Perfil dos pacientes em cuidados paliativos atendidos pela fisioterapia na assistência domiciliar de um hospital oncológico / Profile of patients in palliative care treated by physiotherapy in home care at an oncology hospital

O envelhecimento populacional e o aumento das doenças crônicas não transmissíveis, dentre elas o câncer, têm exigido a incorporação dos Cuidados Paliativos (CP) às redes assistenciais em saúde. Assim, o objetivo deste estudo foi descrever o perfil dos pacientes em cuidados paliativos atendidos pela fisioterapia na assistência domiciliar de um hospital de referência em oncologia. Trata-se de um estudo transversal, quantitativo, retrospectivo e descritivo, da análise de 76 prontuários de pacientes assistidos pela fisioterapia na assistência domiciliar do hospital entre agosto de 2018 a agosto de 2019. A maioria dos pacientes era do sexo feminino (n=51, 67,11%), da raça/cor negra (n=46, 60,52%), na faixa etária de 60 a 80 anos (n=36, 47,37%). O câncer de mama (n= 22, 28,95%), pulmão (n=11, 14,47%) e próstata (n=8, 10,53%) foram os mais frequentes e a maioria apresentava progressão da doença. Por fim, o principal motivo para o acompanhamento pela fisioterapia estava relacionado a funcionalidade e mobilidade. A caracterização dos pacientes que necessitam de atendimento fisioterapêutico na assistência domiciliar de um hospital de referência em oncologia faz-se necessário para melhor planejamento do cuidado pois tais informações podem direcionar possibilidades terapêuticas, permitindo maior efetividade no tratamento.

Population aging and the increase in chronic non-communicable diseases, including cancer, have required the incorporation of Palliative Care (PC) into health care networks. Thus, the objective of this study was to describe the profile of patients in palliative care treated by physiotherapy in home care at an oncology reference hospital. This is a cross-sectional, quantitative, retrospective and descriptive study, analyzing 76 medical records of patients assisted by physiotherapy in the hospital's home care between August 2018 and August 2019. The majority of patients were female (n=51, 67.11%), of black race/color (n=46, 60.52%), aged between 60 and 80 years (n=36, 47, 37%). Breast (n=22, 28.95%), lung (n=11, 14.47%) and prostate (n=8, 10.53%) cancers were the most common and the majority showed disease progression. Finally, the main reason for physiotherapy monitoring was related to functionality and mobility. The characterization of patients who require physiotherapeutic care in home care at an oncology reference hospital is necessary for better care planning as such information can direct therapeutic possibilities, allowing greater effectiveness in treatment.

BREAST-Q Translation and Linguistic Validation to European Portuguese.

INTRODUCTION: Evaluating the impact of surgical treatment on health-related quality of life of breast cancer patients has become increasingly relevant, particularly for reconstructive procedures. The BREAST-Q consists of a broadly used patient-reported outcome measure to assess the impact of breast surgery on the health-related quality of life of these patients. The aim of this study was to translate and linguistically validate the BREAST-Q reconstructive module to European Portuguese. MATERIAL AND METHODS: The translation and linguistic validation process was based on the International Society for Pharmacoeconomics and Outcomes Research guidelines and started after obtaining permission from the original authors (developers). It involved two direct English to European Portuguese translations and a back translation, maintaining conceptual and cultural equivalence, an expert panel discussion, cognitive interviews with five patients and a final consensus. RESULTS: The forward translations led to the revision of three conceptually distinct items. The backward translation resulted in predominantly wording discrepancies and the three conceptual disparities noted in the back translation were revised on a consensual version. All material was openly discussed with the original authors and in an expert panel meeting. One item was changed after the cognitive interviews. The final consensual version was obtained. CONCLUSION: This stepwise approach allowed to linguistically validate the BREAST-Q reconstructive module to European Portuguese so that it can be used in the Portuguese population. Additionally, the applied methodology may serve to support and guide other instruments for linguistic validation.

