Câncer gastrointestinal: dificuldades para o acesso ao diagnóstico e tratamento

O câncer do trato gastrointestinal tem sua importância no perfil de mortalidade do Brasil, estando entre os dez mais incidentes do país. A detecção precoce garante uma melhor qualidade de vida para os doentes oncológicos, porém frequentemente estes chegam aos centros de tratamento em fase avançada da doença. O estudo objetiva investigar as dificuldades de acesso ao diagnóstico e tratamento para os pacientes com câncer gastrointestinal atendidos pelo Sistema Único de Saúde. Com este intuito, realizou-se uma pesquisa observacional descritiva e sob a forma de um questionário foram coletados dados de pacientes em tratamento em dois hospitais públicos de Belém, no período de março a junho de 2013. Preencheram os critérios de inclusão 122 pacientes que foram agrupados em diferentes trajetórias de atendimento. Além disso, foram também obtidas informações registradas nos prontuários desses pacientes. A análise dos dados demonstrou que o diagnóstico da doença em 68,1% foi realizado pelo médico generalista; a maior dificuldade, nessa fase, foi o acesso ao diagnóstico gerando gastos com exames, pois a maioria dos pacientes (68,9%) não realizou exames especializados através do Sistema Único de Saúde, mas com recursos próprios. Nos centros/ unidades de referência em oncologia, as dificuldades relatadas por 56 pacientes começam com a marcação da consulta médica, ocorrendo demora do agendamento pela instituição para 94,6% desses doentes. A falta de leito para internação foi apontada como o maior entrave (54.4%) para iniciar a terapêutica cirúrgica, particularmente para o câncer gástrico e de cólon e reto. A análise das trajetórias percorridas pelos doentes, desde o inicio dos sintomas até o atendimento na unidade de referência, revela que o diagnóstico da doença em 50% dos pacientes ocorreu somente após 10 meses do inicio dos sintomas, e o tratamento iniciou só depois de 90 dias do diagnóstico. O tempo que os pacientes permanecem sintomáticos sem um diagnóstico impacta negativamente no prognóstico. Nesta pesquisa, os casos de câncer gástrico e de cólon e reto foram diagnosticados tardiamente (estádio IV e IIIB) e, por conseguinte o tratamento não ocorreu no prazo desejável.

Intra-abdominal pressure as a predictor of acute kidney injury in postoperative abdominal surgery

Objectives: The purpose of this study was to determine if intra-abdominal pressure (IAP) could predict acute renal injury (AKI) in the postoperative period of abdominal surgeries, and which would be its cutoff value. Patients and methods: A prospective observational study was conducted in the period from January 2010 to March 2011 in the Intensive Care Units (ICUs) of the University Hospital of Botucatu Medical School, UNESP. Consecutive patients undergoing abdominal surgery were included in the study. Initial evaluation, at admission in ICU, was performed in order to obtain demographic, clinical surgical and therapeutic data. Evaluation of IAP was obtained by the intravesical method, four times per day, and renal function was evaluated during the patient's stay in the ICU until discharge, death or occurrence of AKI. Results: A total of 60 patients were evaluated, 16 patients developed intra-abdominal hypertension (IAH), 45 developed an abnormal IAP (>7 mmHg) and 26 developed AKI. The first IAP at the time of admission to the ICU was able to predict the occurrence of AKI (area under the receiver-operating characteristic curve was 0.669; p=0.029) with the best cutoff point (by Youden index method) >= 7.68 mmHg, sensitivity of 87%, specificity of 46% at this point. The serial assessment of this parameter did not added prognostic value to initial evaluation. Conclusion: IAH was frequent in patients undergoing abdominal surgeries during ICU stay, and it predicted the occurrence of AKI. Serial assessments of IAP did not provided better discriminatory power than initial evaluation.

Effects of therapeutic approach on the neonatal evolution of very low birth weight infants with patent ductus arteriosus

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Characterization of the clonal profile of MRSA isolated in neonatal and pediatric intensive care units of a University Hospital

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Painful procedures and analgesia in the NICU: what has changed in the medical perception and practice in a ten-year period?

