Frequency of post-treatment disease after excisional procedure in stage IA1 squamous cervical carcinoma - a case series.

Early stages of cervical cancer in young women need conservative treatments. Electrosurgical therapies (LLETZ, LEEP, SWETZ, NETZ) have been recommended for these women. However, there are recommendations to perform a second excision when the specimen margins are not free of disease. This can lead to some important complications. This article aims to verify the frequency of residual invasive or microinvasive disease after the excisional procedure in women with IA1CC. Data on women with IA1CC diagnosed between 1990 and 2022, were retrieved from medical records. Post-treatment disease was detected during a second surgical procedure or postoperative follow-up. Among the 69 included women, three (4.3 percent; CI95 percent 0-9.2) had residual microinvasive lesions, while none showed invasive disease during a second procedure or follow-up. Only the age of 37 years or more was significantly related to the presence of preinvasive or microinvasive residual lesions. Nearly 80 percent of the women who underwent a second procedure showed no residual lesions. The absence of invasive disease in a second procedure or during the follow-up of these women and the large proportion of women with no residual lesion questions the need for a new surgical procedure even when the surgical margins of the initial specimen are involved.

Contribuição da terapia ocupacional para a organização da rotina de mulheres submetidas a tratamento cirúrgico para câncer de mama: um enfoque nas Atividades Instrumentais de Vida Diária (AIVD) / Contribution of occupational therapy to the organization of the routine of women submitted to surgical treatment for breast cancer: a focus on Instrumental Activities of Daily Living (IADL)

Resumo Introdução Mastectomia radical modificada e quadrantectomia são os principais tratamentos cirúrgicos para o câncer de mama; no entanto, podem ocasionar desordens físicas, mentais, sociais e ocupacionais à paciente e sua rede de apoio. Objetivo Analisar o efeito de orientações terapêuticas ocupacionais pré-cirúrgicas na rede de apoio de mulheres submetidas à cirurgia para tratamento de câncer de mama para organizar sua rotina pós-cirúrgica com foco nas Atividades Instrumentais de Vida Diária (AIVD). Método Trata-se de um estudo qualitativo, descritivo-exploratório e longitudinal realizado com 14 mulheres diagnosticadas com câncer de mama e indicadas à cirurgia eletiva, consistindo em orientações personalizadas a sua rede de apoio. Os dados foram coletados em dois momentos: pré- e pós-cirúrgico (após 30 dias) por meio de entrevista semiestruturada via videoconferência gravada e explorados por análise de conteúdo. Resultados As principais orientações fornecidas aos familiares incluíam estratégias para adaptação, graduação e delegação das atividades mais significativas para as participantes. Os achados da pesquisa foram divididos nas seguintes categorias: Família como rede de apoio e o processo de recuperação; Desafios do cuidado; Retorno ao desempenho das AIVD; Segurança da integridade física e emocional; e O terapeuta ocupacional como rede de apoio. As participantes destacaram a relevância do estudo e anseio por ampla cobertura assistencial da terapia ocupacional. Conclusão Os achados sugerem eficácia nas intervenções voltadas à organização da rotina de mulheres mastectomizadas a partir da instrumentalização da rede de apoio para o cuidado colaborativo.

Abstract Introduction Modified radical mastectomy and quadrantectomy are the main surgical treatments for breast cancer; however, they can cause physical, mental, social and occupational disorders to the patient and her support network. Objective To analyze the effect of preoperative occupational therapeutic guidance on the support network of women undergoing breast cancer surgery aiming to organize their postoperative routine with a focus on Instrumental Activities of Daily Living (IADL). Method This is a qualitative, descriptive-exploratory, longitudinal study conducted with 14 women diagnosed with breast cancer and referred to elective surgery, consisting of personalized guidance to their support network. Data were collected at two moments: pre- and post-operatively (30 days after surgery) through recorded semi-structured interviews via videoconference, and explored by content analysis. Results The main guidance provided to family members consisted of strategies for adaptation, grading, and delegating of the activities most significant to the participants. The findings were divided into the following categories: Family as a support network and the recovery process; Care challenges; Resuming IADL performance; Assurance of physical and emotional integrity; The occupational therapist as a support network. The participants highlighted the relevance of the study and their desire for broad Occupational Therapy assistance coverage. Conclusion The findings suggest the efficacy of interventions aimed at the routine organization of women who have undergone mastectomy based on the instrumentalization of their support network for collaborative care.

Negative histology in cervical specimens obtained with the "see and treat" method among women at a referral center in Rio de Janeiro, Brazil: a cross-sectional study.

BACKGROUND: According to the Brazilian Guidelines on Cervical Cancer Screening, women with cytopathologic diagnosis of high-grade intraepithelial lesion, abnormal colposcopic findings, fully visible squamocolumnar junction and age 25 years or older should be treated at the first visit ("see and treat-S&T"). The main limitation to this approach is the risk of overtreatment, identified by histology without preinvasive lesion. The objectives of this study were to identify the overtreatment rate in women undergoing S&T in cervical cancer prevention at a referral center with extensive experience with the method and to detect possible factors associated with this rate. METHODS: This was a cross-sectional study that analyzed records from a database with 616 women submitted to S&T from 1996 to 2017. Negative histology was defined as the following histopathologic results: human papillomavirus without cervical intraepithelial neoplasia (CIN), inflammatory, low-grade squamous intraepithelial lesion, and CIN 1. RESULTS: Of the 616 women, there were 52 (8.44%, 95%CI 6.25-10.64%) with a histopathologic report without preinvasive cervical lesion. No statistical association was found between this outcome and age or a significant downward trend over time. CONCLUSION: The overtreatment rate in this study can be considered low and consistent with the acceptable rates reported in the literature, reinforcing the prevailing Brazilian guideline, in which the benefits of immediate treatment outweigh the risk of losses following biopsy.

