Les résidents de première année en médecine d’urgence pratiquent-ils assez de réanimations et d’autres procédures cliniques pour répondre aux exigences d’un cursus de compétence par conception?

Background: With the transition to a Competence by Design (CBD) curriculum, Fellow of the Royal College of Physicians in Emergency Medicine (FRCP-EM) training has created guidelines on experiences residents should have before progressing. We sought to quantify adult medical resuscitations and clinical procedures completed by PGY1 FRCP-EM residents to compare them to CBD requirements with the aim to identify areas of limited exposure requiring curriculum revisions prior to nation-wide CBD implementation. Methods: Twenty-two PGY1 residents from four FRCP-EM programs recorded their activities from July 2017 to June 2018 in an online log that tracked resuscitations and procedures along with role assumed, supervision, and level of comfort. Results: In total 515 resuscitations were logged with the median number per resident 15 (range 0 to 98). The most frequent resuscitation was altered mental status and the least was unstable dysrhythmia. 557 total procedures were logged with the median number 75 (range 8 to 273). The most frequent procedure done was simple laceration repair and the least frequent was intraosseous access. Conclusions: Unstable dysrhythmias and cardiorespiratory arrest along with intraosseous access and arthrocentesis are low event clinical exposures. In the era of CBD, the misalignment of entrustrable professional activity (EPA) targets and curriculum delivery should be monitored/reviewed to ensure expectations are realistic and that sufficient exposures are available.Contexte: Dans le cadre de la transition vers un programme d’études axé sur la compétence par conception (CPC), la formation pour devenir Fellow of the Royal College of Physicians en médecine d’urgence (FRCP-EM) a créé des lignes directrices sur l’expérience que les résidents devraient avoir avant de progresser. Nous avons tenté de quantifier les réanimations médicales d’adultes et les procédures cliniques effectuées par les résidents de première année de la formation postdoctorale en FRCP-EM pour les comparer aux exigences du programme de CPC dans le but d’identifier les domaines où l’exposition est limitée, nécessitant une révision du programme d’études avant la mise en œuvre de la CPC à l’échelle nationale. Méthodes : De juillet 2017 à juin 2018 vingt-deux résidents de première année de 4 programmes FRCP-EM ont entré dans un journal en ligne chaque réanimation ou procédure pratiquée ainsi que des informations comme le rôle qu’ils avaient assumé, la supervision et le niveau de confort éprouvé. Résultats : Au total, 515 réanimations ont été enregistrées, le nombre médian par résident étant de 15 (de 0 à 98). La réanimation la plus fréquente était l’altération de l’état mental et la moins fréquente était la dysrythmie instable. Parmi les 557 autres procédures enregistrées, avec un nombre médian de 75 (de 8 à 273), la plus fréquente était la réparation de lacérations simples et la moins fréquente était l’accès intra-osseux. Conclusions : Les dysrythmies instables et les arrêts cardio-respiratoires ainsi que l’accès intra-osseux et l’arthrocentèse sont pratiqués en faible nombre. À l’ère de la CPC, le décalage entre les ciblesd’activités professionnelle confiable (EPA) et le cursus proposé dans le programme d’études devrait être surveillé ou revu pour s’assurer que les attentes sont réalistes et que les résidents ont accès à une exposition suffisante

Existe cura em psicanálise? : Uma clínica para o intratável

This work aims to explore the dynamics of the cure in psychoanalysis, passing through a literary perspective. We begin by locating the idea of cure in psychoanalysis as the cure of the intractable, by thinking the logic of the cure through an aesthetic dimension. Next, we advance the idea of a literary subject, with the myth as a guiding element of a literary body that sustains its own existence. We adopt Kafka’s idea of minor literature to understand the fragmented subject inserted in the culture. We then propose the neologism 'vereedades’, playing on the proximity of the words ‘truth’ and ‘path’ in Portuguese ('verdade' and 'veredas') to explore curative dynamics, in which the subject explores his/her own style.Este trabalho visa explorar a dinâmica da cura em psicanálise, passando por uma perspectiva literária. Iniciamos localizando a ideia de cura em psicanálise como a cura do intratável, pensando a lógica da cura via uma dimensão estética. Na sequência, seguimos com a noção de sujeito literário, com o mito como um norte de um corpo literário que sustenta a própria existência do sujeito. Adotamos a ideia de uma literatura menor de Kaka para compreender o sujeito fragmentado em sua inserção na cultura. Então propomos o neologismo ‘veredades’, brincando com a proximidade das palavras ‘verdade’ e ‘veredas’ para explorar a dinâmica da cura, em que o sujeito explora seu próprio estilo

