Palliative care for patients with HIV/AIDS admitted to intensive care units. / Cuidados paliativos no paciente com HIV/AIDS internado na unidade de terapia intensiva.

OBJECTIVE: To describe the characteristics of patients with HIV/AIDS and to compare the therapeutic interventions and end-of-life care before and after evaluation by the palliative care team. METHODS: This retrospective cohort study included all patients with HIV/AIDS admitted to the intensive care unit of the Instituto de Infectologia Emílio Ribas who were evaluated by a palliative care team between January 2006 and December 2012. RESULTS: Of the 109 patients evaluated, 89% acquired opportunistic infections, 70% had CD4 counts lower than 100 cells/mm3, and only 19% adhered to treatment. The overall mortality rate was 88%. Among patients predicted with a terminally ill (68%), the use of highly active antiretroviral therapy decreased from 50.0% to 23.1% (p = 0.02), the use of antibiotics decreased from 100% to 63.6% (p < 0.001), the use of vasoactive drugs decreased from 62.1% to 37.8% (p = 0.009), the use of renal replacement therapy decreased from 34.8% to 23.0% (p < 0.0001), and the number of blood product transfusions decreased from 74.2% to 19.7% (p < 0.0001). Meetings with the family were held in 48 cases, and 23% of the terminally ill patients were discharged from the intensive care unit. CONCLUSION: Palliative care was required in patients with severe illnesses and high mortality. The number of potentially inappropriate interventions in terminally ill patients monitored by the palliative care team significantly decreased, and 26% of the patients were discharged from the intensive care unit.

[The rehabilitation cares at the lepers]. / Prise en charge de la lèpre en Médecine physique et réadaptation.

Leprosy elimination (<1/100 000) is almost reached all around the world, although, but disabled people are still a lot, and they need rehabilitation as soon as possible. The different lesions (neurological, dermatologic and joint) must be treated in order to protect from handicap. Physical rehabilitation medicine can help with a global and polyvalent coverage. Therapeutic education and reinsertion are an important part.

Diagnóstico de enfermagem em cuidados paliativos: uma proposta no centro de alta complexidade em oncologia do hospital joão de barros barreto/pará / Nursing diagnosis in palliative care: a proposal in the center of high complexity in oncology hospital João de Barros Barreto / Pará

O presente estudo te como tema a sistematização do cuidado de enfermagem ao paciente com câncer avançado sob cuidados paliativos no centro de alta complexidade em oncologia (CACON) do Hospital Universitário João de Barros Barreto (HUJBB) em Belém do Pará. Cuidado paliativo impõe-se na atualidade pelo crescimento das doenças crônico-degenerativas e pelo aumento da expectativa de vida da população e pela necessidade vigente de um cuidado à saúde humanizado, onde o enfermeiro é um profissional fundamental na consolidação desse cuidado humano associando sua arte e seu conhecimento científico. Este trabalho tem como objetivo promover uma reflexão acerca do cuidado de enfermagem sistematizado, individualizado e humanizado e cuidados paliativos. Discute sobre o cuidado e o processo de enfermagem relacionado ao paciente oncológico sob cuidados paliativos. Proporciona a elaboração de diagnósticos de enfermagem, a criação de um impresso específico para o histórico de enfermagem bem como um específico para o registro de plano de cuidado com base nos possíveis diagnósticos evidenciados; na intenção de sistematizar e registrar o cuidado prestado, ou seja, uma sistematização de conduta a partir de uma revisão bibliográfica. Portanto, espera-se contribuir para a qualidade de vida destes pacientes juntamente com um cuidado de enfermagem sistematizado, planejado e humanizado.

Thalidomide as an anti-cancer agent.