Introdução: A avaliação do impacto do tratamento cirúrgico na qualidade de vida relacionada com a saúde de doentes com cancro da mama é cada vez mais relevante, particularmente para procedimentos reconstrutivos. O questionário BREAST-Q é um instrumento de avaliação de resultados reportados pelos doentes amplamente utilizado para avaliar o impacto da cirurgia mamária na qualidade de vida relacionada com a saúde. O objetivo deste estudo foi a tradução e validação linguística do módulo reconstrutivo do questionário BREAST-Q para o Português Europeu. Material e Métodos: O processo de tradução e validação linguística foi baseado nas normas da International Society for Pharmacoeconomics and Outcomes Research. Iniciou-se pela obtenção da autorização dos autores para realizar a tradução. Foram feitas duas traduções diretas independentes de inglês para português europeu e uma tradução reversa, mantendo a equivalência conceptual e cultural, discussão por um painel de especialistas, entrevistas cognitivas a cinco doentes e um consenso final. Resultados: As traduções diretas levaram à revisão de três itens nos quais foram encontradas diferenças conceptuais. A tradução reversa resultou em diferenças predominantemente literárias. Apenas um item foi alterado após as entrevistas cognitivas. Todo o material registado durante o processo de tradução foi discutido abertamente com os autores originais e com o painel de especialistas, culminando numa versão final consensual. Conclusão: Esta abordagem estruturada permitiu validar linguisticamente o módulo reconstrutivo do BREAST-Q para português europeu, permitindo a sua utilização na população portuguesa. Adicionalmente, a metodologia aplicada poderá servir de suporte e guia para outras validações linguísticas.

Identification of parathyroid glands: anatomical study and surgical implications.

While performing thyroid surgery, the unintentional lesion of parathyroid glands and laryngeal nerves results in a profound alteration in patient's quality of life. To minimize thyroid surgery morbidity, the surgeon must have an in-depth knowledge of the thyroid gland morphology and its anatomical relations in the anterior compartment of the neck. This work intended to simulate total thyroidectomies using cadaver parts and isolate fragments that may correspond to parathyroid glands. The thyroid glands and "eventual" parathyroid glands were then submitted to histological study. Ninety-two cadaver parts were used for macroscopic dissection. A total of 242 fragments were isolated, 154 of which were confirmed through histological study to be parathyroid glands. In 36 cases, all "eventual" parathyroid glands isolated during dissection were confirmed through histological verification. In 40 cases, some glands were confirmed. In 16 cases, none of the "eventual" parathyroid glands was confirmed. The 92 thyroid glands isolated during dissection were also submitted to histological study. In 21 thyroid glands, 16 parathyroid glands were identified in the histological cuts: 8 sub-capsular, 8 extra-capsular, 6 intra-thyroidal. There was no statistical difference between the dimensions of the parathyroid glands. Parathyroid gland identification and preservation are sometimes a challenge during thyroid surgery, difficulty that has been demonstrated during dissection of cadaver parts.

Toxic epidermal necrolysis: the experience of Coimbra's burn unit.

INTRODUCTION: Toxic Epidermal Necrolysis is a drug-induced life-threatening systemic disease, characterized by extensive dermoepidermal detachment and mucositis. At least 95% of cases are believed to be drug-induced. SCORTEN is a scoring system used to stratify severity and predict mortality. Treatment demands immediate withdrawal of the causative drug and early transfer to a burn centre for specific and intensive care. MATERIAL AND METHODS: Authors have performed a retrospective study of 21 consecutive patients with SJS/ Toxic Epidermal Necrolysis admitted in the Burn Centre of Coimbra's University Hospital, between January 1999 and December 2010, and have compared the actual mortality rate with that predicted by SCORTEN, in order to assess the predictive capacity of SCORTEN. Analysis of results and treatment options were conducted. Data were analysed in SPSS 17.0®. RESULTS: Thirteen females (61.9%) and 8 males (38.1%) were treated, mean age 55.6 ± 23.7 years and with a mean of 51% ± 22.4% epidermal detachment. The overall observed mortality rate was 47.6% and the one predicted by SCORTEN 42.2%. Immediate withdrawal of the causative drug and early transfer of the patient to our burn centre were the basis of treatment. CONCLUSION: Toxic Epidermal Necrolysis pathophysiology remains to be clarified and no specific treatment has unequivocally proven to be effective. SCORTEN seems to be an accurate scoring system for estimation of mortality rate.

