Úlceras por pressão relacionadas com o colar cervical na pessoa em situação crítica: Protocolo de prevenção / Collar-related pressure ulcers in the critically ill person: Prevention protocol

O colar cervical é um dispositivo médico, projetado para criar uma restrição mecânica do movimento da coluna cervical, com o objetivo de proteger o doente de possíveis lesões cervicais e da sua consequência. No entanto, a natureza rígida do seu design causa um aumento da pressão, forças de torção, cargas térmicas e deformação contínua da pele e tecidos moles subjacentes. Simultaneamente, o colar cervical é usado para tratar uma potencial lesão, mas causa outra lesão evitável. As úlceras por pressão são a complicação mais comum e evitável associada à utilização de colares cervicais, as designadas de úlceras por pressão relacionadas com o colar cervical (dispositivo médico). Alguns estudos sobre úlceras por pressão relacionadas com o colar cervical em vítimas de trauma referem taxas de incidência mais baixas quando é utilizado um protocolo de prevenção destas lesões. Neste sentido, recorreu-se método de Delphi com o objetivo da obtenção de consenso, por um painel de peritos, acerca das intervenções de enfermagem preventivas e os fatores de risco de úlceras por pressão relacionadas com o colar cervical, bem como sobre os conceitos e definições enquadradores a incluir no protocolo de prevenção, na pessoa em situação crítica, no contexto de UCI. Foram propostas na primeira ronda doze intervenções preventivas de enfermagem, dezanove fatores de risco e quatro conceitos e definições enquadradores. No final da segunda e última ronda e com as sugestões dos peritos obtiveram consenso catorze intervenções de enfermagem preventivas, vinte fatores de risco, e dez conceitos e definições enquadradores. As rondas foram realizadas através de um questionário online e os níveis de consenso foram previamente estabelecidos (concordância ?90%, mediana ?3; intervalo interquartil ?1). As intervenções de enfermagem preventivas, os fatores de risco e as definições e conceitos enquadradores, reúnem um conjunto de itens essenciais para a construção de um protocolo de prevenção de úlceras por pressão relacionadas com o colar cervical, na pessoa em situação crítica, internada em UCI em Portugal.

Bridging Learning in Medicine and Citizenship During the COVID-19 Pandemic: A Telehealth-Based Case Study.

BACKGROUND: COVID-19 presented great challenges for not only those in the field of health care but also those undergoing medical training. The burden on health care services worldwide has limited the educational opportunities available for medical students due to social distancing requirements. OBJECTIVE: In this paper, we describe a strategy that combines telehealth and medical training to mitigate the adverse effects of the COVID-19 pandemic. METHODS: A toll-free telescreening service, Telecoronavirus, began operations in March 2020. This service was operated remotely by supervised medical students and was offered across all 417 municipalities (14.8 million inhabitants) in the Brazilian state of Bahia. Students recorded clinical and sociodemographic data by using a web-based application that was simultaneously accessed by medical volunteers for supervision purposes, as well as by state health authorities who conducted epidemiological surveillance and health management efforts. In parallel, students received up-to-date scientific information about COVID-19 via short educational videos prepared by professors. A continuously updated triage algorithm was conceived to provide consistent service. RESULTS: The program operated for approximately 4 months, engaging 1396 medical students and 133 physicians. In total, 111,965 individuals residing in 343 municipalities used this service. Almost 70,000 individuals were advised to stay at home, and they received guidance to avoid disease transmission, potentially contributing to localized reductions in the spread of COVID-19. Additionally, the program promoted citizenship education for medical students, who were engaged in a real-life opportunity to fight the pandemic within their own communities. The objectives of the education, organization, and assistance domains of the Telecoronavirus program were successfully achieved according to the results of a web-based post-project survey that assessed physicians' and students' perceptions. CONCLUSIONS: In a prolonged pandemic scenario, a combination of remote tools and medical supervision via telehealth services may constitute a useful strategy for maintaining social distancing measures while preserving some practical aspects of medical education. A low-cost tool such as the Telecoronavirus program could be especially valuable in resource-limited health care scenarios, in addition to offering support for epidemiological surveillance actions.

The benefit of HER2-targeted therapies on overall survival of patients with metastatic HER2-positive breast cancer--a systematic review.

