The need for training in palliative care for physicians in other specialties: Brazilian nephrologists empowerment (or appropriation) on renal supportive care.

BACKGROUND: Renal Supportive/Palliative Care is gaining gradual recognition as a patient-centered care approach that should be integrated to the traditional disease-centered model of care, mainly in elder patients with advanced chronic kidney disease (CKD). The objective of this study was to assess knowledge, perceptions, attitude, experience and interest in palliative care among renal care providers. METHODS: Online survey, administered between May 23 to June 13, 2017 to members of the Brazilian Society of Nephrology (BSN). Participants self-reported knowledge and behaviors regarding renal palliative care. RESULTS: A total of 3,738 e-mails were sent, 224 (6%) providers completed the survey. Most respondents were under 50 years old (68.5%) and were nephrologists (98.2%). A request from a competent patient to discontinue dialysis would not be honored by 46% and 63% would probably continue dialysis if a patient become severely demented. On the other hand, respondents with ≥15 years of experience were more prone to stop dialysis (P=0.01) in patients who became permanently and severely demented. Respondents working only in private practice were more willing to continue dialysis in a severely demented patient than those working in a public healthcare system or both (P=0.02). Additionally, 87% of respondents would probably withhold dialysis in a permanently unconscious patient and 92% probably would not resuscitate a patient with a Do Not Resuscitate (DNR) order. Among factors that would have importance on a decision to not initiate dialysis, patient preferences (98.2%), advanced dementia (95%), poor clinical conditions (93.7%) and family wishes (92.3%) were top ranked by respondents. Most respondents routinely evaluate HRQoL (62%), pain and other symptoms ( 79%) and were very interested (96%) in improving knowledge about renal supportive care. CONCLUSIONS: Brazilian nephrologists are often unaware of patient autonomy, more prone to withholding than withdrawing dialysis and deem wishes of the family quasi as important as patient preferences in the shared decision making process. Most Participants answered to evaluate pain and quality of life related to health (HRQoL) routinely and have great interest to learn about renal palliative care.

Performance of four ischemic stroke prognostic scores in a Brazilian population.

OBJECTIVE: Ischemic stroke (IS) prognostic scales may help clinicians in their clinical decisions. This study aimed to assess the performance of four IS prognostic scales in a Brazilian population. METHOD: We evaluated data of IS patients admitted at Hospital Paulistano, a Joint Commission International certified primary stroke center. In-hospital mortality and modified Rankin score at discharge were defined as the outcome measures. The performance of National Institutes of Health Stroke Scale (NIHSS), Stroke Prognostication Using Age and NIHSS (SPAN-100), Acute Stroke Registry and Analysis of Lausanne (ASTRAL), and Totaled Health Risks in Vascular Events (THRIVE) were compared. RESULTS: Two hundred six patients with a mean ± SD age of 67.58 ± 15.5 years, being 55.3% male, were included. The four scales were significantly and independently associated functional outcome. Only THRIVE was associated with in-hospital mortality. With area under the curve THRIVE and NIHSS were the scales with better performance for functional outcome and THRIVE had the best performance for mortality. CONCLUSION: THRIVE showed the best performance among the four scales, being the only associated with in-hospital mortality.

Performance of four ischemic stroke prognostic scores in a Brazilian population / Desempenho de quatro escalas de prognóstico de AVCI em uma população brasileira

ABSTRACT Objective Ischemic stroke (IS) prognostic scales may help clinicians in their clinical decisions. This study aimed to assess the performance of four IS prognostic scales in a Brazilian population. Method We evaluated data of IS patients admitted at Hospital Paulistano, a Joint Commission International certified primary stroke center. In-hospital mortality and modified Rankin score at discharge were defined as the outcome measures. The performance of National Institutes of Health Stroke Scale (NIHSS), Stroke Prognostication Using Age and NIHSS (SPAN-100), Acute Stroke Registry and Analysis of Lausanne (ASTRAL), and Totaled Health Risks in Vascular Events (THRIVE) were compared. Results Two hundred six patients with a mean ± SD age of 67.58 ± 15.5 years, being 55.3% male, were included. The four scales were significantly and independently associated functional outcome. Only THRIVE was associated with in-hospital mortality. With area under the curve THRIVE and NIHSS were the scales with better performance for functional outcome and THRIVE had the best performance for mortality. Conclusion THRIVE showed the best performance among the four scales, being the only associated with in-hospital mortality.

RESUMO Objetivo Escalas de avaliação prognóstica do acidente vascular cerebral isquêmico (AVCI) podem ajudar decisões clinicas. O objetivo deste estudo foi avaliar o desempenho de quatro escalas prognósticas em uma população brasileira. Método Foram avaliados os dados de pacientes admitidos com AVCI no Hospital Paulistano, um hospital acreditado pela “Joint Commission International”. A mortalidade intra-hospitalar e a escala de Rankin foram definidos como desfechos de evolução clínica. O desempenho de quatro escalas: National Institutes of Health Stroke Scale (NIHSS), Stroke Prognostication Using Age and NIHSS (SPAN-100), Acute Stroke Registry and Analysis of Lausanne (ASTRAL) e Totaled Health Risks in Vascular Events (THRIVE) foi comparado. Resultados Foram incluídos duzentos e seis pacientes, com uma idade média de 67,58 ± 15,5 anos, sendo 55,3% dos sexo masculino. Todas as quatro escalas associaram-se de forma independente com prognóstico funcional. Apenas o THRIVE correlacionou-se com a mortalidade hospitalar. O THRIVE e o NIHSS tiveram melhor desempenho para prognóstico funcional e o THRIVE teve o melhor desempenho para mortalidade pela área sob a curva. Conclusão O THRIVE mostrou-se a escala com melhor performance, sendo a única correlacionada com a mortalidade hospitalar.