Fatores determinantes para a escolha da especialidade médica no Brasil

Fundamento. A escolha da especialidade médica é complexa e multifatorial. A importância dos diferentes fatores varia mundialmente e está associada a diferentes valores e sistemas de educação. O objetivo do estudo é identificar os fatores que determinam essa escolha no Brasil. Métodos. Um questionário foi enviado, via internet (eletronic mail), para graduandos dos seis anos do curso de medicina, solicitando informações demográficas e a avaliação de fatores que influenciam na escolha da especialidade médica. Resultados. A idade média foi de 22 anos. Quanto à influência de familiares, 42,5% dos alunos têm pelo menos um médico como parente próximo, sendo as especialidades mais comuns desse parente: Pediatria, Ginecologia e Obstetrícia e Oftalmologia. A quantidade de respondentes que declararam certeza da carreira a ser seguida ao entrar na faculdade foi 19%, enquanto essa certeza foi de 22,2% na ocasião da pesquisa. Afinidade pela especialidade e estilo de vida foram fatores avaliados como importantes ou muito importantes por mais de 95% dos respondentes. Urgência em ganhar dinheiro rápido, tempo curto de residência, alto rendimento inicial e influência familiar foram os fatores avaliados como menos importantes pelos respondentes na escolha de sua especialidade. Quase metade dos respondentes (49,7%) descartaram uma especialidade que cogitaram fortemente, as principais razões para isso foram ter descoberto não ter afinidade pela especialidade pela qualidade de vida. Conclusões. Afinidade e estilo de vida são os fatores determinantes da escolha e da rejeição de especialidade médica em nosso meio.Background. Choosing medical specialty is complex and depends on multiple factors. The importance of the different factors varies across the world, according to different values and systems of education. The purpose of this study is to identify the determining factors involved in this choice among medical students in Brazil. Methods. A questionnaire was sent by email to medical students from first to sixth year of a selected institution, asking demographic information and the evaluation of factors that may influence the choice of the medical specialty. Results. The mean age was 22 years. Regarding the influence of relatives, 42.5% of the students has at least one physician as a close relative, the most common specialties of this relative were: Pediatrics, Gynecology and Obstetrics and Ophthalmology. 19% of the respondents declared being sure of the career when they entered University, while 22.2% of them were sure about the choice at the occasion of the study. Affinity for the specialty and lifestyle were evaluated as important or very important by more than 95% of respondents. Urge to earn money fast, short time of medical residency, high initial profit and family influence were the factors evaluated as less important by the respondents. Almost half of the respondents (49.7%) rejected a specialty they had strongly cogitated once. The main reasons for this were the lifestyle and the fact that they discovered not having affinity for the specialty. Conclusions. Affinity and medical lifestyle are the defining factors in choosing and rejecting a medical specialty in Brazil

Comparing financing models for supplementary healthcare in appendectomy: activity-based costing (fee-for-service) vs. diagnosis related group remuneration (bundled payment) – a systematic review and meta-analysis

ABSTRACT Purpose: In Brazil, healthcare services traditionally follow a fee-for-service (FFS) payment system, in which each medical procedure incurs a separate charge. An alternative reimbursement with the aim of reducing costs is diagnosis related group (DRG) remuneration, in which all patient care is covered by a fixed amount. This work aimed to perform a systematic review followed by meta-analysis to assess the effectiveness of the Budled Payment for Care Improvement (BPCI) versus FFS. Methods: Our work was performed following the items of the PRISMA report. We included only observational trials, and the primary outcome assessed was the effectiveness of FFS and DRG in appendectomy considering complications. We also assessed the costs and length of hospital stay. Meta-analysis was performed with Rev Man version 5.4. Results: Out of 735 initially identified articles, six met the eligibility criteria. We demonstrated a shorter hospital stay associated with the DRG model (mean difference = 0.39; 95% confidence interval – 95%CI – 0.38–0.40; p < 0.00001; I2 = 0%), however the hospital readmission rate was higher in this model (odds ratio = 1.57; 95%CI 1.02–2.44, p = 0.04; I2 = 90%). Conclusions: This study reveals a potential decrease in the length of stay for appendectomy patients using the DRG approach. However, no significant differences were observed in other outcomes analysis between the two approaches

Does warm-up training in a virtual reality simulator improves surgical performance? A prospective randomized analysis

