Avaliação do tratamento quimioterápico paliativo com o esquema LDE- paclitaxel em pacientes portadores de metástases ósseas por neoplasia maligna / Evaluation of palliative chemotherapy treatment with the LDEpaclitaxel regimen in patients with bone metastases from malignant neoplas

Introdução: Pacientes com câncer em estádios avançados e metástases ósseas frequentemente não apresentam condições clínicas para a realização de esquemas quimioterápicos convencionais subsequentes, restringindo as opções de tratamento. Anteriormente, demonstramos que nanopartículas artificiais lipídicas (LDE), semelhantes à lipoproteína de baixa densidade (LDL) rica em colesterol, são captadas por tecidos malignos, e quando associadas aos quimioterápicos, após injeção pela via endovenosa, reduz drasticamente a toxicidade do tratamento. Os objetivos deste presente estudo foram avaliar a resposta clínica ao tratamento quimioterápico com paclitaxel (PTX) associado à LDE; avaliar as toxicidades clínicas e laboratorial, e a capacidade da associação LDE-PTX em reduzir a dor oncológica relacionada às metástases ósseas em pacientes com carcinoma de mama, próstata e pulmão, previamente tratados e não elegíveis para tratamento quimioterápico convencional subsequente. Métodos: Dezoito pacientes (8 com câncer de mama, 5 de próstata e 5 de pulmão) com metástases ósseas foram incluídos. O tratamento consistiu no esquema LDE-PTX na dose convencional do PTX (175 mg/m2 de superfície corpórea de 3/3 semanas) e os pacientes foram avaliados por resposta clínica, redução da dor óssea, uso de medicamentos opióides, e ocorrência de fraturas ósseas patológicas. Resultados: No total, 104 ciclos de quimioterapia foram realizados, e nenhum paciente apresentou toxicidade clínica, laboratorial, assim como não houve fraturas patológicas. Dos 18 pacientes incluídos, 9 tiveram sobrevida livre de progressão de doença 6 meses. Houve em todos os pacientes redução da dor óssea, permitindo substituição da medicação opióide por analgésico não opióide. Conclusão: A melhora significativa na dor óssea sem que tenha ocorrido toxicidade do tratamento, e o tempo de não progressão de doença 6 meses na metade dos pacientes sugere que esses pacientes tenham se beneficiado consistentemente do tratamento com a LDE-PTX. Portanto, a LDE-PTX pode tornar- se uma opção terapêutica interessante em pacientes com carcinomas de próstata, mama ou pulmão em estágios avançados e sem condições clínicas de se submeterem a outros esquemas quimioterápicos convencionais

Introduction: Patients with advanced cancer and bone metastases usually do not have clinical conditions to perform additional conventional chemotherapy regimens, restricting treatment options. Previously, we showed that lipid core nanoparticles (LDE), similar to cholesterol-rich low-density lipoprotein (LDL), are taken up by malignant tissues, and when associated to chemotherapy, after endovenous injection, it drastically decreases the toxicity of the treatment. The objectives of this study were to evaluate the clinical response to chemotherapy treatment with paclitaxel (PTX) associated with LDE; to evaluate the clinical and laboratorial toxicities, and the ability of the LDE-PTX to reduce cancer pain related to bone metastases in patients with breast, prostate or lung carcinoma, previously treated and not eligible for subsequent conventional chemotherapy treatment. Methods: Eighteen patients (8 with breast cancer, 5 with prostate and 5 with lung) with bone metastases were included. Treatment consisted of the LDE-PTX regimen at a conventional dose of PTX (175 mg/m2 body surface area, 3/3 weeks) and patients were evaluated for clinical response, reduction in bone pain, use of opioid medications, and the occurrence of pathological bone fractures. Results: In total, 104 chemotherapy cycles were performed, and none of the patients showed clinical or laboratorial toxicities, as well as there were no pathological fractures. Of the 18 patients evaluated, 9 had progression-fee survival 6 months. Patients had decrease in bone pain allowing replacement of opioid medication by another non-opioid analgesic. Conclusion: Significant improvement in bone pain without treatment toxicity, and time to disease progression of 6 months in half of the patients suggest that these patients have consistently benefited with LDE-PTX treatment. Therefore, LDE-PTX may become an interesting therapeutic option in patients with advanced stage of prostate, breast or lung carcinomas and without clinical conditions to undergo other conventional chemotherapy regimens

Educação em saúde bucal em uma pré-escola: planejamento estratégico para o desenvolvimento de atividades lúdicas / Oral health education in pre-school: strategic planning for the development of ludic activities

Trata-se de um relato de experiência, que descreve, sob estratégia narrativo-argumentativa, as significâncias político-pedagógicas atreladas ao planejamento estratégico de ações de educação em saúde bucal vivenciadas em um ambiente escolar e experimentadas por acadêmicos estagiários de um curso de Odontologia. Após análise detalhada, algumas inferências se destacaram: o reconhecimento do ambiente escolar como território fértil para o desenvolvimento de ações promotoras de saúde; a efetividade do instrumento "TPC" (Teorizar-Praticar-Criticar) no direcionamento dos acadêmicos estagiários no planejamento estratégico de atividades de educação em saúde bucal; a importância de se disseminar, em espaços científicos, os aprendizados advindos de experimentações práticas de estágios.