Elaboração de um instrumento de sistematização da assistência de enfermagem: relato de experiência

Objetivo: descrever a experiência do enfermeiro residente de enfermagem cirúrgica na elaboração de um instrumento de sistematização da assistência de enfermagem baseado na teoria das necessidades humanas básicas de Wanda Aguiar Horta. Métodos: trata-se de uma pesquisa descritiva, exploratória com abordagem qualitativa, do tipo relato de experiência realizada em hospital púbico. Resultados: criação de um instrumento que contempla todas as fases do processo de enfermagem baseado na teoria das necessidades humanas básicas, onde a assistência de enfermagem seria sistematizada e documentada e, assim, arquivada no prontuário do paciente. Conclusão: o instrumento elaborado é uma importante estratégia para a organização das ações e operacionalização do processo de enfermagem

Uncertainty in climate change impacts on water resources in the Rio Grande Basin, Brazil

We quantify uncertainty in the impacts of climate change on the discharge of Rio Grande, a major tributary of the Paraná River in South America and one of the most important basins in Brazil for water supply and hydro-electric power generation. We consider uncertainty in climate projections associated with the greenhouse-gas emission scenarios (A1b, A2, B1, B2) and increases in global mean air temperature of 1 to 6° C for the HadCM3 GCM (Global Circulation Model) as well as uncertainties related to GCM structure. For the latter, multimodel runs using 6 GCMs (CCCMA CGCM31, CSIRO Mk30, IPSL CM4, MPI ECHAM5, NCAR CCSM30, UKMO HadGEM1) and HadCM3 as baseline, for a +2° C increase in global mean temperature. Pattern-scaled GCM-outputs are applied to a large-scale hydrological model (MGB-IPH) of Rio Grande Basin. Based on simulations using HadCM3, mean annual river discharge increases, relative to the baseline or control run period (1961–1990), by +5% to +10% under the SRES emissions scenarios and from +8% to +51% with prescribed increases in global mean air temperature of between 1 and 6° C. Substantial uncertainty in projected changes to mean river discharge (−28% to +13%) under the 2° C warming scenario is, however, associated with the choice of GCM. We conclude that, in the case of Rio Grande Basin, the most important source of uncertainty derives from the GCM rather than the emission scenario or the magnitude of rise in mean global temperature

Campo geral, de Guimarães Rosa, e Pedro Páramo, de Juan Rulfo : um estudo sobre as estruturas de poder

