Daniel Sigulem

Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages

OBJECTIVE To assess whether a warning system based on mobile SMS messages increases the adherence of HIV-infected Brazilian women to antiretroviral drug-based treatment regimens and their impressions and satisfaction with respect to incoming messages. DESIGN A randomized controlled trial was conducted from May 2009 to April 2010 with HIV-infected Brazilian women. All participants (n=21) had a monthly multidisciplinary attendance; each participant was followed over a 4-month period, when adherence measures were obtained. Participants in the intervention group (n=8) received SMS messages 30 min before their last scheduled time for a dose of medicine during the day. The messages were sent every Saturday and Sunday and on alternate days during the working week. Participants in the control group (n=13) did not receive messages. MEASUREMENTS Self-reported adherence, pill counting, microelectronic monitors (MEMS) and an interview about the impressions and satisfaction with respect to incoming messages. RESULTS The HIV Alert System (HIVAS) was developed over 7 months during 2008 and 2009. After the study period, self-reported adherence indicated that 11 participants (84.62%) remained compliant in the control group (adherence exceeding 95%), whereas all 8 participants in the intervention group (100.00%) remained compliant. In contrast, the counting pills method indicated that the number of compliant participants was 5 (38.46%) for the control group and 4 (50.00%) for the intervention group. Microelectronic monitoring indicated that 6 participants in the control group (46.15%) were adherent during the entire 4-month period compared to 6 participants in the intervention group (75.00%). According to the feedback of the 8 participants who completed the research in the intervention group, along with the feedback of 3 patients who received SMS for less than 4 months, that is, did not complete the study, 9 (81.81%) believed that the SMS messages aided them in treatment adherence, and 10 (90.90%) responded that they would like to continue receiving SMS messages. CONCLUSION SMS messaging can help Brazilian women living with HIV/AIDS to adhere to antiretroviral therapy for a period of at least 4 months. In general, the results are encouraging because the SMS messages stimulated more participants in the intervention group to be adherent to their treatment, and the patients were satisfied with the messages received, which were seen as reminders, incentives and signs of affection by the health clinic for a marginalized population.

Kidney transplantation from living unrelated donors.

OBJECTIVE To compare patient and graft survival of recipients of kidneys from living, unrelated donors (LUDs); cadaveric donors; and living, related donors (LRDs) matched for zero (mismatched), one, or two (identical) haplotypes. DESIGN Cohort study. SETTING Sixty-three renal transplantation centers affiliated with the Brazilian Transplantation Registry (accounting for more than 95% of the transplantation activity in Brazil). PATIENTS Patients having renal transplantation between January 1987 and March 1991. Of 2892 patients, 165 (6%) received transplants from LUDs; 964 (33%), from cadaveric donors; 183 (6%), from zero haplotype, HLA-matched LRDs; 1259 (44%), from one haplotype-matched LRDs; and 321 (11%), from two haplotype-matched LRDs. MEASUREMENTS Patient and graft survival. Patients were followed for an average of 15.8 months. RESULTS After adjustment for age, race, diagnosis of primary disease, history of previous transplantation, cyclosporine use, and number of transplants from LUDs per center, patient survival did not differ statistically for recipients of kidneys from LUDs and recipients of cadaveric kidneys (risk ratio [RR], 1.16; 95% Cl, 0.68 to 1.98). Little difference was seen between the adjusted death rate for recipients of zero haplotype-matched LRDs and recipients of cadaveric kidneys (RR, 1.13; Cl, 0.69 to 1.87). Similarly, in a multivariate analysis, recipients of kidneys taken from LUDs and zero haplotype-matched LRDs had a risk for graft failure that did not differ statistically from that of cadaveric kidney recipients (RR, 0.74; Cl, 0.45 to 1.22 and RR, 0.82; Cl, 0.53 to 1.25, respectively). CONCLUSIONS Graft survival for recipients of kidneys from LUDs is similar to that from zero haplotype-matched LRDs and is at least as good as that achieved with cadaveric transplants.

