Experiência de reforma curricular com participação da comunidade acadêmica e ensino baseado em competências / Curricular Reform Experience with Academic Community Participation and Competency-Based Education

Resumo: Introdução: Repensar os processos de ensino-aprendizagem é tarefa contínua dentro da escola médica, devendo haver aplicação das melhores evidências. Embora as necessidades de mudanças sejam amplamente conhecidas, os meios para realizá-las não o são. Por isso, este relato objetiva descrever a metodologia utilizada por uma faculdade tradicional do ensino em medicina durante seu processo de reforma curricular, o qual contou com a participação ativa da comunidade acadêmica. Relato de experiência: Para a reforma da matriz, foi nomeada uma comissão composta por alunos, docentes e funcionários. Seguindo os princípios do Design Thinking, organizaram-se os conhecimentos prévios e estruturaram-se os processos de escuta dos diferentes sujeitos. Optou-se por desenvolver uma matriz baseada em competências, com disciplinas integradas horizontalmente e priorização de atividades práticas, de modo a permitir uma redução da carga horária global do curso. As reformas implementadas exigiram alterações institucionais complexas para além da matriz, como a mudança da cultura avaliativa, a implementação do portfólio e outras questões de currículo oculto. Discussão: Superou-se o desafio de criar processos flexíveis e sustentáveis porque a comunidade foi capacitada para colaborar na gestão do ensino. Para além de coordenadores e diretores, todos os agentes do processo de aprendizagem devem ser reunidos de forma horizontal com participação ativa na proposição de mudanças. Barreiras e distanciamentos em relação à literatura podem ser enfrentados, devendo-se admitir as limitações para preservar identidades próprias e garantir projetos viáveis. Conclusão: A formação de profissionais competentes é o objetivo dos currículos em medicina, que devem ser revistos continuamente. A reforma descrita permitiu o fortalecimento de vínculos com a comunidade, entregando um projeto representativo e adequado à realidade específica.

Abstract: Introduction: Rethinking the teaching-learning process is a continuous task in medical training, with the constant requirement of applying the best evidence. Although the needs for change are widely known, the means to carry them out are not. Therefore, this report aims to describe the methodology used by a traditional medical school during its curricular reform process, which had the active participation of the academic community. Experience: A committee for curricular reform was appointed, including students, academic and professional staff. Following the principles of Design Thinking, prior knowledge was organized and listening processes were structured. A competency-based matrix was developed, with horizontally integrated disciplines and prioritization of practical activities, allowing for reduced total class hours of the course. The implemented reforms required complex institutional changes beyond the matrix, such as changing the evaluative culture and the implementation of the portfolio, in addition to other hidden curricular issues. Discussion: The challenge of creating flexible and sustainable processes seems to be overcome by empowering the community to collaborate with the educational management. In addition to coordinators and directors, all agents of the learning process must be brought together horizontally with active participation in proposing changes. Barriers and distances in relation to literature can be faced, and limitations must be admitted in order to preserve appropriate identities and guarantee viable projects. Conclusion: Training competent professionals is the goal of curricula, which must be continually reviewed. The reform described allowed for the strengthening of ties between the community, delivering a representative project that was adequate to the specific reality.

Prognostic factors for incomplete response in thyroid microcarcinoma: an analysis of initial response to therapy in 517 patients

ABSTRACT Objective: Although thyroid microcarcinoma (TMC) usually has a favorable prognosis, some patients present a higher risk of disease recurrence or persistence. Thus, we aimed at identifying possible risk factors associated with an incomplete response to therapy in TMC. Subjects and methods: This was a retrospective study of 517 patients with TMC treated with total thyroidectomy, with or without radioactive iodine (RAI) therapy, reclassified after 1.1 ± 0.4 years according to the response to treatment into "favorable" (excellent/indeterminate) or "unfavorable" (biochemical/structural incomplete) responses. We evaluated participants' age, sex, tumor size, histological variants, multifocality, presence of vascular/lymphatic/perineural invasion, extrathyroidal extension, metastatic lymph nodes (LN), and distant metastasis. The effect of RAI therapy on the response range was analyzed in a given subgroup. Results: The mean age observed was 46.4 ± 12.0 years, and 89.7% were female. We noted 97.5% with papillary carcinoma, 27.8% with multifocality and 11.2% with LN metastasis. Although the majority of patients had a low risk of recurrence/persistence (78%), 75% were submitted to RAI therapy. Incomplete response (20.7%) was associated with multifocality (p=0.041; OR=1.619) and metastatic LN (p=0.041; OR=1.868). These variables were strongly correlated (p=0.000; OR=3.283). No cut-off of tumor size was identified as a predictor of incomplete response by the receiver operating curve analysis. RAI treatment did not influence the response of patients with multifocality or LN metastasis. Conclusion: Multifocality and LN metastasis are independent risk factors for incomplete response in TMC patients and are strongly correlated. Additional RAI therapy was not associated with a more favorable response in these subgroups.

