Resumo Fundamentos: A insatisfação dos profissionais de saúde dos serviços de urgência tem influência negativa na qualidade do cuidado ao infarto agudo do miocárdio (IAM) e na fixação desses profissionais. Objetivo: Avaliar a satisfação de médicos com a estrutura de atendimento e diagnóstico de serviços públicos de urgência na Região Ampliada Norte de Minas Gerais, previamente à implantação da linha de cuidado ao IAM. Métodos: Estudo transversal, que incluiu médicos das unidades de emergência do SAMU e de hospitais regionais nível II, III e IV. Foi avaliada a satisfação usando a escala CARDIOSATIS-Team. O escore mediano para cada item, a escala global e os domínios foram calculados e então comparados por grupos, utilizando o teste não paramétrico de Mann-Whitney. Foi avaliada a correlação entre tempo de formação e nível de satisfação com o método de Spearman. Um valor-p < 0,05 foi considerado significativo. Resultados: De 137 médicos incluídos, 46% trabalhavam no SAMU. A maior parte dos entrevistados demonstrou insatisfação geral com a estrutura de atendimento, cuja mediana da escala global foi 2,0 (intervalo interquartil [IQ] 2,0-4,0). A maioria dos médicos do SAMU demonstrou-se insatisfeita quanto a atendimento prestado (54%), estrutura para condução das doenças cardiovasculares (52%) e tecnologia disponível para diagnóstico (54%). Na avaliação da satisfação global, evidenciou-se que a insatisfação dos médicos do SAMU foi menor quando comparada à dos médicos de urgência hospitalar. Os médicos de hospitais nível III/IV demonstraram maior satisfação global quando comparados aos de hospitais nível II. Conclusão: Este estudo demonstrou insatisfação geral dos médicos dos serviços de urgência na região em relação à estrutura de atendimento às emergências cardiovasculares.

Abstract Background: The dissatisfaction of health professionals in emergency services has a negative influence on both the quality of care provided for acute myocardial infarction (AMI) patients and the retention of those professionals. Objective: To assess physicians’ satisfaction with the structure of care and diagnosis at the emergency services in the Northern Region of Minas Gerais before the implementation of the AMI system of care. Methods: This cross-sectional study included physicians from the emergency units of the ambulance service (SAMU) and level II, III and IV regional hospitals. Satisfaction was assessed by using the CARDIOSATIS-Team scale. The median score for each item, the overall scale and the domains were calculated and then compared by groups using the non-parametric Mann-Whitney test. Correlation between time since graduation and satisfaction level was assessed using Spearman correlation. A p value < 0.05 was considered significant. Results: Of the 137 physicians included in the study, 46% worked at SAMU. Most of the interviewees showed overall dissatisfaction with the structure of care, and the median score for the overall scale was 2.0 [interquartile range (IQR) 2.0-4.0]. Most SAMU physicians expressed their dissatisfaction with the care provided (54%), the structure for managing cardiovascular diseases (52%), and the technology available for diagnosis (54%). The evaluation of the overall satisfaction evidenced that the dissatisfaction of SAMU physicians was lower when compared to that of hospital emergency physicians. Level III/IV hospital physicians expressed greater overall satisfaction when compared to level II hospital physicians. Conclusion: This study showed the overall dissatisfaction of the emergency physicians in the region assessed with the structure of care for cardiovascular emergencies.