Decision support system for the diagnosis of schizophrenia disorders

Clinical decision support systems are useful tools for assisting physicians to diagnose complex illnesses. Schizophrenia is a complex, heterogeneous and incapacitating mental disorder that should be detected as early as possible to avoid a most serious outcome. These artificial intelligence systems might be useful in the early detection of schizophrenia disorder. The objective of the present study was to describe the development of such a clinical decision support system for the diagnosis of schizophrenia spectrum disorders (SADDESQ). The development of this system is described in four stages: knowledge acquisition, knowledge organization, the development of a computer-assisted model, and the evaluation of the systems performance. The knowledge was extracted from an expert through open interviews. These interviews aimed to explore the experts diagnostic decision-making process for the diagnosis of schizophrenia. A graph methodology was employed to identify the elements involved in the reasoning process. Knowledge was first organized and modeled by means of algorithms and then transferred to a computational model created by the covering approach. The performance assessment involved the comparison of the diagnoses of 38 clinical vignettes between an expert and the SADDESQ. The results showed a relatively low rate of misclassification (18-34%) and a good performance by SADDESQ in the diagnosis of schizophrenia, with an accuracy of 66-82%. The accuracy was higher when schizophreniform disorder was considered as the presence of schizophrenia disorder. Although these results are preliminary, the SADDESQ has exhibited a satisfactory performance, which needs to be further evaluated within a clinical setting.

O papel do ensino a distância na educação médica continuada: uma análise crítica

This paper reviews findings of recent literature which have systematically evaluated outcomes of continuing medical education programs worldwide, methods for measuring especific demands in medical areas, and quality and reliability of contents related to such programs. Particular features of the Brazilian health context and internet technologies are described, as well as possible directions towards life-long medical education development in Brazil for the next few years.

Renal Accumulation of 99mTC-Dmsa in the Artificially Perfused Isolated Rat Kidney

In order to investigate aspects of the renal handling of 99mTc-DMSA, 68 isolated rat kidneys were artificially perfused. The experimental groups were: Group 1 (no. = 32)-oxygenated filtering kidneys; Group 2 (no. = 29)-oxygenated non-filtering kidneys; Group 3 (no. = 7)-anaerobic non-filtering kidneys. We conclude that the 99mTc-DMSA complex is strongly bound to albumin, is not filtered and is removed from perfusion fluid through the renal peritubular capillary route and that this occurs by an active process which depends upon aerobic metabolism. This process has a high capacity and is not inhibited by probenecid.

Desenvolvimento e avaliação de um programa multimídia de computador para ensino de drenagem pleural

OBJECTIVE: To develop a multimedia educational computer program designed to teach pleural drainage techniques to health professionals, as well as to evaluate its efficacy. METHODS: We planned and developed a program, which was evaluated by 35 medical students, randomized into two groups. Group 1 comprised 18 students who studied using the program, and group 2 comprised 17 students who attended a traditional theoretical class given by an experienced teacher. Group 1 students were submitted to two subjective evaluations using questionnaires, and both groups took an objective theoretical test with multiple choice questions and descriptive questions. The results of the theoretical test were compared using the Mann-Whitney test. RESULTS: The subjective evaluation of the technological aspects and content of the program ranged from excellent to very good and good. The software was considered highly instructive by 16 students (88.9%), and 17 students (94.4%) thought it might partially substitute for traditional classes. Between the two groups, there was no significant difference in the multiple choice test results, although there was such a difference in the descriptive question results (p < 0.001), group 1 students scoring higher than did those in group 2. CONCLUSIONS: The computer program developed at the Federal University of Sao Paulo Paulista School of Medicine proved to be a feasible means of teaching pleural drainage techniques. The subjective evaluation of this new teaching method revealed a high level of student satisfaction, and the objective evaluation showed that the program was as efficacious as is traditional instruction.

Orientação temporal e funções executivas na predição de mortalidade entre idosos: estudo Epidoso

