Avaliação do Conhecimento em Cuidados Paliativos em Estudantes durante o Curso de Medicina / Evaluation of Medical Students' Knowledge of Palliative Care

RESUMO Introdução É crescente a necessidade de uso de cuidados paliativos (e de suporte em cuidados) nas áreas de saúde, em especial na Medicina. Isto acontece devido ao envelhecimento populacional e ao aumento da prevalência das doenças crônicas não transmissíveis, especialmente câncer metastático e demência avançada. Assim, é muito importante iniciar o processo de ensino-aprendizagem em cuidados paliativos já no curso de graduação em Medicina. Objetivo Avaliar os conhecimentos em cuidados paliativos (CCP)em alunos do curso de Medicina da Escola Superior de Ciências da Saúde (Brasília, DF), bem como averiguar se há ganho de CCP entre os alunos da primeira, quarta e sexta séries. Método Realizou-se um estudo transversal com aplicação de questionário anônimo, com perguntas sobre idade, gênero e mais 19 perguntas sobre CCP. Tais questionários foram aplicados separadamente aos alunos da primeira, quarta e sexta séries do curso de Medicina. Foi usado o teste de Kolmogorov-Smirnov (análise de normalidade). Já o teste de Kruskal-Wallis comparou os três grupos (primeira, quarta e sexta séries), e, caso houvesse diferença com significância estatística, a análise post hoc seria realizada com o teste de Mann-Whitney com correção de Bonferroni (valor de p significativo se <0,016).Resultados: Participaram do estudo 193 estudantes (taxa de inclusão:76,8%;IC95%:71,0%-81,8%), com idades de 23,6±4,3 anos, sendo 100 mulheres (51,8%). Os CCP baseados no número de respostas consideradas corretas por aluno na primeira, quarta e sexta séries foram, em mediana (interquartil), 4,00(2,00-5,00), 10,00(9,00-12,75) e 12,00(10,25-14,00), respectivamente (p< 0,001). Quando comparadas diretamente a primeira com a quarta série, e a primeira com a sexta série, a diferença estatística persiste (p<0,001 e p<0,001, respectivamente); já a comparação entre quarta e sexta séries não demonstra diferença estatística significativa (p:0,041). Conclusão O CCP entre os alunos não é bom, e o ganho de CCP entre a quarta e a sexta série não apresentou significância estatística. Isto denota a necessidade de melhorar o processo de ensino-aprendizagem em cuidados paliativos, principalmente nos cenários do internato.

ABSTRACT Background There is a growing need to use palliative care (and support care) in health areas, particularly in Medicine. This is due to an aging population and the increased prevalence of chronic non-communicable diseases, especially metastatic cancer and advanced dementia. Thus, it is very important to start the teaching-learning process in palliative care during undergraduate medical training. Purpose To evaluate: (1) knowledge in palliative care (KPC) among medical students at the Escola Superior de Ciências da Saúde medical school (Brasília, DF), and (2) the gain in KPC among first, fourth and sixth-year students. Method A cross-sectional study involved the application of an anonymous questionnaire with questions about age, gender, and 19 questions about KPC. These questionnaires were applied separately to the students. The Kolmogorov-Smirnov test was applied. Thereafter, the Kruskal-Wallis test compared the 3 groups (first, fourth and sixth year students), and when any statistically significant difference was verified, post hoc analysis was performed using the Mann-Whitney test with Bonferroni correction (p < 0.016).Results: The study included 193 students (inclusion rate: 76.8%; 95%CI: 71.0%-81.8%), 23.6±4.3 years-old, 100 women (51.8%). The median KPC(interquartile) scores based on the number of correct responses per student of the first, fourth and sixth year of the course were: 4.00(2.00-5.00), 10.00(9.00-12.75), 12.00(10.25-14.00), respectively (p <0.001). When directly comparing the first and fourth year students, and the first and sixth year students, the statistical difference persists (p <0.001 and p <0.001, respectively); but the analysis between fourth and sixth year students shows no statistical difference (p=0.041). Conclusion KPC among our students is limited, and KPC gain between the fourth and sixth years of study was not statistically significant. This shows the need to improve the process of teaching and learning in palliative care, especially in internship scenarios.