Abstract: INTRODUCTION: Chagas disease currently affects 5.7 million people in Latin America and is emerging in non-endemic countries. There is no consensus concerning the efficacy of trypanocidal therapy for patients with the chronic form of the disease. We evaluated cardiac function and sociodemographic, clinical, and serologic characteristics of a group of asymptomatic Trypanosoma cruzi-seropositive former blood donors, and compared the effects of benznidazole treatment applied for different lengths of time. METHODS: Blood donors who screened positive for T. cruzi between 1998 and 2002 were recruited 10 years later for follow-up (n = 244); 46 individuals had received treatment. Three subjects had terminated treatment prematurely. The remaining 43 individuals were divided into two groups: individuals who had received benznidazole therapy for 50-60 days (n = 28; BT ≤60 group) or more than 60 days (n = 15; BT >60). Serologic assays, biochemical tests, electrocardiographic, echocardiographic, and clinical examinations were performed on all participants. Parasite loads were determined by qualitative and quantitative polymerase chain reaction. RESULTS: Parasitemia was significantly reduced in the BT ≤60 and BT >60 groups compared with the untreated group. There were no differences in epidemiologic profiles or clinical, biochemical, electrocardiographic, or echocardiographic data between any of the groups. CONCLUSIONS: Despite elimination or significant reduction in parasitemia in patients with chronic Chagas disease who received benznidazole, there was no clinical difference between those who were treated for >60 days and those treated for a shorter duration. Furthermore, the adverse effects of benznidazole appear to be less severe than previous reports would suggest.

Resumo Fundamento: A doença coronariana é a principal causa de morte no Brasil. No sistema público de saúde brasileiro, a mortalidade hospitalar por infarto agudo do miocárdio é elevada. O Projeto Minas Telecardio 2 tem o objetivo de implantar a linha de cuidado do infarto na Região Ampliada Norte de Minas Gerais (MG), com vistas à redução da morbimortalidade hospitalar. O objetivo deste estudo foi descrever o perfil dos casos de síndrome coronariana aguda (SCA) atendidos no período que precedeu à implantação do programa. Métodos: Estudo prospectivo observacional dos pacientes com SCA admitidos entre junho de 2013 e março de 2014 nas seis portas de entrada de urgência de Montes Claros e acompanhados até a alta hospitalar. Resultados: No período do estudo, 593 pacientes foram admitidos com SCA (idade média 63 ± 12 anos, 67,6% homens), com 306 (51,6%) casos de angina instável, 214 (36,0%) de infarto com supradesnivelamento do ST (IAMCSST) e 73 (12,3%) com infarto sem supradesnivelamento do ST (IAMSSST). A mortalidade total para IAMCSST foi 21% e a intra-hospitalar foi de 17,2%. Nos pacientes com IAMCSST, 46,0% foram submetidos a terapia de reperfusão, com 88 angioplastias primárias e seis trombólises. AAS foi administrado a 95,1% dos pacientes nas primeiras 24 horas e a 93,5% na alta, inibidores do P2Y12 foram administrados a 88,7% dos participantes nas primeiras 24 horas e a 75,1% na alta. Ao todo, 73,1% receberam heparina nas primeiras 24 horas. Conclusão: Foram observadas baixa taxa de reperfusão em pacientes com IAMCSST e adesão limitada aos tratamentos preconizados para abordagem da SCA na Região Ampliada Norte de MG. Estas observações possibilitam oportunidades para melhoria do cuidado em saúde.

Abstract Background: Coronary artery disease is the main cause of death in Brazil. In the Brazilian public health system, the in-hospital mortality associated with acute myocardial infarction is high. The Minas Telecardio 2 Project (Projeto Minas Telecardio 2) aims at implementing a myocardial infarction system of care in the Northern Region of Minas Gerais (MG) to decrease hospital morbidity and mortality. The aim of this study was to describe the profile of the patients with acute coronary syndrome (ACS) cared for in the period that preceded the implementation of the system of care. Methods: Observational, prospective study of patients with ACS admitted between June 2013 and March 2014 to six emergency departments in Montes Claros, MG, and followed up until hospital discharge. Results: During the study period, 593 patients were admitted with a diagnosis of ACS (mean age 63 ± 12 years, 67.6% men), including 306 (51.6%) cases of unstable angina, 214 (36.0%) of ST-elevation myocardial infarction (STEMI), and 73 (12.3%) of non-ST-elevation myocardial infarction (NSTEMI). The total STEMI mortality was 21%, and the in-hospital mortality was 17.2%. In the STEMI patients, 46,0% underwent reperfusion therapy, including primary angioplasty in 88 and thrombolysis in six. Overall, aspirin was administered to 95.1% of the patients within 24 hours and to 93.5% at discharge, a P2Y12 inhibitor was administered to 88.7% participants within 24 hours and to 75.1% at discharge. A total of 73.1% patients received heparin within 24 hours. Conclusion: We observed a low reperfusion rate in patients with STEMI and limited adherence to the recommended ACS treatment in the Northern Region of MG. These observations enable opportunities to improve health care.

