Evolución y desafíos en la formación médica de posgrado en Brasil / Evolution and challenges in postgraduate medical training in Brazil

La especialización médica es un gran desafío porque necesita preparar un profesional recién egresado en el especialista que la po-blación quiere y necesita para asegurar mejores condiciones de atención a la salud. La construcción de un sistema para la capacitación de estos profesionales es un gran desafío dada la característica de la formación en servicio, es decir, los profesionales en formación trabajan directamente en la asistencia, dependiendo de instalaciones adecuadas, aparatos, tutores médicos y un programa teórico que garantice el desarrollo del aprendizaje según los parámetros técnicos más actuales. Un desafío adicional es la cantidad y diversidad de instituciones involucradas, desde hospitales universitarios con tradición docente hasta hospitales privados donde el desempeño se limita a la prestación de servicios. En este artículo, buscamos mostrar la trayectoria de la construcción de este sistema en Brasil, que desde hace cerca de 40 años se ha mejorado y ampliado ante la creciente demanda de atención de calidad por parte de la población.

Medical specialization is a challenge because it needs to prepare a newly graduated professional as the specialist that the population wants to ensure better conditions in health care. The construction of a system for training these professionals is a challenging given the characteristic of in-service training where professionals work directly with patients, depending on adequate facilities, equipment, medical tutors, and theoretical programs that guarantee the development of learning within the most current technical parameters. An additional challenge is the number and diversity of institutions involved, including university hospitals that have a tradition of teaching and private hospitals where the performance is based on practice. We seek to show in this article the trajectory of the construction of this system in Brazil, which for about 40 years has been improving and expanding to fulfill the population ́s growing demand for quality care.

Yellow fever in children and adolescents previously immunized in Minas Gerais State, Brazil.

Background - Yellow fever (YF) is a viral hemorrhagic fever that is transmitted by arthropods. It can occur with little symptomatic manifestations to the most fulminant forms. The most effective way to avoid YF is through vaccination. There is a lack of information about the immune response of the vaccine in childhood. Methods - We described children and adolescents with YF who had been previously immunized in Minas Gerais State from July 2017 to June 2018. Results - 527 cases of YF were observed representing an incidence of 7.6/100,000 inhabitants. Only 26 patients (4.9%) were ≤ 20 years and 501 (95.1%) were > 20 years. Only 9 vaccinated patients were ≤ 20 years and 15 were > 20 years. 34.6% (9/26) of YF patients ≤ 20 years were previously vaccinated and 3% (15/501) of those > 20 years (p < 0.001). The median age at vaccination was 1 year between those ≤ 20 years and 31 years between those > 20 years (p = 0.002). Among 9 vaccinated children and adolescents ≤ 20 years, age ranged from 7 to 18 years, the most described symptoms were fever (88%), headache (77%), myalgia (77%), and abdominal pain (66%). All patients recovered from the disease and none died. Conclusion - Prior YF vaccination may be associated with mild forms of the disease in children and adolescents. YF vaccination in the first years of life may be associated with poor vaccine response and high infection rates in this group as it fail to seroconvert a significant proportion of infants.

A experiência assistencial da Fhemig na atenção a doenças infecciosas respiratórias agudas durante o enfrentamento da epidemia de Influenza A H1N1, no estado de Minas Gerais em 2009 / Fhemig experience in the care of acute respiratory infectious diseases during the fight against the H1N1 Influenza epidemic in Minas Gerais State in 2009

A epidemia pelo vírus influenza A H1N1 no estado de Minas Gerais mobilizou a sociedade e a resposta articulada dos serviços de saúde em ações coordenadas pelo Comitê Estadual. Objetivo: descrever o atendimento ambulatorial e hospitalar para doenças respiratórias infecciosas agudas realizado nas Unidades da rede Fhemig nas semanas epidemiológicas 33 a 41 de 2009. Método: estudo prospectivo de dados fornecidos semanalmente pelas unidades assistenciais à administração central, para fins de monitoramento e gestão da clínica. Resultados: ocorreu um total de 1.396 atendimentos no período em 11 unidades na região metropolitana de Belo Horizonte e interior do estado, com 29 por cento de internações em enfermarias e 6,7 em CTI, predomínio de pacientes de 15-24 anos, 42,4 por cento sem fatores de risco para complicações e 2,4 por cento de óbitos; 50 por cento (698) dos casos receberam antiviral oseltamivir. O pico de atendimentos ocorreu na 35ª semana (entre 30/08 e 05/09/2009). Confirmou-se influenza A H1N1 em 2,4 por cento dos casos atendidos e 399 exames permaneciam pendentes. Insuficiência renal dialítica, uso de ventilação mecânica e vasopressores foram preditores de óbito. Pneumonia associada à ventilação elevou o risco de óbito em 76 por cento (RR:1,76; IC 95 por cento 1,07-2,88). Conclusão: a Fhemig participou de forma articulada no processo assistencial durante a epidemia e desenvolveu mecanismos de gestão da clínica de forma a garantir a qualidade assistencial e responder à demanda da sociedade, junto com os demais parceiros.