The impact of minimal extrathyroidal extension in the recurrence of papillary thyroid cancer patients

ABSTRACT Objective We aimed to evaluate the impact of minimal extrathyroidal extension (mETE) alone on the risk of recurrence of papillary thyroid carcinoma (PTC). The impact of other factors, including multifocality, age, tumor size, and stimulated thyroglobulin (sTg) values was also assessed. Subjects and methods We retrospectively analyzed 1,108 PTC patients from a medical institution, who presented tumors ≤ 4 cm without any adverse characteristics other than mETE. Patients were classified according to their response to initial treatment 12 to 24 months after surgery as proposed by the 2015 American Thyroid Association (ATA) guideline. Statistical analysis was performed using multivariate logistic regression and receiver operating characteristic (ROC) curve. Results In the multivariate logistic regression analysis, mETE did not have an impact on the response to initial treatment (p = 0.44), similar to multifocality, age, and tumor size. Initial Tg value was the only variable associated with a poor response (p < 0.01, odds ratio = 1.303, 95% confidence interval 1.25-1.36). The ROC analysis revealed that Tg was significant (area under curve = 0.8750); the cutoff value of sTg as a predictor of poor response was 10 ng/mL (sensitivity = 72.2%, specificity = 98.5%). Conclusion For low-risk PTC presenting mETE as the only aggressive feature, the initial sTg value is essential to identify patients who may have a poor response after initial treatment and benefit from further treatment. Arch Endocrinol Metab. 2020;64(3):251-6

Elastography for the evaluation of thyroid nodules in pediatric patients / A elastografia na avaliação de nódulos tireoidianos em pacientes pediátricos

Abstract Objective: To evaluate the usefulness of elastography (using manual compression) as an additional diagnostic tool for children and adolescents with thyroid nodules. Materials and Methods: This was a prospective study conducted between September 2012 and August 2013 at a hospital in Brazil. We performed elastography, ultrasound, and fine-needle aspiration biopsy in 32 patients between 6 and 18 years of age who had, in total, 38 thyroid nodules. Results: The elastography findings correlated with the histopathological diagnosis in 78.5% of cases. In three patients, an unnecessary thyroidectomy could have been avoided if the elastography results had been prioritized. Only one malignant thyroid nodule was found to show high elasticity. Conclusion: Our results suggest that high elasticity of a nodule on elastography is associated with a low risk of thyroid cancer. If further confirmed in other studies, elastography may prove useful as a complementary test for screening thyroid nodules in children.

Resumo Objetivo: Avaliar a utilidade da elastografia (usando compressão manual) como uma ferramenta adicional de diagnóstico em crianças e adolescentes com nódulos da tireoide. Materiais e Métodos: Este foi um estudo prospectivo realizado entre setembro de 2012 e agosto de 2013 em um hospital no Brasil. Realizamos elastografia, ultrassonografia e biópsia por aspiração com agulha fina em 32 pacientes com idade entre 6 e 18 anos que tinham, no total, 38 nódulos tireoidianos. Resultados: Os achados da elastografia em relação ao histopatológico foram corretos em 78,5% dos casos. A elastografia poderia ter evitado a tireoidectomia desnecessária de três pacientes. Apenas um nódulo maligno da tireoide foi classificado como E1. Conclusão: Nossos resultados sugeriram que a alta elasticidade de um nódulo na elastografia está associada a um baixo risco de câncer de tireoide. Caso se confirme em outros estudos, a elastografia pode ser útil como teste de triagem complementar de nódulos tireoidianos em crianças.

