University Admission Test Associates with Academic Performance at the End of Medical Course in a PBL Medical Hybrid Curriculum.

PURPOSE: Most studies assessing the value of the university admissions test (UAT) to predict academic performance at the end of a medical course were carried out on lecture-based medical courses. However, the association between performance in the UAT with academic achievement at the end of medical course in a problem-based learning (PBL) medical hybrid curriculum remains controversial. The aim of this study was to correlate marks in the UAT with those obtained in the Organized Structured Clinical Examination (OSCE), in the progress testing (PT), and in the final marks of the clerkship (FMC). METHODS: We used data from 48 medical students. A single and a multiple dependency studies were performed to assess bivariate and multiple correlation between the UAT or the essay scores (dependent variables) and the OSCE, PT, and FMC (independent variables). Pearson test, multiple linear regression, and ANOVA tests were used and a p-value < 0.05 was considered significant. RESULTS: In the bivariate analysis, only the UAT and FMC marks were correlated (r=0.34; p=0.02). However, the multiple dependency study showed a moderate correlation among UAT, OSCE, PT, and FMC marks (r=0.46; p=0.01). No correlation was found between the essay scores and PT, FMC, and OSCE scores. CONCLUSION: Our study shows that UAT marks, but not essay scores, can predict academic achievement, particularly in terms of clinical competence (FMC) at the end of a medical course in a PBL hybrid curriculum.

Abnormalities in electrocardiographic ventricular repolarization in patients with dengue virus infection.

INTRODUCTION: Dengue virus infection (DENV) is an arboviral disease that affects millions of people in many countries throughout the world every year. The disease is caused by the bite of a mosquito (Aedes aegypti and / or Aedes albopictus). The symptoms/signs observed in this arboviral disease are unspecific, and the blood count usually shows leukopenia and thrombocytopenia. Although ECG changes may be observed in DENV, little is known about parameters of ventricular repolarization in patients with this condition. Accordingly, the aim of this study was to evaluate the QTc and QT interval dispersion to detect ventricular repolarization changes in patients with DENV. METHODOLOGY: Ninety-three consecutive patients seen during DENV epidemics in a small town with non-complicated DENV were included; 93 normal individuals served as controls. Clinical data, blood count and the 12-lead ECG were obtained from each individual. RESULTS: The QTc duration was higher in patients with DENV in comparison to controls. Furthermore, 5% of DENV patients had abnormal lengthening of the QTc interval. No difference regarding QT interval dispersion was observed between DENV patients and controls. No DENV patient had increased lengthening of the QT interval dispersion. CONCLUSIONS: Myocardial repolarization changes do occur in patients with DENV. Having into account the potential impact of these changes on patients' outcome, and because 12-lead ECG is not routinely recommended in the setting of DENV in our country, we recommend that a 12-lead ECG be taken from each patient with this condition during DENV epidemics.

Abordagem inicial em pacientes com hipertensão arterial de difícil controle / Initial approach in patients with hard-to-control hypertension

A hipertensão refratária é definida como ausência de controleda pressão arterial, o que para a maioria dos indivíduos significa valores ≤ 140 x 90 mmHg, com o uso de três agentes hipotensores de classes distintas em doses plenas, sendo um deles um diurético. A terapia inadequada é a principal causa de hipertensão refratária, em grande parte ocasionada pela dificuldade da adesão pelos pacientes às medidas medicamentosas e não-medicamentosas prescritas pelo corpo clínico. Em adição, pacientes com hipertensão classificados como estádio III, principalmente os com lesão de órgão-alvo, podem ser portadores de formas secundárias de hipertensão, as quais devem ser investigadas sistematicamente. Somados, a análise clínica criteriosa, a escolha adequada das combinações de tratamento medicamentoso e o esforço para implementar medidas terapêuticas não medicamentosas, a adoção de medidas para melhorar a adesão, o uso da monitorização da pressão arterial ambulatorial e, mesmo em casos selecionados, a internação do paciente são estratégias importantes para se obter o controle da pressão arterial no alvo desejado.

The resistant hypertension is defined as blood pressure that remains elevated above treatment goals, usually≤ 140 x 90 mmHg, despite administration of an optimal three drug regimen that includes a diuretic. Suboptimaltherapy is the main cause of resistant hypertension, and many patients are non compliance to life stile modifications and drug therapy recommended. More over,patients classified as hypertension stage III, mainly with target-organ damage, could have secondary forms of hypertension that must be systematically investigated. Together, carefully clinical analysis, correct drug-treatment selection, efforts in implement life style modifications, adoption of strategies to improve adherence, use of ambulatory blood pressure monitoring and, in some instances, control of blood pressure under inpatients conditions are some strategies to achieve blood pressure control in patients with hard-to-control hypertension.

Influence of chronic renal failure on stereoselective metoprolol metabolism in hypertensive patients.

