Spiritual Distress, Hopelessness, and Depression in Palliative Care: Simultaneous Concept Analysis.

Spiritual distress, hopelessness, and depression are concepts that are often used in palliative care. A simultaneous concept analysis (SCA) of these concepts is needed to clarify the terminology used in palliative care. Therefore, the aim of this study is to conduct a SCA of spiritual distress, hopelessness, and depression in palliative care. A SCA was performed using the methodology of Haase's model. A literature search was conducted in March 2020 and updated in April 2022 and April 2024. The search was performed on the following online databases: CINAHL with Full-Text, MEDLINE with Full-Text, MedicLatina, LILACS, SciELO, and PubMed. The search was achieved without restrictions on the date of publication. A total of 84 articles were included in this study. The results highlight that the three concepts are different but also share some overlapping points. Spiritual distress is embedded in the rupture of their spiritual/religious belief systems, a lack of meaning in life, and existential issues. Hopelessness is a sense of giving up and an inability to control and fix the patient's situation. Finally, depression is a state of sadness with a multi-impaired situation. In conclusion, refining the three concepts in palliative care is essential since it promotes clarification and enhances knowledge development towards intervention.

Cervical Cancer Screening with DNA-HPV Testing and Precancerous Lesions Detection: A Brazilian Population-based Demonstration Study.

OBJECTIVE: To evaluate the rates of precancerous lesions, colposcopy referral, and positive predictive value (PPV) by age groups of a population-based screening with DNA-HPV testing. METHODS: The present demonstration study compared 16,384 HPV tests performed in the first 30 months of the program with 19,992 women tested in the cytology screening. The colposcopy referral rate and PPV for CIN2+ and CIN3+ by age group and screening program were compared. The statistical analysis used the chi-squared test and odds ratio (OR) with 95% confidence interval (95%CI). RESULTS: The HPV tests were 3.26% positive for HPV16-HPV18 and 9.92% positive for 12 other HPVs with a 3.7 times higher colposcopy referral rate than the cytology program, which had 1.68% abnormalities. Human Papillomavirus testing detected 103 CIN2, 89 CIN3, and one AIS, compared with 24 CIN2 and 54 CIN3 detected by cytology (p < 0.0001). The age group between 25 and 29 years old screened by HPV testing had 2.4 to 3.0 times more positivity, 13.0% colposcopy referral, twice more than women aged 30 to 39 years old (7.7%; p < 0.0001), and detected 20 CIN3 and 3 early-stage cancer versus 9 CIN3 and no cancer by cytology screening (CIN3 OR= 2.10; 95%CI: 0.91-5.25; p = 0.043). The PPV of colposcopy for CIN2+ ranged from 29.5 to 41.0% in the HPV testing program. CONCLUSION: There was a significant increase in detections of cervix precancerous lesions in a short period of screening with HPV testing. In women < 30 years old, the HPV testing exhibited more positivity, high colposcopy referral rate, similar colposcopy PPV to older women, and more detection of HSIL and early-stage cervical cancer.

OBJETIVO: Avaliar as taxas de lesões pré-cancerosas, encaminhamento para colposcopia e valor preditivo positivo (VPP) por faixas etárias de rastreamento populacional com teste DNA-HPV. MéTODOS: O presente estudo de demonstração comparou 16.384 testes de HPV realizados nos primeiros 30 meses do programa com 19.992 mulheres testadas no rastreio citológico. Os programas foram comparados por taxa de encaminhamento de colposcopia e VPP para NIC2+ e NIC3+ por faixa etária. A análise estatística utilizou o teste de qui-quadrado e odds ratio (OR, na sigla em inglês) com intervalo de confiança (IC) de 95%. RESULTADOS: Os testes de HPV foram 3,26% positivos para HPV16-HPV18 e 9,92% positivos para 12 outros HPVs, com uma taxa de encaminhamento de colposcopia 3,7 vezes maior do que o programa de citologia, que teve 1,68% de anormalidades. O teste de HPV detectou 103 NIC2, 89 NIC3 e um AIS, em comparação com 24 NIC2 e 54 NIC3 detectados por citologia (p < 0,0001). O rastreio por teste de HPV no grupo etário 25 a 29 anos teve 2,4 a 3,0 vezes mais positividade, 13,0% de encaminhamento para colposcopia, 2 vezes mais que mulheres de 30 a 39 anos (7,7%; p < 0,0001), e detectou 20 NIC3 e 3 cânceres em estágio inicial versus nove NIC3 e nenhum câncer pelo rastreio citológico (NIC3 OR= 2,10; 96%CI: 0,91­5,25; p = 0,043). O VPP da colposcopia para NIC2+ variou de 29,5 a 41,0% no programa de teste de HPV. CONCLUSãO: Houve um aumento significativo na detecção de lesões pré-cancerosas do colo do útero em um curto período de rastreamento com teste de HPV. Em mulheres < 30 anos, o teste de HPV exibiu mais positividade, alta taxa de encaminhamento para colposcopia com VPP semelhante a mulheres mais velhas, e mais detecção de HSIL e de câncer cervical em estágio inicial.