Thalidomide is a glutamic acid derivative initially introduced as a sedative hypnotic nearly forty years ago. It was withdrawn following numerous reports linking it to a characteristic pattern of congenital abnormalities in babies born to mothers who used the drug for morning sickness. It has gradually been re-introduced into clinical practice over the past two decades, albeit under strict regulation, since it was found to be useful in the management of erythema nodosum leprosum and HIV wasting syndrome. Recognition of its anti-angiogenic effect led to its evaluation in the treatment of various malignancies, where angiogenesis has been shown to play an important role. Numerous clinical trials done over the past four years have confirmed the significant anti-myeloma activity of this drug. It has also shown promise in preliminary trials in the treatment of a variety of different malignant diseases. The mechanisms of its antineoplastic effects continue to be the focus of ongoing research. It has become clear that even though its anti angiogenic effects play a significant role in the anti-tumor activity, there are other properties of this drug which are responsible as well. It also possesses anti-TNF alpha activity, which has led to its evaluation in several inflammatory states. In this concise review, we briefly describe the historical background and pharmacological aspects of this drug. We have concisely reviewed the current knowledge regarding mechanisms of its anti-neoplastic activity and the results of various clinical trials in oncology.

Thalidomide: emerging role in cancer medicine.

Thalidomide--removed from widespread clinical use by 1962 because of severe teratogenicity--has antiangiogenic and immunomodulatory effects, including the inhibition of tumor necrosis alpha factor. It has now returned to practice as an effective oral agent in the management of various disease states including erythema nodosum leprosum, for which it was approved by the U.S. Food and Drug Administration in 1998, and more recently certain malignancies, including multiple myeloma. Although thalidomide's mechanism of action remains incompletely understood, considerable insight has been generated by extensive preclinical studies in multiple myeloma. Moreover, clinical trials have confirmed benefit in relapsed disease, and the role of thalidomide in treating newly diagnosed patients is currently under study. Its use in other tumors is under evaluation, with promise in renal cell carcinoma, prostate cancer, glioma, and Kaposi's sarcoma. Activity has also been demonstrated in chronic graft-versus-host disease and in symptom relief as part of palliative care.

Potential novel uses of thalidomide: focus on palliative care.

Thalidomide, after being banned from the market in the early 1960s because of the worldwide teratogenesis disaster, is currently being rediscovered because of its multiple therapeutic effects in various serious diseases and symptoms. Original studies examined the anxiolytic, mild hypnotic, anti-emetic and adjuvant analgesic properties of this drug. Subsequently, thalidomide was found to be highly effective in managing the cutaneous manifestations of leprosy (erythema nodosum leprosum) and even to be superior to aspirin (acetylsalicylic acid) in controlling leprosy-associated fever. Recent research shows promising results with thalidomide in patients with progressive bodyweight loss related to advanced cancer and HIV infection. Thalidomide therapy of diseases such as tuberculosis, sarcoidosis, aphthous ulcers in HIV syndrome and Behcet's disease, rheumatoid arthritis, multiple myeloma, graft-versus-host disease, pyoderma gangrenosum, inflammatory bowel disease, Sjögren's syndrome, lupus erythematosus and a variety of solid tumours is currently being explored. Furthermore, in preliminary studies, thalidomide has been found to be effective in several syndromes related to advanced cancer, such as the cancer cachexia syndrome, chronic nausea, insomnia, profuse sweating and pain. Whether thalidomide has a therapeutic effect on neoplastic fever has yet to be elucidated. These intriguing features make the use of the drug potentially attractive for palliative care. In addition, by a distinct mechanism of action compared with most other drugs, thalidomide offers the possibility of combined treatment with other agents with non-overlapping toxicities. The mechanism of action of thalidomide is probably based on the suppression of tumour necrosis factor-alpha and the modulation of interleukins. However, it is not possible to identify a single dominant mechanism, since the action of cytokines and the effect of thalidomide appear to be complex. This review article discusses the original uses and teratogenic effects of thalidomide within its historical context and, linking recent research at the molecular level with clinical findings, aims to provide the reader with insight into the current understanding of its biological actions, toxicities and potential benefits.

[Leprosy surgery: retrospective study in Madagascar]. / La chirurgie de la lèpre: étude rétrospective à Madagascar.

