Impact of COVID-19 pandemic on surgical activity in the Brazilian private healthcare system.

INTRODUCTION: Surgical volume was drastically reduced in many countries due to challenges imposed by the COVID-19 pandemic. OBJECTIVES: We sought to estimate the number of cancelled surgical and diagnostic procedures within the Brazilian private healthcare system between 2020 and 2021 over the course of the COVID-19 pandemic, and to project the procedural backlog generated for specific elective and time-sensitive surgeries, and diagnostic procedures. METHODS: Data were systematically extracted from the Brazilian national regulatory agency for the private healthcare system and included (i) quarterly and annual surgical and diagnostic volume, and (ii) the number of private health insurance beneficiaries between January 2016 and June 2021. Based on pre-pandemic data we estimated the expected number of surgical and diagnostic procedures that failed to be performed between 2020 and 2021. RESULTS: The average quarterly surgical and diagnostic procedures declined by 29.5% in 2020 and by 21.5% in 2021 compared to 2019. In 2020, such reduction reflected a lower number of diagnostic procedures under anesthesia (-35.1%), as well as elective (-14.7%), time-sensitive (-18.8%), and urgent (-4.6%) surgeries. In the first half of 2021, though the surgical and diagnostic procedures increased compared to 2020, they remained significantly below their historical average. The estimated backlogs were 134.385,64 for total surgical procedures, 2.634,64 for bariatric surgery and arthroplasty revision (elective surgeries), 2.845,61 for oncologic (time-sensitive) surgeries, and 304.193,99 for diagnostic procedures, requiring 1.7, 15.9, and 6.8 years, respectively, to make up for such backlogs. CONCLUSION: There was a major decline on the number of surgical and diagnostic procedures due to the COVID-19 pandemic. Despite a slight recovery of elective surgeries throughout the pandemic, many time-sensitive surgeries and diagnostic procedures were cancelled, with potential medium- to long-term consequences to patients and the system as a whole.

Physical fitness, hormonal profile, nutritional and psychological aspects assessment of transgender women volleyball players submitted to physical tests: protocol paper of a prospective cohort.

To evaluate aerobic capacity, strength and other physiological, nutritional, and psychological variables which may influence the performance of transgender women (TW) athletes and compare them to cisgender women (CW) and cisgender men (CM) athletes, as well as changes in TW performance over the course of a year. Prospective cohort study including three groups: TW, CW and CM volleyball athletes. Subjects will be comprehensively assessed at two different moments: baseline and after 6-12 months of adequate hormonal therapy. Evaluation will comprise clinical, medical, nutritional and psychological interviews, incremental treadmill cardiopulmonary exercise testing, hand grip strength test, vertical jump test, analysis of sleep quality (Pittsburgh Sleep Quality Index), hormonal profile, echocardiogram, analysis of resting energy expenditure, assessment of bone mass and body composition through dual-energy X-ray absorptiometry scans, and untargeted metabolomic analysis. CW and CM matched by age, body mass index and level of physical activity will undergo a similar evaluation. The assessment of the strength, aerobic capacity, haematological, nutritional and psychological status of TW using gold-standard tests will contribute to understanding the impact of oestrogen therapy on the exercise performance of these athletes and how they compare with CW and CM.

Breaking bad news in neurology: assessing training, perceptions, and preparedness among residency programs in Brazil.

OBJECTIVE: • Neurology trainees and program directors recognized a lack of structured breaking bad news training. • Program directors reported that many factors hinder the implementation of breaking bad news education. • Trainees felt capable of breaking bad news, but most did not have lectures, simulations, nor feedback. • Trainees acknowledged negative feelings when breaking bad news, including sadness and helplessness. We aimed to evaluate how breaking bad news training was implemented in neurology residency programs in Brazil and to assess the perception and preparedness of trainees and program directors. METHODS: We performed a cross-sectional descriptive study. Neurology trainees and program directors were recruited from the Brazilian Academy of Neurology registry through convenience sampling. Participants answered a survey evaluating the breaking bad news training at their institution and their preparedness and perception towards the topic. RESULTS: We collected 172 responses from 47 neurology institutions from all five socio-demographic regions of Brazil. More than 77% of trainees were dissatisfied with their breaking bad news training, and around 92% of program directors believed their programs required substantial improvement. Approximately 31% of neurology trainees reported never having a lecture about communicating bad news, 66% reported never having a simulated training, and nearly 61% never received feedback regarding their communication abilities. Moreover, 59% of program directors acknowledged that feedback was not a standard practice and nearly 32% reported the absence of any specific training. CONCLUSION: This study suggested that the breaking bad news training in neurology residencies across Brazil is deficient and highlighted challenges to achieve this core competency. Program directors and trainees recognized the importance of the topic, and program directors acknowledged that many factors hinder the ability to implement formal training. Given the relevance of such a skill to patient care, every effort should be made to provide structured training opportunities during residency.