Introdução: Os simuladores cirúrgicos de realidade virtual (SCRV) têm se mostrado uma ferramenta valiosa no treinamento e formação em laparoscopia. Tendo em vista a eficácia dos SCRV, novas utilidades têm sido propostas para estes equipamentos. Assim como nos esportes, onde fazer aquecimento antes do exercício comprovadamente melhora o desempenho, acredita-se que praticar no SCRV antes de operar pode melhorar a performance cirúrgica. Objetivo: Verificar se há benefício na prática de aquecimento pré-operatório quanto à performance cirúrgica. Materiais e Métodos: Vinte estudantes de medicina com bases em laparoscopia foram divididos em 2 grupos (I e II). O grupo I realizou uma colecistectomia videolaparoscópica em modelo suíno. O grupo II realizou o mesmo procedimento só que realizando previamente aquecimento préoperatório em SCRV. Os desempenhos dos dois grupos foram confrontados quanto aos parâmetros quantitativos (tempo para dissecção do pedículo da vesícula, tempo para clipagem do pedículo, tempo para secção do pedículo, tempo para remoção da vesícula, tempo operatório total, sangramento aspirado) e parâmetros qualitativos (noção de profundidade, destreza bimanual, eficiência, manejo de tecidos e autonomia) baseado em uma escala previamente validada, em que quanto maior a nota, melhor o resultado. Os dados foram submetidos à análise estatística com nível de significância de 5%. Resultados: O grupo que realizou aquecimento préoperatório apresentou resultados significativamente melhores quanto a tempo para dissecção do pedículo da vesícula (271 ± 173 s vs 714 ± 590 s, p = 0,012), tempo para clipagem do pedículo (173 ± 165 s vs 330 ± 141 s, p = 0,004), tempo para secção do pedículo (68 ± 30 s vs 110 ± 42 s, p = 0,019), sangramento aspirado (57 ± 27 mL vs 114 ± 112,59 mL, p = 0,006), noção de profundidade (4,5 ± 0,7 vs 3,3 ± 0,67, p = 0,004), destreza bimanual (4,2 ± 0,78 vs 3,3 ± 0,67, p = 0,004), manejo de tecidos (4,2 ± 0,91 vs 3,6 ± 0,66, p = 0,012) e autonomia (4,9 ± 0,31 vs 3,6 ± 0,96, p = 0,028). Não houve diferença significativa quanto ao tempo para remoção da vesícula (909 ± 2 73 s vs 694 ± 258 s, p = 0,088), tempo operatório total (1536 ± 306 s vs 1852 ± 663 s, p = 0,188) e eficiência (4 ± 0,66 vs 3,6 ± 0,69, p = 0,320). Conclusão: A prática de aquecimento pré-operatório parece trazer benefício no desempenho cirúrgico mesmo em indivíduos com pequena experiência em laparoscopiaIntroduction: Virtual reality surgical simulators (VRSS) have been showing themselves as a valuable tool in laparoscopy training and education. Taking in consideration the effectiveness of the VRSS, new uses for this tool have been purposed. In sports, warming up before exercise clearly shows benefit in performance. It is hypothesized that warming up in the VRSS before going to the operating room may show benefit in surgical performance. Objective: We aim to verify whether there is benefit in surgical performance when a preoperatory warm-up is performed using a VRSS. Materials and Methods: Twenty medical students with basic knowledge in laparoscopy were divided into two groups (I and II). Group I performed a laparoscopic cholecystectomy in a porcine model. Group II performed the same procedure but performing previously a pre-operative warm-up in a VRSS. The performance between both groups was compared regarding quantitative parameters (gallbladder pedicle dissection time, pedicle clipping time, pedicle cutting time, gallbladder removal time, total operative time and aspirated blood loss) and qualitative parameters (depth perception, bimanual dexterity, efficiency, tissue handling and autonomy) based on a previously validated score system, in which the higher the score, better the result. Data was analyzed with level of significance of 5%. Results: The warm-up group revealed significantly better results regarding gallbladder pedicle dissection time (271 ± 173 s vs. 714 ± 590 s, p = 0.012), the pedicle clipping time (173 ± 165 s vs. 330 ± 141 s, p = 0.004), for pedicle cutting time (68 ± 30 s vs. 110 ± 42 s, p = 0.019), aspirated blood loss (57 ± 27 mL vs. 114 ± 112.59 mL, p = 0.006), depth perception (4.5 ± 0.7 vs. 3,3 ± 0.67, p = 0.004), bimanual dexterity (4.2 ± 0.78 vs. 3.3 ± 0.67, p = 0.004), tissue handling (4.2 ± 0.91 vs. 3.6 ± 0.66, p = 0.012) and autonomy (4.9 ± 0.31 vs. 3.6 ± 0.96, p = 0.028). There were no significant differences regarding for gallbladder removal time (909 ± 273 s vs. 694 ± 258 s, p = 0.088), total operative time (1536 ± 306 s vs. 1852 ± 663 s, p = 0.188) and efficiency (4 ± 0.66 vs. 3.6 ± 0.69, p = 0.320). Conclusion: The practice of pre-operative warm-up training using VRSS seems to benefit surgical performance even in subject with mild laparoscopic experienc