Screen-and-treat approach in managing cervical cancer precursor lesions: An observational study with 524 women.

OBJECTIVE: To detect factors related to overtreatment with the "Screen-and-treat" approach (S&T) in women with suspicious cervical precancerous lesions. STUDY DESIGN: A retrospective observational study of 524 women with high-grade squamous intraepithelial lesions (HSIL) or more severe (HSIL+) in cytology, treated by the Large Loop Excision of the Transformation Zone (LLETZ): 161 without a previous biopsy (S&T group) and 363 with a previous biopsy (biopsy group) from January 2017 to July 2020. The main outcome was a diagnosis of LLETZ: negative (negative or low-grade squamous intraepithlelial lesion LSIL) or HSIL+. A negative diagnosis was interpreted as "overtreatment." Results were analyzed as a function of the S&T approach (whether previous biopsy or not). Variables were obtained from medical records, and were compared with Chi-square or Fisher's exact test (p, p-value), to estimate the chances of a logistic regression analysis (Odds Ratio, OR, or admitting a Confidence Interval (CI) of 95 %). RESULTS: No differences were observed in groups regarding menopausal status, smoking, hormonal contraceptive use, colposcopy findings, LLETZ diagnosis, and recurrence. Comparing biopsy vs S&T groups, the frequency of women over 40 years was 28.4 % vs 39.7 % (p = 0.011), and transformation zone type 3 was 12.2 vs 26.8 % (p < 0.001), respectively. In women managed by S&T, when compared to a LLETZ diagnosis, an HSIL+ result was more frequent in women presenting with TZ 1 (93.1 % TZ1 vs 78.5 % TZ2 vs 73.8 % TZ3, p = 0.008) and in women with abnormal colposcopy (92.9 % abnormal vs 38.1 % negative, p < 0.001). Multiple regression analysis found that women with negative colposcopic findings presented a higher risk for negative LLETZ diagnosis (LSIL/Negative final histology) (18.6; 6.18-56.02). CONCLUSIONS: No difference was observed in the LLETZ diagnosis in women who did or did not use the S&T approach: it was adequate for women referred by cytological HSIL along with high-grade colposcopic findings.

Cervical Cancer Screening with DNA-HPV Testing and Precancerous Lesions Detection: A Brazilian Population-based Demonstration Study / Rastreamento do câncer do colo do útero com teste de DNA-HPV e detecção de lesões precursoras: um estudo de demonstração de base populacional brasileiro