To compare the use of analgesia versus neonatologists' perception regarding analgesic use in painful procedures in the years 2001, 2006, and 2011. This was a prospective cohort study of all newborns admitted to four university neonatal intensive care units (NICUs) during one month in 2001, 2006, and 2011. The frequency of analgesic prescription for painful procedures was evaluated. Of the 202 neonatologists, 188 answered a questionnaire giving their opinion on the intensity of pain during lumbar puncture (LP), tracheal intubation, mechanical ventilation (MV), and postoperative period (PO) using a 10-cm visual analogic scale (VAS; pain >3cm). For LP, 12% (2001), 43% (2006), and 36% (2011) were performed using analgesia. Among the neonatologists, 40-50% reported VAS >3 for LP in all study periods. For intubation, 30% received analgesia in the study periods, and 35% (2001), 55% (2006), and 73% (2011) of the neonatologists reported VAS >3 and would prescribe analgesia for this procedure. As for MV, 45% (2001), 64% (2006), and 48% (2011) of patient-days were under analgesia; 56% (2001), 57% (2006), and 26% (2011) of neonatologists reported VAS >3 and said they would use analgesia during MV. For the first three PO days, 37% (2001), 78% (2006), and 89% (2011) of the patients received analgesia and more than 90% of neonatologists reported VAS >3 for major surgeries. Despite an increase in the medical perception of neonatal pain and in analgesic use during painful procedures, the gap between clinical practice and neonatologist perception of analgesia need did not change during the ten-year period.

Cancelamento de cirurgias eletivas: dos motivos à compreensão do itinerário Agendamento-Centro Cirúrgico

Pós-graduação em Enfermagem - FMB

Opportunistic microorganisms in patients with head and neck trauma

The use of antimicrobial agents has facilitated the dissemination of multi-resistant microorganisms, compromising dental and medical treatment. The aim of this study was to evaluate the distribution of different opportunistic microbial species in patients who suffered head and neck trauma, under temporary maintenance in nosocomial environment, particularly intensive care units, on the occurrence of such microorganisms in the oral cavity of the patients. It was selected 38 patients subjected to head and neck traumas. After emergency surgical procedures, clinical samples of saliva, sub and supragingival biofilms and mucosal surfaces were collected at two different moments: just after stabilization of the patient and soon after patients’ release from medical units. The presence of opportunistic and superinfecting microorganisms was evaluated by culture on selective and non-selective media, and the presence of the family Enterobacteriaceae, as well as genera Enterococcus, Pseudomonas, and Staphylococcus was assessed by PCR. It was found that the use of antimicrobials, even for short periods of time was sufficient to facilitate colonization by microorganisms of the families Enterobacteriaceae and Pseudomonadaceae, as well as yeasts and enterococci. These results support the concept that medical and dental teams should make a periodically change of antimicrobials used in treatment protocols in hospital for head and neck trauma patients, in order to minimize dissemination of opportunistic or superinfecting microorganisms.

Role of the clinical pharmacist in detection of drug therapy problemas in critically impatients: experience report

This is an experience report on clinical pharmacy in New York, United States of America, in a teaching hospital, describing the results of drug therapy monitoring in critically ill patients, as well as interventions to solve or prevent identified drug therapy problems. The cross-sectional study was conducted by the clinical staff at the Surgical Intensive Care Unit during August 20th to 24th, 2012. Blood counts, serum levels of certain antibiotics, microbiological cultures and their antibiotic susceptibility, possible drug interactions, dosage of each drug prescribed and the compatibility between the route of administration and pharmaceutical form were assessed daily through review of electronic medical records. Twenty seven patients were followed up and 16 drug therapy problems were identified: Unnecessary drug therapy (seven), adverse drug reaction (four), needs additional drug therapy (two), noncompliance (two) and dosage too low (one). After evaluation, the drug therapy problems and their pharmaceutical interventions were reported to clinical pharmaceutical responsible for the Surgical ICU, as well as the multidisciplinary team. Further, the clinical outcomes were monitored and interventions were classified as to its acceptance. Data demonstrate that clinical pharmacists can contribute to the security and proper use of medications, as the trigger tools for intensive monitoring helps in early detection of drug therapy problems and patient safety.