A intervenção do terapeuta ocupacional junto às pessoas-hospitalizadas: adotando a abordagem dos cuidados paliativos / The occupational theraphy intervention with people in hospitalization using the paliative care aproach

Resumo Introdução: Um dos maiores problemas de saúde no Brasil é a prevalência de doenças crônicas. A WHO sugere que pacientes com essas doenças recebam cuidados paliativos (CP) desde o diagnóstico. O terapeuta ocupacional pode colaborar no cuidado de pessoas hospitalizadas com ações que promovam dignidade e qualidade de vida ao paciente. Objetivos: Compreender a abordagem de cuidados paliativos adotada por terapeutas ocupacionais no cuidado de pessoas com doenças crônicas; e, conhecer a organização dos cuidados paliativos nos hospitais gerais de Curitiba. Método: É um estudo qualitativo cuja coleta de dados realizou-se através de entrevistas semiestruturadas gravadas para posterior transcrição, categorização, análise e discussão dos resultados. Para tratamento e análise dos dados, utilizou-se a técnica de análise de conteúdo. Resultados: Foram identificadas e discutidas as categorias: "cuidados paliativos nos hospitais gerais de Curitiba: organização do serviço" e "Intervenção do terapeuta ocupacional baseada na abordagem dos cuidados paliativos". Na primeira abrangeu-se a organização dos CP e as dificuldades enfrentadas pelas entrevistadas na prática dessa abordagem; na segunda, foram incluídas as avaliações utilizadas, objetivos e intervenções realizadas. Conclusão: Os relatos demonstraram que a abordagem estava associada à fase final da vida. O tipo de avaliação realizada dependia da organização do serviço de terapia ocupacional da instituição. Os objetivos das intervenções eram condizentes com os princípios dos CP. A realização de atividades significativas foi a principal intervenção citada e todas elas buscavam a promoção da qualidade de vida, bem-estar e manutenção da vida ativa.

Abstract Introduction: One of the worst issues of Brazilian public health is the prevalence of chronic diseases. The WHO suggests that patients who have these diseases should receive Palliative Care (PC) since the diagnostic. The occupational therapist can help in the cares of this hospitalized people, with actions which improve their life quality as well as dignity. Objectives: Comprehend the approach of PC adopted by occupational therapists on the care of hospitalized people with chronicle diseases and know about the structure of palliative care on Curitiba's General Hospitals. Method: It's a qualitative study which collects data from a semi-structured recorded interview for posterior transcription, categorization, analysis and discussion of the results. For the treatment and analysis of data a analysis of content technique was used. Results: It was identified and discussed these following categories: "Palliative Cares inside Curitiba's hospitals: service organization" and "The occupational therapist intervention based in the Palliative Care approach". In the first one the organizations and the struggle that the interviewers have based in this approach experience were included; the second one included the assessments used, objectives and interventions performed. Conclusion: The reports show that the approach was associated with life's final stage. The type of assessment realized depended on the organization of the institution occupational therapy service. The objectives of the interventions were in keeping with the PC principles. The execution of significant activities was the main related intervention and all of them looked for the improvement of life quality, well being and active life conservation.

Reformulação curricular dos cursos de Terapia Ocupacional: resultados e desafios de um percurso / Curricular reformulation of Occupational Therapy courses: results and challenges of a trajectory / Reformulación curricular de los cursos de Terapia Ocupacional: resultados y desafíos de un recorrido

Este artigo relata o processo de reformulação curricular do Curso de Terapia Ocupacional da Universidade Federal do Paraná ocorrido no período de 2013 a 2016. As justificativas para a reformulação foram: a necessidade de alinhamento com as atuais políticas públicas nacionais e os parâmetros nacionais e internacionais para formação profissional. O processo ocorreu de modo participativo e problematizador, culminando em uma matriz curricular delineada por eixos e ênfases específicas, com 3.305 horas distribuídas em cinco anos. A proposta pedagógica contempla a diversidade teórico-prática e didático-metodológica dos docentes. Consideraram-se também: a especificidade da formação em período noturno, o perfil dos estudantes ingressantes, a necessidade de redução nos índices de retenção e evasão, e as mudanças no mercado de trabalho. O desafio agora é a implantação gradativa e a avaliação continuada do novo currículo, de modo a garantir a formação esperada.(AU)

This article describes the process of curricular reformulation of the Occupational Therapy Course of the Federal University of Paraná that took place between 2013 and 2016. The reasons for the reformulation were the need to adapt to current national public policies and national and international parameters for professional education. The process was based on a participatory and problem-raising methodology, culminating in a curricular matrix defined by specific axes and emphases, with 3,305 hours distributed over five years. The pedagogical proposal took into account the theoretical-practical and didactic-methodological diversity of professors. It also considered the specificity of evening classes, the profile of entry-level students, the need to reduce retention and dropout rates, and changes in the labor market. The current challenge is the gradual implementation and ongoing evaluation of the new curriculum to ensure the expected education.(AU)

Este artículo relata el proceso de reformulación curricular del Curso de Terapia Ocupacional de la Universidad Federal de Paraná realizado en el período de 2013 a 2016. Las justificativas para la reformulación fueron la necesidad de alineamiento con las actuales políticas públicas nacionales y los parámetros nacionales e internacionales para formación profesional. El proceso ocurrió de forma participativa y de problematización, culminando en una matriz curricular delineada por ejes y énfasis específicos, con 3.305 horas distribuidas en cinco años. La propuesta pedagógica incluye la diversidad teórico-práctica y didáctico-metodológica de los docentes. También se consideró la especificidad de la formación en período nocturno, el perfil de los estudiantes entrantes, la necesidad de reducción en los índices de retención y evasión y los cambios en el mercado de trabajo. Ahora, el desafío es la implantación gradual y la evaluación continuada del nuevo currículo, para garantizar la formación esperada.(AU)