PROBLEM: The Brazilian population lacks equitable access to specialized health care and diagnostic tests, especially in remote municipalities, where health professionals often feel isolated and staff turnover is high. Telehealth has the potential to improve patients' access to specialized health care, but little is known about it in terms of cost-effectiveness, access to services or user satisfaction. APPROACH: In 2005, the State Government of Minas Gerais, Brazil, funded the establishment of the Telehealth Network, intended to connect university hospitals with the state's remote municipal health departments; support professionals in providing tele-assistance; and perform tele-electrocardiography and teleconsultations. The network uses low-cost equipment and has employed various strategies to overcome the barriers to telehealth use. LOCAL SETTING: The Telehealth Network connects specialists in state university hospitals with primary health-care professionals in 608 municipalities of the large state of Minas Gerais, many of them in remote areas. RELEVANT CHANGES: From June 2006 to October 2011, 782 773 electrocardiograms and 30 883 teleconsultations were performed through the network, and 6000 health professionals were trained in its use. Most of these professionals (97%) were satisfied with the system, which was cost-effective, economically viable and averted 81% of potential case referrals to distant centres. LESSONS LEARNT: To succeed, a telehealth service must be part of a collaborative network, meet the real needs of local health professionals, use simple technology and have at least some face-to-face components. If applied to health problems for which care is in high demand, this type of service can be economically viable and can help to improve patient access to specialized health care.

SITUACIÓN: La falta de igualdad en el acceso de la población brasileña a la asistencia sanitaria especializada y a las pruebas diagnósticas, en especial, en municipios remotos, en los que los profesionales sanitarios suelen sentirse aislados y la rotación de personal es alta. La telesalud tiene el potencial de mejorar el acceso de los pacientes a la asistencia sanitaria especializada, pero se dispone de poca información en cuanto a la eficacia en relación a los costes, al acceso a los servicios o a la satisfacción del usuario. ENFOQUE: En el año 2005, el gobierno del estado de Minas Gerais, Brasil, financió el establecimiento de la Red de telesalud con la intención de conectar los hospitales universitarios con los departamentos sanitarios de municipios remotos del estado, así como para ayudar a los profesionales a que pudieran proporcionar asistencia y realizar electrocardiografías y consultas a distancia. La red utiliza equipos de bajo coste y ha empleado varias estrategias para superar las barreras del uso de la telesalud. MARCO REGIONAL: La red de telesalud conecta a los especialistas de los hospitales universitarios estatales con los profesionales de asistencia sanitaria primaria en 608 municipios del extenso estado de Minas Gerais, muchos de ellos en áreas remotas. CAMBIOS IMPORTANTES: Desde junio de 2006 hasta octubre de 2011, se realizaron 782 773 electrocardiogramas y 30.883 consultas a distancia a través de la red y se formó a 6.000 profesionales sanitarios en su uso. La mayor parte de estos profesionales (97%) estaban satisfechos con el sistema, que ofrece una buena eficacia en relación a los costes, es económicamente viable y evitó el 81% de las referencias de casos potenciales a centros distantes. LECCIONES APRENDIDAS: Para conseguir resultados, un servicio de telesalud debe formar parte de una red colaborativa, cubrir las necesidades reales de los profesionales sanitarios locales, utilizar tecnologías simples y tener al menos algunos componentes cara a cara. Si se aplica a los problemas sanitarios para los que existe una alta demanda de asistencia, este tipo de servicio puede ser económicamente viable y ayudar a mejorar el acceso del paciente a la asistencia sanitaria especializada.

