Palliative Care in Advanced Alzheimer's Disease Dementia: Evaluation of the Answers Given by Caregivers and Physicians to the Accuracy of Surprise Question, as a Prognostic Tool.

Introduction: Alzheimer's disease (AD) dementia is the sixth leading cause of death in the United States. The surprise question (SQ) "Would you be surprised if this patient were to die within the next 12 months?" was used to identify death-risk patients, who could benefit from palliative care. Objective: To examine the prognostic accuracy of the SQ by physicians and caregivers in outpatients with AD dementia. Methods: This is a longitudinal and prospective study involving 101 patients along 1 year, applying the SAS 9.2 software and adopting a .05 P-value to assess the variables that influenced answers to the accuracy of SQ using the chi-square test. Results: 27 patients (26.7%) died during the follow-up. When caregivers answered the SQ, it presented a 51.8% sensitivity (CI 31.9 - 71.3), a 66.7% negative predictive value (20.7 - 63.6), a 56.2% specificity (CI 29.8 - 80.2), and a 40.9% positive predictive value of (CI 43.0 - 85.4) with a 53.4% accuracy (CI 38.5 - 68.4). When physicians answered, the SQ had an 88.8% sensitivity (CI 70.8 - 97.6), a 40% negative predictive value (CI 5.2 - 85.3), a 12.5% specificity (CI 1.5 - 38.3), a 63.1% positive predictive value (CI 45.9 - 78.1) with a 60.4% accuracy (CI 45.8 - 75). Conclusion: SQ remains a good tool with high sensitivity for the identification of patients with advanced AD dementia when presented to the attending physician for planning palliative advanced care with accuracy of 60.4% and caregivers' accuracy of 53.4%.

Lições da pandemia de Covid-19: um estudo quali-quantitativo com estudantes de Medicina e médicos recém-formados / Lessons from the Covid-19 pandemic: a quali-quantitative study with newly graduated doctors and medical students

Resumo: Introdução: A pandemia de Covid-19 impactou negativamente a saúde mental de médicos e estudantes de Medicina. Muito tem sido discutido sobre as lições aprendidas, no que se refere a aspectos clínicos, de diagnóstico, tratamento e prevenção. Entretanto, os médicos são treinados para o cuidado dos pacientes, o que envolve técnica e humanidade. Objetivo: Este estudo apresenta e discute as lições e reflexões aprendidas por internos de Medicina e médicos recém-formados durante a pandemia de Covid-19. Método: Trata-se de um estudo quali-quantitativo realizado durante a segunda quinzena de setembro de 2020 (seis meses após o início da pandemia) por meio de formulário em plataforma digital. Todos os alunos do internato e todos os médicos formados desde 2018 nas três faculdades de Medicina de Sergipe foram convidados a participar da pesquisa. Resultado: Obtiveram-se 148 questionários respondidos, dos quais quatro não continham respostas nos campos abertos. Quanto ao estágio de formação universitária, 36,5% eram recém-formados (n = 54), dos quais 90,7% trabalharam na linha de frente do atendimento aos pacientes com Covid-19. Ao serem questionados sobre os principais aprendizados que a pandemia havia trazido, 41 respostas estiveram voltadas para a paciência, a imprevisibilidade do futuro e a resiliência no enfrentamento das adversidades. Aproximadamente 42% (n = 62) dos participantes conheciam ao menos uma pessoa que faleceu por Covid-19, e isso se associou à necessidade de aproveitar o tempo, a vida e as pessoas (p = 0,009). Um total de 34 respostas (23%) demonstrou uma atitude positiva de reaprendizado e esperança quando os participantes foram perguntados sobre como imaginavam o trabalho e o ensino médico após pandemia. A necessidade de um retorno cauteloso foi citada em 34 (23%) respostas. Conclusão: Os estudantes de Medicina e os médicos recém-formados relataram aprendizados relacionados à paciência e resiliência. A perda de familiares e amigos por Covid-19 esteve relacionada à necessidade de aproveitar o momento presente.

Abstract: Introduction: The COVID-19 pandemic has affected the mental health of doctors and medical students. There has been plenty of discussion about the lessons learned, in relation to clinical aspects, diagnosis, treatment and prevention. However, doctors are trained in patient care, which involves technique and humanity. Objective: Presentation and discussion of lessons learned from the COVID-19 pandemic for medical interns and newly graduated doctors. Method: This is a quali-quantitative study performed in the second half of September 2020 (six months after the start of the pandemic) using a digital platform. All medical internship students and all physicians graduated since 2018 from the three medical schools in Sergipe-NE-Brazil were invited to participate. Result: 148 forms were obtained, and four of them did not contain answers in the open fields. As regards the university training internship, 36.5% were newly graduated physicians (n=54), of which 90.7% worked on the front line of care for patients with COVID-19. When asked about the main lessons that the pandemic brought, 41 responses referred to patience, unpredictability of the future and resilience in facing the adversities of the pandemic. About 42% (n=62) of the participants knew at least one person who died of COVID-19, and this was associated with the need to enjoy time, life and people (p=0.09). A total of 34 participants (23%) responded with a positive attitude of relearning and hope when asked about how they imagined work and medical education after the pandemic. The need for a cautious return was cited in 34 (23%) responses. Conclusion: Newly qualified doctors and medical students reported learnings related to patience and resilience. The loss of family and friends by COVID-19 was associated with the need to seize the moment.