Breaking bad news in neurology: assessing training, perceptions, and preparedness among residency programs in Brazil

ABSTRACT Objective We aimed to evaluate how breaking bad news training was implemented in neurology residency programs in Brazil and to assess the perception and preparedness of trainees and program directors. Methods We performed a cross-sectional descriptive study. Neurology trainees and program directors were recruited from the Brazilian Academy of Neurology registry through convenience sampling. Participants answered a survey evaluating the breaking bad news training at their institution and their preparedness and perception towards the topic. Results We collected 172 responses from 47 neurology institutions from all five socio-demographic regions of Brazil. More than 77% of trainees were dissatisfied with their breaking bad news training, and around 92% of program directors believed their programs required substantial improvement. Approximately 31% of neurology trainees reported never having a lecture about communicating bad news, 66% reported never having a simulated training, and nearly 61% never received feedback regarding their communication abilities. Moreover, 59% of program directors acknowledged that feedback was not a standard practice and nearly 32% reported the absence of any specific training. Conclusion This study suggested that the breaking bad news training in neurology residencies across Brazil is deficient and highlighted challenges to achieve this core competency. Program directors and trainees recognized the importance of the topic, and program directors acknowledged that many factors hinder the ability to implement formal training. Given the relevance of such a skill to patient care, every effort should be made to provide structured training opportunities during residency.

Palliative care in Hospitalized Middle-Aged and Older Adults With COVID-19.

CONTEXT: As COVID-19 overwhelms health systems worldwide, palliative care strategies may ensure rational use of resources while safeguarding patient comfort and dignity. OBJECTIVE: To describe palliative care practices in hospitalized middle-aged and older adults in two of the largest COVID-19 treatment centers in Sao Paulo, Brazil. METHODS: Retrospective cohort. Eligible patients were those aged 50 years or older hospitalized between March and May 2020 with a laboratory confirmation of SARS-CoV-2 infection. Palliative care implementation was defined as present if medical notes indicated a decision to limit escalation of life support measures, or when opioids or sedatives were prescribed for palliative management of symptoms. RESULTS: We included 1162 participants (57% male, median 65 years). Overall, 21% were frail and 54% were treated in intensive care units, but only 17% received palliative care. Stepwise logistic regression demonstrated that age ≥80 years, dementia, history of stroke or cancer, frailty, having a PaO2/FiO2<200 or a C-reactive protein ≥150mg/dL at admission predicted palliative care implementation. Patients placed under palliative care stayed longer (13 vs.11 days) and were more likely to die in hospital (86 vs.27%). They also spent more days in ICU and received vasoactive drugs, hemodialysis, and invasive ventilation more frequently. CONCLUSIONS: One in five middle-aged and older adults hospitalized with COVID-19 received palliative care in our cohort. Patients who were very old, multimorbid, frail, and had severe COVID-19 were more likely to receive palliative care. However, it was often delayed until advanced and invasive life support measures had already been implemented.

Accuracy of echocardiography and chest tomography for pulmonary hypertension screening in patients awaiting lung transplantation.

