A pergunta surpresa em medicina geral e familiar na doença oncológica e em doença de órgão

Tese de mestrado, Cuidados Paliativos, Universidade de Lisboa, Faculdade de Medicina, 2018INTRODUÇÃO A reforma e expansão da rede nacional de cuidados paliativos portuguesa aumenta a necessidade de ferramentas de selecção de doentes para referenciação que sejam simples e eficazes. A Pergunta Surpresa (PS) – Ficaria surpreendido se este doente morresse durante o próximo ano? – poderá atingir este fim, mas não existem estudos a medir a sua acuidade quando utilizada por Médicos de Família (MF) em doentes com doença crónica avançada. OBJECTIVO Medir a acuidade da PS aos seis e 12 meses de seguimento, quando aplicada pelos MF a doentes com doença crónica avançada. DESENHO DE ESTUDO Estudo de coorte prospectiva pragmático. CONTEXTO E PARTICIPANTES Foi pedido aos MF, recrutados da Rede de Médicos Sentinela (RMS) ou por convite pessoal, que seleccionassem da sua lista de utentes, os doentes com neoplasia (Neo) sólida estádio IV; insuficiência cardíaca congestiva (ICC) grau III/IV NYHA; insuficiência renal crónica (IRC) grau IV/V; doença pulmonar obstrutiva crónica (DPOC) em estádio III/IV. De Janeiro a Abril 2017 os MF reportaram as características demográficas, patologias crónicas e resposta à PS a seis e 12 meses para cada um dos doentes incluídos. MEDIÇÕES Medimos a acuidade da PS com Intervalos de Confiança (IC) de 95%. Fizemos uma análise exploratória dos dados para perceber se algumas das variáveis medidas influenciaria a efectividade diagnóstica da PS.RESULTADOS Nesta dissertação constam os resultados de uma análise interina aos seis meses. A nossa amostra é composta por 22 MF. Foram incluídos 209 doentes, 34% com neoplasias, 33% com ICC, 20% com IRC e 16% com DPOC. Do total de doentes, 37% tinha uma resposta de “não surpreendido” à PS a seis meses e 65% à PS a 12 meses. Obtivemos informação de seguimento para 96% (n=201) dos doentes. A PS a seis meses teve uma sensibilidade de 63.9% (48.2% – 79.6%) e uma especificidade de 67.3% (60.1% – 74.4%), com um valor preditivo positivo (VPP) de 29.9% (19.6% – 40.1%) e valor preditivo negativo (VPN) de 89.5% (84.1% – 94.9%) CONCLUSÃO O VPP 29.9% e VPN 89.5% apontam para que a PS aos 6 meses não seja uma ferramenta precisa. Aguardaremos o término do seguimento de 12 meses para analisar e publicar os resultados finais.BACKGROUND Portugal’s reform and expansion of its palliative care network increases the need of simple and effective referral instruments. The surprise question (SQ) “Would you be surprised if this patient were to die in the next year?”, may achieve this end, but there are no studies measuring its accuracy in Portuguese Primary Care. OBJECTIVE To measure the accuracy of the SQ at 6 and 12 months of follow-up, when applied by GP to patients with advanced chronic disease. DESIGN Pragmatic follow up study. SETTING/SUBJECTS Participant General Practitioners (GP), recruited from the Portuguese General Practitioner Sentinel Network and invited personally, were asked to select all patients from their list with: 1) solid cancer, stage IV; 2) congestive heart failure (CHF) NYHA stages III/IV; 3) chronic kidney disease (CKD), stages IV/V; and 4) chronic obstructive pulmonary disease (COPD), stages III/IV. They answered the SQ at 6 and 12 months for every patient, along with reporting their demographics and chronic conditions from January to April 2017. MEASUREMENTS We measured the diagnostic accuracy properties of the SQ with 95% confidence interval. RESULTS The current report is the interim analysis after six months of follow-up. Our sample is composed of 22 GP. A total of 209 patients were included, 34% suffered from cancer, 33% of CHF, 20% of CKD and 16% of COPD. Of these, 37% had a “not surprised” response for the SQ at 6 months and 65% for the SQ at 12 months. We obtained follow up information from 96% (n=201) of patients. The SQ at six months had a sensitivity of 63.9% (48.2% – 79.6%) and specificity of 67.3% (60.1% – 74.4%), with a Positive Predictive Value (PPV) of 29.9% (19.6% – 40.1%) and a Negative Predictive Value (NPV) 89.5% (84.1% – 94.9%). CONCLUSION The PPV 29.9% and NPV 89.5% highlight the fact that the SQ at 6 months is not an accurate tool. Our group will continue this research to publish the final results after the 12-month follow-up completion