Mental health and illness of medical students and newly graduated doctors during the pandemic of SARS-Cov-2/COVID-19.

INTRODUCTION: SARS-Cov-2 virus pandemic causes serious emotional consequences. It has occurred widespread medical courses suspension, and graduations were anticipated. Field hospitals, set up to treat patients with mild to moderate COVID-19, were the main workplaces of newly graduated doctors. OBJECTIVE: To assess the impact of SARS-Cov-2/COVID-19 pandemic on mental health of medical interns and newly graduated doctors. METHOD: This is a cross-sectional study performed using a digital platform. Links to forms were sent in two moments: moment 1 (M1), at the beginning of the pandemic, in the first half of April/2020 and moment 2 (M2), after six months of pandemic, in the second half of September/2020. All students from the medical internship and all doctors graduated since 2018 from the three medical schools in Sergipe-NE-Brazil were invited. RESULTS: 335 forms were answered in April and 148 in September. In M1 88.9% considered themselves exposed to excess of information about COVID-19, which was associated with anxiety symptoms (p = 0.04). Long family physical distance was also associated with these symptoms, as increased appetite (p = 0.01), feeling shortness of breath (p = 0.003) and sweating (p = 0.007). Fear of acquire COVID-19 was reported as intense by almost half of participants, and of transmitting by 85.7% in M1. In M2 41.2% reported the death of friends or relatives. Psychiatric illness was described by 38.5% and psychotropic drugs use by 30.1% in M1, especially those who lived alone (p = 0.03) and the single ones (p = 0.01). Alcohol intake was reported by 54.3%, and among doctors graduated in 2020 it increased from 50% in M1 to 85% in M2 (p = 0.04). CONCLUSION: The pandemic had a negative impact on the mental health of medical students and newly graduated doctors. Exposure to excessive COVID-19 information and family physical distance were associated to anxiety symptoms. Among doctors graduated in 2020, alcohol intake increased during pandemic evolution.

Cardiopulmonary exercise testing in patients with left bundle branch block and preserved ejection fraction / Teste de Esforço cardiopulmonar em portadores de bloqueio do ramo esquerdo e fração de ejeção preservada

BACKGROUND: Left bundle branch block (LBBB) has prognostic significance in patients with congestive heart failure. However, its influence is not well established in patients with preserved systolic ventricular function. OBJECTIVE: To evaluate the implications of LBBB presence in the cardiovascular performance of patients with preserved left ventricular systolic function (LVEF). METHODS: 26 LBBB patients (61.3 ± 8.2 years of age) and 23 healthy individuals (58 ± 6.8 years of age) with LVEF > 0.5 underwent cardiopulmonary exercise testing (CPET). RESULTS: CPET analysis revealed: peak oxygen consumption (VO2 ) predicted in the LBBB group was 87.2 ± 15.0% versus 105.0 ± 15.6% (p < 0.0001); peak oxygen pulse predicted in LBBB group was 98.6 ± 18.6% vs 109.9 ± 13.5% (p = 0.02); VO2 predicted anaerobic threshold in LBBB group was 67.9 ± 13.6% vs 70.2 ± 12.8% (p = 0.55); ΔVO2 /Δload in the LBBB group was 15.5 ± 5.51 versus 20.7 ± 7.3 ml.min-1.watts-1 (p = 0.006); ventilation / carbon dioxide production (VE/VCO2 slope) in LBBB group was 29.8 ± 2.9 versus 26.2 ± 2.9 (p = 0.0001) and VO2 recovery time in the LBBB group was 85.2 ± 11.8 vs. 71.5 ± 11.0 seconds (p = 0.0001). LBBB was an independent marker for VE/VCO2 slope increase. CONCLUSION: LBBB presence in individuals with preserved LVEF did not affect cardiovascular performance, but there was an increase of the VE/VCO2 slope in comparison to the control group.

