Impact of a multifaceted strategy in end-of-life care in a tertiary hospital: A quasi-experimental study.

OBJECTIVE: To evaluate the impact of a multifaceted strategy for quality end-of-life care in a tertiary public hospital in Brazil. METHODOLOGY: The study design was quasi-experimental. The multifaceted strategy was applied between January and June 2017, and involved training the healthcare team in end-of-life discussions, the creation and documentation of advance directives, and consultation with the team specialized in palliative care. The periods analyzed were the pre-test period (Time 1, July 2015 to June 2016) and the post-test period (Time 2, July 2017 to June 2018). RESULTS: Time 1 involved 302 deaths, with an average hospital stay of 21 days; Time 2 involved 410 deaths, with an average hospital stay of 16 days. Patients were prescribed morphine (44.04% vs. 36.3% [p = 0.367]), methadone (9.60% vs. 4.39% [p = 0.247]), midazolam (43.05% vs. 47.80% [p = 0.73]), blood transfusions (31.13% vs. 24.63% [p = 0.828]), enteral feeding (56.62% vs. 38.54% [p = 0.59]) and antibiotic therapy (50.73% vs. 50.73% [p = 0.435]). CONCLUSION: This study found no changes in the end-of-life care quality indicators after the strategy was implemented. Multimodal educational strategies that develop communication skills in palliative care may enhance the quality of end-of-life care.

Palliative care in Brasil: present and future.

OBJECTIVE: To estimate the human resources and services needed to meet the demand of the Brazilian population who would benefit from palliative care, based on the population growth projection for 2040. METHODS: Population and mortality estimates and projections were obtained from the Brazilian Institute of Geography and Statistics. Service needs were estimated based on literature data. RESULTS: The expected increase in the Brazilian population for 2000-2040 is 31.5%. The minimum estimate of patients with palliative care needs was 662,065 in 2000 and 1,166,279 in 2040. The staff required for each hundred thousand inhabitants would increase from 1,734 to 2,282, the number of doctors needed would increase from 4,470 to 6,274, and the number of nurses from 8,586 to 11,294, for the same period. CONCLUSION: The definition of a national strategy predicting the increasing palliative care needs of the population is necessary. The expansion of the support network for chronic and non-transmissible diseases is necessary, but the training of existing human resources at all levels of attention to perform palliative actions can be a feasible alternative to minimize the suffering of the population.

Palliative care in Brasil: present and future

SUMMARY OBJECTIVE: To estimate the human resources and services needed to meet the demand of the Brazilian population who would benefit from palliative care, based on the population growth projection for 2040. METHODS: Population and mortality estimates and projections were obtained from the Brazilian Institute of Geography and Statistics. Service needs were estimated based on literature data. RESULTS: The expected increase in the Brazilian population for 2000-2040 is 31.5%. The minimum estimate of patients with palliative care needs was 662,065 in 2000 and 1,166,279 in 2040. The staff required for each hundred thousand inhabitants would increase from 1,734 to 2,282, the number of doctors needed would increase from 4,470 to 6,274, and the number of nurses from 8,586 to 11,294, for the same period. CONCLUSION: The definition of a national strategy predicting the increasing palliative care needs of the population is necessary. The expansion of the support network for chronic and non-transmissible diseases is necessary, but the training of existing human resources at all levels of attention to perform palliative actions can be a feasible alternative to minimize the suffering of the population.

RESUMO OBJETIVO: Estimar as necessidades de recursos humanos e serviços necessários para o atendimento de pacientes que se beneficiariam de cuidados paliativos a partir da projeção de crescimento da população brasileira até 2040. MÉTODO: As estimativas e projeções populacionais e de mortalidade foram obtidas nos dados do Instituto Brasileiro de Geografia e Estatística e do Sistema Único de Saúde. As estimativas de estrutura de serviços e recursos humanos foram realizadas a partir de dados da literatura. RESULTADOS: A expectativa de aumento da população brasileira entre 2000 e 2040 é de 31,5%. A estimativa mínima de pacientes com necessidades de cuidados paliativos foi de 662.065 em 2000 e é de 1.166.279 em 2040. O número de equipes necessárias para cada 100 mil habitantes passaria de 1.734 para 2.282 no mesmo período; o número de médicos foi de 4.770 para 6.274 e o número de enfermeiros necessários para atender as demandas dessa população foi de 8.586 para 11.294 nesse espaço de tempo. CONCLUSÃO: A definição de uma estratégia nacional prevendo a necessidade de cuidados crescentes da população se torna necessária. A expansão da rede de assistência a doenças crônicas e não transmissíveis se mostra necessária, porém a capacitação de recursos humanos já existentes em todos os níveis de atenção para desempenhar ações paliativas pode ser uma alternativa factível para minimizar o sofrimento da população.

