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Experience from the Three First Months
of LPM Radio as a Vehicle for Continuing
Medical Education (CME) for Cardiologists
through the Internet (I)
Schapachnik, Edgardo; Piombo, Alfredo;
Vidal, Martín; Guebel, Ariel;
Guebel, Diego; Schapachnik, Alejo;
Schapachnik, Fernando Pablo
Curso Universitario de Dolor. Curso de
Formación de Investigadores Clínicos.
Radio L.P.M. Buenos Aires, Argentina
Introduction: The experiences carried out on the I with the development of thematic Forums, clinical athenaeums, courses, symposia, congresses and access to Medline, turn the I into a resource for CME, for professionals who otherwise would not have the chance to obtain access to such contents. Transmission through a radio station enlarges the reach of such experience. Objective: To analyze the programs broadcast from the LPM Radio, http://www.radio-lpm.com.ar , since March 19th, 2001.
Material and Methods: The programs were designed to be made up by 25-minute thematic modules in order to tackle varied subjects, mainly in the cardiological area. There were 22 specialists called with this purpose. The programs were completed with short sections with the goal of recalling medicine historical facts and current news.
Results: The following topics were dealt with in the form of interviews with experts: Evidence-Based Medicine, GP IIb/IIIa inhibitors, Heparines, Calcium Blockers in BP, Sudden Cardiac Death I, Interventionist Cardiology in Coronary Unit, Syncope, Anti-arrhythmic Drugs, Pediatric Arrhythmias, Hypertensive Crisis, Heart Failure I and II, Chagas Disease I and II, Acute Coronary Syndromes in seniors, Estatins, Non-Q Wave Infarction, Anti-thrombotic agents I and II, Brugada Syndrome, Instructional Programs in Resuscitation Addressed to Population, Post Operative Pain, COX2 Inhibitors.
Besides, there were brief historical quotations and two news sections.
Conclusions: The approach on these 23 sections in three months can make up a thematic index that in an entertaining and conversational way, provides educational contents to professionals who have access to the I, by means of the resource of a radio station with specific programs.
The experiences carried out on the Internet (I) with the development of Thematic Forums (1), clinical athenaeums, courses (2), symposia (3), congresses (4,5), Forum activities devoted to Continuing Medical Education for Cardiologists (6), and access to Medline, turn the net into a resource for CME for Cardiologists, for professionals who otherwise would not have the chance to obtain access to such contents.
While a project on CME through the Internet is being created, it is appealing to imagine an educational experience being shared with hundreds or thousands of people from faraway places united under a common interest. The only boundaries would be one's own interests.
Educators, institutions, Scientific Societies, transmit a knowledge that will be beneficial for those who receive it. It is in their best interest that such knowledge should be grasped.
"Educators" commit to quality. "Students" commit to responsibility regarding the use of the contents received.
The concept of Distance Education changes somehow the factors of the knowledge transmission/acquisition process.
Those who wish to learn no longer go to the Academic Center; instead it is the latter that displays an array of offers in the homes of the hundreds or thousands who are interested.
The Hospital is no longer the only one to provide the best post-degree education through the Medical Residence System, through Courses or Athenaeums, or traditional forms for successive generations to update permanently. To these, others more modern are added. Now, it is possible to conceive providing and spreading education beyond seas and boundaries.
When this equation is conjugated in the first person, the interested party, i.e. a doctor who cannot take part in an Athenaeum or a Course just because s/he lives in a faraway place from our own, or in other country, can now have access to varied programs.
Therefore, daily activities, jobs, the time necessarily devoted to home and family, and dwelling are no longer obstacles in the process of learning, instead all these aspects can be integrated.
"Availability of distance education and training services is now an accepted way of enhancing access to knowledge and skills, and boosting participation in the educational process for those who, otherwise, would not be able to take part (7)."
These statements are facts generalizing the concept of distance education to a specific type of it: the one we have been implementing through the Internet with a projective view as to how it will be in the following years.
In fact, a wise implementation of resources and tools provided by the Internet, isolated or mixed, makes it possible not only to imagine, but to obtain real access currently, or in relatively short periods; and even more, not only to implement it in those periods of time, but to analyze the experiences of what has already been done in distance education.
Distance Education through the Internet or Teleformación (term used in Spain to differentiate it from other forms of Continuing Education), not only is it a project, but also an adjustment, improvement, optimization, and generalization of experiences which are already being developed, and that are mentioned in the commented quotes.