Terapia Ocupacional em Saúde da Mulher: impacto dos sintomas do climatério na atividade profissional / Occupational Therapy in Women's Health: impact of climacteric symptoms on professional activity / Terapia Ocupacional em Salud de la Mujer: impacto de los síntomas climatéricos en la actividad profesional

O climatério é um processo natural na vida das mulheres, pelo qual muitas passam sem queixas, enquanto outras apresentam sintomas que variam em intensidade e diversidade. Sabese, também, que os distúrbios do comportamento presentes nesse processo são influenciados pelas características sociais e pessoais de cada mulher. Além das alterações biopsicossociais presentes no climatério, há, ainda, as exigências relacionadas à atividade de trabalho, a qual é foco deste estudo, cujo objetivo é compreender quais os impactos do período do climatério no desempenho da atividade profissional. Esta pesquisa caracteriza-se como um estudo qualitativo do tipo descritivo. O estudo qualitativo permite que as participantes da pesquisa falem por si, levando o pesquisador a compreender o significado do fenômeno estudado, ou seja, a relação entre o climatério, seus sinais e sintomas, e o desempenho da atividade profissional, na perspectiva de funcionárias de um hospital. Participaram da pesquisa nove funcionárias de diferentes setores, com idades entre 45 e 59 anos. Utilizou-se como instrumento de coleta de dados um roteiro de entrevista semiestruturado elaborado pela própria pesquisadora. Para análise de informações, foi utilizada a técnica de análise de conteúdo de Bardin (2009), da qual obtiveram-se duas categorias principais, denominadas: "Compreensão do climatério" e "Impactos na atividade de trabalho". Pode-se compreender, através dos relatos,que há impacto decorrente dos sintomas do climatério na atividade de trabalho e que modificações nessa atividade beneficiariam as participantes.

Climacteric is a natural process in the life of women, through which many undergo without complaints, while others present symptoms that vary in intensity and diversity. It is known, also, that the behavioral disorders present in this process are influenced by the social and personal characteristics of each woman. Besides the biopsychosocial changes present in the climacteric, there are, also, the requirements related to the work activity, which is the focus of this study, whose objective is to understand the impacts of the climacteric period on the performance of professional activity. This research is characterized as a qualitative study of the descriptive type. The qualitative study allows the participants of the research to speak for themselves, leading the researcher to understand the meaning of the phenomenon studied , that is, the relations between the climacteric, its signs and symptoms, and the performance of professional activity, from the perspective of female employees of a hospital. Nine female employees from different sectors, aged 45-59, participated in the study. A semi-structured interview script developed by the researcher herself was used as a data collection instrument. For information analysis, the content analysis technique of Bardin (2009) was used, from which two main categories were obtained, denominated: "Understanding the climacteric" and "Impacts on work activity". It can be understood, from the reports, that there is an impact due to climacteric symptoms in the work activity and that modifications in this activity would benefit the participants.

El climaterio es un proceso natural en la vida de las mujeres, en la que muchos van sin quejas, a otros los síntomas varían en intensidad y diversidad. Es conocido también, que los trastornos de comportamiento presentes en este proceso están influenciados por las características sociales y personales de cada mujer. Además de las alteraciones biopsicosociales presentes en el climaterio existen los requisitos relacionados con la actividad laboral, que es el foco de este estudio, cuyo objetivo es entender lo que los impactos de la etapa del climaterio en el desempeño de actividades profesionales. Esta investigación se caracteriza como un estudio descriptivo cualitativo. El estudio cualitativo permite a los participantes de la encuesta hablan por sí mismos, lo que lleva a los investigadores a entender el significado del fenómeno estudiado, es decir, la relación entre lo climaterio, sus signos y síntomas, y el desempeño de la actividad profesional, la perspectiva de los empleados de un hospital. Los participantes eran nueve empleados de diferentes sectores, com edades entre 45 a 59 años. Se utilizó como instrumento de recolección de datos de una guía de entrevista semiestructurada preparado por el investigador. Para el análisis de la información se utilizó el análisis de contenido de Bardin (2009), que se obtuvo en dos categorías principales llamados "Comprensión climaterio" y "Los impactos sobre la actividad laboral". Se puede entender a través de los informes que hay impacto de los síntomas climatéricos em la actividad laboral, y los cambios en esta actividad beneficiaría a los participantes.

Roles of CDKN1A gene polymorphisms (rs1801270 and rs1059234) in the development of cervical neoplasia.

The CDKN1A gene product is a p53 downstream effector, which participates in cell differentiation, development process, repair, apoptosis, senescence, migration, and tumorigenesis. The objective of our study was investigated the importance of two polymorphisms in the CDKN1A gene, rs1801270 (31C>A) and rs1059234 (70C>T), for the development of cervical lesions in a Southeastern Brazilian population (283 cases, stratified by lesion severity, and 189 controls). CDKN1A genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and/or DNA sequencing. CDKN1A 31A allele presents a genetic pattern of protection for the development of high-grade cervical lesions (CC vs CA genotype: OR = 0.60; 95 % CI = 0.38-0.95; p = 0.029; CA+AA vs CC genotype: OR = 0.60; 95 % CI = 0.39-0.93; p = 0.021). Allele distributions of the CDKN1A 70C>T polymorphism were also different between the two study groups, with the CDKN1A 70T allele being less prevalent among cases. Moreover, the double heterozygote genotype combination 31CA-70CT decreases the chance of developing high-grade squamous intraepithelial lesion (HSIL) and cancer (OR = 0.55; 95 % CI = 0.32-0.93; p = 0.034) by 50 %, representing a protective factor against the development of more severe cervical lesions.