Translation and validation of the Portuguese version of the surprise question

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INTERNET DAS COISAS E SEUS IMPACTOS POSITIVOS NO AMBIENTE EDUCACIONAL

A tecnologia está cada vez mais presente dentro das empresas como um ativo facilitador na busca e no compartilhamento de informações, por isso é necessário saber protegê-las, pois elas têm um grande valor no âmbito profissional. A partir dessa visão, desenvolveu-se esse trabalho com o objetivo de criar uma Política de Segurança da Informação para a instituição de ensino superior.  A necessidade da criação da política se deu a partir do resultado de uma pesquisa quantitativa em que foi possível identificar o baixo nível de maturidade por parte dos funcionários da instituição, no que diz respeito a segurança da informação. A política tem como objetivo proteger os ativos de tecnologia da instituição, determinando normas a serem seguidas para reduzir os incidentes resultantes da falta de proteção. DOI: https://doi.org/10.6084/m9.figshare.682880

Short-term delay in neural response with multifocal contact lens might start at the retinal level

Introduction Multifocal simultaneous imaging challenges the visual system to process the multiple overlaps of focused and defocused images. Retinal image processing may be an important step in neuroadaptation to multifocal optical images. Our aims are, firstly to evaluate the short-term effect of different multifocal contact lenses (MF) on retinal activity in young healthy subjects (Experiment#1) and secondly, to evaluate any changes in retinal activity in presbyopic patients fitted with MF over a 15-day period (Experiment#2). Methods In Experiment-#1, 10 emmetropic healthy young subjects were included to evaluate the short-term effect of different MFs designs. In Experiment #2, 4 presbyopic subjects were included to wear MF for 15 days. Following the ISCEV Standards, multifocal electroretinograms (mfERGs) were recorded to evaluate different retinal regions under different conditions: with single vision contact lens (SVCL) and with center-distance and center-near MF. Results In Exp#1 the peak time of N1, P1 and N2 were found to be delayed with the MF (p <= 0.040). There was a significant reduction for N1 amplitude in all retinal regions (p < 0.001), while for P1 and N2 amplitudes this reduction was more significant in the peripheral regions (p < 0.005, ring 5 to 6). With center-near MF the mean response density (nV/deg(2)) showed a significant decrease in all wave components of the mfERGs response, particularly from Ring 3 to Ring 6 (p < 0.001, all Rings). In Exp#2, the mean mfERG response is similar between SVCL and center-distance MF, while center-near MF showed an increase in implicit time N1 and P1 on day 1 that tends to recover to baseline values after 15 days of MF wear. Conclusions significant changes in the mfERGs responses were found with the MF lens, being most noticeable with the center-near MF lens design. The present results suggest that the observed delay in cortical response described during the adaptation to multifocality may partially begin at the retina level.This study was founded by Portuguese Foundation for Science and Technology (FCT, PTDC/FIS-OPT/0677/2014); FCT Strategic Funding (UID/FIS/04650/2013) and FCT-SFRH/BPD/92365/2013 (to Paulo Fernandes) and FCT-SFRH/BD/136684/2018 (to Ana Amorim-de Sousa)

Fiber Post Etching with Hydrogen Peroxide: Effect of Concentration and Application Time