Common mental disorders in patients undergoing lower limb amputation: a population-based sample.

BACKGROUND: Amputations result in a variety of limitations that have emotional consequences for patients. The aim of the present study was evaluate non-psychotic disorders and their associated factors in a sample of people with lower limb amputations. METHOD: A cross-sectional study was conducted that assessed the association of sociodemographic and clinical variables in relation to psychiatric disorders evaluated through the Self Reporting Questionnaire (SRQ-20) for patients undergoing lower limb amputation. The association between the outcome of the SRQ-20 and the other variables was assessed with the chi-square and Student's t test; to explore the magnitude of association adjusted for covariates, a logistic regression model was developed. RESULTS: One hundred-thirty eight (138) patients were interviewed, and a prevalence of 43% (60/138) was observed for patients with mental disorders assessed with the SRQ-20 questionnaire. We also observed that male patients (p = 0.017) and those who were married (p = 0.035) had a lower rate of psychological problems; those who were not considered independent (p = 0.036) and those with a greater number of morbid conditions (p = 0.036) showed a higher positivity in relation to psychological morbidity (p = 0.003). Logistic regression analysis showed that only the associated chronic diseases (p = 0.0328) and lack of independence (p = 0.0197) remained significant. CONCLUSIONS: Given the high prevalence of mental disorders related to the number of associated morbid conditions and to the situation of dependency among lower limb amputees, the psychological and social assessment of these people is recommended, in addition to encouraging their self-care and the return to their activities.

Fat and fiber consumption are associated with peripheral arterial disease in a cross-sectional study of a Japanese-Brazilian population.

BACKGROUND: The Western diet plays a role for the epidemics of obesity and related diseases. This study examined a possible association between peripheral arterial disease (PAD) and the dietary components of Japanese immigrants living in Brazil. METHODS AND RESULTS: In this cross-sectional study, 1,267 subjects (aged > or =30 years) with complete dietary, clinical and laboratory data were studied according to a standardized protocol. Ankle-to-brachial index was used to identify subjects with PAD. The overall prevalence of PAD was 14.6%. Subjects with PAD were older, had lower education and higher mean values of blood pressure, triglycerides, and fasting and 2-h plasma glucose levels compared with those without the disease. Among the subjects with PAD, the consumption of fiber from whole grains (3.0 vs 3.4 g, p=0.001) and linoleic acids (11.0 vs 11.7 g, p=0.017) were lower and intake of total (72.8 vs 69.1 g, p=0.016) and saturated fatty acids (17.4 vs 16.3 g, p=0.012) were higher than those without PAD. Results of multiple logistic regression analysis showed a significant association between PAD with high total fat intake, low intake of fiber from fruit and oleic acid, independently of other variables. CONCLUSIONS: Despite limitations in examining the cause - effect relationship, the data support the notion that diet could be important in reducing the occurrence of PAD.

Peroneal nerve palsy due to compartment syndrome after facial plastic surgery.

A 25-year-old white man, right after bilateral rhytidoplasty, presented with agitation, necessitating use of haloperidol. Some hours after, he developed severe pain in his legs and a diagnosis of neuroleptic malignant syndrome (NMS) was considered. Even with treatment for NMS he still complained of pain. A diagnosis of lower limb compartment syndrome (CS) was done only 12 hours after the initial event, being submitted to fasciotomy in both legs, disclosing very pale muscles, due to previous ischemia. This syndrome was not explained only by facial surgery, his position and duration of the procedure. It can be explained by a sequence of events. He had a history of pain in his legs during physical exercises, usually seen in chronic compartment syndrome. He used to take anabolizant and venlafaxine, not previously related, and the agitation could be related to serotoninergic syndrome caused by interaction between venlafaxine and haloperidol. Rhabdomyolysis could lead to oedema and ischemia in both anterior leg compartment. This report highlights the importance of early diagnosis of compartment syndrome, otherwise, even after fasciotomy, a permanent disability secondary to peripheral nerve compression could occur.

