TelessaúdeRS

OBJECTIVE: The purpose of this systematic review is to summarize information on the use of teledentistry in the diagnosis of oral lesions. MATERIALS AND METHODS: A systematic literature search conducted in August 2018 included articles published until December 2018 in 4 databases. Two reviewers evaluated the search results separately. If they were uncertain as to whether to include an article, a third reviewer made the final decision. Studies related to the diagnosis of oral lesions using teledentistry were included. The methodological quality of the studies was analyzed using the Quality Assessment of Studies of Diagnostic Accuracy. RESULTS: Eleven articles were included in the study. The selected articles were published between 1999 and 2018, predominantly in developing countries. The professionals acting as patient examiners are dental students and dentists, as well as other health professionals. Most of the patients evaluated in the studies were from rural populations or locations distant from large centers. The tools used to obtain patient data were smartphones, videoconference, email, questionnaires, histopathological exams, and telemedicine applications and systems. Most studies concluded that there is a high level of agreement between teledentistry and clinical consultation and that the use of this resource for diagnostic purposes can reduce costs and the travel time to consult a specialist personally. Nine of the 11 studies were of good quality. CONCLUSIONS: Teledentistry has the potential to improve the care quality related to diagnosis and management of oral lesions, shortening distances between patients who need specialized diagnoses and specialists.

BACKGROUND: Difficulties in diagnosis of oral mucosal lesions are a significant cause of delayed oral cancer diagnosis, and this difficulty may be due to gaps in knowledge. This study evaluated the diagnostic skills of primary healthcare professionals regarding oral cancer and presented them with an e-learning course. MATERIALS AND METHODS: Forty-seven primary healthcare professionals (32 dentists and 15 nondentists) enrolled in a 24-h course on oral medicine delivered through an e-learning platform. A test, based on 33 clinical images of oral lesions, was used to evaluate the diagnostic skills of participants. The participants were requested to classify each lesion as benign, potentially malignant, or malignant as well as to inform their clinical impression. Three specialists also took the test as the gold standard. RESULTS: Twenty-seven participants completed the test. Nondentists and dentists showed a comparable sensitivity of 68.8 ± 11.1 and 63.7 ± 15.8, respectively. Specialists performed somewhat better; however, the difference was not statistically significant (81.0% ± 4.1%, p = 0.16). Dentists and specialists (70.0% ± 16.6% and 95.5% ± 3.1%, respectively) showed higher specificity than nondentists (39.3 ± 20.6, p < 0.01). Nondentists had a higher number of unanswered questions (p < 0.01) for classification and clinical impression (50.0% ±45.1% and 72.0% ± 25.0%, respectively) than dentists (5.7% ±11.9% and 19.8% ± 20%, respectively). Both dentists and nondentists had low attendance in the course (44.57% ± 37.38% and 26.53% ± 26.53%, respectively, p = 0.26). To the best of our knowledge, this is the first study to assess the diagnostic skills of public health workers belonging to different professional categories. CONCLUSION: Both dentists and nondentists have a fairly good capacity for discriminating the nature of oral lesions. Early squamous cell carcinoma is the most challenging situation and remains an issue to be addressed.

Introduction The demand for specialty care is rising worldwide. In the state of Rio Grande do Sul, Brazil, more than 150,000 people were waiting for specialist consultations in 2013. A telemedicine programme (RegulaSUS) developed referral protocols, audited waitlisted cases, authorised/prioritised referrals by risk and discuss deferred cases primary-care physician. This study assesses the effectiveness of RegulaSUS. Methods A retrospective cohort analysis with contemporaneous controls was performed from June 2014 to June 2016. Six medical specialties included in RegulaSUS (50,185 patients) were compared to 50,124 control patients waitlisted according to the usual routine (scheduled for specialty consultation at the next available date). The groups were matched (1:1) by semester and year of waitlisting and by the specialty demand-to-supply ratio. Primary outcomes were referral-to-consultation time and number of waitlisted patients. Results The mean referral-to-consultation time was 584.8 days in the intervention group and 607.0 days in controls ( p<0.001). For specialties regulated by RegulaSUS, the mean referral-to-consultation time was 237.6 days for higher-risk patients. At the end of the observation, 26,708 control patients had been unlisted compared to 31,050 patients in the intervention group (reduction of 53.5% vs. 61.9%, respectively; p<0.001). The number of cancelled referrals was lower in the control group ( n=14,403; 28.7%) than in the intervention group ( n=16,387; 32.7%; p<0.001). Discussion Telemedicine support for primary care effectively decreased the time to specialty consultation, reduced the number of waitlisted patients and allowed sicker patients to reach a specialist faster.