AbstractIntroductionEtching is necessary to expose the fibers and enable both mechanical and chemical bonding of the resin core to the fiber post. This study evaluated the effect of concentration and application time of hydrogen peroxide on the surface topography and bond strength of glass fiber posts to resin cores.MethodsFiber posts were etched with 24% or 50% hydrogen peroxide for 1, 5, or 10 min (n = 10). Posts without any treatment were used as a control. After etching, the posts were silanated and adhesive resin was applied. The posts were positioned into a mold to allow a self-cured resin core to be inserted. The post/resin assembly was serially sectioned into five beams that were subjected to a tensile bond strength test. Data were subjected to two-way ANOVA and Tukey test (α = 0.05). The surface topography was analyzed using scanning electronic microscopy.ResultsNon-etched post presents a relatively smooth surface without fiber exposure. Application of hydrogen peroxide increased the surface roughness and exposed the fibers. All experimental conditions yielded similar bond strength values that were higher than those obtained in the control group.ConclusionBoth 24% and 50% hydrogen peroxide exposure increased the bond strength of resin to the posts, irrespective of the application time

The Portuguese versions of the This Is ME Questionnaire and the Patient Dignity Question: tools for understanding and supporting personhood in clinical care

Background: Modern medicine can be impersonal and routinized, paying insufficient attention to issues of personhood. The Patient Dignity Question (PDQ) and This Is ME (TIME) Questionnaire are clinical tools developed with the aim of probing for personhood, reinforcing dignity and promoting health care attitudes based on looking at people for who they are and not defining them solely based on their medical condition. This study aimed to translate and validate the TIME Questionnaire and the PDQ into European Portuguese, coined as Questionário Este Sou EU (ESEU) and Pergunta da Dignidade (PD), respectively. Methods: A three-stage research design, namely: a forward and back translation process (which included an expert committee panel), collected data on a sample of 43 non-institutionalized active elderly for the validation stage and a final expert panel consultation. Inclusion criteria: being 50 years old or older; ability to provide written informed consent; ability to read, speak and understand Portuguese. Results: The original TIME authors fully endorsed the back translated version. A Portuguese version was created. Forty-three participants (response rate of 62%) were included, 53% of whom were male. The average age was 69 years old (range, 60–80 years old). The interviewed elderly strongly felt that the ESEU’s summary captured their essence as a person beyond whatever health problems they might be experiencing (6.8, SD =0.48), heightened their sense of dignity (6.1, SD =1.48), considered important that health care professionals (HCPs) have access to ESEU’s summary (6.6, SD =0.73) and that this information could affect the way HCPs see and care for them (6.4, SD =0.86), rated on a Likert scale: 1 “strongly disagree”–7 “strongly agree”. According to the experts’ evaluations, the translated ESEU Questionnaire was clear, precise, comprehensible and captured important dimensions of personhood. Conclusions: The Questionário ESEU and the PD are clear, precise, comprehensible and well-aligned in terms of measuring aspects of personhood. This measure could add additional value to the patient-healthcare provider relationship, allowing a new perspective on how healthcare professionals perceive patients in suffering, ensuring they acknowledge not just patienthood, but critical dimensions of personhood.Foundation for Science and Technology (FCT) PhD Fellow Grant number PD/BD/113664/2015 Doctoral Program in Clinical and Health Services Research (PDICSS) funded by FCT Grant number (PD/0003/2013); F Fareleira is funded by Foundation for Science and Technology (FCT) PhD Fellow Grant number PD/BD/132860/2017 Doctoral Program in Clinical and Health Services Research (PDICSS); N Correia Santos: this work has been developed under the scope of the project NORTE-01-0145-FEDER-000013, supported by the Northern Portugal Regional Operational Programme (NORTE 2020), under the Portugal 2020 Partnership Agreement, through the European Regional Development Fund (FEDER), and was co-financed by the Portuguese North Regional Operational Program (ON.2—O Novo Norte), under the National Strategic Reference Framework (QREN), through FEDER. N Correia Santos is supported by a Research Assistantship by the Portuguese Foundation for Science and Technology (FCT, Portugal) through the “FCT Investigator Programme (200 ∞ Ciência)”info:eu-repo/semantics/publishedVersio