Aspectos funcionais das doenças pulmonares fibrosantes / Functional features of fibrotic lung diseases

O objetivo do presente estudo foi avaliar as alterações encontradas na prova de função pulmonar completa, bem como no teste de caminhada de seis minutos, relacionando também a importância dos aspectos funcionais no diagnóstico, na avaliação de resposta ao tratamento e no prognóstico das doenças pulmonares fibrosantes. Assim, nas doenças pulmonares fibrosantes com padrão obstrutivo na prova de função pulmonar completa, deve-se pensar em sarcoidose, linfangioleiomiomatose, pneumonite de hipersensibilidade, histiocitose de células de Langerhans, bronquiolite constritiva e pneumonia intersticial idiopática combinada com enfisema pulmonar. Já na avaliação de resposta ao tratamento, considera-se como má resposta ao tratamento a queda da CVF ≥ 10% e da DLCO ≥ 20%. Em relação ao prognóstico, os pacientes com critérios de má resposta ao tratamento e/ou SpO2≤ 88% no teste de caminhada de seis minutos apresentam uma pior sobrevida.

Lung cyst: an unusual manifestation of Niemann-Pick disease.

Niemann-Pick disease is a rare inherited autosomal recessive disorder, currently classified into six subtypes and characterized by the intracellular accumulation of sphingomyelin in the liver, spleen, lungs, bone marrow or brain. The main pulmonary abnormalities described in high-resolution computed tomography (HRCT) of the chest consist of thickening of the interlobular septa and ground-glass opacities. This case report describes a patient with subtype B Niemann-Pick disease characterized by cysts and ground-glass opacities that were detected on HRCT of the chest.

Placental transmogrification of the lung presenting as giant bullae with soft-fatty components.

A 44-year-old man presented with progressive dyspnea and a previous pneumothorax. Chest CT scan showed a mediastinal shift due to giant bullae containing soft tissue and fatty components in the left lower lung lobe, and a right upper lung lobe partially collapsed. The pulmonary function tests revealed forced vital capacity (FVC) 53% (of the predicted) and forced vital capacity in 1s (FEV1) 52%. Then, resection of the lower lobe was performed with intention to prevent other pneumothoraxes and to revert the upper lobe collapse. The pathological examination showed a placental transmogrification of the lung (PTL). One month after the surgery, the patient was asymptomatic, the pulmonary function tests normalized and the upper lobe was well expanded. In conclusion, we described the first CT finding of soft tissue and fatty components within the PTL-related bullae, and the PTL should be considered in the differential diagnosis of pulmonary lesions with soft-fatty and air components.

The effect of massive weight loss on pulmonary function of morbid obese patients.

STUDY OBJECTIVES: To test if morbid obesity causes pulmonary function changes and if massive weight loss have effect on pulmonary function (especially in subjects with BMI>or=60 kg/m(2)). PARTICIPANTS: Thirty-nine morbid obese subjects before and after massive weight loss. MEASUREMENTS AND RESULTS: Patients had baseline BMI>or=40 kg/m(2), pulmonary function test (PFT) before and after surgery for gastric volume reduction and massive weight loss, and presented no complaints unrelated to obesity. Based on initial BMI, the patients were divided in groups A (BMI 40-59.9 kg/m(2)) and B (BMI>or=60 kg/m(2)). Initially, group A (n=28) had normal PFT, however group B (n=11) presented FVC and FEV(1) measurements in the lowest limit of normality (with normal FEV(1)/FVC), significantly different from group A. After massive weight loss, the group B compared to A had a significant improvement in FVC (23.7% vs. 9.7%, P=0.012) and FEV(1) (25.6% vs. 9.1%, P=0.006); thus the initial difference in FVC and FEV(1) between groups no longer existed after weight loss. CONCLUSIONS: These results point out that the severe morbid obesity (BMI>or=60 kg/m(2)) may lead to pulmonary function impairment and presents more prominent pulmonary function gain after massive weight reduction. The possible clinical implications of these results are that PFT abnormalities in subjects with BMI<60 kg/m(2) should probably be interpreted as consequence of intrinsic respiratory disease and that severe morbid obese patients may be encouraged to lose weight to improve their pulmonary function, especially those with concomitant pulmonary disorders.