The influence of chronic renal failure on the stereoselective metabolism of rac-metoprolol was investigated in 15 hypertensive patients, 7 of them with chronic renal failure and 8 with normal renal function. They were treated with rac-metoprolol (200 mg) for 7 days. The patients of both groups presented stereoselectivity in metoprolol metabolism, favoring the formation of 1'R-alpha-hydroxymetoprolol (AUC(1(')R/1(')S)(0-24) approximately 2.5) and (R)-metoprolol acidic metabolite (AUC((S)/(R))(0-24) = 0.8), the latter resulting in the plasma accumulation of (S)-metoprolol (AUC((S)/(R))(0-24) = 1.2). Patients with chronic renal failure presented plasma accumulation of the 4 alpha-hydroxymetoprolol isomers and of both metoprolol acidic metabolite enantiomers. A 50% reduction in Cl(R) does not explain the 3- to 4-fold plasma accumulation of metoprolol acidic metabolite in this group, suggesting that other pathways of metoprolol elimination are affected in chronic renal failure in addition to renal excretion. Chronic renal failure does not change the stereoselective kinetic disposition of metoprolol but modifies its stereoselective metabolism, inducing some of the CYP enzymes involved in the formation of the metoprolol acid metabolite.

[Relationship between regular attendance to ambulatory appointments and blood pressure control among hypertensive patients]. / Relação entre a assiduidade às consultas ambulatoriais e o controle da pressão arterial em pacientes hipertensos.

OBJECTIVE: Our objective was to determine the rate of hypertensive patients with controlled BP (BP < 140 x 90 mmHg) and to study its relationship with regular attendance to ambulatory appointments. METHODS: A total of 245 medical records from patients followed up at the Unidade Clínica de Hipertensão Arterial (Clinical Unit of Arterial Hypertension) HCFMRP-USP for a period of one year were randomly and retrospectively reviewed. The patients were classified as assiduous (A) and as regularly absent to scheduled appointments (F), with the second group being defined as those who failed to appear longer than 30 days after the scheduled appointment. The mean of three measurements prior to the date of the scheduled appointment was calculated to determine the rate of patients with controlled BP. Compliance with the treatment was inferred through a questionnaire applied by the nurse team before the appointment. RESULTS: From the 245 patients analyzed, 220 were classified as A (89.7%) and 25 (10.3%) as F. Group A patients showed a higher rate of BP control than F patients (30% vs. 8%, p = 0.02, Fischer exact test). Compliance with pharmacological treatment was higher in A patients than in F patients (91% vs. 56 %, p < 0.05) as well as to non-pharmacological treatment (63% vs. 44%, p < 0.05). CONCLUSION: Although the rate of blood pressure control was low in the population studied, lower compliance with the treatment and BP control was observed in individuals who usually missed the scheduled appointments.

Relação entre a assiduidade às consultas ambulatoriais e o controle da pressão arterial em pacientes hipertensos / Relationship between regular attendance to ambulatory appointments and blood pressure control among hypertensive patients

OBJETIVO: Nosso objetivo foi determinar a taxa de pacientes hipertensos com a pressão arterial (PA) controlada (<140X90 mmHg) e estudar sua relação com a assiduidade às consultas ambulatórias. MÉTODOS: Foram analisados, de forma aleatória e retrospectiva, 245 prontuários de pacientes hipertensos seguidos na Unidade Clínica de Hipertensão Arterial do HCFMRP-USP no período de um ano. Os pacientes foram classificados como assíduos (A) e faltosos (F) definidos como atraso a consulta agendada em prazo maior que 30 dias. A média das três medidas anteriores a data do agendamento foi calculada para a determinação da taxa de pacientes com a PA controlada (<140x90 mmHg). A observância ao tratamento proposto foi inferida através de questionário aplicado durante a pré-consulta pela equipe de enfermagem. RESULTADOS: Dos 245 pacientes analisados, 220 foram classificados como A (89,7 por cento) e 25 (10,3 por cento) como F. Os pacientes do grupo A mostraram uma maior taxa de controle da PA quando comparados com F (30 por cento vs 8 por cento, p=0,02, teste exato de Fischer). A aderência relatada pelos pacientes ao tratamento farmacológico foi maior nos pacientes A que F (91 por cento vs 56 por cento, p<0,05) assim como para o tratamento não farmacológico (63 por cento vs 44 por cento, p<0,05). CONCLUSAO: Embora a taxa de controle da pressão arterial seja baixa na população estudada, observa-se pior aderência ao tratamento e controle da PA em indivíduos com hábito de faltar às consultas agendadas.