Distúrbios do sono e doenças neurodegenerativas

As doenças neurodegenerativas são caracterizadas por morte neuronal excessiva e prematura em parte do cérebro, afetando inúmeros eventos fisiológicos do corpo, entre eles o sono. Portanto, visando melhorar os sintomas motores e cognitivos subjacentes da condição degenerativa e, por consequência, a qualidade de vida global, deve-se buscar primordialmente a qualidade do sono desses pacientes. O objetivo desta revisão é analisar na literatura os transtornos do sono relacionados às doenças neurodegenerativas. Tratou-se de um estudo bibliográfico, realizado por meio de indexadores internacionais através de pesquisa eletrônica nas bases de dados, Scielo, CAPES e Medline, no período de 2001 a 2015. Foram utilizados os descritores: doenças neurodegenerativas, fenômenos cronobiológicos, transtornos do sono e ritmo circadiano. Foi possível correlacionar de maneira consistente os distúrbios do sono como consequência das doenças neurodegenerativas. Independente do tratamento especifico de cada doença, sanar os distúrbios do sono acarretou em melhor qualidade de vida para os pacientes. Para os distúrbios no ciclo circadiano e hipoventilação noturna encontrou-se como tratamento, respectivamente, o uso de melatonina e ventilação não invasiva

Desempenho de pacientes esquizofrênicos no Stroop Color Word Test e responsividade eletrodérmica após administração aguda de canabidiol (CBD)

OBJECTIVE: The last decade has seen increasing evidence of dysfunctions in the endogenous cannabinoid system in schizophrenia and of its relationship with the typical cognitive impairment of the disorder. Studies in animal models, healthy volunteers, and psychotic patients clearly suggest an antipsychotic-like effect of cannabidiol. This study investigated the effects of cannabidiol on selective attention in 28 schizophrenic patients using the Stroop Color Word Test and on these patients' electrodermal responsiveness to auditive stimuli. METHOD: The subjects attended two experimental sessions, the first one without the administration of drugs. In the second session the subjects were divided into three groups that received either a single dose of cannabidiol 300mg or cannabidiol 600mg or placebo. RESULTS: The three groups did not differ significantly with respect to electrodermal measures in the two experimental sessions. When the first and second sessions were compared improved performance was found in all three groups, with patients who received placebo and cannabidiol 300mg performing better than those who received cannabidiol 600mg. CONCLUSION: The single, acute administration of cannabidiol seems to have no beneficial effects on the performance of schizophrenic patients in the Stroop Color Word Test, although the hypothesis that chronic administration may lead to improvement cannot be disregarded.OBJETIVO: Descobertas relativas a possíveis disfunções do sistema canabinóide endógeno na esquizofrenia e sua relação com o prejuízo cognitivo característico da doença têm aumentado durante a última década. Estudos com modelos animais, voluntários saudáveis e pacientes psicóticos sugerem claramente que o canabidiol possui efeitos antipsicóticos. Este estudo investigou os efeitos do canabidiol sobre a atenção seletiva por meio do Stroop Color Word Test e a responsividade eletrodérmica a estímulos auditivos em 28 pacientes com esquizofrenia. MÉTODO: Duas sessões experimentais foram realizadas, a primeira sem a administração de drogas. Na segunda sessão, os sujeitos foram divididos em três grupos que receberam dose única de canabidiol 300mg, canabidiol 600mg ou placebo. RESULTADOS: Os três grupos não diferiram significativamente no que se refere às medidas eletrodérmicas nas duas sessões experimentais. Os três grupos apresentaram melhora da primeira para a segunda avaliação, com os grupos placebo e canabidiol 300mg superiores ao grupo canabidiol 600mg. CONCLUSÃO: A administração aguda de canabidiol em dose única parece não ter efeitos benéficos sobre o desempenho de pacientes com esquizofrenia no Stroop Color Word Test, embora estes dados não sejam suficientes para refutar a hipótese de que a administração continuada de canabidiol possa resultar em melhora no funcionamento cognitivo em esquizofrenia