OBJECTIVE: To examine the accuracy of a pulmonary hypertension screening strategy based on a combination of echocardiographic data and tomographic measurements (pulmonary artery diameter and pulmonary artery diameter to ascending aorta diameter ratio) in patients with chronic lung disease referred for lung transplantation. METHODS: A retrospective observational study with patients with pulmonary emphysema or fibrosis referred for transplantation between 2012 and 2016. Pulmonary hypertension was defined as mean pulmonary artery pressure ≥25mmHg, or between 21 and 24mmHg, with pulmonary vascular resistance >3 Wood units on right heart catheterization. Tomographic measurements were made by two independent radiologists. RESULTS: This sample comprised 13 patients with emphysema and 19 patients with pulmonary fibrosis. Of these, 18 had pulmonary hypertension. The level of agreement in tomographic measurements made by radiologists was high (intraclass correlation coefficients 0.936 and 0.940, for pulmonary artery diameter and pulmonary artery diameter to ascending aorta diameter ratio, respectively). Areas under the ROC curves constructed for pulmonary artery diameter, pulmonary artery diameter to ascending aorta diameter ratio, and pulmonary artery systolic pressure as predictors of pulmonary hypertension were 0.540, 0.629 and 0.783, respectively. The sensitivity, specificity and negative predictive value of pulmonary artery systolic pressure ≥40mmHg were 67%, 79% and 65%, respectively. The combined criterion (pulmonary artery diameter to ascending aorta diameter ratio >1 and/or pulmonary artery systolic pressure ≥40mmHg) achieved sensitivity of 72%, specificity of 79%, and a negative predictive value of 69%. CONCLUSION: Measurements of pulmonary artery and ascending aorta diameter were highly reproducible. The association of pulmonary artery and aortic diameter >1 and/or pulmonary artery systolic pressure ≥40mmHg improved the sensitivity and the negative predictive value for pulmonary hypertension screening. This strategy demands prospective validation to assess safety and cost-effectiveness.

Barriers to enrollment in pulmonary rehabilitation: medical knowledge analysis.

OBJECTIVE: To assess clinicians' knowledge about pulmonary rehabilitation, and identify the barriers faced when referring patients with health insurance to pulmonary rehabilitation. METHODS: This was a survey-based cross-sectional study conducted in 2019, at a private reference hospital in São Paulo, Brazil. Eligible participants were physicians registered with the following specialties: internal medicine, geriatrics, cardiology, pulmonology or thoracic surgery. RESULTS: We collected 72 responses, and 99% of participants recognized chronic obstructive pulmonary disease as a potential indication for pulmonary rehabilitation; less often (75%), they listed interstitial lung disease, bronchiectasis and pulmonary hypertension. Most participants (67%) incorrectly associated pulmonary rehabilitation with lung function improvement, while 28% of cardiologists and 35% of internists/geriatricians failed to recognize benefits on mood disorders. Notably, 18% of participants recommended pulmonary rehabilitation only to patients on supplemental oxygen and 14% prescribed only home physical therapy, patterns more commonly seen among non-respiratory physicians. The three most perceived barriers to referral and adherence were health insurance coverage (79%), transportation to pulmonary rehabilitation center (63%) and lack of social support (29%). CONCLUSION: Financial, logistic and social constraints pose challenges to pulmonary rehabilitation enrollment, even for patients with premium healthcare insurance. Moreover, physician knowledge gaps may be an additional barrier to pulmonary rehabilitation referral and adherence. Providing continued medical education, incorporating automatic reminders in electronic medical records, and using telerehabilitation tools may improve pulmonary rehabilitation referral, adherence, and ultimately, patient care.

Clinical outcomes and quality of life of COVID-19 survivors: A follow-up of 3 months post hospital discharge.

BACKGROUND: Over 66 million people worldwide have been diagnosed with COVID-19. Therefore, understanding their clinical evolution beyond hospital discharge is essential not only from an individual standpoint, but from a populational level. OBJECTIVES: Our primary aim was to assess the impact of COVID-19 on health-related quality of life (HRQoL) 3 months after hospital discharge. Additionally, we screened for anxiety and depression and assessed important clinical outcomes. METHODS: This was a single-center cohort study performed in Sao Paulo (Brazil), in which participants were contacted by telephone to answer a short survey. EQ-5D-3L was used to assess HRQoL and clinical data from patients' index admission were retrieved from medical records. RESULTS: We contacted 251 participants (59.8% males, mean age 53 years old), 69.7% of which had presented with severe COVID-19. At 3 months of follow-up, 6 patients had died, 51 (20.3%) had visited the emergency department again and 17 (6.8%) had been readmitted to hospital. Seventy patients (27.9%) persisted with increased dyspnoea and 81 had a positive screening for anxiety/depression. Similarly, patients reported an overall worsening of EQ-5D-3L single summary index at 3 months compared to before the onset of COVID-19 symptoms (0.8012 (0.7368 - 1.0) vs. 1.0(0.7368 - 1.0), p < 0.001). This affected all 5 domains, but especially pain/discomfort and anxiety/depression. Only female sex and intensive care requirement were independently associated with worsening of HRQoL. CONCLUSION: Patients hospitalized for COVID-19 frequently face persistent clinical and mental health problems up to 3 months following hospital discharge, with significant impact on patients' HRQoL.