Peroneal nerve palsy due to compartment syndrome after facial plastic surgery

A 25-year-old white man, right after bilateral rhytidoplasty, presented with agitation, necessiting use of haloperidol. Some hours after, he developed severe pain in his legs and a diagnosis of neuroleptic malignant syndrome (NMS) was considered. Even with treatment for NMS he still complained of pain. A diagnosis of lower limb compartment syndrome (CS) was done only 12 hours after the initial event, being submitted to fasciotomy in both legs, disclosing very pale muscles, due to previous ischemia. This syndrome was not explained only by facial surgery, his position and duration of the procedure. It can be explained by a sequence of events. He had a history of pain in his legs during physical exercises, usually seen in chronic compartment syndrome. He used to take anabolizant and venlafaxine, not previously related, and the agitation could be related to serotoninergic syndrome caused by interaction between venlafaxine and haloperidol. Rhabdomyolisis could lead to oedema and ischmemia in both anterior leg compartment. This report highlights the importance of early diagnosis of compartment syndrome, otherwise, even after fasciotomy, a permanent disability secondary to peripheral nerve compression could occur.

Logo após ritidoplastia bilateral, um jovem de 25 anos apresentou agitação, necessitando uso de haloperidol. Algumas horas após, desenvolveu dor intensa em membros inferiores, e o diagnóstico de síndrome neuroléptica maligna foi considerado. Mesmo com o tratamento para tal, persistiu com dor. Após 12 horas do início do quadro, foi realizado o diagnóstico de síndrome compartimental de membros inferiores e o jovem foi submetido a fasciotomia bilateral. Uma seqüência de eventos desencadeou esta síndrome, já que sua ocorrência dificilmente seria justificada pela cirurgia facial e/ou posição do paciente durante o procedimento. O jovem apresentava previamente dor em membros inferiores aos exercícios, sugerindo a ocorrência de uma síndrome compartimental crônica. Ele fazia uso de anabolizantes e venlafaxina, não relatado no início do quadro, e a agitação poderia ser explicada por uma síndrome serotoninérgia desencadeada pela interação deste último medicamento e haloperidol. A rabdomiólise secundária a estes eventos causou edema e isquemia nos compartimentos anteriores de ambos os membros inferiores, levando a uma compressão secundária do nervo fibular. O caso em questão ilustra a importância do diagnóstico precoce da síndrome compartimental pois, caso contrário, mesmo com fasciotomia, uma complicação permanente devido à compressão de nervos periféricos pode se estabelecer.

Macrovascular disease in a Japanese-Brazilian population of high prevalence of metabolic syndrome: associations with classical and non-classical risk factors.

BACKGROUND: The Japanese-Brazilian Diabetes Study detected high prevalence of metabolic syndrome (MS) in a population of Japanese ancestry living in Brazil. We describe the prevalence of macrovascular disease (MVD) and its association with classical and non-classical cardiovascular risk factors in this population. METHODS: An overall of 1163 individuals were studied; diagnosis of MVD was based on a score obtained from medical history, ankle-brachial pressure index and electrocardiogram, defining three groups: no MVD, possible MVD and definite MVD. RESULTS: Prevalence of MVD was 14.3% (possible MVD: 11.2%; definite MVD: 3.1%). Individuals with MS had higher rates of MVD (16.9% versus 11.2%; p<0.05). Comparing to no MVD, age, 2 h plasma glucose, anti-LDL(+) and anti-LDL(-) levels, and urinary albumin-to-creatinine ratio were higher in both categories with MVD; waist-to-hip ratio, fasting plasma glucose, HbA1c, total-to-HDL cholesterol ratio and triglycerides were higher in that with definite MVD; systolic blood pressure and homocysteine were higher in that with possible MVD. Using logistic regression, systolic blood pressure, smoking habit and anti-LDL(+) were independently associated with MVD. CONCLUSION: MVD is highly prevalent in Japanese-Brazilians and its association with MS was confirmed. A novel marker of lipoprotein modifications--anti-LDL(+) antibody--could be useful in identifying individuals at higher risk.