This is a report on an experience that describes, under a narrative-argumentative strategy, the political-pedagogical significance linked to the strategic planning of oral health education actions experienced in a school environment and experienced by university trainees from a Dentistry course. After a detailed analysis, some inferences were observed: the recognition of the school environment as a fertile territory for the development of health-promoting actions; the effectiveness of the "TPC" (Theorize-Practice-Criticize) instrument in directing university trainees in the strategic planning of oral health education activities; the importance of disseminating, in scientific spaces, the learning from practical experimentation during internships.

Implicit Bias and Caring for Diverse Populations: Pediatric Trainee Attitudes and Gaps in Training.

The objective of this study was to determine the attitudes, skill level, and preferred educational interventions of pediatric residents related to implicit bias and caring for diverse patient populations. A cross-sectional survey of pediatric residents at a single, large urban residency program was utilized. Surveys were completed by 88 (55%) residents who were 69% female and 35% non-White or mixed race. Almost all residents felt that it was very or extremely important to receive training on health disparities, diverse patient populations, and implicit bias. Self-assessment of skill level revealed that residents felt confident in areas often covered by cultural competency curricula, such as interpreter use, but were less confident in other areas. The top 3 areas identified for further training included implicit bias, working with transgender and gender nonconforming patients, and weight bias. For the majority of diversity and bias-related skills, prior training was significantly correlated with higher skill level (P < .05).

Difficulty in distinguishing malignant gastric lymphoma from advanced gastric cancer: Focusing on endoscopic findings of the Borrmann type.

ABSTRACT: Malignant gastric lymphoma (MGL) accounts for a small proportion (upto 5%) of gastric malignancies. However, unlike for advanced gastric cancer (AGC) that requires surgical treatment, the standard treatments for MGL are chemotherapy and radiotherapy. Hence, the initial impression of the endoscopist is critical for the differential diagnosis and for planning future treatment. The purpose of this study was to assess the endoscopic diagnostic accuracy and the possibility of distinguishing between AGC and MGL depending on the endoscopist's experience.A total of 48 patients who had MGL, and 48 age and sex-matched patients who had AGC were assessed by endoscopic review at a tertiary referral hospital between June 2008 and February 2017. Two endoscopic specialists reviewed the endoscopic findings and divided these diagnoses into 5 groups: Borrmann type (1, 2, 3, and 4) and early gastric cancer-like type. After this, 7 experts and 8 trainees were asked to complete a quiz that was comprised of 6 images for each of the 96 cases and to provide an endoscopic diagnosis for each case. The test results were analyzed to assess the diagnostic accuracy according to the pathologic results, endoscopic subgroups, and endoscopists' experience. For inter-observer agreement was calculated with Fleiss kappa values.The overall diagnostic accuracy of endoscopic findings by the experts was 0.604 and that by the trainees was 0.493 (P = .050). There was no significant difference in the diagnosis according to the final pathology (lymphoma cases, 0.518 vs 0.440, P = .378; AGC cases, 0.690 vs 0.547, P = .089, respectively). In the subgroup analysis, the experts showed significantly higher diagnostic accuracy for the endoscopic Borrmann type 4 subgroup, including lymphoma or AGC cases, than the trainees (P = .001). Inter-observer agreement of final diagnosis (Fleiss kappa, 0.174) and endoscopic classification groups (Fleiss kappa, 0.123-0.271) was slightly and fair agreement.The experts tended to have a higher endoscopic diagnostic accuracy. Distinguishing MGL from AGC based on endoscopic findings is difficult, especially for the beginners. Even if the endoscopic impression is AGC, it is important to consider MGL in the differential diagnosis.

Global Health Education in the Time of COVID-19: An Opportunity to Restructure Relationships and Address Supremacy.

Global health and its predecessors, tropical medicine and international health, have historically been driven by the agendas of institutions in high-income countries (HICs), with power dynamics that have disadvantaged partner institutions in low- and middle-income countries (LMICs). Since the 2000s, however, the academic global health community has been moving toward a focus on health equity and reexamining the dynamics of global health education (GHE) partnerships. Whereas GHE partnerships have largely focused on providing opportunities for learners from HIC institutions, LMIC institutions are now seeking more equitable experiences for their trainees. Additionally, lessons from the COVID-19 pandemic underscore already important lessons about the value of bidirectional educational exchange, as regions gain new insights from one another regarding strategies to impact health outcomes. Interruptions in experiential GHE programs due to COVID-19-related travel restrictions provide an opportunity to reflect on existing GHE systems, to consider the opportunities and dynamics of these partnerships, and to redesign these systems for the equitable benefit of the various partners. In this commentary, the authors offer recommendations for beginning this process of change, with an emphasis on restructuring GHE relationships and addressing supremacist attitudes at both the systemic and individual levels.