Barriers to enrollment in pulmonary rehabilitation: medical knowledge analysis / Barreiras à inclusão na reabilitação pulmonar: análise do conhecimento médico

ABSTRACT Objective To assess clinicians' knowledge about pulmonary rehabilitation, and identify the barriers faced when referring patients with health insurance to pulmonary rehabilitation. Methods This was a survey-based cross-sectional study conducted in 2019, at a private reference hospital in São Paulo, Brazil. Eligible participants were physicians registered with the following specialties: internal medicine, geriatrics, cardiology, pulmonology or thoracic surgery. Results We collected 72 responses, and 99% of participants recognized chronic obstructive pulmonary disease as a potential indication for pulmonary rehabilitation; less often (75%), they listed interstitial lung disease, bronchiectasis and pulmonary hypertension. Most participants (67%) incorrectly associated pulmonary rehabilitation with lung function improvement, while 28% of cardiologists and 35% of internists/geriatricians failed to recognize benefits on mood disorders. Notably, 18% of participants recommended pulmonary rehabilitation only to patients on supplemental oxygen and 14% prescribed only home physical therapy, patterns more commonly seen among non-respiratory physicians. The three most perceived barriers to referral and adherence were health insurance coverage (79%), transportation to pulmonary rehabilitation center (63%) and lack of social support (29%). Conclusion Financial, logistic and social constraints pose challenges to pulmonary rehabilitation enrollment, even for patients with premium healthcare insurance. Moreover, physician knowledge gaps may be an additional barrier to pulmonary rehabilitation referral and adherence. Providing continued medical education, incorporating automatic reminders in electronic medical records, and using telerehabilitation tools may improve pulmonary rehabilitation referral, adherence, and ultimately, patient care.

RESUMO Objetivo Avaliar o conhecimento dos médicos sobre reabilitação pulmonar e identificar as barreiras que eles encontram ao encaminhar pacientes com seguro saúde para reabilitação pulmonar. Métodos Trata-se de estudo transversal com uso de questionário, realizado em 2019, em um hospital privado de referência em São Paulo. Os participantes elegíveis eram médicos registrados nas seguintes especialidades: clínica médica, geriatria, cardiologia, pneumologia ou cirurgia torácica. Resultados Foram coletadas 72 respostas, e 99% dos participantes reconheceram doença pulmonar obstrutiva crônica como possível indicação para reabilitação pulmonar; com menor frequência (75%), listaram doença pulmonar intersticial, bronquiectasia e hipertensão pulmonar. A maioria dos participantes (67%) associou incorretamente a reabilitação pulmonar à melhora da função pulmonar, ao passo que 28% dos cardiologistas e 35% dos clínicos/geriatras deixaram de reconhecer os benefícios nos transtornos de humor. Notavelmente, 18% dos participantes somente recomendaram reabilitação pulmonar para pacientes em uso de oxigênio suplementar, e 14% prescreveram apenas fisioterapia domiciliar, padrão mais comumente visto entre médicos que não são especialistas em transtornos respiratórios. As três barreiras mais percebidas para encaminhamento e adesão foram cobertura de seguro saúde (79%), transporte para centro de reabilitação pulmonar (63%) e falta de apoio social (29%). Conclusão Restrições financeiras, logísticas e sociais representam desafios para a inclusão na reabilitação pulmonar, mesmo para pacientes com planos de seguro de saúde da categoria premium. Além disso, as lacunas de conhecimento dos médicos podem ser uma barreira adicional para o encaminhamento e a aceitação da reabilitação pulmonar. Educação médica continuada, lembretes automáticos nos prontuários eletrônicos e ferramentas de telerreabilitação podem melhorar o encaminhamento para reabilitação pulmonar, a adesão e, por fim, o atendimento ao paciente.

