Entrustable professional activities for Junior Brazilian Medical Students in community medicine

Background: Entrustable professional activities (EPAs) have been defined to promote the workplace participation of undergraduate medical students, generally in the context of high-income countries with a focus on the secondary and tertiary health care sectors. These EPAs have limited applicability to training and health care contexts in low- to middle-income countries that have a focus on primary health care, for instance, the context of community medicine. The purpose of this article is to report the process and results of defining EPAs for undergraduate medical training in a community health care setting. Methods: A modified Delphi study was performed to develop EPAs for the training of medical students in community medicine during their first and second years of education at the Marilia Medical School (FAMEMA), Brazil. The supervision level was operationalized in terms of a student's ability to perform the EPA autonomously in an effective and safe manner with supervision readily available on request. Panellists (9 physicians and 6 nurses) rated the completeness of the proposed list of EPAs and EPA categories on four-point Likert scales. The threshold for consensus among panellists was a mean content validity index of at least 80%. Results: Consensus was reached after two Delphi rounds, resulting in 11 EPAs for undergraduate medical education and training in community medicine. These EPAs were organized into three overarching EPA domains: integrality of care for individual health needs in all phases of the life cycle (5 EPAs), integrality of care for family health needs (3 EPAs), and integrality of care for community health needs (3 EPAs). For each EPA, descriptions of the following categories were created: title; specifications and limitations; conditions and implications of the entrustment decision; knowledge, skills, and attitudes; links to competencies; and assessment sources. Conclusion: The resulting 11 EPAs for training medical students in community medicine expand the application of the EPA framework to both early undergraduate medical education and the context of primary health care. This report can support and guide other medical schools in their attempts to train students in primary health care contexts and to incorporate EPAs into their curricula

EDUCAÇÃO PERMANENTE EM SAÚDE: CONCEPÇÕES E PRÁTICAS DE FACILITADORES

A aplicação da Educação Permanente em Saúde (EPS) solicita a interlocução de um facilitador cuja ação repercute na efetividade da Política de EPS. O objetivo desta pesquisa foi analisar as atuais concepções e práticas dos facilitadores de Educação Permanente formados pelo Curso de Formação de Facilitadores em EPS por uma agência parceira oficial do governo. Tratou-se de uma pesquisa de campo exploratória descritiva com abordagem quanti-qualitativa, com 31 indivíduos que anteriormente concluíram satisfatoriamente o curso, afim de se avançar em seus processos de capacitação. Os resultados alternam entre concepções adequadas e superficiais, confusão de modelos pedagógicos e apontam distância entre a teoria e a prática. Sugere-se que a formação de facilitadores de educação permanente para o Sistema Único de Saúde seja seguida por processos pedagógico e avaliativo constantes a fim de assegurar o desenvolvimento desta prática

Experiência discente com o ensino remoto na pandemia por SARS-COV-2 em um centro universitário

The COVID-19 pandemic promoted the need for social distancing, which, in turn, forced educational institutions to adopt technologies that allowed the continuation of face-to-face studies, in a safer way, in the remote modality. The adaptation to this format had to be fast. Thus, this study aimed to understand the perception of students from a university center in the rural area of São Paulo. The participants were invited by email to answer a self-administered online questionnaire about their experience during the adoption of this emergency measure by institution. This questionnaire included objective questions involves, for example, the perception of their skills in using virtual platforms and impact on mental health and academic performance. In a qualitative way, questions were raised about benefits and challenges of implementing remote teaching. Varied perceptions were found, indicating that there were benefits in the implementation of the virtual modality, but also that there were points to be improved.A pandemia de COVID-19 promoveu a necessidade de distanciamento social, que, por sua vez, obrigou as instituições de ensino a adotarem tecnologias que permitiram a continuação dos estudos presenciais de maneira mais segura, na modalidade remota. A adaptação para esse formato precisou ser rápida. Assim, este estudo visou compreender a percepção de estudantes de um centro universitário do interior paulista nesse novo cenário de aprendizagem. Os participantes foram convidados por e-mail a responder um questionário autoaplicável on-line sobre a experiência vivida durante a adoção desta medida emergencial pela instituição. Esse formulário contou com perguntas objetivas envolvendo, por exemplo, a percepção sobre suas habilidades no uso das plataformas virtuais e o impacto na saúde mental e desempenho acadêmico. Ademais, de forma qualitativa, interrogou-se sobre benefícios e desafios da implementação do ensino remoto. Encontraram-se percepções variadas, indicando que houve benefícios na implementação da modalidade virtual, mas também que houve pontos a serem melhorados

Inhibition of neutrophil activity improves cardiac function after cardiopulmonary bypass