Transmission through a radio station, which would add to the mentioned experiences, would enhance the range of such experience.
The purpose of this communication is to endorse what has been said, and to analyze the programs broadcast from LPM Radio http://www.radio-lpm.com.ar since March 19th, 2001, during the first three months of existence, with the objective of programs on Continuing Medical Education for Cardiologists, which could be extended to other disciplines.
MATERIAL AND METHODS
The programs were designed to be made up by 25-minute, thematic modules, in order to approach varied current topics, mostly in the cardiological area. There were 22 specialists called, most of them working in Hospitals in Buenos Aires, and also from San Pablo, Brazil, and Seattle, Washington, USA. Such programs were completed with short sections devoted to recall historical facts of medicine, current news, and messages from the program Salud Siempre (Health For Ever) by the PAHO/WHO.
The following topics were dealt with, as interviews to experts:
1. Evidence-based medicine, by Dr. Carlos Tajer (What is and what is not Evidence-based Medicine? Which literature provides certainty? What can be said on the great medical facts? Revolutionary advancements in medicine; Examples of thrombolytics; The? truth? about bloodletting; Design on trials and clinical applications for conclusions; Industry and great trials; How is evidence generated? How is it financed? Critics to EBM: the quantitative and the qualitative; How is study design planned? Training in EBM.)
2. GP IIb/IIIa inhibitors, by Dr. Alfredo Piombo (Characteristics of pharmacological group, IIb/IIIa receptors; Anti-glycoproteic inhibitors and/or aspirin? Characteristics of abciximab and synthetic inhibitors; Abciximab and revascularization procedures; Uses in acute coronary syndromes; TARGET Study, GUSTO IV Study, EPISTENT Study, TACTICS TIMI 18 Study; Invasive and non-invasive strategies in unstable angina; Tirofiban; Low and high risk patients; Cost/effectiveness; Massive use? Is it possible? Is it worth? Association between fibrinolytics and anti-glycoproteic inhibitors; ASSENT III Study; Hemorrhage complications; Association of low molecular weight heparins and anti-glycoproteic inhibitors (NICE 3 Study); Relationship between troponine and results from use of anti-glycoproteic inhibitors; PRISM Study; GUSTO IV Study; CAPTURE Study; PARAGON B Study; Smoking, diabetes and results from use of anti-glycoproteic inhibitors; Differences between different kinds.)
3. Low molecular weight heparins, by Dr. Alfredo Piombo (Where do low molecular weight heparins stand in current treatment for acute coronary syndromes? What is the evidence? Which are the results from its use in unstable angina and AMI? Which is the advantage of early association of enoxaparin and streptokinase in treatment for AMI. Are there differences when choosing between non-fractioned and low molecular weight heparin, and the different heparins of the last kind for these treatments? Main teachings from ESSENCE, from FRAXIS, and TIMI 11B; Results from the ESSENCE Study regarding inter-regional differences observed in Non-Q AMI; How monitoring for anti-coagulation should be according to the different heparins used? FRISC Study with dalteparin; Choice of kind of heparin; Final advice on use of LMW heparins in unstable angina and Non-Q AMI.)
4. Calcium blockers in high blood pressure, by Dr. Alberto Villamil (Regarding beta-blockers, diuretics, ACEI, where do calcium blockers stand in treatment for HBP? In which clinical situations these would be the first choice? In terms of ?hard? end points as prevention for AMI, Stroke and/or death, where would they stand? Which would be the role of these drugs in cases with renal involvement and proteinuria? Benefits or not in use of calcium blockers in seniors (commentaries about the HOT Study); Would there be any benefits from its prescription to diabetic patients or to all these, after the HOPE Study? Would it be better to prescribe ramipril? Where do nifedipine (including OROS formulations), diltiazem, verapamil, amlodipine, felodipine, lacidipine, etc., stand currently in treatment for HBP? Nifedipine: old and new pharmacological presentations; would there be any benefits from prescribing these drugs as a choice against hydrochlorothiazide in seniors? HBP and heart failure: where does amlodipine stand? Which is the role of fixed combinations of calcium antagonists with ACEI?)