Thyroglobulin levels before radioactive iodine therapy and dynamic risk stratification after 1 year in patients with differentiated thyroid cancer

ABSTRACT Objectives: We sought to assess the relationship between stimulated thyroglobulin (sTg) before radioactive iodine therapy (RIT), and the dynamic risk stratification 1 year after treatment, and to establish the utility of the sTg as a predictor of response to therapy in these patients. A retrospective chart review of patients with differentiated thyroid cancer (DTC) who underwent RIT after surgery and were followed for at least 1 year, was carried out. Subjects and methods: Patients were classified according to the dynamic risk stratification 1 year after initial treatment. The sTg values before RIT were compared among the groups. ROC curve analysis was performed. Results: Fifty-six patients were enrolled (mean age 44.7 ± 14.4 years, 80.7% had papillary carcinoma). Patients with excellent response had sTg = 2.1 ± 3.3 ng/mL, those with indeterminate response had sTg = 8.2 ± 9.2 ng/mL and those with incomplete response had sTg = 22.4 ± 28.3 ng/mL before RIT (p = 0.01). There was a difference in sTg between excellent and incomplete response groups (p = 0.009) while no difference was found between indeterminate and either excellent or incomplete groups. The ROC curve showed an area under the curve of 0.779 assuming a sTg value of 3.75 ng/mL. Conclusion: Our study results suggest that the higher the sTg before RIT, the greater the likelihood of an incomplete response to initial treatment. A sTg cut-off of 3.75 ng/mL was found to be a good predictor of response to initial treatment in patients with DTC.

Aplicabilidade clínica da hemoglobina glicada na evolução do paciente com hiperglicemia hospitalar / Clinical applicability of glycated hemoglobin in the evolution of patients with hospital hyperglycemia

INTRODUÇÃO: O Diabetes Mellitus (DM) consiste em uma doença crônica ocasionada pela hiperglicemia. Sabe-se que essa patologia esta presente em aproximadamente 10% das internações hospitalares, e que uma porcentagem significativa dos pacientes com Diabetes Mellitus apresenta-se sem diagnóstico prévio no momento da internação. A hiperglicemia pode provocar efeitos deletérios no organismo como processo inflamatório. OBJETIVO: Avaliar a HbA1c como ferramenta diagnóstica e preditiva da evolução clínica de pacientes com e sem diagnóstico de Diabetes Mellitus, avaliada durante período de internação hospitalar e sua relação com as complicações hospitalares. MÉTODOS: Foram avaliados 100 pacientes no período de um ano e verificado através do protocolo Institucional NUMAD (Núcleo de assistência ao Paciente Diabético) os valores de hemoglobina glicada HbA1c em pacientes com hiperglicemia. RESULTADOS: Os pacientes sem diagnóstico prévio de Diabetes Mellitus apresentaram HbA1c entre 5,8% e 7,5%, com a mediana do tempo de internação de 9 dias, sem complicações. Os pacientes com Diabetes Mellitus que evoluíram com complicações, apresentaram HbA1c entre 7,3% e 12,4% e correspondiam a 20% do estudo, com tempo de internação de 34,5 dias. DISCUSSÃO: Estudos descrevem a prevalência de hiperglicemia relacionada a mortalidade e período de internação hospitalar, e principalmente em relação a hemoglobina glicada como marcador de gravidade independente da patologia. Nosso estudo demonstrou a importância dessa ferramenta como um aliado ao tratamento hospitalar. CONCLUSÃO: A HbA1c demonstrou em nosso estudo ser um marcador prognóstico e preditivo importante em pacientes com hiperglicemia hospitalar.

INTRODUCTION: Diabetes Mellitus (DM) is a chronic disease caused by hyperglycemia. It is known that this disease is present in approximately 10% of hospital admissions, and there is a significant percentage of patients with Diabetes Mellitus presents with no previous diagnosis at admission. Hyperglycemia can cause deleterious effects in the body as an inflammatory process. OBJECTIVE: To evaluate the HbA1c as a diagnostic and predictive tool outcome of patients with and without diagnosis of Diabetes Mellitus, performed during hospital stay and its relation with the hospital complications. METHODS: A total of 100 patients in the period of a year and verified by the Institutional NUMAD protocol (service core to Diabetic Patients) the glycated hemoglobin HbA1c in patients with hyperglycemia. RESULTS: Patients with no previous diagnosis of Diabetes Mellitus had HbA1c between 5.8% and 7.5%, with the median length of stay of nine days without complications. Patients with Diabetes Mellitus who developed complications, had HbA1c between 7.3% and 12.4% and accounted for 20% of the study, with hospital stay of 34.5 days. DISCUSSION: Studies describe the prevalence of hyperglycemia related mortality and hospital stay, and especially in relation to glycated hemoglobin as a marker of severity regardless of pathology. Our study demonstrated the importance of this tool as an ally to the hospital treatment. CONCLUSION: HbA1c demonstrated in our study to be a prognostic and predictive marker important in patients with hospital hyperglycemia.