Abstract Objective To evaluate the rates of precancerous lesions, colposcopy referral, and positive predictive value (PPV) by age groups of a population-based screening with DNA-HPV testing. Methods The present demonstration study compared 16,384 HPV tests performed in the first 30 months of the program with 19,992 women tested in the cytology screening. The colposcopy referral rate and PPV for CIN2+ and CIN3+ by age group and screening program were compared. The statistical analysis used the chi-squared test and odds ratio (OR) with 95% confidence interval (95%CI). Results The HPV tests were 3.26% positive for HPV16-HPV18 and 9.92% positive for 12 other HPVs with a 3.7 times higher colposcopy referral rate than the cytology program, which had 1.68% abnormalities. Human Papillomavirus testing detected 103 CIN2, 89 CIN3, and one AIS, compared with 24 CIN2 and 54 CIN3 detected by cytology (p < 0.0001). The age group between 25 and 29 years old screened by HPV testing had 2.4 to 3.0 times more positivity, 13.0% colposcopy referral, twice more than women aged 30 to 39 years old (7.7%; p < 0.0001), and detected 20 CIN3 and 3 early-stage cancer versus 9 CIN3 and no cancer by cytology screening (CIN3 OR= 2.10; 95%CI: 0.91 -5.25; p = 0.043). The PPV of colposcopy for CIN2+ ranged from 29.5 to 41.0% in the HPV testing program. Conclusion There was a significant increase in detections of cervix precancerous lesions in a short period of screening with HPV testing. In women < 30 years old, the HPV testing exhibited more positivity, high colposcopy referral rate, similar colposcopy PPV to older women, and more detection of HSIL and early-stage cervical cancer.

Resumo Objetivo Avaliar as taxas de lesões pré-cancerosas, encaminhamento para colposco pia e valor preditivo positivo (VPP) por faixas etárias de rastreamento populacional com teste DNA-HPV. Métodos O presente estudo de demonstração comparou 16.384 testes de HPV realizados nos primeiros 30 meses do programa com 19.992 mulheres testadas no rastreio citológico. Os programas foram comparados por taxa de encaminhamento de colposcopia e VPP para NIC2+ e NIC3+ por faixa etária. A análise estatística utilizou o teste de qui-quadrado e odds ratio (OR, na sigla em inglês) com intervalo de confiança (IC) de 95%. Resultados Os testes de HPV foram 3,26% positivos para HPV16-HPV18 e 9,92% positivos para 12 outros HPVs, com uma taxa de encaminhamento de colposcopia 3,7 vezes maior do que o programa de citologia, que teve 1,68% de anormalidades. O teste de HPV detectou 103 NIC2, 89 NIC3 e um AIS, em comparação com 24 NIC2 e 54 NIC3 detectados por citologia (p < 0,0001 ). O rastreio por teste de HPV no grupo etário 25 a 29 anos teve 2,4 a 3,0 vezes mais positividade, 13,0% de encaminhamento para colposcopia, 2 vezes mais que mulheres de 30 a 39 anos (7,7%; p < 0,0001 ), e detectou 20 NIC3 e 3 cânceres em estágio inicial versus nove NIC3 e nenhum câncer pelo rastreio citológico (NIC3 OR= 2,10; 96%CI: 0,91 -5,25; p = 0,043). O VPP da colposcopia para NIC2+ variou de 29,5 a 41,0% no programa de teste de HPV. Conclusão Houve um aumento significativo na detecção de lesões pré-cancerosas do colo do útero em um curto período de rastreamento com teste de HPV. Em mulheres < 30 anos, o teste de HPV exibiu mais positividade, alta taxa de encaminhamento para colposcopia com VPP semelhante a mulheres mais velhas, e mais detecção de HSIL e de câncer cervical em estágio inicial.

Brazilian Society of Surgical Oncology consensus on fertility-sparing surgery for cervical cancer.

OBJECTIVE: Several controversies remain on conservative management of cervical cancer. Our aim was to develop a consensus recommendation on important and novel topics of fertility-sparing treatment of cervical cancer. METHODS: The consensus was sponsored by the Brazilian Society of Surgical Oncology (BSSO) from March 2020 to September 2020 and included a multidisciplinary team of 55 specialists. A total of 21 questions were addressed and they were assigned to specialists' groups that reviewed the literature and drafted preliminary recommendations. Further, the coordinators evaluated the recommendations that were classified by the level of evidence, and finally, they were voted by all participants. RESULTS: The questions included controversial topics on tumor assessment, surgical treatment, and surveillance in conservative management of cervical cancer. The two topics with lower agreement rates were the role of minimally invasive approach in radical trachelectomy and parametrial preservation. Additionally, only three recommendations had <90% of agreement (fertility preservation in Stage Ib2, anti-stenosis device, and uterine transposition). CONCLUSIONS: As very few clinical trials have been developed in surgery for cervical cancer, most recommendations were supported by low levels of evidence. We addressed important and novel topics in conservative management of cervical cancer and our study may contribute to literature.