Introdução: A necrólise epidérmica tóxica é uma doença sistémica grave, potencialmente fatal, caracterizada por febre, descolamento dermoepidérmico extenso e erosão das mucosas. Em 95% dos casos, consiste numa reacção idiossincrática à administração de fármacos. A gravidade da doença é estratificada através da aplicação de uma escala de previsão da mortalidade, denominada SCORTEN. O tratamento obriga à suspensão imediata do fármaco suspeito e à referenciação do doente a uma Unidade de Queimados capaz de assegurar um tratamento específico.Material e Métodos: Estudo retrospectivo de 21 doentes internados com SJS/ Necrólise Epidérmica Tóxica na Unidade de Queimados dos Hospitais da Universidade de Coimbra, entre Janeiro de 1999 e Dezembro de 2010 com avaliação dos resultados e das opções terapêuticas. Comparação das taxas de mortalidade desses doentes com as previstas pelo SCORTEN, no sentido de avaliar a capacidade preditiva desta escala. Os dados foram analisados no programa SPSS 17.0®.Resultados: Foram internados 13 doentes do sexo feminino (61,9%) e 8 do sexo masculino (38,1%), com média de idades de 55,6 ± 23,7 anos e com 51% ± 22,4% de superfície corporal atingida. A taxa de mortalidade dos doentes internados foi de 47,6% e a prevista pelo SCORTEN foi de 42,2%. %. O tratamento instituído centrou-se na remoção imediata do fármaco suspeito e na referenciação precoce do doente para a unidade.Conclusão: A fisiopatologia da necrólise epidérmica tóxica não está completamente esclarecida, pelo que não existe actualmente uma terapêutica específica, comprovadamente eficaz. A utilização do SCORTEN permite uma previsão adequada da taxa de mortalidade nestes doentes.

Madelung disease: a not-so-rare disorder.

Madelung disease is characterized by the formation of diffuse uncapsulated lipomata in different body areas and is responsible for severe cosmetic deformities. Although it is described as a rare entity in the literature, at our department it is seen quite often. The authors make a revision of the literature on this disease and then report on the cases of Madelung disease operated between January 2003 and October 2008 at the Plastic surgery department of Coimbra University Hospital.

Induction of multifunctional human immunodeficiency virus type 1 (HIV-1)-specific T cells capable of proliferation in healthy subjects by using a prime-boost regimen of DNA- and modified vaccinia virus Ankara-vectored vaccines expressing HIV-1 Gag coupled to CD8+ T-cell epitopes.