Calculse de vias urinárias em ambulatório do sistema único de saúde - estudo de modelo de atendimento em saúde pública / Urolithiasis in public health services - a prevention protocol for outpatients

Objetivo :A calculose de vias urinarias apresenta altos níveis de incidência e recorrência, segundo dados de literatura, importando em gastos para o sistema de saúde. Métodos Foram analisadas retrospectivamente 2.648 consultas realizadas em ambulatório público desenhado para o atendimento de pacientes com litíase, no Ambulatório de Especialidades do Sistema único de Saúde em Ribeirão Preto, cidade de médio porte no interior do estado de São Paulo e que apresenta a maior concentração de médicos por habitantes do país. Resultados:Apresenta-se a prevalência, alguns aspectos epidemiológicos, clínicos, de tratamento e do seguimento da urolitíase. Discussão :Ressalta-se que, quanto ao estudo da doença, há o limite imposto pela atividade exercida em ambulatório público, considerando-se a pesquisa de calciúria, oxalúria e uricosúria. Enfatiza-se o alto nível de abandono e a pronta resolutividade do método. Conclusões :Propõe-se uma atividade que nao resulte em gastos adicionais para o Estado, exercida por neurologista e com enfoque na prevenção da doença, utilizando um protocolo de atendimento desenhado para o sistema público.

Associações fixas de drogas anti-hipertensivas: vantagens e desvantagens na prática clínica / Antihypertensive fixed-drugs associations: advantages and disadvantages in the clinical practice

O tratamento anti-hipertensivo, para alcançar os objetivos maiores representados por redução de morbidade e mortalidade, busca a redução da pressão arterial. Para alcançar-se a normalização da pressão arterial via de regra, são necessárias associações de medicamentos de diferentes classes terapêuticas. A utilização de medicamentos anti-hipertensivos em baixas doses concorre para uma menor ocorrência de efeitos adversos, já que os efeitos colaterais são, via de regra, dependentes das doses utilizadas. Assim, a utilização de associações fixas de anti-hipertensivos em baixas doses apresenta os benefícios de uma maior probabilidade de controle efetivo da pressão arterial, uma vez que, se apropriadamente associados os princípios terapêuticos empregados, haverá uma potencialização de efeitos. A adesão ao tratamento, um grande desafio no tratamento anti-hipertensivo, será maior com a utilização de uma única tomada diária em contrapartida à utilização de duas medicações. As possíveis associações fixas de medicamentos anti-hipertensivos em baixas doses, seus benefícios e as limitações no contexto do tratamento da hipertensão arterial sistêmica são discutidos objetivando a um melhor controle da pressão arterial.

Dynamic and kinetic disposition of nisoldipine enantiomers in hypertensive patients presenting with type-2 diabetes mellitus.

OBJECTIVE: Nisoldipine (N) is a dihydropyridine calcium antagonist marketed as a racemic mixture and used for the treatment of hypertension. In the present study, we investigated the influence of type-2 diabetes mellitus (DM) on the enantioselective pharmacokinetic and dynamic parameters of N. METHODS: Seventeen hypertensive patients, nine of them with DM, were investigated in a cross-over study with administration of rac-N as coat-core tablets (20 mg day(-1)) or placebo for 15 days each. Serial blood samples (0-24 h) were collected on the 15th day, and 24-h ambulatory blood pressure (BP) monitoring was simultaneously evaluated. N enantiomers in plasma samples were analysed using chiral high-performance liquid chromatography combined with gas chromatography/mass spectrometry. The enantiomeric ratios differing from one were evaluated using the Wilcoxon test, and the results are reported as means with the 95% confidence intervals. A lidocaine (L) test was carried out as an in vivo marker of CYP3A4 (and CYP1A2) activities. RESULTS: The following differences were observed between the (+)-N and (-)-N enantiomers, respectively, in the patients presenting with DM (means and ranges): C(max) 3.9 (1.7-6.1) ng ml(-1) versus 0.7 (0.4-1.0) ng ml(-1), AUC(0-24) 51.5 (29.0-74.0) ng ml(-1) h versus 9.4 (5.9-12.8) ng ml(-1) h, and Cl/f 3.6 (1.9-5.4) l h(-1) kg(-1) versus 18.7 (11.7-25.7) l h(-1) kg(-1). The Cl/f value of (+)-N was lower (Mann-Whitney test) in patients with DM: 6.0 (4.3-7.5) l h(-1) kg(-1) versus 3.6 (1.9-5.4) l h(-1) kg(-1). The same observation was made for the (-)-N, with Cl/f reaching 38.8 (26.8-51.0) l h(-1) kg(-1) and 18.7 (11.7-25.7) l h(-1) kg(-1) for the non-diabetic and DM groups, respectively. The L test resulted in higher ratios (P < 0.05) of plasma L/MEGX concentrations (30 min after i.v. L) for DM (11.1 vs 18.6). N significantly reduced systolic and diastolic BP (P < 0.05, Wilcoxon test) in all patients investigated relative to placebo. No differences in BP reduction were observed between diabetic and non-diabetic patients. N significantly increased noradrenaline concentrations in plasma of both patient groups. The data also demonstrated that the plasma concentrations of noradrenaline 30 min after N administration were lower (P < 0.05) in diabetic (mean 2.86 pmol ml(-1)) than in non-diabetic patients (4.80 pmol ml(-1)). CONCLUSIONS: The present data permit us to infer that type-2 diabetes mellitus alters the kinetic disposition of the (+)-N eutomer and (-)-N distomer, presumably due to a lower activity of CYP3A4, although it does not modify the clinical effect brought about by the reduction in BP.