PROBLÈME: La population brésilienne manque d'un accès équitable aux soins de santé spécialisés et aux tests de diagnostic, surtout dans les communes reculées, où les professionnels de santé se sentent souvent isolés et où la rotation du personnel est élevée. La télésanté peut améliorer l'accès des patients aux soins de santé spécialisés, mais on sait peu de choses de son rapport coût-efficacité, de l'accès aux services ou de la satisfaction des utilisateurs. APPROCHE: En 2005, le gouvernement de l'État de Minas Gerais, au Brésil, a financé la création d'un réseau de télésanté, visant à relier les hôpitaux universitaires aux services de santé municipaux reculés de l'État, à soutenir les professionnels dans la téléassistance et à effectuer des télé-électrocardiographies et téléconsultations. Le réseau utilise un équipement à faible coût et a recouru à diverses stratégies pour surmonter les obstacles relatifs à l'utilisation de la télésanté. ENVIRONNEMENT LOCAL: Le réseau de télésanté relie les spécialistes des hôpitaux universitaires de l'État aux professionnels des services de santé primaires de 608 communes du grand État de Minas Gerais, beaucoup d'entre eux se trouvant dans des zones reculées. CHANGEMENTS SIGNIFICATIFS: De juin 2006 à octobre 2011, 782 773 électrocardiogrammes et 30 883 téléconsultations ont été effectués par l'intermédiaire du réseau, et 6 000 professionnels de santé ont été formés à son utilisation. La plupart de ces professionnels (97%) se sont montrés satisfaits du système qui offrait un bon rapport coût-efficacité, était économiquement viable et évitait 81% des renvois potentiels de cas vers des centres éloignés. LEÇONS TIRÉES: Pour être un succès, un service de télésanté doit faire partie d'un réseau collaboratif, satisfaire les besoins réels des professionnels de santé locaux, utiliser une technologie simple et disposer d'au moins quelques éléments en face à face. En cas d'application à des problèmes sanitaires pour lesquels la demande de soins est élevée, ce type de service peut être économiquement viable et aider à améliorer l'accès des patients aux soins de santé spécialisés.

FUNDAMENTO: Embora as doenças cardiovasculares sejam a maior causa de morbimortalidade em todo Brasil, o acesso das populações de cidades pequenas à eletrocardiografia e à avaliação cardiológica é limitado. O uso da telecardiologia para facilitar o acesso da população de municípios remotos à eletrocardiografia e à segunda opinião em cardiologia é promissora, entretanto não foi formalmente testada. OBJETIVO: Avaliar a viabilidade de se implantar o sistema público de telecardiologia de baixo custo em pequenas cidades brasileiras. MÉTODOS: Foram selecionadas 82 cidades do Estado de Minas Gerais, com população < 10.500 habitantes, > 70% de cobertura pelo Programa Saúde da Família (PSF), com interesse do gestor e acesso pela internet. Em cada município foi instalado um aparelho de eletrocardiógrafo (ECG) digital, com subsequente treinamento da equipe. A implantação foi coordenada pelo HC/UFMG, em conjunto com outros quatro hospitais universitários mineiros (UFU, UFTM, UFJF e UNIMONTES). Os ECGs foram realizados nos municípios e enviados pela internet para análise imediata em plantão de telecardiologia. Realizaram-se discussões de casos médicos on-line e off-line e cursos de atualização via web. RESULTADOS: No período de implantação, foram treinados 253 profissionais de saúde. De julho de 2006 a novembro de 2008, o projeto atendeu 42.664 pacientes, realizando 62.865 ECGs. Foram efetuados 2.148 atendimentos de urgência e 420 teleconsultorias. A avaliação intermediária apontou boa aceitação da tecnologia implantada e uma diminuição de 70% de encaminhamentos de pacientes para outros centros de referência. CONCLUSÃO: É factível a utilização de recursos habituais de informática para facilitar o acesso de populações de cidades pequenas à eletrocardiografia e avaliação cardiológica especializada.