Cervical Cancer Screening with HPV Testing: Updates on the Recommendation / Rastreamento do câncer do colo de útero com teste de HPV: Atualizações na recomendação

Abstract The present update is a reassessment of the 2018 'Guidelines for HPV-DNA Testing for Cervical Cancer Screening in Brazil' (Zeferino et al.)9, according to the changes observed in new international guidelines and knowledge updates. The most relevant and recent guidelines were assessed. Questions regarding the clinical practice were formulated, and the answers considered the perspective of the public and private sectors of the Brazilian health system. The review addressed risk-based strategies regarding age to start and stop screening, the use of cytology and colposcopy to support management decisions, treatment, follow-up strategies, and screening in specific groups, including vaccinated women. The update aims to improve the prevention of cervical cancer and to reduce overtreatment and the misuse of HPV testing.

Resumo Esta atualização é uma reavaliação das "Recomendações para o uso de testes de DNAHPV no rastreamento do câncer do colo do útero no Brasil" (Zeferino et al., 2018),9 de acordo com as mudanças observadas nas novas recomendações internacionais, além das atualizações no conhecimento. As recomendações mais relevantes e recentes foram avaliadas. Questões referentes à prática clínica foram formuladas, e as respostas consideraram a perspectiva do sistema de saúde brasileiro, tanto público quanto privado. Esta revisão abrange estratégias baseadas em risco sobre idade para início e término de rastreamento, o uso da citologia e colposcopia para apoiar as condutas, tratamento, estratégias de seguimento, e rastreamento em grupos específicos, incluindo mulheres vacinadas. Esta atualização tem o objetivo de melhorar as estratégias de prevenção do câncer do colo de útero e reduzir o supertratamento e o uso incorreto dos testes de HPV.

Cervical Cancer Screening with HPV Testing: Updates on the Recommendation.

The present update is a reassessment of the 2018 'Guidelines for HPV-DNA Testing for Cervical Cancer Screening in Brazil' (Zeferino et al.)9, according to the changes observed in new international guidelines and knowledge updates. The most relevant and recent guidelines were assessed. Questions regarding the clinical practice were formulated, and the answers considered the perspective of the public and private sectors of the Brazilian health system. The review addressed risk-based strategies regarding age to start and stop screening, the use of cytology and colposcopy to support management decisions, treatment, follow-up strategies, and screening in specific groups, including vaccinated women. The update aims to improve the prevention of cervical cancer and to reduce overtreatment and the misuse of HPV testing.

Esta atualização é uma reavaliação das "Recomendações para o uso de testes de DNA-HPV no rastreamento do câncer do colo do útero no Brasil" (Zeferino et al., 2018),9 de acordo com as mudanças observadas nas novas recomendações internacionais, além das atualizações no conhecimento. As recomendações mais relevantes e recentes foram avaliadas. Questões referentes à prática clínica foram formuladas, e as respostas consideraram a perspectiva do sistema de saúde brasileiro, tanto público quanto privado. Esta revisão abrange estratégias baseadas em risco sobre idade para início e término de rastreamento, o uso da citologia e colposcopia para apoiar as condutas, tratamento, estratégias de seguimento, e rastreamento em grupos específicos, incluindo mulheres vacinadas. Esta atualização tem o objetivo de melhorar as estratégias de prevenção do câncer do colo de útero e reduzir o supertratamento e o uso incorreto dos testes de HPV.

Organization of cervical cancer screening with DNA-HPV testing impact on early-stage cancer detection: a population-based demonstration study in a Brazilian city.