Percepções sobre as mudanças nas atividades cotidianas e nos papéis ocupacionais de mulheres no climatério / Perceptions on daily activities changes and occupational roles of women in climacteric stage

O climatério é definido como o processo natural do ciclo de vida feminino, inerente à transição da fase reprodutiva para a fase não reprodutiva, e tem o seu marco principal com a menopausa. Durante esse período, a mulher perpassa por várias mudanças fisiológicas, emocionais, sociais e econômicas, que podem impactar negativamente nas atividades exercidas. Com o objetivo de analisar as percepções e os significados atribuídos pelas mulheres atendidas no Ambulatório de Climatério do HC-UFPR sobre o impacto nas atividades cotidianas e nos papéis ocupacionais, realizou-se uma pesquisa exploratória e qualitativa através de um questionário estruturado com dados socioeconômicos, contendo também um check-list autoaplicável e uma entrevista semiestruturada, com aferição dos dados através de técnicas de análise de conteúdo. Observou-se que o preconceito social e o desconhecimento pela mulher sobre as mudanças ocorridas nessa fase se constituem em barreiras para realização de diversas atividades, afetando os cuidados necessários com a saúde e, consequentemente, prejudicando a sua qualidade de vida. Em contrapartida, nesse período, muitas mulheres apresentam maior habilidade de adaptação, descobrindo novas atividades, realizando planos adiados e desempenhando novos papéis ocupacionais. Constata-se a importância da compreensão sobre as mudanças, as percepções e os significados do climatério pela própria mulher e pelos profissionais, para a formulação de uma assistência integral e na qual se valorize a sua individualidade.

A comparison between type 3 excision of the transformation zone by straight wire excision of the transformation zone (SWETZ) and large loop excision of the transformation zone (LLETZ): a randomized study.

BACKGROUND: The management of preinvasive cervical lesions has the objective to ensure the absence of invasive lesions and to prevent progression to cancer. Excisional procedures have been preferred to treat these lesions as they report the presence of unsuspected invasive lesions and the status of surgical margins, allowing inferring full excision when such are free of disease. The purpose of this study is to determine whether Straight Wire Excision of the Transformation Zone (SWETZ) is a better alternative than Large Loop Excision of the Transformation Zone (LLETZ-cone) as a type 3 excision of the Transformation Zone (TZ) to reduce incomplete excision and concerning other outcomes of surgical interest. METHOD: Randomized controlled trial including women who needed type 3 excision of the TZ referred to a colposcopy clinic after cytological screening between January 2008 thru December 2011. The interventions were performed using local anesthesia and sedation in an inpatient basis by different experienced surgeons. The study enrolled and randomized 164 women, of which 82 were allocated to each group. After exclusions, 78 remained in SWETZ and 76 in LLETZ-cone groups for the analysis of outcomes of surgical interest and 52 and 54, respectively, for the margins analysis. RESULTS: There was an even distribution between the groups after randomization and exclusions, concerning mean age, parity, current smoking, prior cytological diagnosis and histopathological diagnosis obtained in cone specimen even after exclusions. We observed significantly higher risk of compromised or damaged endocervical margin in specimens resulting from the LLETZ-cone in relation to SWETZ (RR 1.72, 95% CI: 1.14 to 2.6), with an absolute risk reduction (ARR) of 26.4% (95% CI: 8.1 to 44.8) for patients operated by SWETZ. The specimens obtained by SWETZ showed less fragmentation (ARR = 19.8%, 95% CI: 10.3 - 29.3%), but the procedure took longer. There were complications in 5.6% of the procedures, with no significant differences between the groups. CONCLUSION: This study showed a lower proportion of compromised or damaged endocervical surgical margin in specimens resulting from SWETZ in relation to LLETZ-cone. SWETZ demonstrated to be more efficient than LLETZ-cone concerning less fragmentation of the specimen obtained. However, it accounted for longer surgical time. Both techniques showed morbidity TRIAL REGISTRATION: Number at ClinicalTrials.gov: NCT01929993 (June 10, 2012).

Effects of MDM2 promoter polymorphisms on the development of cervical neoplasia in a Southeastern Brazilian population.

We investigated the importance of two adjacent functional polymorphisms in the Murine Double Minute 2 (MDM2) gene, SNP285 G > C and SNP309 T > G, for the development of cervical lesions in a Southeastern Brazilian population (293 cases and 184 controls). MDM2 genotyping was performed by PCR-RFLP (Polymerase Chain Reaction-Restriction Fragment Length Polymorphism) and/or DNA sequencing. MDM2 SNP309 has potential as a biomarker of cervical neoplasia in non-smokers, patients with family history of cancer, or those who had late sexual debut (>16 years). Besides, this polymorphism may help identify women at risk of developing severe cervical lesion at a young age (<30 years).

Association of CDKN2A polymorphisms with the severity of cervical neoplasia in a Brazilian population.

Variants of p16(INK4a) and p14(ARF), encoded by the CDKN2A locus, may respond differently to the presence of human papillomavirus (HPV). We investigated the potential association of two CDKN2A polymorphisms, 500C > G (rs11515) and 540C > T (rs3088440), with cervical neoplasia in patients with cervical lesions and healthy controls (n = 492). Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP), single-strand conformation polymorphism (SSCP) and/or DNA sequencing techniques were employed for genotyping. The 500G allele was found higher, whereas the 540T/T genotype was less frequent in patients with more severe lesions. The CDKN2A variants may have the potential to be markers for the management of patients with cervical neoplasia.

Recurrence of cervical intraepithelial neoplasia in human immunodeficiency virus-infected women treated by means of electrosurgical excision of the transformation zone (LLETZ) in Rio de Janeiro, Brazil.