Fundação Hospitalar do Estado de Minas Gerais (FHEMIG): protocolo-guia de atendimento domiciliar e hospitlar de casos suspeitos ou confirmados de Influenza A (H1N1) / Fundação Hospitalar do Estado de Minas Gerais (FHEMIG): guide-line for home and hospital care monitoring suspect or confirmes cases of Influenza A (H1N1)

Este protocolo, de elaboração continuada, foi realizado pela Fundação Hospitalar do Estado de Minas Gerais como instrumento de organização e atualização do atendimento, em diversos níveis hierarquizados do Sistema Único de Saúde, desde a sua indicação de internação até a alta hospitalar, para garantir o melhor atendimento para os pacientes, o sucesso das ações de abordagem de casos clínicos e a biossegurança dos profissionais envolvidos no manejo dos pacientes.

Hospital Foundation of Minas Gerais State has conducted continual development of this protocol, as an instrument for care organization and updating in several hierarchical levels of the Unified Health System, since its statement of admission to the hospital to ensure better care for patients, the successful actions for dealing with cases, and biosecurity for the professionals involved in the patients? management.

Low frequency of side effects following an incidental 25 times concentrated dose of yellow fever vaccine.

In August/1999, a group of 14 adults from the staff of a private hospital in Contagem - Minas Gerais State, Brazil, received unintentionally a 25 times concentrated dose of the 17-DD yellow fever vaccine (Bio-Manguinhos), due to a mistake at the reconstitution step. All patients were clinically and laboratorially evaluated at days 5, 13 and 35 post vaccination. Frequency of side effects and clinical observations of this group of individuals were not different from the observed in recipients immunized with normal doses of the vaccine. At the second and third evaluation none of the subjects reported symptoms. None of the patients presented abnormalities at the physical examination at none of the time points and in all cases the blood examination was normal, except for a reduced number of platelets that was detected in one subject at the first and second evaluation and reverted to normal at third evaluation. At the first evaluation point, 8 subjects were serum negative and 6 serum positive for yellow fever at the plaque reduction neutralization test. In 5 subjects the observed titre was 10 times higher as the baseline of 2.36 Log10 mUI/ml. The samples collected at second and third evaluation (13th and 35th days) demonstrated that all subjects responded to the vaccination with the exception of one that did not present a positive result in any of the samples collected. This evaluation confirms the safety of the 17-DD yellow fever vaccine.

Low frequency of side effects following an incidental 25 times concentrated dose of yellow fever vaccine

In August/1999, a group of 14 adults from the staff of a private hospital in Contagem -- Minas Gerais State, Brazil, received unintentionally a 25 times concentrated dose of the 17-DD yellow fever vaccine (Bio-Manguinhos), due to a mistake at the reconstitution step. All patients were clinically and laboratorially evaluated at days 5, 13 and 35 post vaccination. Frequency of side effects and clinical observations of this group of individuals were not different from the observed in recipients immunized with normal doses of the vaccine. At the second and third evaluation none of the subjects reported symptoms. None of the patients presented abnormalities at the physical examination at none of the time points and in all cases the blood examination was normal, except for a reduced number of platelets that was detected in one subject at the first and second evaluation and reverted to normal at third evaluation. At the first evaluation point, 8 subjects were serum negative and 6 serum positive for yellow fever at the plaque reduction neutralization test. In 5 subjects the observed titre was 10 times higher as the baseline of 2.36 Log10 mUI/ml. The samples collected at second and third evaluation (13th and 35th days) demonstrated that all subjects responded to the vaccination with the exception of one that did not present a positive result in any of the samples collected. This evaluation confirms the safety of the 17-DD yellow fever vaccine

Dengue: uma nova abordagem / Dengue: a reappraisal

Os conceitos de dengue clássico, com ou sem hemorragia, e da febre hemorrágica do dengue (FHD) que, pode cursar sem fenômenos hemorrágicos, com ou sem síndrome do choque do dengue (SCD) säo revistos neste artigo. As definiçöes clássicas propostas, úteis em outros tempos, geram confusäo e dificultam a tomada de decisöes no momento do tratamento dos pacientes com as formas graves da doença porque deixaram de incorporar novos conceitos e avanços terapêuticos. A classificaçäo do dengue proposta neste trabalho, e apresentada em fluxograma, incorpora os conceitos atuais de sepse, síndrome da resposta inflamatória sistêmica (SIRS) e síndrome da angústia respiratória do adulto (SARA). A nova classificaçäo serve de guia para orientar a conduta terapêutica inicial e aproxima o tratamento do dengue aos protocolos e rotinas já implantados nos diversos centros hospitalares de urgência, facilitando a atuaçäo dos serviços de saúde em situaçöes de surtos epidêmicos

Piomiosite tropical / Tropical pyomyosistis: case report

A piomiosite é uma doença bacteriana, típica do clima tropical e de reconhecimento crescente em climas temperados. Afeta os grandes grupos musculares do esqueleto, formamdo abcessos profundos, usualmente associados ao S. Aureus. Em nosso meio näo há uma comunicaçäo sistemática quanto à sua ocorrência. Descreveremos quatro casos de nossa causuística, diagnosticados no período de março/91 a julho/92.