Background: Cervical cancer is a preventable disease, and the Brazilian screening is opportunistic and has low impact. The current study evaluated an initiative to organize screening using DNA-HPV testing as a replacement for cytology. Methods: This demonstration study examined information from 16 384 DNA-HPV tests for screening in women aged 25-64 years from Indaiatuba city between October 2017-March 2020. The comparison was 20 284 women screened using cytology between October 2014-March 2017. The flowchart indicates the repetition of a negative test in five years. HPV16- and/or HPV18-positive tests and the 12 pooled high-risk HPV-positive tests with abnormal liquid-based cytology were referred for colposcopy. If cytology was negative, the HPV test was repeated in 12 months. The analyses evaluated coverage, age-group compliance, and cancer detected. Findings: After 30 months, the coverage projection was greater than 80%. The age compliance for the HPV test was 99.25%, compared to 78.0% in the cytology program. The HPV test program showed 86.8% negative tests and 6.3% colposcopy referrals, with 78% colposcopies performed. The HPV testing program detected 21 women with cervical cancer with a mean age of 39.6 years, and 67% of cancers were early-stage compared to 12 cervical cancer cases detected by cytological screening (p=0.0284) with a mean age of 49.3 years (p=0.0158), and one case of early-stage (p=0.0014). Interpretation: Organizing cervical cancer screening using DNA-HPV testing demonstrated high coverage and age compliance in a real-life scenario, and it had an immediate impact on cervical cancer detection at an early-stage. Funding: University of Campinas, Indaiatuba City, and Roche Diagnostics.

Rastreamento do câncer do colo do útero com teste de DNA-HPV: atualizações na recomendação / Cervical cancer screening with DNA-HPV testing: updates on the recommendation

Esta é uma atualização da recomendação de especialistas publicada em 2018 para o uso do teste de detecção do DNA-HPV de alto risco no rastreamento do câncer do colo do útero no Brasil, de acordo com as mudanças observadas nas diretrizes internacionais e atualizações do conhecimento. As recomendações mais relevantes e recentes foram revisadas. Questões referentes à prática clínica foram formuladas, e as respostas consideraram a perspectiva do sistema de saúde brasileiro, tanto público quanto privado. Essa revisão abrange estratégias baseadas em risco sobre idade para início e término de rastreamento, o uso da citologia e colposcopia para apoiar as condutas, tratamento, estratégias de seguimento, e rastreamento em grupos específicos, incluindo mulheres vacinadas. O objetivo é melhorar as estratégias de prevenção do câncer do colo do útero e reduzir o supertratamento e o uso incorreto dos testes de HPV.(AU)

Conservative treatment of microinvasive squamous cell carcinoma of the cervix stage IA1: Defining conization height to an optimal oncological outcome.

OBJECTIVE: This paper searches an ideal cone height for stage definition and safe treatment of cervical microinvasive squamous carcinoma stage IA1 (MIC IA1), avoiding excessive cervix resection, favoring a future pregnancy. METHODS: A retrospective study was performed involving 562 women with MIC IA1, from 1985 to 2013, evaluating cone margin involvement, depth of stromal invasion, lymph vascular invasion, conization height, and residual uterine disease (RD). High-grade squamous lesions or worse detection was considered recurrence. Univariate and multivariate regression analyses were performed, including age, conization technique (CKC, cold-knife, or ETZ, excision of transformation zone), and pathological results. Conization height to provide negative margins and the risk of residual disease were analyzed. RESULTS: Conization was indicated by biopsy CIN2/3 in 293 cases. Definitive treatments were hysterectomy (69.8%), CKC (20.5%), and ETZ (9.7%). Recurrence rate was 5.5%, more frequent in older women (p = 0.030), and less frequent in the hysterectomy group (p = 0.023). Age ≥40 years, ETZ and conization height are independent risk factors for margin involvement. For ages <40 years, 10 mm cone height was associated with 68.6% Negative Predictive Value (NPV) for positive margins, while for 15 mm and 25 mm, the NPV was 75.8% and 96.2%, respectively. With negative margins, the NPV for RD varied from 85.7-92.3% for up to 24 mm cone height and 100% from 25 mm. CONCLUSION: Conization 10 mm height for women <40 years provided adequate staging for almost 70%, with 10% of RD and few recurrences. A personalized cone height and staging associated with conservative treatment are recommended.

End-of-life: An urgent update in nursing terminology.