Introduction: Planetary health (PH) has emerged as a leading field for raising awareness, debating, and finding solutions for the health impacts of human-caused disruptions to Earth's natural systems. PH education addresses essential questions of how humanity inhabits Earth, and how humans affect, and are affected by, natural systems. A pilot massive open online course (MOOC) in PH was created in Brazil in 2020. This MOOC capitalized on the global online pivot, to make the course accessible to a broader audience. This study describes the process of course creation and development and assesses the impact evaluation data and student outcomes of the PH MOOC. Methods: The PH MOOC pilot was launched in Brazilian Portuguese, using the TelessaúdeRS-UFRGS platform on 4/27/2020 and concluded on 7/19/2020 with a total load of 80 h. It was composed of 8 content modules, pre and post-test, 10 topics in a forum discussion, and an optional action plan. This study analyzes the course database, profile of participants, answers to questionnaires, forum interaction, and action plans submitted. Results: Two thousand seven hundred seventy-seven participants enrolled in the course, of which 1,237 (44.54%) gave informed consent for this study. Of the 1,237 participants who agreed to participate in the research, 614 (49.8%) completed the course, and 569 (92.67%) were accredited by TelessaúdeRS-UFRGS. The majority of the participants were concerned with climate change, trained in the health area, and worked in primary health care in places that lacked ongoing sustainability programs. Two hundred forty-one action plans were submitted, major topics identified were food and nutrition, infectious diseases, and garbage and recycling. Discussion: The use of the PH lens and open perspective of the course centered the need to communicate planetary health topics to individuals. The local plans reflected the motto of “think global and act local.” Brazil presents a context of an unprecedented social, political, and environmental crisis, with massive deforestation, extensive fires, and biomass burning altering the biomes, on top of an ongoing necropolitical infodemic and COVID-19 pandemic. In the face of these multiple challenges, this MOOC offers a timely resource for health professionals and communities, encouraging them to address planetary challenges as fundamental health determinants.

Novos desafios epidemiológicos e demográficos demandam novas formas de organizar os sistemas de saúde. O presente ensaio propõe a telessaúde como ferramenta organizativa, capaz de suavizar o triângulo de ferro da atenção à saúde e de facilitar a busca pelo triple aim, pelo seu potencial de aumento do acesso e qualidade com redução de custo. A integração da telessaúde ao processo de referência e transição entre serviços assistenciais aumenta a resolutividade da Atenção Primária à Saúde (APS), favorece a coordenação do cuidado, promove adesão terapêutica, diminui reinternações e estimula a prevenção quaternária. Este ensaio propõe a telessaúde como metasserviço que confere densidade tecnológica à APS e permite que ela se torne coordenadora efetiva do cuidado, passando a organizar o fluxo de informações, pessoas e insumos. Frente às inovações propostas, é essencial avaliar o impacto de ações já existentes de telessaúde para viabilizar a sua aplicação como metasserviço de saúde.

Objective: This study aimed to establish the utility values of different health states associated with diabetic retinopathy in a Brazilian sample to provide input to model-based economic evaluations. Subjects and methods: This cross-sectional study was performed in a sample of patients with type 2 diabetes mellitus (T2D) who underwent teleophthalmology screening at a primary care service from 2014 to 2016. Five diabetic retinopathy health states were defined: absent, non-sight-threatening, sight-threatening, and bilateral blindness. Utility values were estimated using the Brazilian EuroQol five dimensions (EQ-5D) tariffs. Descriptive statistics were calculated. Analysis of covariance was performed to adjust the utility values for potential confounders. Results: The study included 206 patients. The mean ( standard deviation [SD]) utility value was 0.765 0.19 (95% confidence interval [CI], 0.740-0.790). The adjusted mean utility value was 0.748 (95% CI, 0.698-0.798) in patients without diabetic retinopathy, 0.752 (95% CI, 0.679-0.825) in those with non-sight-threatening state, 0.628 (95% CI, 0.521-0.736) in those with sight-threatening state, and 0.355 (95% CI, 0.105-0.606) in those with bilateral blindness. A significant utility decrement was found between patients without diabetic retinopathy and those with a sight-threatening health state (0.748 vs. 0.628, respectively, p = 0.04). Conclusions: The findings suggest that a later diabetic retinopathy health state is associated with a decrement in utility value compared with the absence of retinopathy in patients with T2D. The results may be useful as preliminary input to model-based economic evaluations. Further research is needed to investigate the impact of diabetic retinopathy on health-related quality of life in a sample more representative of the Brazilian population.