Study of the histological profile of papillary thyroid carcinomas associated with Hashimoto's thyroiditis / Estudo do perfil histológico de carcinomas papilíferos de tireoide associados à tireoidite de Hashimoto

OBJECTIVE: To investigate the association between the histological parameters of papillary thyroid cancer (PTC) and the presence of Hashimoto's thyroiditis (HT). MATERIALS AND METHODS: Histological samples from patients with PTC were reviewed by an endocrine pathologist. The following parameters were analyzed: presence of concomitant HT, multifocality, presence of nodal metastasis, tumor size, vascular invasion, perineural infiltration, histological variant, and pathological staging. Clinical data included gender and age at the time of the diagnosis. RESULTS: A total of 94 cases of PTC were reviewed. There was a predominance of women (85.1% vs. 14.9%) and median age at presentation was 45.13 years. The presence of HT was significantly associated with greater occurrence of multifocal tumors (p = 0.004), early pathological stage (p = 0.02), and smaller tumor size (p = 0.025). CONCLUSIONS: Patients with PTC associated with HT had significantly smaller tumors, more often multifocal and in an earlier stage than their counterparts without HT. A better understanding of the immune response involved in these tumors may be useful for future strategies on the prevention and for the development of new therapeutic approaches for this group of neoplasms.

OBJETIVO: Investigar a associação entre parâmetros histológicos do carcinoma papilífero da tireoide (CPT) e a presença de tireoidite de Hashimoto (TH). MATERIAIS E MÉTODOS: Amostra de tecidos de CPT foi revista por um médico patologista. Os seguintes parâmetros foram avaliados: presença de TH concomitante, multicentricidade, metástase linfonodal, tamanho tumoral, invasão vascular, infiltração perineural, variante histológica e estadiamento patológico. Os dados clínicos incluíam gênero e idade ao diagnóstico. RESULTADOS: Um total de 94 casos de CPT foi revisto. Houve predomínio do sexo feminino (85,1% vs. 14,9%) e a idade média de apresentação foi de 45,13 anos. A presença de TH foi associada a maior ocorrência de tumores multifocais (p = 0,004), estágios iniciais de estadiamento (p = 0,02) e tumores menores (p = 0,025). CONCLUSÃO: O CPT associado a TH apresentou-se com menor dimensão, maior ocorrência de multifocalidade e em estadiamentos mais iniciais do que os casos de CPT sem TH associada. Um melhor entendimento da resposta imune envolvida nesses tumores pode ser útil para estratégias futuras de prevenção e para o desenvolvimento de novas abordagens terapêuticas para esse tipo de neoplasia.

Efeitos agudos laringológicos e vocais da radioiodoterapia em pacientes com hipertireoidismo por doença de Basedow Graves / Acute effects of radioiodine therapy on the voice and larynx of Basedow-Graves patients

A Doença de Graves constitui a forma mais comum de hipertireoidismo e três abordagens terapêuticas são atualmente utilizadas: uso de medicamentos antitireoideanos, cirurgia e iodo radioativo (I 131). Os efeitos do o I 131 e a indução precoce de hipotireoidismo são conseqüências da destruição induzida do I131 sobre o parênquima tireoideano. São poucos relatos encontrados na literatura acerca dos efeitos da radioioterapia sobre a laringe e conseqüentemente na produção vocal. OBJETIVO: Avaliar os efeitos agudos sobre a voz da radioiodoterapia em pacientes com hipertireoidismo por Doença de Basedow Graves. MATERIAL E MÉTODO: Estudo de corte contemporâneo longitudinal, prospectivo. Procedimentos: Investigação vocal, mensuração do tempo máximo fonatório de /a/ e relação s/z, análise freqüência fundamental (Software Praat), laringoscopia e análise perceptivo-auditiva em três momentos: pré-dose, 4 dias e 20 dias pós dose. Momentos baseados no perfil inflamatório do tecido tireoideano. RESULTADOS: Não houve mudanças estatisticamente significantes nos aspectos vocais e laringológicos nos três momentos avaliados. CONCLUSÃO: A radioiodoterapia não afeta a qualidade vocal.