Although nursing terminologies and classifications represent nursing knowledge across diverse clinical areas, end-of-life care seems under represented in many aspects of these instruments. NANDA- I is an international nursing diagnostic classification widely used in nursing education and research. This taxonomy is based on seven axes, including the axis of time. In this commentary we bring discussion to the need to update nursing terminology by including the term end-of-life in the time axis of NANDA-I. After describing the epidemiologic aspects of end-of-life care and discussing the relevant nursing role, we discuss patients' and family's human responses towards the end-of-life time and circumstance, which are central to defining nursing diagnoses. End-of-life care is one priority in health care, and nursing diagnoses should represent that situation as well. This paper focuses on a specific and international nursing diagnosis classification, NANDA-I, which lacks an end-of-life component to its time axis for defining labels of nursing diagnoses. Attending to the importance of classifications in clinical reasoning, nursing diagnoses could better represent responses towards this health condition, opening new opportunities for increasing nursing roles in clinical practice, and also for new studies aiming to validate nursing diagnoses, and promoting an evidence-based practice by including end-of-life in the axis time.

Cervical cancer in women under 25 years of age and outside the screening age: Diagnosis profile and long-term outcomes.

OBJECTIVE: To evaluate the pattern of cervical cancer (CC) diagnosis and outcomes in women under 25. METHODS: Thirty-two women younger than 25 years of age treated between 2001 and 2016 were studied and the year, symptom or cytology before diagnosis, time since sexual debut, age group, histology, and stage were considered. Data were compared with older age groups, and survival analysis was performed using a subset of them. RESULTS: Thirty-two CC diagnoses (1.5% of all cases) exhibited a positive linear trend (P = 0.075). Driven by cytology, 18 were asymptomatic and 14 were symptomatic (with vaginal bleeding in 11). The mean time since sexual debut was 6.9 years. Advanced stage (44% vs 29%) and adenosquamous histology (12.5% vs 1.7%-5.0%) were higher in younger women. Five-year overall survival rate was 76%, better for squamous cell carcinoma (SCC) (86% vs 43% for other histologies; P = 0.018). There were seven deaths, all within 15 months of diagnosis. Age groups of less than 25 years (53%) and 25-29 years (48.5%) had similar proportions of Stage IA1. CONCLUSION: The rate of CC-diagnosed women under 25 years was 1.5% of all cases, exhibiting more advanced stage and non-SCC histology. For asymptomatic women, cytology allowed the diagnosis at an early stage. Being symptomatic and non-SCC was associated with a higher proportion of advanced stages and poor survival.

Elimination of cervical cancer in low- and middle-income countries: Inequality of access and fragile healthcare systems.

In 2018, WHO called for global action to eliminate cervical cancer. The complexity of the processes involved in terms of prevention is often underestimated. Low- and middle-income countries do not have a robust healthcare framework to ensure high-quality programs. The present article discusses how fragile healthcare systems are barriers to eliminating cervical cancer, and also reports the experience of a Brazilian prevention program. The article considers how cervical cancer can be interpreted as an indicator of inequality: how women's attitudes and access to care determine an early or late diagnosis, and how strategies combining vaccine and DNA-HPV tests are crucial. New vaccine schemes, the critical analysis of local data, strengthening communication, managing sentinel events, and integrating vaccination and screening data for the health information system are some of the key activities to sustainable improvement in both access and quality of care.

Post-radiotherapy hysterectomy does not benefit females with cervical adenocarcinoma.