Non-compliance in heart failure (HF) patients is one of the factors leading to hospital readmissions. Under this perspective, a study was carried out in a university hospital in Rio Grande do Sul, Brazil to describe the compliance with pharmacological and non-pharmacological treatments of patients admitted with decompensated HF, relating the compliance to the number of hospital admissions and readmissions during a years period. The pharmacological compliance was measured through Morisky scale and the non-pharmacological compliance was measured through a previously validated questionnaire. The sample was composed of 252 patients, median age 63 +/- 13, 151 (60%) male. For the pharmacological compliance, 118 (47%) patients demonstrated high compliance, and 45 (18%) adhered to non-pharmacological treatment. There was no relation found between treatment compliance (pharmacological or non-pharmacological) and readmissions. Patients who had been treated for HF, had knowledge about non-pharmacological care and were able to identify congestion symptoms demonstrated high compliance.

OBJECTIVE: To contrast how Brazil's and Canada's different jurisdictional and judicial realities have led to different types of telemedicine and how further scale and improvement can be achieved. COMPOSITION OF THE COMMITTEE: A subgroup of the Besrour Centre of the College of Family Physicians of Canada and Canadian telemedicine experts developed connections with colleagues in Porto Alegre, Brazil, and collaborated to undertake a between-country comparison of their respective telemedicine programs. METHODS: Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of telemedicine in Canada and Brazil. REPORT: Both Brazil and Canada share expansive geographies, creating substantial barriers to health for rural patients. Telemedicine is an important part of a universal health system. Both countries have achieved telemedicine programs that have scaled up across large regions and are showing important effects on health care costs and outcomes. However, each system is unique in design and implementation and faces unique challenges for further scale and improvement. Addressing regional differences, the normalization of telemedicine, and potential alignment of telemedicine and artificial intelligence technologies for health care are seen as promising approaches to scaling up and improving telemedicine in both countries.

A teleconsulta, uma ação de telessaúde, apesar de ser regulamentada em vários países, ainda não é permitida no Brasil. O presente texto explora a situação da teleconsulta na América do Norte, na Europa e em outros países, fazendo um paralelo com a situação nacional dentro da medicina e de outras profissões da saúde. Ao final, por meio do referencial utilizado, é construída uma argumentação de forma a assumir um posicionamento favorável à regulamentação da teleconsulta no país.

BACKGROUND: In healthcare systems in general, access to diabetic retinopathy (DR) screening is limited. Artificial intelligence has the potential to increase care delivery. Therefore, we trained and evaluated the diagnostic accuracy of a machine learning algorithm for automated detection of DR. METHODS: We included color fundus photographs from individuals from 4 databases (primary and specialized care settings), excluding uninterpretable images. The datasets consist of images from Brazilian patients, which differs from previous work. This modification allows for a more tailored application of the model to Brazilian patients, ensuring that the nuances and characteristics of this specific population are adequately captured. The sample was fractionated in training (70%) and testing (30%) samples. A convolutional neural network was trained for image classification. The reference test was the combined decision from three ophthalmologists. The sensitivity, specificity, and area under the ROC curve of the algorithm for detecting referable DR (moderate non-proliferative DR; severe non-proliferative DR; proliferative DR and/or clinically significant macular edema) were estimated. RESULTS: A total of 15,816 images (4590 patients) were included. The overall prevalence of any degree of DR was 26.5%. Compared with human evaluators (manual method of diagnosing DR performed by an ophthalmologist), the deep learning algorithm achieved an area under the ROC curve of 0.98 (95% CI 0.97-0.98), with a specificity of 94.6% (95% CI 93.8-95.3) and a sensitivity of 93.5% (95% CI 92.2-94.9) at the point of greatest efficiency to detect referable DR. CONCLUSIONS: A large database showed that this deep learning algorithm was accurate in detecting referable DR. This finding aids to universal healthcare systems like Brazil, optimizing screening processes and can serve as a tool for improving DR screening, making it more agile and expanding care access.