Background The arterial in line application of the leukocyte inhibition module (LIM) in the cardiopulmonary bypass (CPB) limits overshooting leukocyte activity during cardiac surgery. We now studied in a porcine model whether LIM may have beneficial effects on cardiac function after CPB. Methods German landrace pigs underwent CPB (60 min myocardial ischemia; 30 min reperfusion)without (group I; n=6) or with LIM (group II; n=6). The cardiac indices (CI) and cardiac function were analyzed pre and post CPB with a Swan-Ganz catheter and the cardiac function analyzer. Neutrophil labeling with technetium, scintigraphy, and histological analyses were done to track activated neutrophils within the organs. Results LIM prevented CPB-associated increase of neutrophil counts in peripheral blood. In group I, the CI significantly declined post CPB (post: 3.26 +/- 0.31; pre: 4.05 +/- 0.45 l/min/m2; p<0.01). In group II, the CI was only slightly reduced (post: 3.86 +/- 0.49; pre 4.21 +/- 1.32 l/min/m2; p=0.23). Post CPB, the intergroup difference showed significantly higher CI values in the LIM group (p<0.05) which was in conjunction with higher pre-load independent endsystolic pressure volume relationship (ESPVR) values (group I: 1.57 +/- 0.18; group II: 1.93 +/- 0.16; p<0.001). Moreover, the systemic vascular resistance and pulmonary vascular resistance were lower in the LIM group. LIM appeared to accelerate the sequestration of hyperactivated neutrophils in the spleen and to reduce neutrophil infiltration of heart and lung. Conclusions Our data provide strong evidence that LIM improves perioperative hemodynamics and cardiac function after CPB by limiting neutrophil activity and inducing accelerated sequestration of neutrophils in the spleen

Bases conceptuales de las actividades profesionales a confiar para la educación de profesionales de la salud en Latinoamérica

The concept of entrustable professional activities emerged as an attempt to overcome some of the criticisms to the competency-based medical education approach; it has had a broad impact in practice and health professions education research. It has been disseminated internationally with its English acronym: EPA. This approach proposes to orient assessment and teaching to specific activities in the profession, which allows the integration of several competencies, and to determine which responsibilities can be entrusted to the trainee, in a gradual and explicit manner. The model assumes the definition of levels of supervision that allow progressive autonomy for each EPA, in students or residents, once they demonstrate the required competencies. Practice, supervision and feedback in real clinical scenarios are key to the development of autonomy in EPA performance. The dissemination of the EPA approach is still limited in Latin America, but it has the potential to create a significant contribution to curriculum design and evaluation, and to assessment practices of health professionals across their careers. It provides a deep review of the assumptions under which healthcare professional practice decisions are made, at under and postgraduate levels.Revisión por pare

Efeito do módulo de inativação leucocitária (LIM) na distribuição de 99mTc-granulócitos em porcos submetidos à circulação extracorpórea e à isquemia-reperfusão de coração e pulmões

O uso da circulação extracorpórea desencadeia uma resposta inflamatória sistêmica, que somada às reações em cadeia relacionadas à isquemia-reperfusão de coração e pulmões pode levar a lesões celulares e até falência de órgãos no pós-operatório de cirurgia cardíaca. Vários estudos foram feitos visando melhor entendimento desses processos inflamatórios associados à circulação extracorpórea. Assim, esta revisão abordará os mecanismos de isquemia-reperfusão cardiopulmonar a ativação da cascata inflamatória por esse processo e o papel dos leucócitos na fisiopatologia destas lesões. Serão consideradas as interações de proteínas imunomoduladoras na resposta leucocitária e o bloqueio das mesmas por meio de filtros biológicos, do uso de anticorpos monoclonais e do estímulo à apoptose.The use of extracorporeal circulation starts a whole body inflammatory response that when added with a chain reactions related to heart and lung ischemia-reperfusion may cause cellular injuries and organ failures in the cardiac surgery pos-operative period. Many studies were made to achieve better comprehension of the inflammatory process that occur with use of extracorporeal circulation. So, this review discusses the ischemia- reperfusion events, their large activated inflammatory cascade as well as the leukocytes role on the pathophysiology of their associated injuries. The interactions of immunomodulatory proteins with the leukocitary response and their blockade through leukocytes filters, the monoclonal antibody use and the apoptosis stimuli will be approached too

Estudo da ação do ácido trissódio-cálcio-dietileno-triaminopentaacético (CaNa3DTPA) nas lesões de isquemia-reperfusão em membro posterior de rato