Graves's disease is the most common cause of hyperthyroidism. There are three current therapeutic options: anti-thyroid medication, surgery, and radioactive iodine (I 131). There are few data in the literature regarding the effects of radioiodine therapy on the larynx and voice. The aim and the AIM: os this study was: to assess the effect of radioiodine therapy on the voice of Basedow-Graves patients. MATERIAL AND METHOD: A prospective study was done. Following the diagnosis of Grave's disease, patients underwent investigation of their voice, measurement of maximum phonatory time (/a/) and the s/z ratio, fundamental frequency analysis (Praat software), laringoscopy and (perceptive-auditory) analysis in three different conditions: pre-treatment, 4 days, and 20 days post-radioiodine therapy. Conditions are based on the inflammatory pattern of thyroid tissue (Jones et al. 1999). RESULTS: No statistically significant differences were found in voice characteristics in these three conditions. CONCLUSION: Radioiodine therapy does not affect voice quality.

Caracterização vocal de pacientes com hipertireoidismo e hipotireoidismo / Vocal characterization of patients with hyperthyroidism and hypothyroidism

OBJETIVO: Caracterizar a qualidade vocal, por meio de análise computadorizada e perceptivo-auditiva, de pacientes com hipertireoidismo (grupo A) e hipotireoidismo (grupo B). MÉTODOS: Vinte mulheres não fumantes, com idades entre 18 e 55 anos, atendidas no Ambulatório de Endocrinologia da instituição, foram avaliadas após o diagnóstico clínico e laboratorial de hipertireoidismo ou hipotireoidismo. Os parâmetros investigados foram: tempo da doença, presença de queixa vocal, tempos máximos de fonação /a/, /s/ e /z/, freqüência fundamental (F0), ruído glótico (GNE). Os aspectos avaliados na análise perceptivo-auditiva, foram: coordenação pneumo-fonoarticulatória (coordenada ou incoordenada), pitch, loudness, ataque vocal, ressonância, velocidade de fala e qualidade vocal, que poderia ter até duas das seguintes classificações: neutra, rouca, soprosa, áspera ou tensa, e grau: leve, moderado ou severo. Os dados foram tabulados e analisados estatisticamente através do programa EPI-INFO 6.04b, método qualitativo Fisher, com nível de significância menor do que 0.05. RESULTADOS: A análise perceptivo-auditiva mostrou que sete pacientes hipotireoideos e nove pacientes hipertireoideos apresentaram alteração na qualidade vocal. Oito pacientes em ambos os grupos apresentaram incoordenação pneumo-fonoarticulatória. Oito pacientes do grupo A e seis pacientes do grupo B referiam queixas vocais como rouquidão e voz grossa, respectivamente. Na análise acústica, nove pacientes apresentaram o ruído glótico alterado. CONCLUSÃO: Os resultados evidenciaram grande incidência de alteração vocal nos grupos estudados (grupos dos pacientes com hipertireoidismo e com hipotireoidismo), o que demonstra a relação entre disfonia e disfunções tireoideanas.

PURPOSE: To characterize the vocal quality of subjects with hyperthyroidism (group A), and hypothyroidism (group B) through a computer-aided and auditory-perceptive analysis. METHODS: Twenty non-smoking women with ages between 18 and 55 years from the Endocrinology Ambulatory of the institution were evaluated after clinical and lab diagnosis for hyperthyroidism or hypothyroidism. The parameters investigated were: period bearing the disease, vocal complaint, maximum phonation time /a/, /s/, and /z/, fundamental frequency (F0), glottal noise (GNE). The aspects evaluated in the auditory-perceptive analysis were: pneumo-phono-articulatory coordination (coordinated or uncoordinated), pitch, loudness, vocal attack, resonance, speech speed and vocal quality, that could be classified as one or two of the following: neutral, hoarse, whispered, coarse, or tense, and degree: light, moderate or severe. Data were statistically analyzed through the EPI-INFO 6.04b software, Fisher qualitative method, considering a significance level of 0.05. RESULTS: The auditory-perceptive analysis showed that seven patients with hypothyroidism and nine with hyperthyroidism presented changes in vocal quality. Eight subjects from both groups presented pneumo-phono-articulatory incoordination. Eight subjects from group A and six from group B referred vocal complaints, such as hoarseness and thick voice, respectively. In the acoustic analysis, nine subjects presented change in glottal noise. CONCLUSION: The results showed great incidence of vocal changes on the studied groups (both hyper and hypothyroidism groups), which evidences the relation between dysphonia and thyroidal dysfunctions.