PURPOSE: To evaluate the quality of referrals for a first Rheumatology consultation at a tertiary care center in a southern Brazilian capital (Porto Alegre, RS), having as background findings from a similar survey performed in 2007/2008. Since then, our state has implemented referral protocols and a triage system with teleconsulting support exclusively for referrals from locations outside the capital, permitting a comparison between patients screened and not screened by the new system. METHODS: Physicians of the Rheumatology Service at Hospital Nossa Senhora da Conceição prospectively collected information regarding first visits over a 6-month period (Oct 2017 to March 2018). We recorded demographic characteristics, diagnostic hypotheses, date of referral, and the municipality of origin (within the state of Rio Grande do Sul). We considered adequate referrals from primary health care when a systemic autoimmune inflammatory disease (SIRD) was suspected at first evaluation by the attending rheumatologist. RESULTS: Three hundred fifty-seven patients/appointments were eligible for analysis (193 from the capital and 164 from small and medium towns). In 2007/2008, suspected SIRD occurred in 76/260 (29.2%) and 73/222 (32.9%) among patients from the capital and outside counties, respectively (P = 0.387). In 2017/2018, suspected SIRD occurred in 75/193 (38.9%) and 111/164 (67.7%) in patients from the capital and outside counties, respectively (difference: 28.8, 95% CI: 19.0 to 38.9, P < 0.001), indicating a marked improvement in referrals submitted to the new triage system. CONCLUSION: The quality of Rheumatology referrals in our state improved over the 10-year interval under study, particularly among patients from locations submitted to referral protocols and teleconsulting support.

BACKGROUND: Oral health in childhood is a major problem for global public health. In Brazil, the prevalence of childhood tooth decay varies from 12% to 46%. Dental care treatment in Brazil is almost the exclusive responsibility of primary healthcare (PHC). Therefore, it is essential these professionals are prepared to conduct restorative, endodontic, and exodontic treatments and preventive care in children. INTRODUCTION: Children make up a large proportion of the population in territories requiring advanced dental care provided by PHC in Brazil. To care for these patients, it is necessary to have both manual dexterity and technical knowledge of pediatric dentistry. Accordingly, this study aimed to develop a distance course on pediatric dentistry. MATERIALS AND METHODS: A pretest questionnaire consisting of 15 questions was used to assess initial dental knowledge of participants. After completion of a five-module course, participants retook the same initial dental knowledge questionnaire (post-test). Descriptive statistic and paired t test, one-way analysis of variance, and Pearson and Spearman correlation were used, and a significance level of 5% was set. RESULTS: The majority of participants completing the five-module course were women who earned specialty degrees beyond undergraduate studies and currently worked in PHC (>5 years). Participant performance on the dental knowledge questionnaire after completion of the five-module course improved pre- to post-test. CONCLUSIONS: These data suggest that completion of a distance course on pediatric dentistry can be an effective tool for improving knowledge of pediatric dentistry in PHC professionals.