INTRODUCTION: This study aimed at evaluating the overall survival (OS) gain associated with human epidermal growth factor receptor 2 (HER2)-directed therapies in patients with metastatic breast cancer (mBC). METHODS: A bibliographic search was conducted in PubMed and Cochrane databases. Only phase III randomized controlled trials (RCTs) including HER2-positive (HER2+) mBC patients were included in this review. OS was defined as time from randomization until the occurrence of death from any cause. Studies have been grouped according to the line of treatment, i.e., first-line or second-line or beyond. RESULTS: Nineteen RCTs were eligible for inclusion, of which 12 assessed therapies targeting HER2+ mBC in the first-line setting. OS improved from 20.3 months in the first RCT (standard chemotherapy; Slamon et al. (N Engl J Med 344:783-92, 2001)) evaluating HER2-targeting therapies to 48 months in the study of Swain et al. (Lancet Oncol 14:461-71, 2013), with triple combination of pertuzumab, trastuzumab and docetaxel. Seven RCTs evaluated the OS of HER2-targeting therapies in the second-line setting and beyond. The OS in second-line setting improved from 15.3 months (capecitabine; Cameron et al. (Breast Cancer Res Treat 112:533-43, 2008)) to 30.7 months (trastuzumab emtansine; Verma et al. (N Engl J Med 367:1783-91, 2012)). In the third-line setting, the association of lapatinib and trastuzumab has demonstrated to improve OS to 4.5 months compared with lapatinib alone (14 months vs. 9.5 months; Blackwell et al. (J Clin Oncol 30:2585-92, 2012)). CONCLUSIONS: HER2-directed therapies had an undeniable beneficial impact on the OS of patients with HER2+ mBC. The triple combination of docetaxel, pertuzumab and trastuzumab is associated with a survival extent of more than 4.5 years, compared with a life expectancy of 1.5 years achieved 14 years ago.

Knowledge-attitude-practice survey among Portuguese gynaecologists regarding combined hormonal contraceptives methods.

ABSTRACT Objectives To evaluate knowledge, attitude and practices of Portuguese gynaecologists regarding combined hormonal contraceptives. Methods A cross-sectional survey was conducted among 303 gynaecologists. Results Ninety percent of the gynaecologists considered that deciding on contraceptive methods is a process wherein the woman has her say. Efficacy, safety and the woman's preference were the major factors influencing gynaecologists, while efficacy, tolerability and ease of use were the major factors perceived by the specialists to influence the women's choice. Gynaecologists believed that only 2% of women taking the pill were 100% compliant compared to 48% of those using the patch and 75% of those using the ring. The lower risk of omission was the strong point for the latter methods. Side effects were the main reason to change to another method. Vaginal manipulation was the most difficult topic to discuss. Conclusions Most gynaecologists decided with the woman on the contraceptive method. The main reasons for the gynaecologist's recommendation of a given contraceptive method and the women's choice were different. Counselling implies an open discussion and topics related to sexuality were considered difficult to discuss. Improving communication skills and understanding women's requirements are critical for contraceptive counselling.

[Hepatitis C in drug addicts: access and treatment compliance]. / Hepatite C em toxicodependentes: acompanhamento e acesso à terapêutica.

Currently, hepatitis C is a serious public health problem. It is estimated that there are 180 million people with chronic infection by hepatitis C virus (HCV) worldwide and that the prevalence of this infection in the Portuguese population ranges between 1 and 1.5%. In Portugal, there are neither up-to-date guidelines for treatment, nor recommendations for the diagnosis and management of patients with HCV and, in particular, for the endovenous drug users. The present article gathers consensus information regarding clinical practice and suggests some guidelines to the management and treatment accessibility of drug addicted patients with chronic infection by HCV, in Portugal.

[Epidemiology of atrial fibrillation]. / Epidemiologia da fibrilhação auricular.

Atrial fibrillation (AF) is the most frequent maintained arrhythmia and constitutes a major morbidity cause, especially because of its associated risk of ischemic stoke. Additionally, it represents an independent risk factor for global mortality. The incidence of AF varies, according to different studies, between a minimum of 0.25 per 1000 person/year (women) and 0.9 per 1000 person/year (men) and a maximum of 8.9 per 1000 person/year (women) and 11.5 per 1000 person/year (men). Several cross sectional and prospective studies indicate that the prevalence of AF is inferior to 1% in individuals who are less than 55 years old. It is estimated that this arrhythmia's suffers a significant increase throughout the entire life span, and that its highest raise occurs between the ages of 65 and 80. A Portuguese study performe d between June and November 2003, in the scope of Rede Médicos-Sentinela, showed an AF prevalence of 0.53% in a population of 32,185 Health Centres patients. The mean age of patients suffering from this disease is situated within the interval of 70 to 80 years old. It is inferior for those who suffer from a concomitant cardiovascular disease, being significantly higher for women versus men. The risk factors and comorbidities which are most commonly associated to AF are age, several cardiovascular conditions, alcoholism, family history of AF and hyperthyroidism. Considering the high rate of stroke mortality in Portugal and assuming that AF is present in 15% ischemic stroke triggering and that it increases its risk 2 to 7 times, it can be concluded that knowledge regarding AF's incidence and prevalence in the different age groups will be important in order to improve its level of control, which is essential for preventing stroke and better management of this condition's treatment in the cardiovascular diseases' general context.