CONTEXT AND OBJECTIVE: Human immunodeficiency virus (HIV)-infected women have higher incidence, prevalence, persistence and recurrence of pre-invasive cervical lesions (CIN II or III). The aim here was to investigate the risk of recurrence of CIN II/III among HIV-infected women (HIV+) and uninfected women in a cohort treated by means of large-loop excision of the transformation zone (LLETZ). DESIGN AND SETTING: Cohort study conducted at Instituto Fernandes Figueira/Fundação Oswaldo Cruz (IFF/Fiocruz). METHODS: 60 HIV+ and 209 HIV-negative patients were included in a cohort for follow-up after undergoing LLETZ to treat CIN II/III. A histopathological diagnosis of CIN II/III during the follow-up was taken to constitute recurrence. The following possible confounding variables were assessed: age at treatment and at end of follow-up; histological grade of intraepithelial disease treated; surgical margin involvement; adequacy of colposcopy during the follow-up; CD4+ lymphocyte count; HIV viral load; and type of antiretroviral therapy. RESULTS: Among the 60 HIV+ women, six showed recurrent disease during the follow-up. However, among the 209 HIV-negative women, seven showed a new precursor lesion. The relative risk of disease recurrence in the HIV+ women was 4.21 (95% CI = 1.42 to 12.43). The Kaplan-Meyer curve showed that the risk of recurrence was significantly higher among HIV+ women (log-rank test: P = 0.0111). CONCLUSION: The HIV+ women in our cohort presented a risk of CIN II/III recurrence at least 42% higher than among the HIV-negative women. These patients should form part of a rigorous screening and follow-up protocol for identification and appropriate treatment of cervical cancer precursor lesions.

O processo criativo de pacientes internados para tratamento quimioterápico: uma contribuição a partir do pensamento de D. W. Winnicott / The creative process for chemotherapy in-patients: a contribution from the thought of D. W. Winnicott

A experiência da Terapia Ocupacional no uso de atividades como instrumento terapêutico possibilita a promoção de um espaço de criatividade. Neste sentido o estudo buscou identificar o modo pelo qual o paciente vivencia o processo criativo, ao desenvolver atividades durante o período deinternamento e tratamento quimioterápico. Constituindo-se em um estudo de abordagem clínico qualitativa, que utilizou o referencial teórico da teoria do amadurecimento de D. W. Winnicott. Para sua realização, foram realizados 5 encontrosindividuais com 9 pacientes internados para tratamento quimioterápico. O primeiro encontro foi destinado a entrevista inicial e nos demais encontros a proposta consistiu em realizar uma atividade. Ao final de cada encontro o paciente respondia a uma entrevista semi estruturada, que foi audiogravada e o material coletado transcrito. As informações obtidas foram submetidas à análise de conteúdo. A partir desse processo emergiram seiscategorias temáticas: a vivência do tempo, o brincar no processo criativo, a subjetividade na ação, a criatividade como metáfora, o emergir da criatividade e crença religiosa. Verificou-se que o processo de realização de atividade apresentou-se como um ato criativo que expressava o modo particular pelo qual cada pacienteatribuía sentido e significado as suas experiências no mundo.

The experience of Occupational Therapy using activities as therapeutic tools promotes a space for creativity. Within this context, we sought to identify the way in which the patient experiences the creative process, while developingactivities during his time of hospitalization and chemotherapy. It is a clinical study of qualitative approach and its theoretical framework was guided by the theory of maturation by D. W. Winnicott. To achieve our objective, 5 private meetings wereheld with 9 patients admitted for chemotherapy; the fi rst meetingintended to an initial interview and the following meetings intended to performing an activity. At the end of each meeting the patient responded to a semi-structured interview, which was recorded and later on transcribed. The information collected was later subjectto content analysis. From this process six thematic categories emerged: the experience of time, the play in the creative process, subjectivity in action, creativity as a metaphor, the emergence of creativity and religious belief. It was found that the process of performing an activity showed itself as a creative act that expressed the particular way through which each patient gave meaning and significance to their experiences in the world.

Recurrence of cervical intraepithelial neoplasia in human immunodeficiency virus-infected women treated by means of electrosurgical excision of the transformation zone (LLETZ) in Rio de Janeiro, Brazil / Recorrencia de neoplasias intraepiteliais cervicais em mulheres infectadas com o virus da imunodeficiencia humana tratadas pela exerese eletrocirurgica da zona de transformacao (EZT) no Rio de Janeiro, Brasil

CONTEXT AND OBJECTIVE: Human immunodeficiency virus (HIV)-infected women have higher incidence, prevalence, persistence and recurrence of pre-invasive cervical lesions (CIN II or III). The aim here was to investigate the risk of recurrence of CIN II/III among HIV-infected women (HIV+) and uninfected women in a cohort treated by means of large-loop excision of the transformation zone (LLETZ). DESIGN AND SETTING: Cohort study conducted at Instituto Fernandes Figueira/Fundação Oswaldo Cruz (IFF/Fiocruz). METHODS: 60 HIV+ and 209 HIV-negative patients were included in a cohort for follow-up after undergoing LLETZ to treat CIN II/III. A histopathological diagnosis of CIN II/III during the follow-up was taken to constitute recurrence. The following possible confounding variables were assessed: age at treatment and at end of follow-up; histological grade of intraepithelial disease treated; surgical margin involvement; adequacy of colposcopy during the follow-up; CD4+ lymphocyte count; HIV viral load; and type of antiretroviral therapy. RESULTS: Among the 60 HIV+ women, six showed recurrent disease during the follow-up. However, among the 209 HIV-negative women, seven showed a new precursor lesion. The relative risk of disease recurrence in the HIV+ women was 4.21 (95% CI = 1.42 to 12.43). The Kaplan-Meyer curve showed that the risk of recurrence was significantly higher among HIV+ women (log-rank test: P = 0.0111). CONCLUSION: The HIV+ women in our cohort presented a risk of CIN II/III recurrence at least 42% higher than among the HIV-negative women. These patients should form part of a rigorous screening and follow-up protocol for identification and appropriate treatment of cervical cancer precursor lesions. .