Importance: Integrating artificial intelligence (AI) technologies into gatekeeping holds significant potential, as it efficiently handles repetitive tasks and can process large amounts of information quickly. Objective: To develop and assess the accuracy of an AI model that enhances the gatekeeping process for referrals to specialized care. Design, Setting, and Participants: This diagnostic study comprised referrals from primary care to endocrinology, gastroenterology, proctology, rheumatology, and urology from a retrospective administrative database of patients in Brazil between June 2016 and April 2019. Analysis was performed between December 2022 and July 2024. Main Outcomes and Measures: The algorithm's development and testing comprised 2 stages. Multiple AI models were initially evaluated to train and test the algorithm for categorizing referrals as authorizing or requiring additional information. Subsequently, the model's performance was assessed against an independent set of referrals. Additionally, the current (human) evaluations of gatekeepers were evaluated against the standard. The reference standard was the consensus of 2 physicians with extensive experience. Accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC-ROC) were assessed. Results: The electronic system retrieved 45 039 eligible referrals for the development stage (mean [SD] patient age, 51.9 [15.8] years; 25 458 women [56.5%]). An algorithm utilizing word embeddings and a neural network proved the most effective. In the second phase, 1750 referrals (350 for each specialty) showed a 32% authorization rate according to the reference standard. The AI model achieved an overall accuracy of 0.716 (95% IC, 0.694-0.737), with a sensitivity of 0.542 (95% CI, 0.501 to 0.582) and specificity of 0.801 (95% CI, 0.777 to 0.822). Regarding individual specialties, rheumatology exhibited the highest accuracy (0.811; 95% IC, 0.767-0.849), while proctology had the lowest (0.649; 95% IC, 0.597-0.697). The overall AUC-ROC was 0.765 (95% IC, 0.742-0.788). When compared against the consensus standard, the AI model had higher accuracy and specificity and lower sensitivity than the current approach. Conclusions and Relevance: In this diagnostic study of referral data, a novel AI model effectively distinguished between referrals that warranted immediate authorization and those that required further information with moderate accuracy; it had higher specificity and lower sensitivity than gatekeepers decisions. Implementing this AI model in the gatekeeping process should combine human judgment and AI support to optimize the referral process.

The dentist plays a crucial role in identifying oral lesions as it is their responsibility to conduct the clinical examination for diagnosing diseases in this anatomical region. Dentists should be able to perform simple oral biopsies when this procedure is necessary. However, several studies point out that dentists lack experience and perceive themselves incapable of performing biopsies. This analytical cross-sectional study aimed to assess participants' experiences and perceptions regarding a continuing education activity focused on the biopsy procedure. The secondary aim was to evaluate their ability to determine when a biopsy is indicated. The sample consisted of 228 individuals: 143 dentists and 85 undergraduate dental students who completed questionnaires related to a lecture held in May/2021, as part of the continuing educational activities of the "Red May" Project. Participants completed two questionnaires: the first assessed their experience and self-confidence in performing oral biopsies, whereas the second evaluated their capacity to define when the biopsy is indicated by means the evaluation of 10 clinical cases. The results reveal no significant difference in the percentage of correct answers between dental students and dentists. Regarding the frequency of performing the biopsy procedure, most respondents (69.7%) reported doing so rarely or never. Furthermore, while 31.6% of the participants stated that they perform biopsies depending on the case, 68.4% prefer to refer patients to specialists, such as professionals in Stomatology/Oral Medicine. These findings highlight limitations in the educational preparation of the study population concerning biopsy procedures, oral lesions, and their management. They also indicate a concerning tendency to overestimate knowledge in this area. Thus, this study emphasizes the importance of continuing education and underscores the need to revise academic curricula and provide complementary education for all dental professionals.

Aims In-depth and updated systematic reviews evaluating telephone calls in type 2 diabetes (T2DM) management are missing. This study aimed to assess the effect of this intervention on glycemic control in T2DM patients when compared with usual care. Methods We systematically searched for randomized controlled trials (RCT) on T2DM using Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and LILACS, up to March 2021. The Risk of Bias 2.0 (Rob 2.0) tool and GRADE were used for the quality evaluation. The intervention effect was estimated by the change in glycated hemoglobin (HbA1c). PROSPERO registry CRD42020204519. Results 3545 references were reviewed and 32 were included (8598 patients). Telephone calls, all approaching education, improved HbA1c by 0.33% [95% CI, −0.48% to −0.18%; I 2 = 78%; p < 0.0001] compared to usual care. A greater improvement was found when the intervention included pharmacologic modification (−0.82%, 95% CI, −1.42% to −0.22%; I 2 = 92%) and when it was applied by nurses (−0.53%, 95% CI, −0.86% to −0.2%; I 2 = 87%). Meta-regression showed no relationship between DM duration and HbA1c changes. Conclusion The telephone call intervention provided a benefit regarding T2DM glycemic control, especially if provided by nurses, or if associated with patient education and pharmacological treatment modification.