OBJETIVO: Analisar a capacidade preditiva de indice cognitivo funcional para mortalidade entre idosos. METODOS: Estudo de coorte realizado com 1.667 idosos acima de 65 anos residentes no municipio de Sao Paulo, SP, no periodo 1991-2001. O indice cognitivo funcional foi construido a partir da orientacao temporal e funcoes executivas (fazer compras e tomar medicacao), controlado por variaveis sociodemograficas, habitos de vida, morbidade, autopercepcao de saude, internacao, edentulismo e suporte social. Os obitos ocorridos no periodo foram investigados com familiares em entrevistas domiciliares, em cartorios e registros da Fundacao Seade (ate 2003). Foram calculados riscos relativos brutos e ajustados com respectivos intervalos com 95% de confianca por meio de analise bivariada e multipla com regressao de Poisson, adotando-se p<0,05. RESULTADOS: No modelo multivariado final os fatores de risco independentes identificados pelo indice foram: perda parcial da orientacao temporal ou funcoes executivas (RR=1,37; IC 95%: 1,03;1,83); perda total da orientacao e parcial das funcoes (RR=1,71; IC 95%: 1,24;2,37); perda parcial da orientacao e total das funcoes (RR=1,76; IC 95%: 1,35;2,28); perda total da orientacao e das funcoes (RR=1,64; IC 95%: 1,30;2,06), Quanto as condicoes de saude: internacao (RR=1,45; IC 95%: 1,22;1,73); diabetes (RR=1,20; IC 95%: 1,00;1,44); edentulismo total (RR=1,34; IC 95%: 1,09;1,66). Relacionamento mensal com parentes foi identificado como fator protetor (RR=0,83; IC 95%: 0,69;1,00). CONCLUSOES: O Indice Cognitivo Funcional pode auxiliar clinicos e planejadores em decisoes sobre estrategias de seguimento e prevencao de causas trataveis de deficit cognitivo e perda funcional para diminuir a mortalidade entre os idosos.OBJECTIVE To analyze the predictive ability of a functional cognitive index of mortality in the elderly. METHODS Cohort study performed with 1,667 elderly individuals aged more than 65 years and living in the city of São Paulo, Southeastern Brazil, between 1991 and 2001. Functional cognitive index was constructed from time orientation and executive functions (going shopping and taking medication), controlled by sociodemographic variables, life habits, morbidity, self-perception of health, hospitalization, edentulism and social support. Deaths occurred during this period were analyzed with family members in home interviews, notary public offices and records from the Fundação Seade (State System of Data Analysis Foundation), until 2003. Crude and adjusted relative risks were calculated with their respective 95% confidence intervals, using bivariate and multiple analysis with Poisson regression and p<0.05. RESULTS In the final multivariate model, the following independent risk factors were identified by the index: partial loss of time orientation or executive functions (RR=1.37; 95% CI: 1.03;1.83); total loss of orientation and partial loss of functions (RR=1.71; 95% CI: 1.24;2.37); partial loss of orientation and total loss of functions (RR=1.76; 95% CI: 1.35;2.28); and total loss of orientation and functions (RR=1.64; 95% CI: 1.30;2.06). As regards health conditions, the following were observed: hospitalization (RR=1.45; 95% CI: 1.22;1.73); diabetes (RR=1.20; 95% CI: 1.00;1.44); and total edentulism (RR=1.34; 95% CI: 1.09;1.66). Monthly contact with relatives was identified as a protective factor (RR=0.83; 95% CI: 0.69;1.00). CONCLUSIONS The Functional Cognitive Index can help clinicians and health planners to make decisions on strategies for follow-up and prevention of treatable causes of cognitive deficit and functional loss to reduce mortality in the elderly.

How do experts recognize schizophrenia: the role of the disorganization symptom

OBJECTIVE Research on clinical reasoning has been useful in developing expert systems. These tools are based on Artificial Intelligence techniques which assist the physician in the diagnosis of complex diseases. The development of these systems is based on a cognitive model extracted through the identification of the clinical reasoning patterns applied by experts within the clinical decision-making context. This study describes the method of knowledge acquisition for the identification of the triggering symptoms used in the reasoning of three experts for the diagnosis of schizophrenia. METHOD Three experts on schizophrenia, from two University centers in Sao Paulo, were interviewed and asked to identify and to represent the triggering symptoms for the diagnosis of schizophrenia according to the graph methodology. RESULTS Graph methodology showed a remarkable disagreement on how the three experts established their diagnosis of schizophrenia. They differed in their choice of triggering-symptoms for the diagnosis of schizophrenia: disorganization, blunted affect and thought disturbances. CONCLUSIONS The results indicate substantial differences between the experts as to their diagnostic reasoning patterns, probably under the influence of different theoretical tendencies. The disorganization symptom was considered to be the more appropriate to represent the heterogeneity of schizophrenia and also, to further develop an expert system for the diagnosis of schizophrenia.