Cervical adenocarcinoma is associated with a poor prognosis, which may be caused by the infiltrative growth pattern and metastasis of tumor cells. There is a lack of consensus on hysterectomy after radiotherapy for the improvement of selected cases. The present study aimed to assess the oncological outcome of post-radiotherapy hysterectomy in females with cervical adenocarcinoma. A total of 39 females with cervical adenocarcinoma at stages IB1 to IIIB, managed primarily with radiotherapy with complete response, and underwent extrafascial hysterectomy as consolidation therapy between 1988 to 2015 were studied. Surgery complications and residual disease were evaluated. A comparison group was constructed, comprising 41 females with cervical adenocarcinoma managed with exclusive radiotherapy or chemoradiotherapy demonstrating complete response, without surgery. Descriptive and survival analysis was performed. The groups were comparable in terms of age, cancer stage, radiotherapy (dose and duration) and follow-up, although 67% of hysterectomies were performed prior to 2002 and 46% of the radiotherapy group received chemoradiation. Late complications were similar. There were nine recurrences (23%) in the case series and 10 recurrences (24%) in the radiotherapy group. Residual disease was detected in 56% (22/39) of uterine specimens, of which 12 were up to 10 mm. Residual disease was associated with recurrence (31% vs. 6%, P=0.028). The overall survival rate was 75% for the case series vs. 88% for the radiotherapy group (P=0.579), and the disease-free survival rate was 79-80% for both. Removal of residual disease by hysterectomy did not improve the overall survival rate (P=0.283) and disease-free survival rate (P=0.072). Post-radiotherapy hysterectomy in cervical adenocarcinoma is a feasible procedure with acceptable complications, however, it did not bring relevant benefits in recurrences, disease-free survival, and overall survival rates.

Cervical cancer screening program based on primary DNA-HPV testing in a Brazilian city: a cost-effectiveness study protocol.

BACKGROUND: The causal relationship between high-risk (hr) HPV infection and precancerous lesions or cervical cancer has led to the development of strategies to increase screening performance and prevent this cancer. The increased sensitivity of DNA-HPV testing compared to cervical cytology favors DNA-HPV testing as a primary screening test. Cervical cancer screening in Brazil is opportunistic, and this cancer remains a considerable health problem with a high proportion of diagnoses in advanced stages. This paper aims to describe the design and implementation of the Cervical Cancer Screening Program with primary DNA-HPV testing (CCSP-HPV) planned for Indaiatuba City (SP), Brazil; the strategies to achieve higher population coverage; and a study protocol for cost-effectiveness analyses. METHODS: The CCSP-HPV was designed based on successful guidelines that replaced cervical cytology-based screening by the DNA-HPV test performed at 5-year intervals. The screening will be performed for the female population aged 25-64 years cared for by the public health system and aim to reach 80% coverage after completing the first round. The chosen DNA-HPV test detects 14 hr-HPV types and genotypes HPV-16 and 18. All women with a negative test will be reassessed after five years. Women showing a positive test for HPV-16 and/or 18 will be referred for colposcopy. Those showing the other 12 hr-HPV types will be tested by cytology, and if any abnormality is detected, they will also be referred for colposcopy. The histopathologic evaluation will be reviewed by a pathologist panel and aided by p16 immunohistochemistry. A cost-effectiveness analysis will be performed by a Markov model comparing the cost of the new program and the screening performed by conventional cytology five years prior (2011-2016). DISCUSSION: The new screening program is considered a breakthrough for public health regarding cervical cancer, which is the third leading cause of cancer death among Brazilian women. Achieving at least 80% coverage will have the possibility to change this scenario. The proposed program will provide a modern cervical cancer screening method for women, and information about cost-effectiveness will help other similar places support the decision of implementing cervical cancer screening using the DNA-HPV test.

Novos Tempos, Novos Desafios: Estratégias para Equidade de Acesso ao Ensino Remoto Emergencial / New Times, New Challenges: Strategies to Ensure Equal Access to Emergency Remote Education