Evaluation of lower urinary tract symptoms after robotic-assisted radical prostatectomy and predictors of urinary incontinence

Introdução: o câncer de próstata é o tipo mais comum entre os tumores malignos que afetam o homem. Dentre as opções terapêuticas para o tratamento do câncer de próstata localizado, destaca-se o tratamento cirúrgico pela prostatectomia radical com elevadas taxas de cura, porém com duas complicações possíveis: a incontinência urinária e a disfunção erétil. Apesar de mais infrequente, a incontinência urinária gera imenso impacto na qualidade de vida dos pacientes. Dentre as diversas vias de acesso para a prostatectomia radical, atualmente, a via robótica-assistida tem sido frequentemente utilizada, mundialmente. Objetivo: avaliar a evolução dos sintomas urinários desde o préoperatório até 12 meses após a operação baseado em questionários validados e tentar identificar preditores da incontinência urinária nos pacientes submetidos à prostatectomia radical robótica-assistida. Métodos: foram coletados prospectivamente os dados de 998 pacientes submetidos à prostatectomia radical robótica-assistida pelo mesmo cirurgião desde março de 2010 até maio de 2018. Foram documentados dados demográficos, informações pré-operatórias e pósoperatórias dos pacientes. Também foram aplicados os questionários ICIQ e IPSS no pré-operatório e após 1, 3, 6 e 12 meses de pós-operatório de cada paciente. Os dados foram tabulados e submetidos a análise estatística com significância de 5%. Resultados: de 998 pacientes, 257 preencheram corretamente todos os questionários pré-operatórios e tiveram todos as variáveis a serem estudadas, coletadas. A idade média dos pacientes foi de 60 ± 0,74 anos, o IMC médio foi de 26,88 kg/m2 ± 0,47 kg/m2, PSA pré-operatório foi de 6,15 ng/mL ± 0,36 ng/mL, volume prostático de 38,6 cm3 ± 2,0 cm3, 62 (24%) pacientes tinham tumor ISUP 1, 152 (59%) tumor ISUP 2, 38 (15%) ISUP 3, nenhum paciente com tumor ISUP 4 e 5 (2%) dos pacientes com tumor ISUP 5; tempo operatório total de 149 ± 4,4 minutos, sangramento aspirado de 282 mL ± 24 mL. Verificou-se que o IPSS subia inicialmente e aos 6 meses após a operação, este já se tornava inferior ao valor inicial pré-operatório (7,76 aos 6 meses vs. 9,90 pré-operatório). Quanto às variáveis do ICIQ, houve elevação com a prostatectomia radical e nenhuma delas retornou ao patamar préoperatório. Quanto aos preditores de incontinência urinária, com 1 mês de pósoperatório verificou-se na análise multivariada que idade (OR = 0,95, IC95% 0,912-0,992, p = 0,0057), margem circunferencial (OR = 0,40, IC95% 0,209-0- 791, p = 0 0106) e questão 4 do IPSS (OR = 0,77, IC95% 0,626-0,969, p = 0,0250) foram preditoras de incontinência. Conclusões: o IPSS inicialmente piora após a prostatectomia radical robótica-assistida e depois regride para valores abaixo dos valores pré-operatórios após 6 meses da operação. O ICIQ se eleva com a operação e se estabiliza cerca de 12 meses após a mesma. Idade avançada, margem cirúrgica circunferencial positiva e a quarta questão do IPSS são preditores precoces de incontinência urináriaIntroduction: prostate cancer is the most common type among malignant tumors that affect men. Among the therapeutic options for the treatment of localized prostate cancer, surgical treatment by radical prostatectomy with high cure rates stands out, but with two possible complications: urinary incontinence and erectile dysfunction. Although more infrequent, urinary incontinence has a huge impact on patients\' quality of life. Among the various access techniques for radical prostatectomy, currently, the robotic-assisted tecnhique has been the most accepted worldwide. Objective: to assess the evolution of lower urinary tract symptoms from the preoperative period up to 12 months after the operation based on validated questionnaires and to attempt to identify predictors of urinary continence in patients undergoing robotic-assisted radical prostatectomy. Methods: data were prospectively collected from 998 patients who underwent robotic-assisted radical prostatectomy by the same surgeon from March 2010 to May 2018. Demographic data, preoperative and postoperative information on the patients were documented. The ICIQ and IPSS questionnaires were also applied preoperatively and 1, 3, 6 and 12 months after prostatectomy to each patient. The data was tabulated and submitted to statistical analysis with a significance of 5%. Results: of 998 patients, only 257 correctly completed all preoperative questionnaires and had all variables to be studied, collected. The mean age of the patients was 60 ± 0.74 years, the mean BMI was 26.88 kg/m2 ± 0.47 kg/m2, preoperative PSA was 6.15 ng/mL ± 0.36 ng/mL, a prostate volume of 38.6 cm3 ± 2.0 cm3, 62 (24%) patients had ISUP 1 tumor, 152 (59%) ISUP 2 tumor, 38 (15%) ISUP 3 tumor, no patient with ISUP tumor 4 and 5 (2%) patients with ISUP 5 tumor; total operative time of 149 ± 4.4 minutes, aspirated blood loss was 282 mL ± 24 mL. It was found that the IPSS rose initially and at 6 months after the operation, it was already lower than the initial preoperative value (7.76 at 6 months vs. 9.90 preoperative). As for the ICIQ variables, there was an increase with radical prostatectomy and none of them returned to the preoperative level. Regarding the predictors of urinary continence, 1 month after the operation, in multivariate analysis, age (OR = 0.95, 95% CI 0.912-0.992, p = 0.0057), circumferential margin (OR = 0.40, 95% CI 0.209-0-791, p = 0 0106) and question 4 of the IPSS (OR = 0.77, 95% CI 0.626-0.969, p = 0.0250) were predictors of incontinence.. Conclusions: IPSS initially worsens after robotic-assisted radical prostatectomy and then regresses to values below preoperative values 6 months after the operation. The ICIQ rises with the operation and stabilizes about 12 months after it. Advanced age, positive circumferential surgical higher scores in the fourth question of the IPSS questionnaire are early predictors of urinary incontinenc