Introdução e Objetivo : Verificar quais as possíveis razões que justifiquem o atraso da chegada do paciente com câncer bucal aos setores de maior complexidade de atenção em saúde. Material e Método : O estudo teve como público-alvo cirurgiões-dentistas atuantes em Atenção Primária à Saúde formalmente vinculados ao Projeto TelessaúdeRS (276 potenciais participantes). Foi utilizado um questionário hospedado em software de questionários online, com o link para acesso disponibilizado por correspondência eletrônica e através da homepage do TelessaúdeRS. As respostas foram tabuladas em uma planilha de Excel (Microsoft®). Resultados : Setenta e quatro questionários respondidos (26,8% da amostra inicial); 52,7% relatam não haver Centro de Especialidades Odontológicas para referência na sua Coordenadoria Regional de Saúde; 58,1% consideram como possíveis causas do atraso no diagnóstico de câncer bucal a associação dos fatores: falha do profissional, do paciente, da rede de saúde e falta de informação; em relação à autopercepção de aptidão para rastreamento e diagnóstico de câncer bucal, 71,6% responderam que seriam importantes capacitações. Conclusões : O presente estudo sugere como possíveis razões que justifiquem o atraso da chegada do paciente com câncer bucal aos setores de maior complexidade de atenção em saúde a deficiência da rede de atenção e a necessidade de mais capacitações relacionadas à patologia.

Objetivo: Discutir a associação entre microcefalia e a infecção materna por Zika Vírus. A microcefalia é o tamanho da cabeça menor do que o esperado em comparação com bebês do mesmo sexo e idade. Entre as causas conhecidas, estão as infecções congênitas. O aumento de casos entre outubro e novembro de 2015 no nordeste brasileiro, que coincidiu com a presença da circulação de novo vírus no país, em maio do mesmo ano, criou a hipótese de associação entre a microcefalia e a infecção materna durante a gravidez. O Zika Vírus é um arbovírus similar ao da Febre Amarela e da Dengue, transmitido principalmente através da picada do Aedes aegypti. A provável transmissão por relação sexual e transfusão de sangue, além de outros vetores como o Aedes albopictus e possivelmente até o pernilongo (Culex sp) aumentam a necessidade de cuidados preventivos em relação à infecção. O exame para detecção viral idealmente é realizado até o quinto dia após o início dos sintomas. Sorologias ainda não são amplamente disponíveis no Brasil. Métodos: Revisão narrativa da literatura. Conclusão: A associação entre casos de microcefalia e o Zika Vírus é embasada nos relatos de relação têmporo-espacial, padrão de alterações neurológicas associado a malformações congênitas, presença do RNA viral no líquido amniótico e nos tecidos de fetos. As respostas definitivas de causalidade serão possíveis após pesquisas e disponibilidade de exames laboratoriais. As evidências até agora apoiam fortemente esta hipótese e todas as medidas preventivas devem ser estimuladas.

Objective: The mere dissemination of standard care recommendations has been insufficient to improve clinical results in patients with asthma. The objective of the present study was to evaluate the clinical effectiveness of a multifaceted asthma distance education for primary care providers. Methods: Cluster randomized controlled trial. Full primary care teams were included if they had access to telehealth support and free basic asthma treatment. Before randomization, selected teams indicated asthma patients between 5-45 years old for inclusion. The intervention group received three interactive online sessions, printed educational material, reminders, booklet for patients, and frequent stimulus to use consulting services. The control group received no intervention. Symptomfree days per two weeks was the primary result. Controlled asthma, unscheduled asthma doctor visits, and preventive inhaled corticosteroid use were the secondary results. Six months after intervention, the results were compared with baseline data using generalized estimating equations for repeated measures and clustering effect. Results: Were enrolled 71 primary care teams and 443 individuals. Most patients (60.3%) were female, and 44% were younger than 12 years old. The attendance of interactive sessions by the teams was 50%. The odds ratio (OR) for additional symptom-free day was 1.31 (95%CI 0.61-2.82; p=0.49). For the secondary results, the results were: controlled asthma OR 1.29 (95%CI 0.89-1.87; p=0.18); unscheduled asthma doctor visits OR 0.81 (95%CI 0.60-1.10; p=0.17); and preventive inhaled corticosteroid use OR 1.02 (95%CI 0.71-1.47; p=0.91). Conclusions: Multifaceted distance education in asthma care for primary care providers was not effective to improve patients’ results. Telemedicine needs to deal with significant obstacles in professional education. ClinicalTrials.gov registry: NCT01595971.