IL-17 regulates adipogenesis, glucose homeostasis, and obesity.

Inflammatory mediators have the potential to impact a surprising range of diseases, including obesity and its associated metabolic syndrome. In this paper, we show that the proinflammatory cytokine IL-17 inhibits adipogenesis, moderates adipose tissue (AT) accumulation, and regulates glucose metabolism in mice. IL-17 deficiency enhances diet-induced obesity in mice and accelerates AT accumulation even in mice fed a low-fat diet. In addition to potential systemic effects, IL-17 is expressed locally in AT by leukocytes, predominantly by γδ T cells. IL-17 suppresses adipocyte differentiation from mouse-derived 3T3-L1 preadipocytes in vitro, and inhibits expression of genes encoding proadipogenic transcription factors, adipokines, and molecules involved in lipid and glucose metabolism. IL-17 also acts on differentiated adipocytes, impairing glucose uptake, and young IL-17-deficient mice show enhanced glucose tolerance and insulin sensitivity. Our findings implicate IL-17 as a negative regulator of adipogenesis and glucose metabolism in mice, and show that it delays the development of obesity.

[Cost-effectiveness of trastuzumab in the treatment of early stages breast cancer patients, in Portugal]. / Custo-efectividade de trastuzumab no tratamento de doentes com cancro da mama em estádios iniciais em Portugal.

INTRODUCTION: Despite the important advances observed in the last 25 years in the comprehension of the clinical and biological nature of breast cancer and its treatment, this disease remains a significant cause of cancer morbidity and mortality worldwide. The clinical trial Hera has demonstrated the safety and efficacy of trastuzumab in the treatment of HER2 positive (HER2+) breast cancer patients, in early stages, subsequent to surgery, chemotherapy (neoadjuvante or adjuvant) and radiotherapy, if applied. OBJECTIVES: To evaluate the cost-effectiveness of 1-year trastuzumab treatment versus standard care (observation following standard adjuvant chemotherapy), in patients with HER2+ breast cancer in early stages from the societal and the Portuguese National Health Service (NHS) perspectives. METHODS: A 5-state Markov model with annual transition cycles was developed to estimate the long term health and economic outcomes of HER2+ early breast cáncer patients based on HERA clinical trial results. Portuguese NHS resource use and costs were estimated from a consensus expert panel and published unit costs, respectively. Clinical and economic outcomes were discounted at 3% per annum. The incremental cost-effectiveness ratios per life year gained (LYG) and per quality adjusted life year (QALY) gained were estimated. One-way sensitivity analysis was performed. RESULTS: Considering a 45 year time horizon, treatment with trastuzumab was estimated to increase discounted life expectancy by 2,114 life years and quality-adjusted life expectancy by 2,009 QALYs compared to standard care. Direct and indirect costs were projected to be 61.839 euro and 19.759 euro with trastuzumab and 40.559 euro and 25.392 euro with standard of care. These results corresponded to incremental cost-effectiveness ratios of 10.067 euro and 10.595 euro assuming direct costs only, and of 7.400 euro and 7.789 euro including indirect costs, per life year gained and per QALY gained, respectively. CONCLUSIONS: The 1-year trastuzumab use as adjuvant therapy in HER-2+ early breast cancer patients improves survival and can be considered a cost effective therapy with a high degree of certainty in the Portuguese setting.

[Incremental cost evaluation study of INR self-monitoring versus laboratorial control or monitoring in health care centres, in Portugal]. / Estudo de avaliação do custo incremental da auto-monitorização de INR versus controlo laboratorial ou monitorização no centro de saúde, em Portugal.