5. Sudden death I, by Dr. Jorge González Zuelgaray (Definition: Which would be the most important risk factors to take into account to prevent its occurrence, and how to do it, in an ischemic heart disease scenario? Since more than a 50% of SD episodes happen outside the hospital: how does implementing basic CPR programs influence on prevalence and prognosis? What amount of cardioverter-defibrillators would be necessary to provide a city like Buenos Aires with equipment capable of assisting a SD episode in any place in less than three minutes? Fixed posts would be located in public ways, in large urban areas, or would there be mobile ones? How such a measure would impact on the cost/effectiveness field? Which is the relationship between SD, Hypertrophic Myocardiopathy, and practicing sports? How to prevent it? Brief commentaries on each one of these entities or situations: Brugada Syndrome, Congenital Long QT Syndrome, Arrhythmogenic RV dysplasia, SD in newborn babies; Drugs that extend QT; Pro-arrhythmic effect.)
6. Angioplasty in acute coronary syndromes, by Dr. Oscar Carlevaro (Which are the percutanous revascularization techniques used currently? Differences in results and clinical evolution in the pre and post-stent eras; Does stent must be prescribed in all patients? What kind of stent is the most advisable currently? Intravascular ultrasound: does it have any role in daily practice? When anti-IIb/ IIIa drugs must be prescribed? Differences in results with abciximab, tirofiban, and eptifibatide; multiple vessel angioplasty; Trunk angioplasty.)
7. Syncope, by Dr. Aurora Ruiz (How are syncopes classified? Which are the most frequent syncopes with cardiac origin? What is a neurocardiogenic syncope? Physiopathologic mechanisms in neuracardiogenic syncope; how is a diagnosis for neurocardiogenic syncope done? What is a tilt-test? Methodology; Treatment for neurocardiogenic syncope. Its prognosis in short and long term. Is there still a syncope with unknown origin?).
8. Updating in anti-arrhythmic drugs, by Dr. Carlos Labadet (Which anti-arrhythmic drugs have survived the passage of time? What is the goal of treating a patient with anti-arrhythmic drugs? Brief description of pharmacological features for amiodarone; which post-infarction patients should receive anti-arrhythmic treatment? Amiodarone versus defibrillators: results from the most important studies. Lidocaine in AMI: never again? Are beta-blockers good antiarrhythmic agents?)
9. Arrhythmias in pediatrics, by Dr. Jorge Scaglione (Are the same arrhythmias seen in pediatrics and in adults? Significance of an accurate diagnosis; which is the treatment? Supraventricular paroxysmal tachycardias in neonates and their evolution. Digitalis in Wolff Parkinson White treatment; Use and toxicity of amiodarone in children; Radiofrequency ablation in children; Bradiarrhythmias, Congenital AV blockade; When is a pacemaker prescribed? Are implantable cardioverter-defibrillators used in children? First implantation in Argentina; what an adult doctor must do before the case of a child with arrhythmias?)
10. Hypertensive crisis, by Dr. Pablo Rodríguez (Hypertensive crisis, hypertensive urgency, hypertensive emergency, hypertensive encephalopathy, accelerated-malignant hypertension, are these concepts synonyms? When to use each term? What is the prevalence of these situations? Morbidity and mortality; regarding age and sex, which would the responsible entities be? What is the relationship regarding primary and secondary forms of HBP? According to the above, where to place pre-eclampsia and eclipse? Which is the physiopathologic mechanism of these situations? What role does the renin-angiotensin-aldosterone system play in these situations? How to study these patients in acute situation, and once the acute situation is over?)
11. Heart failure I and II, by Dr. Hernán Doval (How is heart failure diagnosed? Role of clinics, ejection fraction, oxygen consumption; Is it proper to speak of systolic and diastolic failure? From clinical signals, the presence or not of pulmonary rales, and/or jugular engorgement, has any meaning in prognosis? When is ambulatory management of a patient with HF clinical syndrome possible, and when admission must be prescribed? In the latter, when discharge from hospital must be prescribed? How to assess LV ejection fraction? Why is important to do it? Diastolic dysfunction: characterization, pharmacological management, evidence, prognosis; which drugs should be used, and which not? How progression should be in prescription of drugs? With which ones to begin? Diuretics: hydrochlorothiazide or loop diuretics; when to use them? Is it proper to associate them? In which situations?)