Orientador: Prof. Dr. Paulo Astor SoetheTese (doutorado) - Universidade Federal do Paraná, Setor de Ciências Humanas, Programa de Pós-Graduação em Letras. Defesa : Curitiba, 26/09/2019Inclui referências: p. 196-205Resumo: A presente tese, com base em dois textos representativos da literatura latino-americana: Campo Geral (1956), do escritor brasileiro João Guimarães Rosa, e Pedro Páramo (1955), do autor mexicano Juan Rulfo, analisa como a literatura é um importante instrumento de representação, compreensão e de discussão social. Esses dois autores nasceram, cresceram e escreveram sempre ligados a países que passaram por um processo de colonização e de instauração de uma nova sociedade local, pautada no modelo europeu. Com relação às artes, no século XX houve uma ruptura sistemática dessa influência, momento e movimento ao qual Rosa e Rulfo pertencem. Durante esse período, ocorreu a consolidação de uma arte mais representativa do continente latinoamericano, com expressões artísticas que buscavam traços mais fortemente marcados pelas identidades locais e se afastavam cada vez mais da tendência a imitar a arte europeia. Com isso, Rulfo e Rosa, ambientando suas narrativas em regiões interioranas de seus países, contribuem para uma literatura com originalidade e representatividade, que auxilia na construção de uma identidade da América Latina, bem como discutem questões humanas que extrapolam os contornos regionais de suas nações. As obras selecionadas para análise evidenciam como certas estruturas sociais são representadas na literatura de modo a possibilitar que o leitor reflita sobre a organização das sociedades. Assim, nota-se como literatura e reflexão social contribuem diretamente um com o outro, possibilitando a compreensão da dinâmica em que tanto as personagens quanto as pessoas estão envolvidas. Para análise, são destacados três pilares que sustentam estruturas de poder em sociedades latino-americanas até os dias atuais: o patriarcalismo, a religião e a violência, que se mostram presentes na estrutura dos textos rosiano e rulfiano em questão. A presente tese visa discutir como a literatura desses autores representa formas de interdependência e codeterminação desses fatores sociais: o patriarcalismo encontra na religião o discurso adequado para que possa ser legitimado, enquanto religião e patriarcado usam a violência como forma de manutenção da sua ordem. Além da agressão física, que é a mais evidente, as narrativas retratam ainda a violência simbólica e também o medo, sentimento consequente da tradição da violência e uma das bases para a manutenção do poder no sistema religioso. Com isso, nas obras estudadas, analisa-se como Bero, em Campo Geral, e Pedro Páramo, no livro homônimo, representam esse poder patriarcal mantido de forma violenta. Para tal, subjugam as mulheres e as crianças que, nesse sistema, não possuem voz e ficam à mercê das decisões autoritárias. Também é discutido o papel das personagens Vó Izidra, em Campo Geral, e padre Rentería, em Pedro Páramo, que representam o poder religioso, indicando o quanto a religião cristã, presente nos textos analisados, é utilizada para manter estruturas sociais como poder patriarcal. Palavras-chave: Guimarães Rosa; Juan Rulfo; Patriarcado; Religião; Violência.Abstract: This thesis, based on two representative texts of Latin American literature: Campo Geral (1956), by Brazilian writer João Guimarães Rosa, and Pedro Páramo (1955), by Mexican writer Juan Rulfo, analyzes how literature is an important instrument for representation, understanding and social discussion. These two authors were born, raised an wrote always linked to countries that have undergone a process of colonization and the establishment of a new constitution of local society, based on the European model. In relation to the arts, in the twentieth century there was a systematic break from this influence, moment to which Rosa and Rulfo belong. During this period, there was the consolidation of a more representative art of the Latin American continent, with artistic expressions seek genuine traces of their local identities, moving away from the attempt to imitate European art. With that, Rulfo and Rosa, setting their narratives in inland regions of their countries, they contribute to a literature with originality and representativeness, which helps to build an identity of Latin America, as well as discuss human issues that go beyond the regional contours of their nations. The works selected for analysis show how certain social structures are represented in the literature in order to allow the reader to reflect on the organization of societies. Thus, it is noted how literature and social reflection contribute directly to each other, making it possible to understand of the dynamics in which both characters and people are involved. For analysis, three pillars are highlighted that sustain power structures in Latin American societies to the present day: patriarchalism, religion and violence, which are present in the structure of the texts of Rosa and Rulfo in question. The present thesis aims to discuss how the literature of these authors represents forms of interdependence and codetermination of these social factors: the patriarchalism finds in religion the proper discourse so that it can be legitimized, while religion and patriarchy use violence to maintain their order. Beyond physical aggression, which is the most evident, the narratives also portray symbolic violence as well as fear, a consequent feeling of the tradition of violence and one of the bases for the maintaining of power in the religious system. Thus, in the works studied, is analyzed how Bero, in Campo Geral, and Pedro Páramo, in the book of the same name, represent this patriarchal power maintained violently. To do so, they subdue women and children who, in this system, they have no voice and are at the mercy of authoritarian decisions. The role of the characters Grandmother Izidra, in Campo Geral, and priest Rentería, in Pedro Páramo, are also discussed, who represent the religious power, indicating how much the Christian religion, present in the corpus, is used to maintain the social structures like the patriarchal power. Keywords: Guimarães Rosa; Juan Rulfo; Patriarchy; Religion; Violence

Expanding Paramedicine in the Community (EPIC): study protocol for a randomized controlled trial.

