Use of epidemiological data as the basis for developing a medical curriculum.

CONTEXT AND OBJECTIVE: Epidemiology may help educators to face the challenge of establishing content guidelines for the curricula in medical schools. The aim was to develop learning objectives for a medical curriculum from an epidemiology database. DESIGN AND SETTING: Descriptive study assessing morbidity and mortality data, conducted in a private university in São Paulo. METHODS: An epidemiology database was used, with mortality and morbidity recorded as summaries of deaths and the World Health Organization's Disability-Adjusted Life Year (DALY). The scoring took into consideration probabilities for mortality and morbidity. RESULTS: The scoring presented a classification of health conditions to be used by a curriculum design committee, taking into consideration its highest and lowest quartiles, which corresponded respectively to the highest and lowest impact on morbidity and mortality. Data from three countries were used for international comparison and showed distinct results. The resulting scores indicated topics to be developed through educational taxonomy. CONCLUSION: The frequencies of the health conditions and their statistical treatment made it possible to identify topics that should be fully developed within medical education. The classification also suggested limits between topics that should be developed in depth, including knowledge and development of skills and attitudes, regarding topics that can be concisely presented at the level of knowledge.

Use of epidemiological data as the basis for developing a medical curriculum / O uso de dados epidemiológicos como base para o desenvolvimento de um currículo médico

CONTEXT AND OBJECTIVE: Epidemiology may help educators to face the challenge of establishing content guidelines for the curricula in medical schools. The aim was to develop learning objectives for a medical curriculum from an epidemiology database. DESIGN AND SETTING: Descriptive study assessing morbidity and mortality data, conducted in a private university in São Paulo. METHODS: An epidemiology database was used, with mortality and morbidity recorded as summaries of deaths and the World Health Organization's Disability-Adjusted Life Year (DALY). The scoring took into consideration probabilities for mortality and morbidity. RESULTS: The scoring presented a classification of health conditions to be used by a curriculum design committee, taking into consideration its highest and lowest quartiles, which corresponded respectively to the highest and lowest impact on morbidity and mortality. Data from three countries were used for international comparison and showed distinct results. The resulting scores indicated topics to be developed through educational taxonomy. CONCLUSION: The frequencies of the health conditions and their statistical treatment made it possible to identify topics that should be fully developed within medical education. The classification also suggested limits between topics that should be developed in depth, including knowledge and development of skills and attitudes, regarding topics that can be concisely presented at the level of knowledge.

CONTEXTO E OBJETIVO: A epidemiologia pode auxiliar os educadores a enfrentar o desafio de estabelecer diretrizes para o conteúdo dos currículos em escolas médicas. O objetivo foi desenvolver objetivos de aprendizagem para um currículo médico por meio de um banco de dados epidemiológicos. TIPO DE ESTUDO E LOCAL: Estudo descritivo avaliando dados de morbidade e mortalidade, realizado por universidade particular em São Paulo. MÉTODOS: O banco de dados epidemiológicos com morbidade e mortalidade registrados como resumo de causas de morte e o Disability-Adjusted Life Year (DALY) da Organização Mundial de Saúde foi utilizado. A pontuação desenvolvida considerou probabilidades de mortalidade e morbidade. RESULTADOS: A pontuação apresenta uma classificação dessas condições de saúde para ser utilizada por uma comissão responsável pelo desenho curricular, considerando seus quartis superior e inferior, designando, respectivamente, maior e menor impacto na morbidade e mortalidade. Dados de três países foram utilizados para comparação internacional, mostrando resultados distintos. As pontuações resultantes indicaram temas a serem desenvolvidos pela taxonomia educacional. CONCLUSÃO: A frequência das condições de saúde e seu tratamento estatístico possibilitaram a identificação de temas que devem ser plenamente desenvolvidos em educação médica. A classificação sugere também limites entre tópicos que devem ser desenvolvidos em profundidade, incluindo o conhecimento e o desenvolvimento de habilidades e atitudes, a respeito de tópicos que podem ser concisamente apresentados ao nível de conhecimento.

Short-term outcome of cervical intraepithelial neoplasia grade 2: considerations for management strategies and reproducibility of diagnosis.