Teaching elliptical excision skills to novice medical students: a randomized controlled study comparing low- and high-fidelity bench models

Background: The search for alternative and effective forms of training simulation is needed due to ethical and medico-legal aspects involved in training surgical skills on living patients, human cadavers and living animals. Aims : To evaluate if the bench model fidelity interferes in the acquisition of elliptical excision skills by novice medical students. Materials and Methods: Forty novice medical students were randomly assigned to 5 practice conditions with instructor-directed elliptical excision skills' training (n = 8): didactic materials (control); organic bench model (low-fidelity); ethylene-vinyl acetate bench model (low-fidelity); chicken legs' skin bench model (high-fidelity); or pig foot skin bench model (high-fidelity). Pre- and post-tests were applied. Global rating scale, effect size, and self-perceived confidence based on Likert scale were used to evaluate all elliptical excision performances. Results : The analysis showed that after training, the students practicing on bench models had better performance based on Global rating scale (all P < 0.0000) and felt more confident to perform elliptical excision skills (all P < 0.0000) when compared to the control. There was no significant difference (all P > 0.05) between the groups that trained on bench models. The magnitude of the effect (basic cutaneous surgery skills' training) was considered large (>0.80) in all measurements. Conclusion : The acquisition of elliptical excision skills after instructor-directed training on low-fidelity bench models was similar to the training on high-fidelity bench models; and there was a more substantial increase in elliptical excision performances of students that trained on all simulators compared to the learning on didactic materials.

Análise da pressão intra-abdominal em pacientes submetidos à cirurgia abdominal oncológica internados em Unidade de Terapia Intensiva

Pós-graduação em Pesquisa e Desenvolvimento (Biotecnologia Médica) - FMB

Periocular basal cell carcinoma: cost of topical immunotherapy versus estimated cost of surgical treatment

Purpose: The objective of this study was to compare the estimated cost of clinical and surgical treatment for basl cell carcinoma of the eyelid. Methods: This was a pilot study of 12 patients with basal cell carcinoma receiving treatment with 5% imiquimod cream at the ocular plastic surgery center, medical school University of Sao Paulo (HC-FMUSP, Brazil). The cost of clinical treatment was estimated based on the time of treatment and amount of medication consumed by patients in the home setting. The cost of surgical treatment was estimated by ophthalmologists with experience in reconstructive plastic surgery based on analysis of images of the same patients. Surgeons responded to a questionnaire with four questions about surgical technique, surgical materials required, estimated duration of surgery and type of anesthesia. Results: Immunotherapy lasted from 8 to 12 weeks. All patients reported each cold-stored sachet with 5% imiquimod cream lasted 3 days. According to the institution, a box with 12 sachets costs BRL 480.00. Patients required 1.58-3.11 boxes for complete treatment, corresponding to a total cost of BRL 758.40-1,492.80. Based on image analysis, surgeons evaluated surgery would require 1-3 hours. The estimated cost of surgery room and staff was BRL 263.00, to which the cost of supplies was added. Thus, the total cost of surgical treatment was BRL 272.61-864.82. On the average, immunotherapy was 57,64% more costly than surgical treatment. Conclusions: Malignant eyelid tumors are a common finding in clinical ophthalmology. Surgery is still the treatment of choice at our institution, but immunotherapy with 5% imiquimod cream may be indicated for patients with multiple lesions or high surgical risk and for patients declining surgery for reasons of fear or esthetic concerns. The ability to estimate costs related to the treatment of malignant eyelid tumors is an important aid in the financial planning of health care institutions. Further studies should evaluate the possibility of institutions equating the cost of immunotherapy and surgical treatment by acquiring similar but less expensive medications.

Antimicrobial photodynamic therapy in the non-surgical treatment of aggressive periodontitis: microbiological profile

The aim of this trial was to investigate changes occurring in the subgingival microbiological composition of subjects with aggressive periodontitis, treated with antimicrobial photodynamic therapy (aPDT), in a single episode, or scaling and root planing (SRP), in a split-mouth design on -7, 0, and +90 days. Ten patients were randomly assigned to either aPDT using a laser source in conjunction with a photosensitizer or SRP with hand instruments. Subgingival plaque samples were collected and the counts of 40 subgingival species were determined using checkerboard DNA-DNA hybridization. The data were analyzed using the method of generalized estimating equations (GEE) to test the associations between treatments, evaluated parameters, and experimental times (alpha = .05). The results indicated that aPDT and SRP affects different bacterial species, with aPDT being effective in reducing numbers of A. actinomycetemcomitans than SRP. On the other hand, SRP was more efficient than aPDT in reducing the presence of periodontal pathogens of the Red Complex. Additionally, a recolonization in the sites treated by aPDT was observed, especially for T. forsythia and P. gingivalis. Under our experimental conditions, this trial demonstrates that aPDT and SRP affected different groups of bacteria, suggesting that their association may be beneficial for the non-surgical treatment of aggressive periodontitis.