Accuracy of echocardiography and chest tomography for pulmonary hypertension screening in patients awaiting lung transplantation / Acurácia do ecocardiograma e da tomografia de tórax para rastreamento de hipertensão pulmonar em pacientes aguardando transplante de pulmão

ABSTRACT Objective To examine the accuracy of a pulmonary hypertension screening strategy based on a combination of echocardiographic data and tomographic measurements (pulmonary artery diameter and pulmonary artery diameter to ascending aorta diameter ratio) in patients with chronic lung disease referred for lung transplantation. Methods A retrospective observational study with patients with pulmonary emphysema or fibrosis referred for transplantation between 2012 and 2016. Pulmonary hypertension was defined as mean pulmonary artery pressure ≥25mmHg, or between 21 and 24mmHg, with pulmonary vascular resistance >3 Wood units on right heart catheterization. Tomographic measurements were made by two independent radiologists. Results This sample comprised 13 patients with emphysema and 19 patients with pulmonary fibrosis. Of these, 18 had pulmonary hypertension. The level of agreement in tomographic measurements made by radiologists was high (intraclass correlation coefficients 0.936 and 0.940, for pulmonary artery diameter and pulmonary artery diameter to ascending aorta diameter ratio, respectively). Areas under the ROC curves constructed for pulmonary artery diameter, pulmonary artery diameter to ascending aorta diameter ratio, and pulmonary artery systolic pressure as predictors of pulmonary hypertension were 0.540, 0.629 and 0.783, respectively. The sensitivity, specificity and negative predictive value of pulmonary artery systolic pressure ≥40mmHg were 67%, 79% and 65%, respectively. The combined criterion (pulmonary artery diameter to ascending aorta diameter ratio >1 and/or pulmonary artery systolic pressure ≥40mmHg) achieved sensitivity of 72%, specificity of 79%, and a negative predictive value of 69%. Conclusion Measurements of pulmonary artery and ascending aorta diameter were highly reproducible. The association of pulmonary artery and aortic diameter >1 and/or pulmonary artery systolic pressure ≥40mmHg improved the sensitivity and the negative predictive value for pulmonary hypertension screening. This strategy demands prospective validation to assess safety and cost-effectiveness.

RESUMO Objetivo Avaliar a acurácia de uma estratégia de rastreamento de hipertensão pulmonar baseada na combinação de dados de ecocardiograma com as medidas derivadas da tomografia computadorizada (diâmetro da artéria pulmonar e razão entre diâmetro da artéria pulmonar e diâmetro da aorta ascendente) em pacientes pneumopatas crônicos encaminhados para transplante pulmonar. Métodos Estudo observacional retrospectivo realizado com pacientes com enfisema e fibrose pulmonar avaliados para transplante entre 2012 e 2016. Definiu-se hipertensão pulmonar como pressão arterial pulmonar média ≥25mmHg, ou entre 21 a 24mmHg, com resistência vascular pulmonar >3 unidades Wood no cateterismo direito. As medidas tomográficas foram realizadas por dois radiologistas independentes. Resultados Foram incluídos 13 pacientes com enfisema e 19 com fibrose pulmonar, sendo 18 com hipertensão pulmonar. Houve alta concordância entre os radiologistas em relação às medidas tomográficas (coeficientes de correlação intraclasse para diâmetro da artéria pulmonar de 0,936 e diâmetro da artéria pulmonar/diâmetro da aorta ascendente de 0,940). As áreas abaixo da curva ROC de diâmetro da artéria pulmonar, diâmetro da artéria pulmonar/diâmetro da aorta ascendente, e pressão sistólica da artéria pulmonar como preditores de hipertensão pulmonar foram 0,540, 0,629 e 0,783, respectivamente. A sensibilidade, especificidade e valor preditivo negativo da pressão de sistólica de artéria pulmonar ≥40mmHg foram 67%, 79% e 65%, respectivamente. O critério combinado de diâmetro da artéria pulmonar/diâmetro da aorta ascendente >1 e/ou pressão sistólica da artéria pulmonar ≥40mmHg mostrou sensibilidade de 72%, especificidade de 79%, e valor preditivo negativo de 69%. Conclusão Os diâmetros da artéria pulmonar e da aorta ascendente foram altamente reprodutíveis. A associação entre diâmetro da artéria pulmonar e diâmetro da aorta ascendente >1 e/ou pressão sistólica da artéria pulmonar ≥40mmHg melhorou a sensibilidade e o valor preditivo negativo para rastreamento de hipertensão pulmonar. Essa estratégia requer validação prospectiva para se avaliarem segurança e custo-efetividade.