AIM: To compare two management strategies for cervical intraepithelial neoplasia (CIN) 2, and evaluate reproducibility of the diagnosis. PATIENTS AND METHODS: Ninety (90) women with biopsy-proven CIN2 diagnosed through the Brazilian public health service were randomly allocated into two groups: 45 in prospective follow-up without treatment, and 45 for radical loop electrosurgical excision procedure (LLETZ). As in the real-life situation, pathology-reviewed diagnoses and HPV genotypes were not available. RESULTS: Excision of the lesion proved to be more effective than prospective follow-up in reaching clearance of CIN2 (hazard ratio=3.66; 95% confidence interval 2.02-6.64). However, 44.1% of the lesions regressed without treatment during the 12-month follow-up. CONCLUSION: CIN2 lesions regress without treatment in one year, although an ablative procedure is more effective. However, excision of CIN2 may lead to additional morbidity and costs, and tailoring the management on an individual basis may result in better outcome. Misclassification of CIN2 is not a negligible problem.

Qualidade de vida afetada pelas complicações do tratamento em mulheres com câncer do colo do útero localmente avançado / Affected quality of life by treatment complications in women with cervix cancer

No câncer do colo do útero localmente avançado, são observadas reações adversas do tratamento e da doença. Porém a qualidade de vida destas mulheres não pode ser limitada à condição de sua saúde física e às intervenções clínicas, mas a todas as razões que afetam suas percepções, sentimentos e comportamentos. O objetivo desta revisão é abordar os diferentes aspectos da qualidade de vida, bem como os efeitos adversos do tratamento e identificar terapias que minimizem os aspectos negativos. É também abordado o papel do profissional de enfermagem na oferta de conforto e segurança às mulheres e seus familiares, principalmente nos momentos que antecedem a morte, pensando-se em uma qualidade de vida integral. A revisão de recentes publicações tornou possível observar que a qualidade de vida destas mulheres é afetada radicalmente e de forma negativa tanto pela doença como pelos efeitos agressivos do tratamento, principalmente nos casos de mau prognóstico.

Prevalence of codon 72 P53 polymorphism in Brazilian women with cervix cancer

The p53 codon 72 polymorphism seems to be associated with HPV-carcinogenesis, although controversial data have been reported. A series of Brazilian women with cervix carcinomas were analyzed. Ninety-nine (67 percent) of 148 women were found to be homozygous (arg/arg) for the arginine polymorphism, and 49 (33 percent) were heterozygous (arg/pro). This polymorphism may be an important determinant of the risk for cervix cancer, but does not seem to be sufficient for carcinogenesis.

Regulation of cell cycles is of key importance in human papillomavirus (HPV)-associated cervical carcinogenesis.

The rapid progress in molecular biology has allowed the identification of the genes involved in different functions of normal cells and has also improved our understanding of the mechanisms of human carcinogenesis. The human papillomavirus (HPV) is a small double-stranded DNA tumor virus and its genes can manipulate cell cycle control to promote viral persistence and replication. The E6 and E7 proteins of high-risk HPV bind to cell cycle regulatory proteins and interfere with both G1/S and G2/M cell cycle checkpoints much more effectively than the low-risk HPV. The difference between the ability of low and high-risk HPV types to induce immortalization and transformation may well lie in their abilities to interact with the various cell cycle components, resulting in the loss of multiple cell cycle checkpoints, which are important in host genome fidelity, thus potentially resulting in accumulation of genetic abnormalities. Cervical cancer is one of the leading malignancies in women worldwide, with substantial morbidity and mortality. According to current concepts, HPV is recognized as the single most important causal agent in the pathogenesis of this cancer. HPV infection clearly precedes the development of malignancy, while being regularly associated with cervical cancer precursor lesions (all grades of squamous intraepithelial lesions). HPV-infected low-grade squamous intraepithelial lesion (SIL) has three possible outcomes: a) it may regress; b) it can persist; or c) it can make a clinical progression to in situ or invasive carcinoma. It has been well established by prospective cohort studies that the spontaneous regression rate increases in parallel with follow-up duration. In contrast, the clinical progression of lesions usually takes place quite rapidly, i.e. during the first two years from diagnosis. The mechanisms responsible for this divergent clinical behavior of HPV-associated squamous intraepithelial lesions are largely unknown, but currently under intense study in different laboratories worldwide.