Primary structure, behavioral and electroencephalographic effects of an epileptogenic peptide from the sea anemone Bunodosoma cangicum.

The primary structure of cangitoxin (CGX), a 4958 Da peptide from the sea anemone Bunodosoma cangicum, was determined: GVACRCDSDGPTVRGNSLSGTLWLTGGCPSGWHNCRGSGPFIGYCCKK. CGX contains all the 11 residues that are conserved and the 5 that are conservatively substituted within or between the type 1 and type 2 sequences of sea anemone peptides with specific action on voltage-sensitive sodium channels. Furthermore, it also has 6 identities (Asp9, Arg14, Asn16, Leu18, Trp33 and Lys48) and 1 homology (Arg36) in the 8 residues of the pharmacophore of the sea anemone ApB which are essential for interaction with mammalian sodium channels. The intrahippocampal injection of CGX induces several sequential behavioral alterations--episodes of akinesia alternating with facial automatisms and head tremor, salivation, rearing, jumping, barrel-rolling, wet dog shakes and forelimb clonic movements--and the electroencephalography analysis shows that they were followed by important seizure periods that gradually evolved to status epilepticus that lasted 8-12 h, similar to that observed in the acute phase of the pilocarpine model of epilepsy. These results suggest that CGX may be an important tool to develop a new experimental model of status epilepticus which may contribute to understanding the etiology of epilepsy and to test the effects of new antiepileptic drugs.

Bone marrow necrosis successfully treated with corticosteroid.

A 60-yr-old white woman with CREST syndrome (calcinosis cutis, Raynaud's phenomenon, esophageal involvement, sclerodactyly, telangectasia), idiophatic portal hypertension and esophageal varices presented with a 2-month history of bone pain and severe anemia, requiring erythrocyte transfusion every 5-7 d. Initial laboratory findings were hemoglobin (Hb) 4.4 g/dL, platelets 15 x 10(9)/L, white blood cell count (WBC) 2.7 x 10(9)/L. Bone marrow biopsy showed large areas of BMN, and cultures of bone marrow aspirate were negative. The patient was started on intravenous pulse methylprednisolone (1000 mg/d for 3 d) followed by oral prednisone (1 mg/kg/d), and did not require erythrocyte transfusion thereafter. On the 40th day, our patient had Hb 11.6 g/dL, platelets 120 x 10(9)/L, WBC 6.2 x 10(9)/L. Here, we describe the first report of BMN in a patient with CREST syndrome, the first description of successful treatment with intravenous pulse corticosteroid and discuss the possible immune mechanisms involved in the present case.

A rare cause of hemoptysis: benign sugar (clear) cell tumor of the lung.

A case of benign sugar (clear) cell tumor of the lung with an unusual clinical presentation and its evaluation with computed tomography are reported. A 48-year-old man presented with one episode of hemoptysis. Chest radiographs revealed a round nodule in the lower left lung lobe, and fiberoptic bronchoscopy was normal. On the computed tomography scans, the nodule showed intense post-contrast enhancement (74.7 Hounsfield units). The patient underwent a left thoracotomy, and a segmentectomy was performed. Pathologic examination showed a benign sugar cell tumor of the lung. The patient is alive and has remained free of disease for the last 2 years. To the best of our knowledge, this is the first case report of sugar cell tumor located in lung parenchyma that presented with hemoptysis and the second report of the contrast-enhanced computed tomography findings in this neoplasm.