BackgroundThe incidence of chronic diseases, including diabetes mellitus (DM), heart failure (HF) and chronic obstructive pulmonary disease (COPD) is on the rise. The existing health care system must evolve to meet the growing needs of patients with these chronic diseases and reduce the strain on both acute care and hospital-based health care resources. Paramedics are an allied health care resource consisting of highly-trained practitioners who are comfortable working independently and in collaboration with other resources in the out-of-hospital setting. Expanding the paramedic's scope of practice to include community-based care may decrease the utilization of acute care and hospital-based health care resources by patients with chronic disease.Methods/designThis will be a pragmatic, randomized controlled trial comparing a community paramedic intervention to standard of care for patients with one of three chronic diseases. The objective of the trial is to determine whether community paramedics conducting regular home visits, including health assessments and evidence-based treatments, in partnership with primary care physicians and other community based resources, will decrease the rate of hospitalization and emergency department use for patients with DM, HF and COPD. The primary outcome measure will be the rate of hospitalization at one year. Secondary outcomes will include measures of health system utilization, overall health status, and cost-effectiveness of the intervention over the same time period. Outcome measures will be assessed using both Poisson regression and negative binomial regression analyses to assess the primary outcome.DiscussionThe results of this study will be used to inform decisions around the implementation of community paramedic programs. If successful in preventing hospitalizations, it has the ability to be scaled up to other regions, both nationally and internationally. The methods described in this paper will serve as a basis for future work related to this study.Trial registrationClinicalTrials.gov: NCT02034045. Date: 9 January 2014

Recursos imagéticos e sensoriais na poesia de Alberto Caeiro

O artigo em questão visa estudar pormenorizadamente aspectos da poesia de Alberto Caeiro, heterônimo de Fernando Pessoa. Neste estudo será analisado o poema VIII presente na obra O Guardador de Rebanhos, ressaltando os principais recursos utilizados para a construção do texto poético, com ênfase para os efeitos sensoriais visuais e imagéticos criados no texto

Transfer of learning and patient outcome in simulated crisis resource management : a systematic review

PURPOSE: Simulation-based learning is increasingly used by healthcare professionals as a safe method to learn and practice non-technical skills, such as communication and leadership, required for effective crisis resource management (CRM). This systematic review was conducted to gain a better understanding of the impact of simulation-based CRM teaching on transfer of learning to the workplace and subsequent changes in patient outcomes. SOURCE: Studies on CRM, crisis management, crew resource management, teamwork, and simulation published up to September 2012 were searched in MEDLINE(®), EMBASE™, CINAHL, Cochrane Central Register of Controlled Trials, and ERIC. All studies that used simulation-based CRM teaching with outcomes measured at Kirkpatrick Level 3 (transfer of learning to the workplace) or 4 (patient outcome) were included. Studies measuring only learners' reactions or simple learning (Kirkpatrick Level 1 or 2, respectively) were excluded. Two authors independently reviewed all identified titles and abstracts for eligibility. PRINCIPAL FINDINGS: Nine articles were identified as meeting the inclusion criteria. Four studies measured transfer of simulation-based CRM learning into the clinical setting (Kirkpatrick Level 3). In three of these studies, simulation-enhanced CRM training was found significantly more effective than no intervention or didactic teaching. Five studies measured patient outcomes (Kirkpatrick Level 4). Only one of these studies found that simulation-based CRM training made a clearly significant impact on patient mortality. CONCLUSIONS: Based on a small number of studies, this systematic review found that CRM skills learned at the simulation centre are transferred to clinical settings, and the acquired CRM skills may translate to improved patient outcomes, including a decrease in mortality