BACKGROUND: Although cardiovascular diseases are the main cause of morbimortality in Brazil, the access of small-town populations to electrocardiography and cardiology assessment is limited. The use of telecardiology to assist the access of distant towns to electrocardiography and a second opinion in cardiology is promising; however, it has not been formally assessed. OBJECTIVE: To assess the feasibility of implementing a low-cost public telecardiology system in small Brazilian towns. METHODS: A total of 82 towns in the state of Minas Gerais, with a population < 10,500 inhabitants, presenting > 70% coverage by the Family Health Program (Programa Saude da Familia - PSF), local government compliance and internet access, were selected. Each town was supplied with digital electrocardiography (ECG) device and a team was trained. The implementation was coordinated by HC/UFMG, together with four university hospitals in the state of Minas Gerais (UFU, UFTM, UFJF and UNIMONTES). The ECG assessments were carried out in the towns and sent through the Internet for prompt analysis by an on-duty telecardiology team. Online and offline discussions on the medical cases were carried out through the Internet, as well as refreshment courses. RESULTS: During the implementation period, a total of 253 health professionals were trained. From July 2006 to November 2008, the project assisted 42,664 patients, with a total of 62,865 ECG assessments being performed. A total of 2,148 emergency cases were treated, as well as 420 teleconsultations. The intermediate evaluation showed good acceptance of the implemented technology and a 70% decrease in patient referrals to other reference centers. CONCLUSION: The use of the customary resources in informatics to assist the access of small-town populations to electrocardiography and specialized cardiology assessment is feasible.

FUNDAMENTO: Aunque las enfermedades cardiovasculares sean la mayor causa de morbimortalidade en todo Brasil, el acceso de las poblaciones de ciudades pequeñas a la electrocardiografía y a la evaluación cardiológica es limitado. El uso de la telecardiología para facilitar el acceso de la población de municipios remotos a la electrocardiografía y a la segunda opinión en cardiología es promisoria, sin embargo no fue formalmente testado. OBJETIVO: Evaluar la viabilidad de implantar el sistema público de telecardiología de bajo costo en pequeñas ciudades brasileñas. MÉTODOS: Fueron seleccionadas 82 ciudades del Estado de Minas Gerais, con población < 10.500 habitantes, > 70% de cobertura por el Programa Salud de la Familia (PSF), con interés del gestor y acceso por internet. En cada municipio fue instalado un aparato de electrocardiógrafo (ECG) digital, con subsecuente entrenamiento del equipo. La implantación fue coordinada por el HC/UFMG, en conjunto con otros cuatro hospitales universitarios mineros (UFU, UFTM, UFJF y UNIMONTES). Los ECGs fueron realizados en los municipios y enviados por internet para análisis inmediato en guardia de telecardiología. Se realizaron discusiones de casos médicos on-line y off-line y cursos de actualización vía web. RESULTADOS: En el período de implantación, fueron entrenados 253 profesionales de la salud. De julio de 2006 a noviembre de 2008, el proyecto atendió 42.664 pacientes, realizando 62.865 ECGs. Fueron efectuadas 2.148 atenciones de urgencia y 420 teleconsultorías. La evaluación intermediaria señaló buena aceptación de la tecnología implantada es una disminución de 70% de encaminamientos de pacientes para otros centros de referencia. CONCLUSIÓN: Es factible la utilización de recursos habituales de informática para facilitar el acceso de poblaciones de ciudades pequeñas a la electrocardiografía y evaluación cardiológica especializada.