CONTEXTO E OBJETIVOS: Mulheres infectadas pelo vírus da imunodeficiência humana (HIV) apresentam maior incidência, prevalência, persistência e recorrência após tratamentos de lesões pré-invasivas do colo uterino (NIC II ou III). O objetivo foi verificar o risco de recorrência de NIC II/III em mulheres infectadas pelo HIV (HIV+) e não infectadas (HIV-) em uma coorte tratada pela exérese eletrocirúrgica da zona de transformação do colo uterino (EZT). TIPO DE ESTUDO E LOCAL: Estudo de tipo coorte realizado no Instituto Fernandes Figueira/Fundação Oswaldo Cruz (IFF/Fiocruz). MÉTODOS: 60 HIV+ e 209 HIV- foram incluídas em uma coorte após terem sido submetidas à EZT para tratamento de NIC II/III. Foi considerado como recorrência o diagnóstico histopatológico de NIC II/III. Foram estudadas as seguintes variáveis possivelmente confundidoras: idade no tratamento e ao final do seguimento, grau histológico da doença intra-epitelial tratada, comprometimento de margens, adequação da colposcopia no seguimento, contagem de linfócitos CD4+, carga viral de HIV e tipo de terapia antiretroviral. RESULTADOS: Dentre as 60 mulheres HIV+, 6 apresentaram doença recorrente durante o seguimento. De 209 HIV-, 7 apresentaram uma nova lesão precursora. O risco relativo de recorrência de doença nas HIV+ foi de 4,21 (IC 95% 1,42-12,43). Uma curva de Kaplan-Meyer mostra que o risco de recorrência é significativamente maior em mulheres HIV+ (teste de log-rank: P = 0,0111). CONCLUSÃO: Mulheres HIV+ em nossa coorte apresentaram risco de recorrência pelo menos 42% maior do que mulheres HIV-. Essas pacientes devem fazer parte de um protocolo de rastreio e acompanhamento rigoroso para identificação e tratamento adequado das lesões precursoras do câncer ...

Effectiveness of see-and-treat for approaching pre-invasive lesions of uterine cervix.

OBJECTIVE: To compare the effectiveness between the see-and-treat (S&T) approach and the conventional one (with prior biopsy) for squamous intraepithelial lesions of uterine cervix. METHODS: A cross-sectional study was conducted with 900 nonpregnant women with cytology suggestive of high grade squamous intraepithelial lesions in the city of Rio de Janeiro, Southeastern Brazil, between 1998 and 2004. The S&T approach consists of a large loop excision of the transformation zone procedure and is recommended when cytology is suggestive of high grade squamous intraepithelial lesion, satisfactory colposcopy with abnormalities compatible with the suspected cytological results, and the lesion is limited to the ectocervix or extends up to one centimeter of the endocervical canal. A subgroup of 336 patients whose colposcopy was considered satisfactory was analyzed, and they were divided into two groups for comparison: patients treated without prior biopsy (n = 288) and patients treated after a biopsy showing high grade squamous intraepithelial lesions (n = 48). Patients who were not treated or only treated more than a year later after recruitment at the colposcopy unit were considered dropouts. RESULTS: Of patients recruited during the study period, 71 were not treated or were only treated for at least a year. The overall dropout rate was 7.9% (95% CI: 6.1;9.7). Mean time elapsed between patient recruitment and treatment was 17.5 days in the S&T group and 102.5 days in the prior biopsy group. Dropout rates were 1.4% (95% CI: 0.04;2.7) and 5.% (95% CI: 0;12.3), respectively (p=0.07). The proportion of overtreated cases (negative histology) in the S&T group was 2.0% (95% CI: 0.4;3.6). CONCLUSIONS: The difference in the mean time elapsed between patient recruitment and treatment indicates that S&T is a time-saving approach The proportion of negative cases from using the S&T approach can be regarded as low.

Effectiveness of see-and-treat for approaching pre-invasive lesions of uterine cervix / Efetividade da abordagem "ver e tratar" em lesões pré-invasivas no colo uterino / Efectividad del abordaje "ver y tratar" en lesiones pre-invasivas en el colon uterino

OBJECTIVE: To compare the effectiveness between the see-and-treat (S&T) approach and the conventional one (with prior biopsy) for squamous intraepithelial lesions of uterine cervix. METHODS: A cross-sectional study was conducted with 900 nonpregnant women with cytology suggestive of high grade squamous intraepithelial lesions in the city of Rio de Janeiro, Southeastern Brazil, between 1998 and 2004. The S&T approach consists of a large loop excision of the transformation zone procedure and is recommended when cytology is suggestive of high grade squamous intraepithelial lesion, satisfactory colposcopy with abnormalities compatible with the suspected cytological results, and the lesion is limited to the ectocervix or extends up to one centimeter of the endocervical canal. A subgroup of 336 patients whose colposcopy was considered satisfactory was analyzed, and they were divided into two groups for comparison: patients treated without prior biopsy (n = 288) and patients treated after a biopsy showing high grade squamous intraepithelial lesions (n = 48). Patients who were not treated or only treated more than a year later after recruitment at the colposcopy unit were considered dropouts. RESULTS: Of patients recruited during the study period, 71 were not treated or were only treated for at least a year. The overall dropout rate was 7.9 percent (95 percent CI: 6.1;9.7). Mean time elapsed between patient recruitment and treatment was 17.5 days in the S&T group and 102.5 days in the prior biopsy group. Dropout rates were 1.4 percent (95 percent CI: 0.04;2.7) and 5. percent (95 percent CI: 0;12.3), respectively (p=0.07). The proportion of overtreated cases (negative histology) in the S&T group was 2.0 percent (95 percent CI: 0.4;3.6). CONCLUSIONS: The difference in the mean time elapsed between patient recruitment and treatment indicates that S&T is a time-saving approach The proportion of negative cases from using the S&T approach can be regarded as low.