12. Chagas disease I and II, by Dr. Héctor Freilij and Dr. Edgardo Schapachnik (When a serologic study should be requested, and when a parasitologic study? Which information provides each one? Why more than one serologic reaction must be requested? Can a clinician manage a patient with a result from just one serologic test? How is it suggested to perform the serologic-diagnostic study of a patient in a low complexity hospital with scant resources? In which clinical situations a Strout should be prescribed, or a microhematocrit, a xenodiagnosis, or hemoculture? In which clinical situations more sophisticated studies, such as PCR reaction, anti beta receptor antibodies, etc. could be carried out, or all of them are saved exclusively for research? Which study is suggested for a blood bank? Which the management should be, before a pregnant, chagasic patient? What should be done with a newborn baby from a chagasic mother? Longitudinal follow-up in treated children: results. How and when to suspect an acute Chagas? Manifest and occult forms. Myocarditis prevalence and clinical presentation in acute Chagas; How a patient in an indefinite stage is characterized? How s/he should be studied? When a parasiticide treatment should be established in chronic parasited patients? Heart transplantation.)
13. Acute coronary syndrome in seniors, by Dr. Juan Gagliardi (Why to approach the topic of acute coronary syndrome in seniors? Increase of admittance incidence? Greater clinical risk both in AMI as in UA? Which mechanisms would be involved in pathogenesis of acute ischemic coronary syndromes in seniors? Besides plaque accident: large coronary involvement? Decrease in coronary flow reserve? Poor adjustment to ischemia? Which would be the reperfusion strategies in seniors? Advantages and disadvantages of thrombolytics; which thrombolytics? SK versus Tpa; Stroke incidence; Advantages of PTCA; Surgery in seniors with acute coronary syndrome; Evolution of results in large centers; Therapeutic uses in seniors with AMI or UA; Hypolipemiant agents in seniors, do they work? Meta-analysis of main studies in coronary event incidence.)
14. Estatins, by Dr. Mario Ciruzzi (What estatins are? Operation mechanism; Are they different among themselves or do they have a class effect? Main conclusions from the 4S, CARE and WOSCOPS Studies; Most important teachings from the PRESEA Study; Do these drugs have favorable effects besides lipids reduction? (Inflammation, thrombosis) Adverse effects by estatins.)
15. Non-Q infarction, by Dr. Carlos Barrero (Non-Q infarction, acute ischemic coronary syndromes without ST segment depression; Non-transmural AMI: who's who? Prevalence of non-Q AMI. Pathophysiology of non-Q AMI; is a spontaneous non-Q AMI equivalent to a post-thrombolytic one? What are the differences? Are all non-Q AMI the same? Non-Q AMI, Q AMI, and unstable angina: similarities and differences; Medical Treatment: any difference with AMI Q type? Heparin: yes, no, which one? A routine Cineangiography should be carried out in non-Q AMI? VANQWISH Study: was it good or bad? If an unstable angina has troponine increase: is it a non-Q AMI?)
16. Anti-thrombotic agents orally, by Dr. Marcelo Casey and Dr. Alfredo Piombo (Aspirin; Operation mechanism; Doses; Prescriptions in ischemic heart disease; Main trials; Oral anti-glycoprotein IIb-IIIa; Operation mechanism; Doses; Prescription in ischemic heart disease; Main trials; Oral anticoagulant agents in ischemic heart disease; Any prescription? Clopidogrel; Operation mechanism; Differences to ticlopidine; CAPRIE Study; CURE Study: design, results, conclusions; Must clopidogrel be prescribed to all patients with non-Q UA/AMI? Management of complications.)
17. Brugada syndrome, by Dr. Andrés Perez Riera (How to conceptualize Brugada syndrome? Why the entity is considered a channel dysfunction? What is the natural history of the syndrome? Which is its prevalence? Which are the similarities and differences between the Brugada syndrome and the LQT3 variant from the long QT syndrome? Diagnosis and differential diagnosis; Therapeutic approach.)
18. Training programs in CPR for the population, by Mr. Alex Otman (How to plan an Education Program addressed to the population? Role of the fire and paramedical departments; Community training: experiences; Distribution strategies for fixed and mobile cardioverter-defibrillators; Legislation; USA experience.)
The following topics were also tackled: Post-operative pain, by Dr. Daniel Solis, and COX2 inhibitors, by Dr. Flavio Devoto.
Furthermore, brief historical quotes were broadcast, taken from texts on Cardiology from the first half of the XX Century, as well as two news sections with information regarding Continuing Medical Education through the Internet. During the last month, brief micro-programs were included, from the Salud Siempre series, by the PAHO/WHO.