Resumo: Introdução: Com a suspensão das atividades presenciais e a implementação do ensino remoto do curso de Medicina da Unicamp, foi necessária a elaboração de estratégias para identificar as necessidades dos estudantes para continuidade das aulas nessa nova modalidade. Objetivo: Demonstrar as estratégias desenvolvidas e as soluções encontradas para permitir a equidade de acesso ao ensino remoto no curso de medicina da FCM-Unicamp. Método: São apresentados dados do relatório institucional, elaborado a partir de questionários aplicados para os estudantes do curso de Medicina sobre as dificuldades referentes ao acesso ao ensino remoto emergencial e as ações realizadas para solucionar as principais dificuldades encontradas. Resultados: Constatamos que os anos iniciais do curso apresentam a maior proporção de alunos com dificuldades, embora, em todos os anos, os discentes tenham relatado alguma dificuldade. Os principais problemas identificados foram internet instável e/ou apenas acesso por redes móveis. Verificou-se ainda que os alunos tinham maior dificuldade em acompanhar as atividades síncronas. A maior parte dos alunos mencionou que acompanhava as aulas por computadores e notebooks, mas, muitas vezes, estes eram compartilhados com outros membros da família. Alguns estudantes apontaram também que muitas vezes, não conseguiam acompanhar o curso por falta de aparelhos ou acesso à internet. Nesse caso, computadores e chips de celular e para uso em tablets eram emprestados aos alunos. Houve orientação aos professores para adequação das ferramentas pedagógicas utilizadas. Conclusão: Garantir a equidade de acesso é fundamental para permitir a continuidade dos estudos na transformação do estudo presencial em remoto emergencial. O ato de escutar os alunos sobre as dificuldades em relação ao ensino remoto e a realização de suporte material são ferramentas essenciais para o sucesso dessa estratégia pedagógica. A orientação do corpo docente em relação às dificuldades dos alunos foi importante para adequação do ensino remoto. Essas ações auxiliaram os estudantes na mudança do ensino imposta pelo distanciamento social.

Abstract: Introduction: After the implementation of remote teaching for the academic activities of the Medicine course at UNICAMP, due to the COVID Pandemic, a new strategy was required to identify the needs of students to allow them to keep up with the course in this new pedagogical modality. Objective: To demonstrate the strategies developed and solutions found to allow for equal access to remote education in the medical course at FCM-UNICAMP. Method: We present data from our institutional report based on questionnaires completed by medical students regarding the difficulties related to access to emergency remote education and the actions taken to solve the main difficulties encountered. Results: We identified that the initial years of the course had the highest proportion of students with difficulties, although all students reported some difficulty. The main problems identified were unstable internet and/or only access via mobile networks, and the most significant difficulty was in accessing the synchronous activities. Most students reported attending classes via computer and notebooks, but this device was often shared with other family members, most notably during the pandemic. Thirty-one students reported difficulties that prevented them from following the course adequately due to lack of devices or internet access. One solution was computers and cell phone chips and tablets being loaned out to students. Teachers were instructed to adapt the pedagogical tools used. Conclusion: Ensuring equal access is essential to support studies to continue following the transition from face-to-face classes to emergency remote study. Listening to students about the difficulties concerning remote teaching is an essential tool for the success of this pedagogical strategy. Guidance of the teaching staff in relation to the difficulties encountered by students was important for the adequacy of remote teaching. These actions helped students in the change of teaching imposed by social distancing.

Estimating the public health impact of a national guideline on cervical cancer screening: an audit study of a program in Campinas, Brazil.

BACKGROUND: A Brazilian guideline on cervical cancer screening was released in 2011. The objective was to verify changes in screening indicators around this period. METHODS: An audit study which sample was all screening tests performed by the public health system of Campinas city from 2010 to 2016. Variables were absolute tests numbers, excess tests, intervals and results, by age. For trend analysis was used Cochran-Armitage × 2 and linear regression. RESULTS: Were carried out 62,925 tests in 2010 and 43,523 tests in 2016, a tendency at a reduction (P = 0.001). Excess tests were higher than 50% over the years, with a tendency at a reduction (P < 0.001). Tests performed on women under 25 ranged from 20.2 to 15.4% in the period (P < 0.001), while in the 25-64 years age-group, it ranged from 75.1 to 80.2% (P < 0.001). In 2010 the most frequent interval was annual (47.5%) and in 2016 biennial (34.7%). There was a tendency at a reduction in the proportion of tests performed at the first time and those with an annual interval (P < 0.001), and also a tendency at an increase in tests with intervals equal to or greater than biannual (P < 0.001). We observed a tendency at a reduction in LSIL and HSIL-CIN2 results (P = 0.04 and P = 0.001, respectively), and a tendency at an increase in HSIL-CIN3 result (P = 0.02). CONCLUSION: The proportion of cervical cancer screening tests performed out of the recommendation showed a significant reduction in the period. This indicates a tendency to align cervical cancer screening in Campinas with the standards recommended.