Segmental waveform analysis in the diagnosis of peripheral arterial occlusive diseases.

The duplex exam is widely used in the diagnosis of peripheral arterial occlusive disease. It presents some drawbacks, however, such as calcified plaques, sequential stenosis, and time-consuming examinations. A type of waveform analysis, referred to in this study as segmental analysis, was conducted to try to find solutions to these problems. Parameters of waveform analysis (peak systolic velocity, acceleration time, pulsatility, and resistance indices) taken at the common femoral and popliteal arteries in 177 arterial segments (aortoiliac and femoropopliteal) were compared to angiography results in a prospective manner. The statistical analysis showed an accuracy rate above 95% for all parameters in defining hemodynamic-significant (stenosis and occlusions) lesions in both segments. Also, a combination of measurements (parallel tests) was used to differentiate between hemodynamic-significant stenosis and occlusions, showing sensitivity and specificity rates between 84.8% and 94.8%. Findings from this study show that the hemodynamics of an arterial segment can be evaluated by segmental waveform analysis. It can also be used as a screening test for peripheral arterial occlusive diseases alone or combined with the standard duplex color exam.

Desenvolvimento e validação de escala para avaliar qualidade de vida em pacientes com câncer avançado

Aborda o câncer como um problema de saúde pública mundial e no Brasil. Salienta a importância do trabalho multidisciplinar em Oncologia, dirigido para a prevenção, o diagnóstico precoce, o tratamento e a melhora da qualidade de vida dos pacientes com câncer. Sugere que ensino do tratamento da dor deve ser estimulado nos programas de graduação, residência, especialização e pós-graduação em Medicina

O perfil dos profissionais envolvidos em assistência médica em quatro hospitais de Porto Alegre / The profile of professionals involved in medical care in 4 hospitals from Porto Alegre

Foi feito um estudo transversal em uma amostra aleatória de profissionais que prestam assistência nos hospitais do Grupo Hospitalar Conceiçäo. Foram investigadas a formaçäo pós-graduada; o envolvimento atual em pesquisa; o número e o tipo de publicaçöes e as participaçöes em congressos no período de 2 anos (outubro de 87 a outubro de 89). Foi aplicado um questionário semifechado a uma amostra aleatória de médicos, enfermeiros, psicólogos, nutricionistas, farmacêuticos e outros profissionais com cursos universitários. Após várias tentativas em obter respostas, 74% dos profissionais selecionados preencheram os questionários. Quarenta e dois profissionais informaram afirmativamente sobre seu envolvimento em pesquisa. A produçäo científica dos profissionais foi apresentada principalmente em congressos e revistas nacionais. Em relaçäo a formaçäo pós-graduada, 10% referiram possuir algum treinamento formal em ensino e pesquisa. Foram discutidas as implicaçöes dos resultados para o exercício de assistência, ensino e pesquisa. A avaliaçäo finalizou com a sugestäo de um programa de incentivo à pesquisa através da estruturaçäo formal, desenvolvimento de linhas de pesquisa e de um projeto de ascençäo funcional em produçäo científica

Dor crônica: dados preliminares da experiência da abordagem multidisciplinar / Chronic pain: experience preliminary data of multidisciplinary approach

Os autores descrevem a experiência do Centro Integrado da Dor (CID) do Hospital Nossa Senhora da Conceiçäo, em Porto Alegre, atendimento a pacientes com dor desde março de 1986, enfocando a importância da abordagem multidisciplinar na decisäo terapêutica para este sintoma täo complexo, tornando-a mais efetiva e menos invasiva possível. Todos os pacientes atendidos foram com dor crônica e o tratamento clínico foi predominante, seguindo-se os procedimentos anestésicos e nenhum paciente necessitou cirurgia