UNLABELLED: Oral anticoagulant therapy with vitamin K blockers has been increasing in the last few years and its effectiveness is directly related to maintaining INR values within the target range. The objective of this study is to evaluate the cost-effectiveness of INR auto-monitoring versus monitoring in a laboratory or a health care centre, in Portugal. METHODOLOGY: The study was conducted from a social perspective and considered only the direct costs. A Markov model was developed that considered the evolution of a hypothetical patient cohort, in annual cycles, with a time horizon of 5 years. For each patient, prothrombin time monitoring was predicted in three different ways: auto-monitoring, laboratory monitoring, and monitoring in a health care centre. The parameters analyzed were life-years gained and QALYs. RESULTS: The auto-monitoring option had a cost-effectiveness per QALY of 542euro/QALY (4.71 QALYs and 4.74 life-years). Health centre monitoring showed a costeffectiveness of 526euro/QALY (4.66 QALYs and 4.70 life-years) and the laboratory option had a cost-effectiveness of 704euro/QALY (4.64 QALYs and 4.68 life-years). CONCLUSIONS: Results showed that auto-monitoring is the option that presents more benefits. Results for both auto-monitoring and monitoring in a health care centre are better than monitoring in a laboratory.

[Characterization of oncological disease: racional, objectives and methodology - perfil study]. / Perfil da doença oncológica em Portugal racional, objectivos e metodologia - estudo perfil.

Oncologic disease is one of the main causes of death in Portugal, as well as a high morbidity rate. Over the past few years, these diseases have been targeted with several strategies which aims at optimizing the use of available therapeutic and diagnostic options. Nevertheless, the amount of quantitative information available regarding the disease, patient profile, and treatment and monitoring practices is very low. In order to optimise the implementation of health policies specifically directed at oncologic diseases reliable and up-to-date information is needed, permitting optimisation and balancing of costs and benefits. The PERFIL national epidemiologic study is a multi-centre, retrospective cohort study which aims at evaluating the clinical practice regarding treatment of 6 neoplasias -colorectal, gastric, breast, prostate, lung, and lymphoma, in Portugal, between 2003 and 2007. This study is based upon data collection from the clinical files of patients being followed in the participating centres from 2003 to 2007. Qualitative evaluation (diagnosis and stage) was collected from the clinical records of all patients seen in each participating centre on a given month in each year from 2003 to 2007. The characterization of both patient profile and treatment and monitoring patterns will be based on a far-reaching analysis of 10,000 of those files, selected in a random and stratified sampling. This article describes the PERFIL study rationale, its objectives, and methodology.

[Guidelines for prevention of febrile neutropenia]. / Orientações para a prevenção da neutropenia febril em doentes submetidos a quimioterapia.

Neutropenia and febrile neutropenia are common consequences of some cytotoxic chemotherapy regimens. This situation leads to modifications of the therapeutic regimen, conducting to either dose reduction or cycle delays. Granulocyte colony stimulating factors are commonly used to minimize chemotherapy cytotoxic effect on the granulocytic series. The objective of this study is to assess the available evidence in what concerns the efficacy and safety of granulocyte colony stimulating factors, in several settings of their use. An extensive bibliographic review was performed, including clinical trials, observational studies, systematic reviews, and international guidelines for neutropenia prophylaxis, which aims to establish recommendations on their use, in adequacy to the National reality.

Cerberus is a feedback inhibitor of Nodal asymmetric signaling in the chick embryo.

The TGF-beta-related molecule Nodal plays an essential and conserved role in left-right patterning of the vertebrate embryo. Previous reports have shown that the zebrafish and mouse Cerberus-related proteins Charon and Cerberus-like-2 (Cerl-2), respectively, act in the node region to prevent the Nodal signal from crossing to the right side, whereas chick Cerberus (cCer) has an unclear function in the left-side mesoderm. In this study, we investigate the transcriptional regulation and function of cCer in left-right development. By analyzing the enhancer activity of cCer 5' genomic sequences in electroporated chick embryos, we identified a cCer left-side enhancer that contains two FoxH1 and one SMAD binding site. We show that these Nodal-responsive elements are necessary and sufficient for the activation of transcription in the left-side mesoderm. In transgenic mouse embryos, cCer regulatory sequences behave as in chick embryos, suggesting that the cis-regulatory sequences of Cerberus-related genes have diverged during vertebrate evolution. Moreover, our findings from cCer overexpression and knockdown experiments indicate that cCer is a negative-feedback regulator of Nodal asymmetric signaling. We propose that cCer and mouse Cerl-2 have evolved distinct regulatory mechanisms but retained a conserved function in left-right development, which is to restrict Nodal activity to the left side of the embryo.