BACKGROUND: Hypertension is a growing problem worldwide, markedly in low- and middle-income countries, where the rate of control slightly decreased. The overall prevalence of hypertension in Brazil is 28.7% among adult individuals and 68.9% in the population aged 60 years and older, and less than a third of patients have controlled blood pressure (BP). The use of technologies-mobile phones and the internet-to implement interventions to reduce blood pressure can minimize costs and diminish cardiovascular risk. Interventions through text messaging and electronic BP monitoring present divergent results. OBJECTIVE: This trial evaluates the effectiveness of interventions-personalized messages and telemonitoring of BP-to reduce systolic BP and improve lifestyle compared to the usual care of patients with hypertension (control group). METHODS: This factorial randomized controlled trial enrolls individuals aged 30 to 75 years who have a mobile phone and internet access with the diagnosis of hypertension under drug treatment with up to 2 medications and uncontrolled BP. Eligible participants should have both increased office BP and 24-hour BP with ambulatory BP monitoring. Participants with severe hypertension (systolic BP ≥180 or diastolic BP ≥110 mm Hg), life threatening conditions, low life expectancy, recent major cardiovascular event (last 6 months), other indications for the use of antihypertensive medication, diagnosis of secondary hypertension, pregnant or lactating women, or those unable to understand the interventions are excluded. Participants are randomly allocate to 1 of 4 experimental arms: (1) Telemonitoring of blood pressure (TELEM) group: receives an automatic oscillometric device to measure BP, (2) telemonitoring by text message (TELEMEV) group: receives personalized, standardized text messages to stimulate lifestyle changes and adhere with BP-lowering medication, (3) TELEM-TELEMEV group: receives both interventions, and (4) control group: receives usual clinical treatment (UCT). Data collection is performed in a clinical research center located in a referent hospital. The primary outcomes are reduction of systolic BP assessed by 24-hour ambulatory BP monitoring (primary outcome) and change of lifestyle (based on dietary approaches to stop hypertension (DASH)-type diet, sodium restriction, weight loss or control, increase of physical activity). RESULTS: This study was funded by two Brazilian agencies: the National Council for Scientific and Technological Development and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul. Enrollment was completed at the end of 2017 (N=231), the follow-up is ongoing, and data analysis is expected to begin in early 2019. A reduction of 24-hour systolic BP of approximately 8.8 [SD 13.1] mm Hg for participants in the BP monitoring group versus 3.4 [SD 11.6] mm Hg in the UCT group is expected. A similar reduction in the text messaging group is expected. CONCLUSIONS: The use of mobile technologies connected to the internet through mobile phones promotes time optimization, cost reduction, and better use of public health resources. However, it has not been established whether simple interventions such as text messaging are superior to electronic BP monitoring and whether both outperform conventional counseling. TRIAL REGISTRATION: ClinicalTrials.gov NCT03005470; https://clinicaltrials.gov/ct2/show/NCT03005470 (Archived by WebCite at http://www.webcitation.org/70AoANESu). Plataforma Brasil CAAE 31423214.0.0000.5327. REGISTERED REPORT IDENTIFIER: RR1-10.2196/9619.

Introduction Minimizing healthcare systems’ resource footprints is crucial. To expand this focus, our objective was to assess the carbon emission reductions achievable through the introduction of telemedicine services at a prominent Brazilian tertiary hospital. Methods This cross-section study included all patients who had remotely held appointments in a Brazilian tertiary hospital. The primary outcome was carbon emissions. The estimated carbon emissions were first calculated based on the distance between the hospital and the patient's home address. After, the calculated distance was multiplied by the amount of carbon estimated according to the type of transport used. Results The study included 28,244 patients undergoing 52,878 remote appointments between March and December 2020, residing in 417 municipalities in Rio Grande do Sul and 80 towns in other Brazilian states. The total sum of distances and carbon gas reduction saved with the implementation of remote consultations amounted to 805,252.00 km and 939,641.94 kg of CO2 emissions, respectively. Discussion Telemedicine initiatives implemented in tertiary hospitals for less than a year result in a large amount of greenhouse gas emissions saved. Telemedicine emerges as a promising strategy with significant potential to mitigate the impact on planetary health.