A reperfusão de membros submetidos à isquemia pode provocar graves alterações estruturais e de metabolismo tecidual, que se acompanham de altas taxas de mortalidade e de morbidade. A peroxidação lipídica é considerada como sendo um dos principais mecanismos de lesão celular em tecidos pós-isquêmicos e o ferro tem sido reconhecido como potenciador nas reações de Fenton e Haber Weiss, que resultam na produção entre outros do radical OH. , altamente lesivo para as membranas celulares. As evidências de que a deferoxamina (DFA) e outros quelantes de ferro atenuaram lesões pós-isquêmicas numa variedade de sistemas orgânicos documentam a participação do ferro na patogênese da lesão tecidual pós-isquêmica. O ácido trissódio-cálcio-dietilenotriaminopentaacético (CaNa3DTPA), outro quelante de ferro com habilidade de quelar íons somente do espaço extracelular, parece ter ação menos deletéria ao metabolismo das células, que a quelação promovida pela DFA. Experimentos também relataram a sua potente ação anti-viral e propriedades antiinflamatórias e imunológicas. Tendo em vista sua ação como quelante de ferro e seu provável papel na resposta inflamatória, já que crescem as evidências da participação lesiva de agentes pró-inflamatórios em tecidos pós-isquêmicos, foi realizado o presente trabalho com o objetivo de testar o efeito de CaNa3DTPA na atenuação das lesões de isquemia-reperfusão em músculos esqueléticos...Acute ischemia and reperfusion of a limb, specially if revascularization is delayed, can induce tissue metabolic and structural changes that can lead to significant morbidity, mortality and amputation rates. It has become increasingly apparent that the central events resulting in cellular injury occur primarily during reperfusion. On reestablishment of reperfusion to postischemic skeletal muscle, reactive oxygen metabolites are liberated, resulting in accelerated oxidative parenchymal injury, much of which is focused at the cellular membrane Hydroxyl radicals generated from a reaction involving O2.- and H2O2 via the superoxide-driven Fenton reaction, which is catalyzed by iron, readily attacks membrane-associated polyunsaturated fatty acids in a free radical process and is believed to be responsible for much of the resulting phospholipid peroxidation and loss of membrane integrity. This reactions suggests that oxygen-mediated damage could be blunted by limiting the availability of iron during reperfusion. Several reports have demonstrated that iron chelators may interfere with the iron-dependent formation of hydroxyl radicals and interrupt this process on reoxygenation in postiischemic skeletal muscle. CaNa3DTPA, a hydrophilic extracelular chelator, binds iron and other ions from the extracellular spaces with extremely high affinity. Experiments have suggested that it could be less deleterious for cell metabolism than chelation from... (Complete abstract, click electronic access below

Educação permanente: uma ferramenta para o desenvolvimento docente na graduação

OBJETIVO: Descrever a percepção dos docentes tutores e dos docentes da Unidade de Prática Profissional (UPP) da primeira série dos cursos de Medicina e Enfermagem da Famema quanto à relevância de participar do programa de Educação Permanente (EP). MÉTODOS: Estudo exploratório com questionário semiestruturado. Empregou-se a técnica de análise temática do Discurso do Sujeito Coletivo. RESULTADOS: A quase totalidade dos sujeitos considerou a atividade de EP como relevante. Os docentes da UPP apontaram ótimo espaço para aprendizagem, troca de experiências e reflexão sobre a prática. As ideias centrais dos tutores foram bom espaço de discussão e reflexão, porém um momento mal aproveitado. CONSIDERAÇÕES: Para os docentes da UPP, a proposta da EP (reflexão sobre a prática) vem sendo atingida, mas não tem respondido às expectativas e ao entendimento dos tutores. Dada a importância do desenvolvimento docente para a sustentação de um currículo inovador, é necessário problematizar os sentidos implícitos nesta fala em busca de uma EP mais responsiva aos tutore

¿Podrían las actividades profesionales confiables mediar servicios de integración docente asistencial en la comunidad?

Competency-based medical education (CBME) is currently the most common type of curriculum used worldwide. However, its limitations include fragmented learning and difficulties to use properly the knowledge, skills, and attitudes acquired using this educational model. Having this in mind, Entrustable Professional Activities (EPA) emerge as a tool to mediate the transfer of the competency-based curriculum into physicians’ professional practice in graduate medical education. Therefore, based on a narrative review of the existing literature on EPA and the authors’ experience in teaching community-based health care integration services, the aim of this paper is to reflect on the possible use of these activities in undergraduate medical education for the development of a CBME model integrated with primary health care and community medicine. The reflections presented here allow suggesting that, although it is a challenging process, incorporating EPA into undergraduate medical education is appropriate to improve the provision of primary health care to individuals, families, and communities in general.En la actualidad, la educación médica basada en competencias (EMBC) es el diseño curricular más utilizado en el mundo. Sin embargo, sus limitaciones incluyen la construcción fragmentada del aprendizaje y dificultades para lograr el uso adecuado de los conocimientos, habilidades y actitudes adquiridos mediante este modelo pedagógico. Considerando lo anterior, las actividades profesionales confiables (APROC) emergen como una herramienta para mediar la transposición del currículo basado en competencias a la práctica profesional en educación médica de posgrado. Por lo tanto, con base en una revisión narrativa de la literatura existente sobre APROC y la experiencia docente de los autores en la integración de la educación y los servicios de salud basados en la comunidad, el propósito de este estudio es reflexionar sobre el posible uso de estas actividades en la formación médica de pregrado para el desarrollo de un modelo de EMBC integrado con la atención primaria de salud y la medicina comunitaria