FUNDAMENTO: O bloqueio do ramo esquerdo (BRE) tem importância prognóstica em portadores de insuficiência cardíaca congestiva. Todavia, a sua influência não está bem estabelecida em pacientes com função ventricular sistólica preservada. OBJETIVO: Avaliar as implicações da presença do BRE no desempenho cardiovascular em pacientes com função sistólica do ventrículo esquerdo (FEVE) preservada. MÉTODOS: Foram submetidos ao teste de esforço cardiopulmonar (TECP), 26 portadores de BRE (61,3 ± 8,2 anos) e 23 indivíduos saudáveis (58 ± 6,8 anos), com FEVE > 0,5. RESULTADOS: A análise do TECP revelou: consumo de oxigênio (VO2 ) pico predito no grupo BRE foi de 87,2 ± 15,0% versus 105,0 ± 15,6% (p < 0,0001); pulso de oxigênio pico predito no grupo BRE foi de 98,6 ± 18,6% versus 109,9 ± 13,5%, (p = 0,02); VO2 predito limiar anaeróbico no grupo BRE foi de 67,9 ± 13,6 % versus 70,2 ± 12,8% (p = 0,55); ∆VO2 /∆carga no grupo BRE foi de 15,5 ± 5,51 versus 20,7 ± 7,3 ml.min-1.watts-1 (p = 0,006); relação ventilação/produção de dióxido de carbono (VE/VCO2 slope) no grupo BRE foi de 29,8 ± 2,9 versus 26,2 ± 2,9 (p = 0,0001) e tempo de recuperação do VO2 no grupo BRE foi de 85,2 ± 11,8 versus 71,5 ± 11,0 segundos (p = 0,0001). O BRE foi marcador independente para o aumento do VE/VCO2 slope. CONCLUSÃO: A presença de BRE em indivíduos com FEVE preservada não comprometeu o desempenho cardiovascular, mas houve aumento do VE/VCO2 slope em relação ao grupo controle.

Isquemia miocárdica investigada com ecocardiografia sob estresse físico em pacientes com incompetência cronotrópica em uso de betabloqueador / Myocardial ischemia during exercise echocardiography in patients with chronotropic incompetence in use of beta blockers

Introdução: Objetivo: Avaliar a influência da utilização de betabloqueador em pacientes com incompetência cronotrópica, submetidos à Ecocardiografia sob Estresse. Método: Estudo observacional, transversal e retrospectivo, realizado entre janeiro/2001 e outubro/2008. Após exclusão de pacientes com precordialgia típica, com doença arterial coronariana estabelecida e que não usavam betabloqueador, foram avaliados 635 pacientes que faziam uso regular desta droga, suspensa 3 dias antes da execução do exame. A amostra foi dividida em 2 grupos: G1 e G2 (com e sem incompetência cronotrópica), que foram comparados quanto à características clínicas, hemodinâmicas, eletrocardiográficas e ecocardiográficas . Resultados: O G1 constituiu-se de 81 pacientes (13 por cento); o G2 de 554 pacientes (87 por cento). Quanto às características, os pacientes do G1 eram idosos (p=0,002), apresentavam mais precordialgia atípica (p=0,013, mais dispnéia durante o exame (p=0,001) e eram sintomáticos (p=0,009). Do ponto de vista ecocardiográfico, não foi possível diferenciar os dois grupos, quanto ao diagnóstico de isquemia miocárdica induzida pelo esforço (p=0,140) e, também quanto ao índice de escore de motilidade do ventrículo esquerdo durante o exercício (p=0,223). Todavia, G1 demonstrou maior índice de massa do ventrículo esquerdo (p=0,001). Conclusão: Isquemia miocárdica investigada com ecocardiografia sob estresse físico foi senelhante nos grupos estudados.

Chronotropic incompetence and coronary artery disease.

OBJECTIVE: Although chronotropic incompetence (CI) represents an independent predictor of mortality and incidence of coronary artery disease, its pathophysiological mechanisms remain unknown. The purpose of this investigation was to evaluate wall motion abnormalities of the left ventricle and location of coronary arterial lesions in patients with and without CI. METHODS: After exclusion of confounding factors, 610 patients (mean age of 58.4 +/- 11 years; 275 men) with ischaemia who underwent exercise echocardiography were studied. Based on heart rate (HR) reached in treadmill testing, patients were divided into two groups: Chl (97 patients who did not reach 85% of maximum HR recommended for age) and ChC (513 patients who achieved 85% of the maximum age-predicted HR). RESULTS: There was a higher frequency of dyspnoea (5.2% vs. 0.6%, P = 0.003), systemic hypertension (69.1% vs. 57.3%, P = 0.031) and obesity (38.1% vs. 22.6%, P = 0.001), and a lower tolerance to effort (dyspnoea as limitation of physical effort: 36.1% vs. 8.0%, P < 0.0001; duration of treadmill test: 4.4 +/- 2.2 vs. 7.2 +/- 2.8, P < 0.0001; METs: 6.0 +/- 2.6 vs. 8.4 +/- 2.9, P = 0.002) in Chl compared to ChC. The wall motion score index (WMSI) was higher in Chl than in ChC, both at rest (1.15 +/- 0.29 vs. 1.07 +/- 0.19, P = 0.011) and after exercise (1.24 +/- 0.29 vs. 1.15 +/- 0.19, P = 0.002). Systolic function, which was evaluated in peak exercise through WMSI, was significantly more altered in the Chl group. The presence of severe injuries in right coronary was independently associated with CI (adjusted OR = 3.57, CI 95%: 1.86-6.87). CONCLUSION: Chronotropic incompetence is associated with ventricular dysfunction in peak exercise and critical right coronary artery lesions.