The viewpoint of health professionals on the role of basic units in the healthcare network of the Brazilian Unified Health System

In the process of creation of the Unified Health System (SUS) as a universal policy seeking to ensure comprehensive care, unscheduled assistance in primary healthcare units (UBS) is an unresolved challenge. The scope of this paper is to analyze the viewpoint of health professionals on the role of primary healthcare units in meeting this demand. It is a transversal study of qualitative data obtained through questionnaires and interviews with 106 medical practitioners from 6 emergency medical services and 190 professionals from 30 units. They explained why people seek emergency care for occurrences pertaining to primary care. The content analysis technique with thematic categories was used for data analysis. Lack of resources and problems with primary health unit work processes (50.8%) were the reasons most frequently cited by emergency care physicians to explain this inadequate demand. Only 33.3% of the health unit professionals agreed that these occurrences should be attended in the primary healthcare services. The limited viewpoint of the role of health services on the unscheduled care, particularly among primary care professionals, possibly leads to restrictive practices for access by the population.

Family Health Strategy Professionals Facing Medical Social Needs: difficulties and coping strategies

Professionals of Family Health Strategy (FHS) work in communities where there are complex medical social problems. These contexts may lead them to psychological suffering, jeopardizing their care for the users, and creating yet another obstacle to the consolidation of FHS as the primary health care model in Brazil. The study investigated the difficulties and coping strategies reported by health professionals of the FHS teams when they face medical social needs of the communities where they work. Focus groups and semi-structured interviews were carried out with 68 professionals of three primary care units in the city of Sao Paulo (Southeastern Brazil). Drug dealing and abuse, alcoholism, depression and domestic violence are the most relevant problems mentioned by the study group. Professionals reported lack of adequate training, work overload, poor working conditions with feelings of professional impotence and frustration. To overcome these difficulties, professionals reported collective strategies, particularly experience sharing during team meetings and matrix support groups. The results indicate that the difficulties may put the professionals in a vulnerable state, similar to the patients they care for. The promotion of specialized and long term support should be reinforced, as well as the interaction with the local network of services and communities leaders. That may help professionals to deal with occupational stress related to medical and social needs present in their routine work; in the end, it may as well contribute to the strengthening of FHS.

Applying validated quality indicators to surgical antibiotic prophylaxis in a Brazilian hospital: Learning what should be learned

Background: Compliance with the best surgical antibiotic prophylaxis practice is usually low despite many published guidelines. Objective: This study investigated compliance with the Hospital Infection Control Committee guideline for antibiotic prophylaxis in a Brazilian hospital using quality indicators. Methods: A retrospective study was carried out from November 2009 to March 2010. Medical records from adult inpatients undergoing cardiac, neurologic, and orthopedic clean surgeries were included. The full compliance index was considered 100% when the antibiotic prophylaxis showed adequacy in all evaluated attributes. Analyses were conducted with 5% significance. Results: Medical records from 101 cardiac, 128 neurologic, and 519 orthopedic surgical patients were evaluated. The compliance index was 4.9%, and the compliance index according to specialty was 5.8%, 3.1%, and 3.0%, respectively, for orthopedic, neurologic, and cardiac surgeries. The attribute route of administration produced the best outcomes, whereas the attribute duration of antibiotic prophylaxis produced the worst. No association was identified between compliance to the attributes and patient characteristics. Conclusion: This study showed a low level of adherence to Hospital Infection Control Committee guidelines for antibiotic prophylaxis. This suggests that different strategies should be implemented to promote the best possible practice in the field of antibiotic prophylaxis with greater surgeon engagement. Copyright (C) 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.