Leprosy is endemic in Madagascar and the diagnosis of leprosy is still done lately. Thus, many patients suffer from multiple and/or severe disabilities. Since a long time, many leprologists argue that surgery is necessary and useful in the treatment of these disabilities. We report the results of a retrospective study done in 25 patients reevaluated 2 to 7 years after surgery. Of these patients: 17 patients (68%) have success, 7 patients (28%) have a partial improvement and only 1 case (4%) had no benefit. These results are encouraging and suggest that surgery must be proposed more often to treat in leprosy disabilities.

[Treatment and rehabilitation of disabilities caused by leprosy at a rural hospital (Kapolowé, Zaïre)]. / Traitement et réhabilitation des infirmités dues à la lèpre dans un hôpital rural (Kapolowé, Zaïre).

Since 1985, we contribute to treat and rehabilitate the leprosy infirmities at Kapolowe District Hospital (Shaba, Zaire). The setting up of a permanent autochtonous Department (Tschibangu), has taken the place of the temporary expeditions. A first follow-up refers to 138 patients, on which 259 interventions have been done: 165 refer to foot ulcerations and theirs septic osteoarticular complications, 75 relate to neuritis, 8 only have been restorative interventions. 75% of our patients have had a good social reinsertion. The 25% relapses show the importance of a good limb prosthesis, of sanitary education of the patients and their supervision when they go back to brushwood. In the initial period, it is necessary to start by performing in cleanliness surgery, otherwise bright restorative interventions would be inefficient.

[Palliative operations for correction of claw fingers]. / Interventions palliatives pour correction des griffes des doigts.

Palliative treatment of palsy of intrinsic muscles of the four fingers classically aims at suppressing claw. But functional restoration is mainly ensured in setting up again the volar flexion, the stage preparing prehension. Three hundred and thirty seven hands have been operated. Each one of the utilized interventions has advantages and drawbacks that have to be known in order to select the best adapted technics, the more or less important stiffness of fingers being the most important criteria. Finally a simple choice is easy and possible, particularly for inexperienced surgeons in the treatment of those paralysis (that become rarer and rarer in the West on account of the success of nervous sutures facing a large number of leprotic hands to operate in endemic countries); it is the metacarpophalangeal stabilization test: the active interphalangeal extension obtained after passive manual stabilization, of metacarpophalangeal joint indicates the degree of proximal interphalangeal residual stiffness, and the indications come in function of these various types of stiffness. Loose PIP joint: residual flexion from 0 degree to 20 degrees: MP capsular shortening, H shaped, and flexor pulley advancement; "Lasso" operation: a single slip of FDS by finger or one FDS for two fingers; Bunnell-Litter's operation: one FDS for 4 fingers; Giraudeau's operation: FCR + fascia lata; Brand's operation: 1st (ECRL) or 2nd (ECRB) + tendon graft; Palande's operation: ECRB + many tailed fascia lata graft fixed at the muscle tendon junction. Stiff PIP Joint: residual flexions from 20 degrees to 60 degrees: modified Bunnell's operation: one FDS for 2 fingers, the FDS of the third used to restaure the opposition; "lasso" operation: one FDS for each finger, or for two fingers. Very stiff PIP joint: residual flexion superior to 90 degrees: proximal interphalangeal joint arthrodesis.

Zancolli's "lasso" operation in intrinsic palsy of leprous origin. A study of twenty-six cases.

Twenty-six cases of Zancolli's "lasso" procedure are presented. They were part of a series of 122 operations performed for leprosy in Central Africa. Nineteen cases with a follow-up of more than 6 months were reviewed. Fifteen of these patients had good or very good results. When claw hand deformities are supple, one flexor superficialis tendon may be used for two fingers; when the fingers are partially stiff, one tendon for each finger should be used. The "lasso" procedure is simple and the results are satisfactory, particularly in this series of patients who did not follow any rehabilitation program.