary intervention in the evolution of non-speficic sub-acute low back pain in the working population : cluster randomised trial

Background: Non-specific low back pain is a common cause for consultation with the general practitioner, generating increased health and social costs. This study will analyse the effectiveness of a multidisciplinary intervention to reduce disability, severity of pain, anxiety and depression, to improve quality of life and to reduce the incidence of chronic low back pain in the working population with non-specific low back pain, compared to usual clinical care. Methods/Design: A Cluster randomised clinical trial will be conducted in 38 Primary Health Care Centres located in Barcelona, Spain and its surrounding areas. The centres are randomly allocated to the multidisciplinary intervention or to usual clinical care. Patients between 18 and 65 years old (n = 932; 466 per arm) and with a diagnostic of a non-specific sub-acute low back pain are included. Patients in the intervention group are receiving the recommendations of clinical practice guidelines, in addition to a biopsychosocial multidisciplinary intervention consisting of group educational sessions lasting a total of 10 hours. The main outcome is change in the score in the Roland Morris disability questionnaire at three months after onset of pain. Other outcomes are severity of pain, quality of life, duration of current non-specific low back pain episode, work sick leave and duration, Fear Avoidance Beliefs and Goldberg Questionnaires. Outcomes will be assessed at baseline, 3, 6 and 12 months. Analysis will be by intention to treat. The intervention effect will be assessed through the standard error of measurement and the effect-size. Responsiveness of each scale will be evaluated by standardised response mean and receiver-operating characteristic method. Recovery according to the patient will be used as an external criterion. A multilevel regression will be performed on repeated measures. The time until the current episode of low back pain takes to subside will be analysed by Cox regression. Discussion: We hope to provide evidence of the effectiveness of the proposed biopsychosocial multidisciplinary intervention in avoiding the chronification of low back pain, and to reduce the duration of non-specific low back pain episodes. If the intervention is effective, it could be applied to Primary Health Care Centres

Encuesta de Salud Oral en España 2015

Las encuestas nacionales sobre salud bucodental tienen como función básica proporcionar una idea de conjunto sobre salud y necesidades de tratamiento poblacional con el fin de vigilar la evolución de las tasas de morbilidad. Nos permiten conocer: - La medida en que los servicios odontológicos existentes responden a las necesidades de la población. - La naturaleza y cuantía de los servicios de prevención y restauración necesarios. - Los recursos necesarios para implantar, mantener, aumentar o reducir los programas de salud bucodental, estimando las necesidades cuantitativas y el tipo de personal requerido. En 1993, el Consejo General de Colegios de Odontólogos y Estomatólogos de España (actualmente denominado Consejo General de Colegios de Dentistas de España) encargó la realización de una encuesta epidemiológica bucodental, siguiendo los criterios establecidos por la Organización Mundial de la Salud (OMS) para la ejecución de estudios transversales tipo Pathfinder. Ese estudio, publicado en 19951, se realizó una década después del anterior, desarrollado en 1984 bajo supervisión de la OMS. En los años 2000, 2005 y 20105 se realizaron las correspondientes encuestas, siempre financiadas el Consejo General de Dentistas. Transcurridos 5 años desde entonces, la necesidad de monitorizar la situación oral de nuestra población es la principal justificación de este proyecto

Imprinted antibody responses against SARS-CoV-2 Omicron sublineages

SARS-CoV-2 Omicron sublineages carry distinct spike mutations and represent an antigenic shift resulting in escape from antibodies induced by previous infection or vaccination. We show that hybrid immunity or vaccine boosters result in potent plasma neutralizing activity against Omicron BA.1 and BA.2 and that breakthrough infections, but not vaccination-only, induce neutralizing activity in the nasal mucosa. Consistent with immunological imprinting, most antibodies derived from memory B cells or plasma cells of Omicron breakthrough cases cross-react with the Wuhan-Hu-1, BA.1 and BA.2 receptor-binding domains whereas Omicron primary infections elicit B cells of narrow specificity. While most clinical antibodies have reduced neutralization of Omicron, we identified an ultrapotent pan-variant antibody, that is unaffected by any Omicron lineage spike mutations and is a strong candidate for clinical development

Imprinted antibody responses against SARS-CoV-2 Omicron sublineages

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron sublineages carry distinct spike mutations resulting in escape from antibodies induced by previous infection or vaccination. We show that hybrid immunity or vaccine boosters elicit plasma-neutralizing antibodies against Omicron BA.1, BA.2, BA.2.12.1, and BA.4/5, and that breakthrough infections, but not vaccination alone, induce neutralizing antibodies in the nasal mucosa. Consistent with immunological imprinting, most antibodies derived from memory B cells or plasma cells of Omicron breakthrough cases cross-react with the Wuhan-Hu-1, BA.1, BA.2, and BA.4/5 receptor-binding domains, whereas Omicron primary infections elicit B cells of narrow specificity up to 6 months after infection. Although most clinical antibodies have reduced neutralization of Omicron, we identified an ultrapotent pan-variant–neutralizing antibody that is a strong candidate for clinical development

Smoking cessation opportunities in severe mental illness (tobacco intensive motivational and estimate risk — TIMER—): study protocol for a randomized controlled trial

There is an increased risk of premature death in people with severe mental illness (SMI). Respiratory disorders and cardiovascular disease are leading causes of increased mortality rates in these patients, and tobacco consumption remains the most preventable risk factor involved. Developing new tools to motivate patients towards cessation of smoking is a high priority. Information on the motivational value of giving the lung age and prevention opportunities is unknown in this high-risk population. In the context of community care, screening and early detection of lung damage could potentially be used, together with mobile technology, in order to produce a prevention message, which may provide patients with SMI with a better chance of quitting smoking.This study receives funding by the Spanish Ministry of Economy, Industry and Competitiveness, Instituto Carlos III (FIS PI16/00802)

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42\ub74% vs 44\ub72%; absolute difference \u20131\ub769 [\u20139\ub758 to 6\ub711] p=0\ub767; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5\u20138] vs 6 [5\u20138] cm H2O; p=0\ub70011). ICU mortality was higher in MICs than in HICs (30\ub75% vs 19\ub79%; p=0\ub70004; adjusted effect 16\ub741% [95% CI 9\ub752\u201323\ub752]; p&lt;0\ub70001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0\ub780 [95% CI 0\ub775\u20130\ub786]; p&lt;0\ub70001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding: No funding