The approach of these 20 programs presented in 23 sections, broadcasting nearly permanently for three months, can make up a thematic index that in an entertaining and colloquial fashion provides educational contents to professionals who have access to the I, through the resource of a radio station with specific programs.
1. Schapachnik E, Pacher A, Kuschnir E, Lombardo R, Garófalo F, Friz HP, Bassino M, Bretal R, Bustamante J, Canestri A, Esandi D, Eskenazi S, Heñín M, Luque C A, Valente JM, Morlans HK, Sanagua J, Interacción por Internet (I) de actividades docentes y académicas en Cardiología (C) (Interaction through the Internet (I) on Teaching and Academic Activities on Cardiology (C)), Brief Communication presented to the XIX Congreso Nacional de Cardiología, FAC (Federación Argentina de Cardiología-Argentine Federation of Cardiology), Mendoza, Argentina, June 2000
2.Schapachnik, E; González Zuelgaray, J.; Scasuzzo, F.; Pérez, A.; Ayala Paredes, F.; García, W.; Ruiz Luque, A.; Schapachnik, F.; Gimpelewicz, C.; Aranda, G.; Del Alamo, R.; Primer Curso de Arritmias por Internet. Experiencia de Educación de postgrado con el uso de una nueva herramienta. (First Course on Arrhythmias on the Internet. Experience on Post-degree Education by Using a New Tool), Brief Communication presented to the XXVI Congreso Argentino de Cardiología, SAC (Sociedad Argentina de Cardiología-Argentine Society of Cardiology), Buenos Aires, Argentina, 1999.
3. Schapachnik E, Pacher A, Evequoz C, Lombardo R, on behalf of the FVCC Group. Utilización de Internet (I) para un Simposio sobre Enfermedad de Chagas (EC) (Use of the Internet (I) for a Symposium on Chagas Disease), Brief Communication presented to the XX Congreso Nacional de Cardiología, FAC, Córdoba, Argentina, April/May 2001.
4. Pacher A, Kuschnir E, Schapachnik E, Lombardo R, Garófalo F, Friz HP, Bassino M, Bretal R, Bustamante J, Canestri A., Esandi D, Eskenazi S, Heñín M, Luque C A, Valente JM, Morlans HK, Sanagua J, Utilización de Internet (I) para actividades científicas y académicas en Cardiología (C) (Use of the Internet (I) for Scientific and Academic Activities on Cardiology (C)). First Prize to Best Work presented to the XIX Congreso Nacional de Cardiología, FAC, Mendoza, Argentina, June 2000.
5. FVCC Group: Schapachnik, E.S.; Bassino, M. Bretal, R.; Bustamante, J.; Canestri, A.; Esandi, D.; Eskenazi, S.; Garófalo, F.; Heñín, M.; Kuschnir, E.; Lombardo, R.; Luque Coqui, A.; Mattar Valente, J.; Morlans Hernández, K.; Pacher, A.; Polo Friz, H.; Sanagua, J. La Enfermedad de Chagas en el Primer Congreso Virtual de Cardiología (PCVC) (Chagas Disease in the First Virtual Congress of Cardiology (FVCC)), Brief Communication presented to the Tercer Simposio de Informática y Salud. 29avas Jornadas Argentinas de Informática e Investigación Operativa (JAIIO), SADIO (Sociedad Argentina de Informática e Investigación Operativa-Argentine Society of Informatics and Operative Investigation), Tandil, Argentina, September 2000.
6. Pacher A, Schapachnik E, Garófalo F, Lombardo R, Kuschnir E, Bassino M, Bretal R, Brunetto J, Bustamante J, Canestri A, Esandi D, Eskenazi S, Garófalo D, Heñín M, Luque Coqui A, Morlans K, Nanfara S, Ortiz Baeza O, Sanagua J, Valente JM, Velez M, Utilización de Internet (I) para un Foro de Educación Contínua en Cardiología (C) (Use of the Internet (I) for a Forum on Continuing Medical Education for Cardiologists), Brief Communication presented to the XX Congreso Nacional de Cardiología, FAC, Córdoba, Argentina, April/May 2001.
7. Bartolomé, A. R.; Underwood, J. D. M. TEEODE Project. Technology Enhanced Evaluation in Open and Distance Education. On the Internet.
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2nd Virtual Congress of Cardiology
Dr. Florencio Garófalo
Dr. Raúl Bretal
Dr. Armando Pacher
Technical Committee - CETIFAC
Copyright© 1999-2001 Argentine Federation of Cardiology
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