A double-blind randomized phase I trial was conducted in human immunodeficiency virus type 1 (HIV-1)-negative subjects receiving vaccines vectored by plasmid DNA and modified vaccinia virus Ankara (MVA) expressing HIV-1 p24/p17 gag linked to a string of CD8(+) T-cell epitopes. The trial had two groups. One group received either two doses of MVA.HIVA (2x MVA.HIVA) (n=8) or two doses of placebo (2x placebo) (n=4). The second group received 2x pTHr.HIVA followed by one dose of MVA.HIVA (n=8) or 3x placebo (n=4). In the pTHr.HIVA-MVA.HIVA group, HIV-1-specific T-cell responses peaked 1 week after MVA.HIVA vaccination in both ex vivo gamma interferon (IFN-gamma) ELISPOT (group mean, 210 spot-forming cells/10(6) cells) and proliferation (group mean stimulation index, 37), with assays detecting positive responses in four out of eight and five out of eight subjects, respectively. No HIV-1-specific T-cell responses were detected in either assay in the 2x MVA.HIVA group or subjects receiving placebo. Using a highly sensitive and reproducible cultured IFN-gamma ELISPOT assay, positive responses mainly mediated by CD4(+) T cells were detected in eight out of eight vaccinees in the pTHr.HIVA-MVA.HIVA group and four out of eight vaccinees in the 2x MVA.HIVA group. Importantly, no false-positive responses were detected in the eight subjects receiving placebo. Of the 12 responders, 11 developed responses to previously identified immunodominant CD4(+) T-cell epitopes, with 6 volunteers having responses to more than one epitope. Five out of 12 responders also developed CD8(+) T-cell responses to the epitope string. Induced T cells produced a variety of anti-viral cytokines, including tumor necrosis factor alpha and macrophage inflammatory protein 1 beta. These data demonstrate that prime-boost vaccination with recombinant DNA and MVA vectors can induce multifunctional HIV-1-specific T cells in the majority of vaccinees.

CD8+ T cell responses to human immunodeficiency viruses type 2 (HIV-2) and type 1 (HIV-1) gag proteins are distinguishable by magnitude and breadth but not cellular phenotype.

The mechanisms underlying the relatively slow progression of human immunodeficiency virus type 2 (HIV-2) compared with HIV-1 infection are undefined and could be a result of more effective immune responses. We used HIV-2 and HIV-1 IFN-gamma enzyme-linked immunospot assays to evaluate CD8(+) T cell responses in antiretroviral-naive HIV-2- ('HIV-2(+)') and HIV-1-infected ('HIV-1(+)') individuals. Gag-specific responses were detected in the majority of HIV-2(+) and HIV-1(+) subjects. Overlapping gag peptide analysis indicated a significantly greater magnitude and breadth of responses in the HIV-1(+) cohort, and this difference was attributable to low responses in HIV-2(+) subjects with undetectable viral load (medians 2107 and 512 spot-forming units per 10(6) PBMC, respectively, p=0.007). We investigated the phenotype of viral epitope-specific CD8(+) T cells identified with HLA-B53- and HLA-B58-peptide tetramers (8 HIV-2(+), 11 HIV-1(+) subjects). HIV-2-specific CD8(+) T cells were predominantly CD27(+) CD45RA(-), and only a minority expressed perforin. The limited breadth and low frequency of CD8(+) T cell responses to HIV-2 gag in aviremic HIV-2(+) subjects suggests that these responses reflect antigen load in plasma, as is the case in HIV-1 infection. Immune control of HIV-2 does not appear to be related to the frequency of perforin-expressing virus-specific CD8(+) T cells.

Parenteral exposure to high HIV viremia leads to virus-specific T cell priming without evidence of infection.

Previous studies on CTL responses in HIV-exposed uninfected individuals assumed that the patients were exposed to replicating HIV, but the possibility that the immune responses detected were primed by exposure to a defective virus or viral antigen could not be excluded. Epidemiological and laboratory analysis of a nosocomial outbreak of acute hepatitis B unequivocally allowed the identification of an HIV-1- and HBV-co-infected patient with high plasma levels of both viruses, as the source case of the epidemics. This clinical setting provided a natural model for testing the HIV-specific T cell response in patients exposed to blood from a patient with highly replicating HIV. Parenteral exposure to both viruses led to acute hepatitis B in five subjects without evidence of HIV-1 infection. Cryopreserved lymphocytes derived from three exposed patients were tested ex vivo in an ELISPOT assay for IFN-gamma release upon stimulation with peptides from structural and non-structural HIV proteins; one of the patients was also tested with four HLA/class I tetramers. Circulating HIV-specific CD8 cells were detected by tetramer staining and a high frequency of T cells were able to release IFN-gamma upon stimulation with HIV peptides, showing in vivo T cell priming by HIV. These results unequivocally demonstrate a HIV-specific cell-mediated immune response in the absence of infection after exposure to highly replicating HIV.