OBJETIVO: Comparar a efetividade do método "ver-e-tratar" (V&T) com a abordagem tradicional (biópsia prévia) das lesões escamosas intraepiteliais do colo uterino. MÉTODOS: Trata-se de um estudo transversal realizado na cidade do Rio de Janeiro, RJ, de 1998 a 2004, com 900 pacientes não gestantes que apresentavam citologia sugestiva de lesão intraepitelial escamosa de alto grau. O método V&T inclui a excisão ampla da zona de transformaçao que é indicada quando a citologia é sugestiva de lesão intra-epitelial escamosa de alto grau, a colposcopia é satisfatória e compatível com a alteração citológica e a alteração colposcópica deve estar limitada à ectocérvice e ao primeiro centímetro do canal cervical. Foi analisado o subgrupo de 336 pacientes com colposcopias consideradas satisfatórias, compreendendo dois grupos para comparação: pacientes tratadas sem biópsia prévia (n=288) versus pacientes tratadas após a biópsia mostrando lesão intraepitelial escamosa de alto grau (n=48). Foram consideradas perdas as pacientes não tratadas ou tratadas apenas um ano ou mais após recrutamento pela clínica de colposcopia, no grupo V&T. RESULTADOS: Das pacientes recrutadas durante o período do estudo, 71 não foram tratadas ou foram tratadas apenas um ano mais tarde, fornecendo uma taxa global de abandonos de 7,9 por cento (IC 95 por cento: 6,1;9,7). O tempo médio entre a captação da paciente e o tratamento foi de 17,5 dias no V&T e 102,5 dias no grupo biópsia prévia. As taxas de perdas foram de 1,4 por cento (IC 95 por cento: 0,04;2,7) no grupo V&T e de 5,9 por cento (IC 95 por cento: 0;12,3) no de biópsia prévia (p=0,07). A proporção de tratamentos desnecessários (histologia negativa) no grupo V&T foi 2,0 por cento (IC 95 por cento: 0,4;3,6). CONCLUSÕES: A diferença de tempo médio entre a captação da paciente e o tratamento indicou que o V&T é um método que poupa tempo. A proporção de casos negativos quando o método V&T foi utilizado pode ser considerada baixa.

OBJETIVO: Comparar la efectividad del método "ver-y-tratar" (V&T) con el abordaje tradicional (biopsia previa) de las lesiones escamosas intraepiteliales del colon uterino. MÉTODOS: Estudio transversal realizado en la ciudad de Rio de Janeiro, Sureste de Brasil, de 1998 a 2004, con 900 pacientes no gestantes que presentaban citología sugestiva de lesión intraepitelial escamosa de alto grado. El método V&T incluye la excisión amplia de la zona de transformación que es indicada cuanto la citología es sugestiva de lesión intraepitelial escamosa de alto grado, la colposcopia es satisfactoria y compatible con la alteración citológica y la alteración colposcópica debe estar limita a la ectocervix y la primer centímetro del canal cervical. Fue analizado el subgrupo de 336 pacientes con colposcopias consideradas satisfactorias, comprendiendo dos grupos para comparación: pacientes tratadas sin biopsia previa (n=288) versus pacientes tratadas posterior a la biopsia mostrando lesión intraepitelial escamosa de alto grado (n=48). Fueron consideradas pérdidas las pacientes no tratadas o tratadas sólo un año o más posterior al reclutamiento por la clínica de colposcopia, en el grupo V&T. RESULTADOS: De las pacientes reclutadas durante el período de estudio, 71 no fueron tratadas o fueron tratadas sólo un año más tarde, suministrando una tasa global de abandonos de 7,9 por ciento (IC 95 por ciento: 6,1;9,7). El tiempo promedio entre la captación de la paciente y el tratamiento fue de 17,5 días en el V&T y 102,5 días en el grupo biopsia previa. Las tasas de pérdidas fueron de 1,4 por ciento (IC 95 por ciento: 0,04;2,7) en el grupo V&T y de 5,9 por ciento (IC 95 por ciento: 0;12,3) en el de biopsia previa (p=0,07). La proporción de tratamientos innecesarios (histología negativa) en el grupo V&T fue 2,0 por ciento (IC 95 por ciento:0,4;3,6). CONCLUSIONES: La diferencia de tiempo promedio entre la captación de la paciente y el tratamiento indicó que el V&T ...

Prevalence of high-grade squamous intraepithelial lesions and cervical cancer among patients with unsatisfactory colposcopic examination, without visible lesion / Prevalência de lesão intra-epitelial escamosa de alto grau e câncer cervical em pacientes sem lesão visível à colposcopia insatisfatória

Context and objetive: Cervical cancer is a serious public health problem in Brazil. For patients with unsatisfactory colposcopic examinations without visible lesions, but with cervical cytological tests suggesting high-grade squamous intraepithelial lesion (HSIL), the national recommendation is to repeat cervical cytological tests after three months. Our aim was to assess the prevalence of HSIL and cancer among patients with initial cervical cytological tests suggestive of HSIL but with unsatisfactory colposcopic examinations without visible lesions, in order to contribute towards the discussion regarding a more effective clinical approach that might diminish the likelihood of patient abandonment of follow-up before appropriate diagnosis and treatment. Design and setting: Cross-sectional study in Colposcopy Clinic of IFF/Fiocruz. Method: Patients admitted between December 1989 and April 2007 with cytological diagnoses of HSIL but with unsatisfactory colposcopic examinations without visible lesions underwent cervical cone biopsy. Results: Sixty-five such patients were included, comprising 33.8 percent with HSIL and 4.6 percent with cancer, confirmed histologically. The other patients presented low-grade squamous intraepithelial lesion (26.1 percent), glandular dysplasia (1.5 percent) and absence of disease (33.8 percent). Cpnclusion: The observed prevalence of cancer and HSIL does not seem to be enough to justify immediate referral for cone biopsies to investigate the cervical canal in these cases. The findings suggest that the recommendation of repeated cytological tests following an initial one with HSIL, among patients with unsatisfactory colposcopic examinations without visible lesions, is appropriate in our setting. Efforts are needed to ensure adherence to follow-up protocols in order to reduce the chances of losses.