Motivations for and Challenges in the Development of Global Medical Curricula: A Scoping Review.

PURPOSE: The aim of this scoping review is to understand the motivations for the creation of global medical curricula, summarize methods that have been used to create these curricula, and understand the perceived premises for the creation of these curricula. METHOD: In 2018, the authors used a comprehensive search strategy to identify papers on existing efforts to create global medical curricula published from 1998 to March 29, 2018, in the following databases: MEDLINE; MEDLINE Epub Ahead of Print, In-Process, and Other Non-Indexed Citations; Embase; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; PsycINFO; CINAHL; ERIC; Scopus; African Index Medicus; and LILACS. There were no language restrictions. Two independent researchers applied the inclusion and exclusion criteria. Demographic data were abstracted from publications and summarized. The stated purposes, methods used for the development, stated motivations, and reported challenges of curricula were coded. RESULTS: Of the 18,684 publications initially identified, 137 met inclusion criteria. The most common stated purposes for creating curricula were to define speciality-specific standards (50, 30%), to harmonize training standards (38, 23%), and to improve the quality or safety of training (31, 19%). The most common challenges were intercountry variation (including differences in health care systems, the operationalization of medical training, and sociocultural differences; 27, 20%), curricular implementation (20, 15%), and the need for a multistakeholder approach (6, 4%). Most curricula were developed by a social group (e.g., committee; 30, 45%) or Delphi or modified Delphi process (22, 33%). CONCLUSIONS: The challenges of intercountry variation, the need for a multistakeholder approach, and curricular implementation need to be considered if concerns about curricular relevance are to be addressed. These challenges undoubtedly impact the uptake of global medical curricula and can only be addressed by explicit efforts to make curricula applicable to the realities of diverse health care settings.

Feedback That Helps Trainees Learn to Practice Without Supervision.

Feedback pedagogies and research tend to focus on immediate corrective actions rather than learning for the longer term. This approach means that feedback may not support trainees who are managing complex, competing, and ambiguous practice situations, often with limited supervision. There is an opportunity to consider how feedback can help medical trainees sustain their own development into the future, including when they have completed formal training. This article explores how feedback pedagogies can facilitate medical trainees' abilities to develop challenging aspects of practice across multiple clinical environments to eventually practice without supervision. From a sociocultural perspective, clinical training takes place within a practice curriculum; each clinical environment offers varying opportunities, which the trainees may choose to engage with. The authors propose feedback as an interpersonal process that helps trainees make sense of both formal training requirements and performance relevant information, including workplace cues such as patient outcomes or colleagues' comments, found within any practice curriculum. A significant pedagogic strategy may be to develop trainees' evaluative judgment or their capability to identify and appraise the qualities of good practice in both themselves and others. In this way, feedback processes may help trainees surmount complex situations and progressively gain independence from supervision.

Core surgical field camps: a new deanery-based model for enhancing advanced skills in core surgical trainees through simulation.

Hands-on wet lab simulation training is a vital part of modern surgical training. Since 2010, surgical 'boot camps' have been run by many UK deaneries to teach core surgical trainees basic entry level skills. Training in advanced skills often requires attendance at national fee-paying courses. In the Wessex Deanery, multiple, free of charge, core surgical 'field camps' were developed to provide more advanced level teaching in the particular specialty preference of each core surgical trainee. After the COVID-19 pandemic, national hands-on courses will be challenging to provide and deanery-based advanced skills training may be the way forward for craft-based specialties. The experiences over 2 years of delivering the Wessex core surgical field camps are shared, giving a guide and advice for other trainers on how to run a field camp.

Librarians collaborate successfully with nursing faculty and a writing centre to support nursing students doing professional doctorates.

This study explores how a three-way collaboration between a University library, writing centre and faculty created avenues of training and support for students within a Doctor of Nursing Practice (DNP) program in an American University. The role of each partner involved in the collaboration is discussed alongside the profile of the DNP students. Lesson planning and classroom techniques for DNP information literacy classes are described and feedback from the partners and the students are discussed. The study confirms that collaboration is effective in improving research and writing skills. D.I.

A Cautionary Tale: The 2019 Orphaning of Hahnemann's Graduate Medical Trainees.

Hahnemann University Hospital provided care for Philadelphians starting in 1848, but its recent history has been riddled with financial turmoil that culminated in its rapid closure in summer 2019. As the hospital shuttered its doors to patients, it also orphaned 583 medical trainees. This crisis exposed vulnerabilities in graduate medical education (GME). In a firsthand account of the situation that developed in Philadelphia and reached academic institutions across the country, the authors reflect on lessons learned that may help leaders at other institutions mitigate the inevitable difficulties that arise when academic hospitals close. These lessons pertain to handling panic and administrative burdens in the aftermath of closure, the importance of well-defined processes, a clear understanding of GME funding, and strategies for placement of trainees that minimize disruption of their education.