Preoperative evaluation of the patient with pulmonary disease.

BACKGROUND AND OBJECTIVES: In daily clinical practice, pulmonary complications related to surgical procedure are common, increasing the morbidity and mortality of patients. Assessment of the risk of pulmonary complications is an important step in the preoperative evaluation. Thus, we review the most relevant aspects of preoperative assessment of the patient with lung disease. CONTENT: Pulmonary risk stratification depends on clinical symptoms and patient's physical status. Age, preexisting respiratory diseases, nutritional status, and continued medical treatment are usually more important than additional tests. Pulmonary function tests are of great relevance when high abdominal or thoracic procedures are scheduled, particularly when lung resection are considered. CONCLUSION: Understanding the perioperative evaluation of the potential risk for developing pulmonary complication allows the medical team to choose the adequate anesthetic technique and surgical and clinical care required by each patient, thereby reducing adverse respiratory outcomes.

Avaliação pré-operatória do paciente pneumopata / Preoperative evaluation of the patient with pulmonary disease / Evaluación preoperatoria del paciente neumópata

Justificativa e objetivos: Na prática clínica diária, complicações pulmonares relacionadas ao procedimento cirúrgico são comuns, o que aumenta a morbidade e mortalidade dos pacientes. A ponderação do risco de complicações pulmonares é um importante passo da avaliação pré-operatória. Dessa forma, fizemos uma revisão dos aspectos mais relevantes da avaliação pré-operatória do paciente pneumopata. Conteúdo: A estratificação do risco pulmonar depende dos sintomas clínicos e do estado físico do doente. Idade, doenças respiratórias preexistentes, estado nutricional e tratamento médico continuado são, geralmente, mais importantes do que exames complementares. Testes de função pulmonar assumem grande relevância quando procedimentos torácicos ou abdominais alto são propostos, especialmente se considerada a realização de ressecção pulmonar. Conclusões: A compreensão da avaliação perioperatória acerca do risco para potencial complicação pulmonar permite à equipe médica escolher adequada técnica anestésica e cuidados clínicos e cirúrgicos que se adequem a cada paciente, o que reduz, portanto, desfechos respiratórios desfavoráveis. .

Background and objectives: In daily clinical practice, pulmonary complications related to surgical procedure are common, increasing the morbidity and mortality of patients. Assessment of the risk of pulmonary complications is an important step in the preoperative evaluation. Thus, we review the most relevant aspects of preoperative assessment of the patient with lung disease. Content: Pulmonary risk stratification depends on clinical symptoms and patient's physical status. Age, preexisting respiratory diseases, nutritional status, and continued medical treatment are usually more important than additional tests. Pulmonary function tests are of great relevance when high abdominal or thoracic procedures are scheduled, particularly when lung resection are considered. Conclusion: Understanding the perioperative evaluation of the potential risk for developing pulmonary complication allows the medical team to choose the adequate anesthetic technique and surgical and clinical care required by each patient, thereby reducing adverse respiratory outcomes. .

Justificación y objetivo: en la práctica clínica diaria son comunes las complicaciones pulmonares relacionadas con el procedimiento quirúrgico, lo que aumenta la morbimortalidad de los pacientes. La ponderación del riesgo de complicaciones pulmonares es un importante paso en la evaluación preoperatoria. Por lo tanto, hicimos una revisión de los aspectos más relevantes de la evaluación preoperatoria del paciente neumópata. Contenido: la estratificación del riesgo pulmonar depende de los síntomas clínicos y del estado físico del enfermo. La edad, enfermedades respiratorias preexistentes, estado nutricional y tratamiento médico continuado son, generalmente, más importantes que los exámenes complementarios. Los test de función pulmonar tienen una gran relevancia cuando se trata de procedimientos torácicos o abdominales altos, especialmente si se tiene en cuenta la realización de la resección pulmonar. Conclusiones: la comprensión de la evaluación perioperatoria acerca del riesgo para la potencial complicación pulmonar, le permite al equipo médico elegir una adecuada técnica anestésica y cuidados clínicos y quirúrgicos que se adecúen a cada paciente, reduciendo así los resultados respiratorios no favorables. .