Bladder exstrophy: reconstructed female patients achieving normal pregnancy and delivering normal babies

PURPOSE: Bladder exstrophy (BE) is an anterior midline defect that causes a series of genitourinary and muscular malformations, which demands surgical intervention for correction. Women with BE are fertile and able to have children without this disease. The purpose of this study is to assess the sexual function and quality of life of women treated for BE. MATERIALS AND METHODS: All patients in our institution treated for BE from 1987 to 2007 were recruited to answer a questionnaire about their quality of life and pregnancies. RESULTS: Fourteen women were submitted to surgical treatment for BE and had 22 pregnancies during the studied period. From those, 17 pregnancies (77.2%) resulted in healthy babies, while four patients (18.1%) had a spontaneous abortion due to genital prolapse, and there was one case (4.7%) of death due to a pneumopathy one week after delivery. There was also one case (5.8%) of premature birth without greater repercussions. During pregnancy, three patients (21.4%) had urinary tract infections and one patient (7.14%) presented urinary retention. After delivery, three patients (21.4%) presented temporary urinary incontinence; one patient (7.14%) had a vesicocutaneous fistula and seven patients (50%) had genital prolapsed. All patients confirmed to have achieved urinary continence, a regular sexual life and normal pregnancies. All patients got married and pregnant older than the general population. CONCLUSIONS: BE is a severe condition that demands medical and family assistance. Nevertheless, it is possible for the bearers of this condition to have a satisfactory and productive lifestyle

Vasopressin in vasoplegic shock in surgical patients: systematic review and meta-analysis