Educação médica continuada online: potencial e desafios no cenário brasileiro

With the intense production and publication of scientific information, it has become difficult for medical professionals to keep up-to-date using only the traditional resources. It is urgent to be come familiar with and participate in continuing training processes. Among other initiatives, the Brazilian Medical Association and the National Medical Board launched the National Program for Online Continuing Medical Education, seeking to disseminate the knowledge produced in large cities to profes sionals in the more remote areas of the country or those with less available time. Based on the assumption that the Knowledge Society requires initial and on-going training for professionals and citizens with a new set of skills to act efficiently and responsibly, these programs should be developed through pedagogical approaches that effectively value, beyond content delivery, a willingness to engage in research, autonomy in the search for information, collaborative spirit, and an ethical stance. To contribute to this discussion, the current article aims to resume the process of formal organization of online continuing medical education in Brazil in didactic and pedagogical terms and to analyze the perspectives of distance education programs.

Time orientation and executive functions in the prediction of mortality in the elderly: Epidoso study

OBJETIVO: Analisar a capacidade preditiva de indice cognitivo funcional para mortalidade entre idosos. METODOS: Estudo de coorte realizado com 1.667 idosos acima de 65 anos residentes no municipio de Sao Paulo, SP, no periodo 1991-2001. O indice cognitivo funcional foi construido a partir da orientacao temporal e funcoes executivas (fazer compras e tomar medicacao), controlado por variaveis sociodemograficas, habitos de vida, morbidade, autopercepcao de saude, internacao, edentulismo e suporte social. Os obitos ocorridos no periodo foram investigados com familiares em entrevistas domiciliares, em cartorios e registros da Fundacao Seade (ate 2003). Foram calculados riscos relativos brutos e ajustados com respectivos intervalos com 95% de confianca por meio de analise bivariada e multipla com regressao de Poisson, adotando-se p<0,05. RESULTADOS: No modelo multivariado final os fatores de risco independentes identificados pelo indice foram: perda parcial da orientacao temporal ou funcoes executivas (RR=1,37; IC 95%: 1,03;1,83); perda total da orientacao e parcial das funcoes (RR=1,71; IC 95%: 1,24;2,37); perda parcial da orientacao e total das funcoes (RR=1,76; IC 95%: 1,35;2,28); perda total da orientacao e das funcoes (RR=1,64; IC 95%: 1,30;2,06), Quanto as condicoes de saude: internacao (RR=1,45; IC 95%: 1,22;1,73); diabetes (RR=1,20; IC 95%: 1,00;1,44); edentulismo total (RR=1,34; IC 95%: 1,09;1,66). Relacionamento mensal com parentes foi identificado como fator protetor (RR=0,83; IC 95%: 0,69;1,00). CONCLUSOES: O Indice Cognitivo Funcional pode auxiliar clinicos e planejadores em decisoes sobre estrategias de seguimento e prevencao de causas trataveis de deficit cognitivo e perda funcional para diminuir a mortalidade entre os idosos.OBJECTIVE To analyze the predictive ability of a functional cognitive index of mortality in the elderly. METHODS Cohort study performed with 1,667 elderly individuals aged more than 65 years and living in the city of São Paulo, Southeastern Brazil, between 1991 and 2001. Functional cognitive index was constructed from time orientation and executive functions (going shopping and taking medication), controlled by sociodemographic variables, life habits, morbidity, self-perception of health, hospitalization, edentulism and social support. Deaths occurred during this period were analyzed with family members in home interviews, notary public offices and records from the Fundação Seade (State System of Data Analysis Foundation), until 2003. Crude and adjusted relative risks were calculated with their respective 95% confidence intervals, using bivariate and multiple analysis with Poisson regression and p<0.05. RESULTS In the final multivariate model, the following independent risk factors were identified by the index: partial loss of time orientation or executive functions (RR=1.37; 95% CI: 1.03;1.83); total loss of orientation and partial loss of functions (RR=1.71; 95% CI: 1.24;2.37); partial loss of orientation and total loss of functions (RR=1.76; 95% CI: 1.35;2.28); and total loss of orientation and functions (RR=1.64; 95% CI: 1.30;2.06). As regards health conditions, the following were observed: hospitalization (RR=1.45; 95% CI: 1.22;1.73); diabetes (RR=1.20; 95% CI: 1.00;1.44); and total edentulism (RR=1.34; 95% CI: 1.09;1.66). Monthly contact with relatives was identified as a protective factor (RR=0.83; 95% CI: 0.69;1.00). CONCLUSIONS The Functional Cognitive Index can help clinicians and health planners to make decisions on strategies for follow-up and prevention of treatable causes of cognitive deficit and functional loss to reduce mortality in the elderly.