Regulation of cell cycles is of key importance in human papillomavirus (HPV)-associated cervical carcinogenesis

The rapid progress in molecular biology has allowed the identification of the genes involved in different functions of normal cells and has also improved our understanding of the mechanisms of human carcinogenesis. The human papillomavirus (HPV) is a small double-stranded DNA tumor virus and its genes can manipulate cell cycle control to promote viral persistence and replication. The E6 and E7 proteins of high-risk HPV bind to cell cycle regulatory proteins and interfere with both G1/S and G2/M cell cycle checkpoints much more effectively than the low-risk HPV. The difference between the ability of low and high-risk HPV types to induce immortalization and transformation may well lie in their abilities to interact with the various cell cycle components, resulting in the loss of multiple cell cycle checkpoints, which are important in host genome fidelity, thus potentially resulting in accumulation of genetic abnormalities. Cervical cancer is one of the leading malignancies in women worldwide, with substantial morbidity and mortality. According to current concepts, HPV is recognized as the single most important causal agent in the pathogenesis of this cancer. HPV infection clearly precedes the development of malignancy, while being regularly associated with cervical cancer precursor lesions (all grades of squamous intraepithelial lesions). HPV-infected low-grade squamous intraepithelial lesion (SIL) has three possible outcomes: a) it may regress; b) it can persist; or c) it can make a clinical progression to in situ or invasive carcinoma. It has been well established by prospective cohort studies that the spontaneous regression rate increases in parallel with follow-up duration. In contrast, the clinical progression of lesions usually takes place quite rapidly, i.e. during the first two years from diagnosis. The mechanisms responsible for this divergent clinical behavior of HPV-associated squamous intraepithelial lesions are largely unknown, but currently under intense study in different laboratories worldwide

Conhecimento, atitude e prática do exame de Papanicolaou em mulheres com câncer de colo uterino / Knowledge, attitudes, and practices related to the Pap smear among women with cervical cancer

O câncer de colo uterino apresenta alta mortalidade no Brasil, apesar dos programas para rastreamento. O objetivo foi analisar conhecimento, atitude e prática do exame de Papanicolaou e entender a näo adesäo das mulheres a este exame. Foram entrevistadas 138 mulheres: noventa com neoplasia intra-epitelial de alto grau e 48 com câncer invasivo de colo uterino. As mulheres com câncer invasivo tiveram prática mais inadequada do exame. No entanto, independente do diagnóstico, mais de 80 por cento delas referiram desmotivaçäo/vergonha, 60 por cento relataram que os médicos näo examinavam e, cerca de 50 por cento apontaram o tempo de espera para a consulta e a demora no agendamento como dificuldades para serem atendidas. Em geral, a prática do exame dependeu da iniciativa do médico e a periodicidade da coleta foi determinada pela procura de consulta devido a sintomas. As mulheres com 56 anos ou mais mostraram maior inadequaçäo no conhecimento, na atitude e na prática. No entanto, aquelas com maior escolaridade conheciam melhor o exame. A maior idade e a menor escolaridade podem estar associados a näo adesäo das mulheres ao exame. A maior idade e a menor escolaridade podem estar associados a näo adesäo das mulheres ao exame, porém as dificuldades sociais e econômicas para conseguir atendimento em saúde precisam ser consideradas para aumentar a prática do exame.

Expressäo protéica de P53 e C-MYC como marcadores no prognóstico do carcinoma de colo uterino / P53 and C-MYC protein expression as markers in the prognostic of the uterine cervix carcinoma

Alguns estudos analisaram a expressäo protética de p53 e c-myc como marcadores no prognóstico do carcinoma de colo uterino, mas a maioria foi realizada em países desenvolvidos, onde há programas de rastreamento eficientes, que podem selecionar estádios iniciais e formas agressivas da doença. O objetivo deste estudo foi analisar a associaçäo destas proteínas com o prognóstico do carcinoma espino-celular invasivo de colo uterino (CEC). Foi de coorte, considerou poder de 80 por cento e IC de 95 por cento. Inculiu 220 mulheres diagnosticadas entre 1992 e 1994, nos estádios Ib-III, seguidas por cinco anos. Os blocos de parafina foram processados para imuno-histoquímica: p53 (Dako DO7) e c-myc (Santa Cruz Biotechnology MX 9E10).