Introdução: O câncer de colo uterino é um grave problema de saúde pública no Brasil. Em pacientes com colpocitologias sugestivas de lesão intra-epitelial escamosa de alto grau (HSIL) e colposcopia insatisfatória sem lesão visível, a recomendação nacional é repetir a colpocitologia após três meses. Nosso objetivo foi medir a prevalência de HSIL e câncer em pacientes com a primeira colpocitologia sugestiva de HSIL e colposcopia insatisfatória sem lesão visível, no intuito de contribuir para a discussão sobre uma conduta clínica mais efetiva e que diminua a probabilidade de perdas de acompanhamento antes do diagnóstico e tratamento adequados. Tipo de estudo e local: Estudo transversal no Ambulatório de Colposcopia do IFF/Fiocruz. MÉTODO: Pacientes recebidas no período de dezembro de 1989 a abril de 2007 com diagnóstico citológico de HSIL sem lesão visível em colposcopias insatisfatórias foram submetidas a conização do colo uterino. Resultados: Foram incluídas 65 pacientes na situação descrita e encontrados 33,8 por cento de HSIL e 4,6 por cento de câncer confirmados histologicamente. Os demais casos apresentaram lesão intra-epitelial escamosa de baixo grau (26,1 por cento), displasia glandular (1,5 por cento) e ausência de doença (33,8 por cento). Conclusão: A prevalência de HSIL ou câncer encontrada não parece suficiente para defender a conduta de encaminhar as pacientes de imediato para conização a fim de investigar o canal cervical. Os achados sugerem que a recomendação de repetir a citologia após uma primeira com HSIL sem lesão visível e colposcopia insatisfatória é apropriada no nosso cenário. Devem ser implementados esforços para adesão às recomendações de acompanhamento e reduzir a chance de perdas.

Prevalence of cervical intraepithelial neoplasia grades II/III and cervical cancer in patients with cytological diagnosis of atypical squamous cells when high-grade intraepithelial lesions (ASC-H) cannot be ruled out / Prevalência de neoplasia intra-epitelial cervical graus II/III e câncer cervical nas pacientes com diagnóstico citológico de células escamosas atípicas, quando não se pode excluir lesão intra-epitelial de alto grau (ASC-H)

Context and objective: The latest update of the Bethesda System divided the category of atypical squamous cells of undetermined significance (ASCUS) into ASC-US (undetermined significance) and ASC-H (high-grade intraepithelial lesion cannot be ruled out). The aims here were to measure the prevalence of pre-invasive lesions (cervical intraepithelial neoplasia, CIN II/III) and cervical cancer among patients referred to Instituto Fernandes Figueira (IFF) with ASC-H cytology, and compare them with ASC-US cases. Design and setting: Cross-sectional study with retrospective data collection, at the IFF Cervical Pathology outpatient clinic. Methods: ASCUS cases referred to IFF from November 1997 to September 2007 were reviewed according to the 2001 Bethesda System to reach cytological consensus. The resulting ASC-H and ASC-US cases, along with new cases, were analyzed relative to the outcome of interest...

Contexto e objetivo: A última atualização do Sistema Bethesda dividiu a categoria de células escamosas atípicas de significado indeterminado (ASCUS) em ASC-US (de significado indeterminado) e ASC-H (quando não se pode excluir lesão intra-epitelial de alto grau). Os objetivos deste estudo foram medir a prevalência da lesão pré-invasiva (Neoplasia Intra-epitelial Cervical, NIC II/III) e câncer cervical, de pacientes que foram encaminhadas ao Instituto Fernandes Figueira (IFF), com citologia ASC-H e compará-la com os casos ASC-US. Tipo de estudo e local: Estudo transversal com coleta de dados retrospectiva, que ocorreu no ambulatório de Patologia Cervical do IFF. Métodos: Casos com diagnóstico de ASCUS recebidos no IFF entre novembro de 1997 a setembro de 2007, foram revisados de acordo com o Sistema Bethesda 2001 até um diagnóstico de consenso. Os casos ASC-H e ASC-US resultantes desta revisão, e os casos novos, foram analisados em relação ao desfecho de interesse...

Prevalence of high-grade squamous intraepithelial lesions and cervical cancer among patients with unsatisfactory colposcopic examination, without visible lesion.

CONTEXT AND OBJECTIVE: Cervical cancer is a serious public health problem in Brazil. For patients with unsatisfactory colposcopic examinations without visible lesions, but with cervical cytological tests suggesting high-grade squamous intraepithelial lesion (HSIL), the national recommendation is to repeat cervical cytological tests after three months. Our aim was to assess the prevalence of HSIL and cancer among patients with initial cervical cytological tests suggestive of HSIL but with unsatisfactory colposcopic examinations without visible lesions, in order to contribute towards the discussion regarding a more effective clinical approach that might diminish the likelihood of patient abandonment of follow-up before appropriate diagnosis and treatment. DESIGN AND SETTING: Cross-sectional study in Colposcopy Clinic of IFF/Fiocruz. METHOD: Patients admitted between December 1989 and April 2007 with cytological diagnoses of HSIL but with unsatisfactory colposcopic examinations without visible lesions underwent cervical cone biopsy. RESULTS: Sixty-five such patients were included, comprising 33.8% with HSIL and 4.6% with cancer, confirmed histologically. The other patients presented low-grade squamous intraepithelial lesion (26.1%), glandular dysplasia (1.5%) and absence of disease (33.8%). CONCLUSION: The observed prevalence of cancer and HSIL does not seem to be enough to justify immediate referral for cone biopsies to investigate the cervical canal in these cases. The findings suggest that the recommendation of repeated cytological tests following an initial one with HSIL, among patients with unsatisfactory colposcopic examinations without visible lesions, is appropriate in our setting. Efforts are needed to ensure adherence to follow-up protocols in order to reduce the chances of losses.