ABSTRACT Purpose: Vasoplegia, or vasoplegic shock, is a syndrome whose main characteristic is reducing blood pressure in the presence of a standard or high cardiac output. For the treatment, vasopressors are recommended, and the most used is norepinephrine. However, new drugs have been evaluated, and conflicting results exist in the literature. Methods: This is a systematic review of the literature with meta-analysis, written according to the recommendations of the PRISMA report. The SCOPUS, PubMed, and ScienceDirect databases were used to select the scientific articles included in the study. Searches were conducted in December 2022 using the terms “vasopressin,” “norepinephrine,” “vasoplegic shock,” “postoperative,” and “surgery.” Meta-analysis was performed using Review Manager (RevMan) 5.4. The endpoint associated with the study was efficiency in treating vasoplegic shock and reduced risk of death. Results: In total, 2,090 articles were retrieved; after applying the inclusion and exclusion criteria, ten studies were selected to compose the present review. We found no significant difference when assessing the outcome mortality comparing vasopressin versus norepinephrine (odds ratio = 1.60; confidence interval 0.47–5.50), nor when comparing studies on vasopressin versus placebo. When we analyzed the length of hospital stay compared to the use of vasopressin and norepinephrine, we identified a shorter length of hospital stay in cases that used vasopressin; however, the meta-analysis did not demonstrate statistical significance. Conclusions: Considering the outcomes included in our study, it is worth noting that most studies showed that using vasopressin was safe and can be considered in managing postoperative vasoplegic shock

Tamsulosin vs. Tadalafil as medical expulsive therapy for distal ureteral stones: a systematic review and meta-analysis

ABSTRACT Purpose: Medical expulsive therapy (MET) is recommended for distal ureteral stones from 5 to 10 mm. The best drug for MET is still uncertain. In this review, we aim to compare the effectiveness of tadalafil and tamsulosin for distal ureteral stones from 5 to 10 mm in terms of stone expulsion rate (SER), stone expulsion time (SET) and the side effect profile. Materials and methods: A comprehensive literature search was conducted on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus and Web of Science, from inception until April 2023. Only randomized controlled trials were included in the analysis. Results: Eleven publications with 1,330 patients were included. We observed that tadalafil has a higher SER (OR 0.55, CI 95% 0.38;0.80, p=0.02, I2=52%) and the same efficacy in SET (MD 1.07, CI 95% -0.25; 2.39, p=0.11, I2=84%). No differences were found when comparing side effects as headache, backache, dizziness, and orthostatic hypotension. Conclusion: Tadalafil has a higher stone expulsion rate than tamsulosin as a medical expulsive therapy for patients with distal stones from 5 to 10 mm without differences in side effects

Does displacement of lower pole stones during retrograde intrarenal surgery improves stone-free status? A systematic review and meta-analysis

ABSTRACT Purpose: Kidney stones are one of the most common urological diseases worldwide. The size and location of the stone are the most important factors in determining the most suitable treatment options. The aim of this review was to evaluate the displacement of lower pole stones. Methods: Three studies assessing the efficacy of translocating kidney stones from the lower pole of the kidney to other locations during retrograde intrarenal surgery published in the last 20 years were included. A systematic search was conducted in the PubMed, Embase, Latin American and Caribbean Health Sciences Literature (LILACS), and Web of Science databases using the following search terms: “Lower pole,” “Lithotripsy.” Meta-analysis was performed using Review Manager version 5.4. Results: Stone-free rates were improved through displacement (odds ratio – OR = -0.15; 95% confidence interval–95%CI -0.24–-0.05; p = 0.002; I2 = 21%), but at the cost of increased surgical duration (mean difference = -12.50; 95%CI -24.06–-0.95; p = 0.03; I2 = 94%). Although this represents a potentially negative outcome, the improvement in clearance rates justifies the additional investment of time and effort. Conclusions: Displacement of lower pole kidney stones for subsequent lithotripsy brings significant benefits in terms of stone-free rate, with no difference in laser energy usage. However, it results in increased surgical time. Despite these factors, the benefits to patients undergoing the procedure are substantial

Assessment of a new kind of surgical simulator. The physical surgical simulator

<div><p>Abstract Purpose: To evaluate whether the use of the physical surgical simulator may benefit the development of laparoscopic skills. Methods: Ten medical students were divided into two groups: the first one performed ten weekly training sessions with a physical surgical simulator - ETX A2 LAP and, afterwards, one laparoscopic cholecystectomy in a porcine model, while the second group performed only a laparoscopic cholecystectomy. Both groups were compared regarding bleeding, total surgical time, time to perform each surgical step and qualitative parameters, based on a previously validated tool. Results: There was no difference in any of the evaluated parameters. Conclusion: We did not find any evidence of benefit in the use of the physical simulator for surgical performance in medical students.</p></div