The applicability of the "surprise question" as a prognostic tool in patients with severe chronic comorbidities in a university teaching outpatient setting

BACKGROUND

Life expectancy in recent decades has increased the prevalence of chronic diseases in the population, requiring an approach to new health topics, such as discussions on quality of life and expectations about death and dying. The concept of advance directives (ADs) gives individuals the opportunity to make known their decisions about the treatments they would like to receive at the end of life. Despite the recognition of relevance in clinical practice, the applicability of the concept presents challenges, including establishing the appropriate prognosis for each patient and the ideal time to approach the patient. Some prognostic tools were developed, such as the surprise question (SQ): "Would you be surprised if your patient died in 12 months?", which is used in some clinical settings to predict patient deaths and to make decisions regarding ADs. The main objective of the present study was to evaluate the behavior of second-year resident physicians (PGY-2) when the SQ was applied.

METHOD

In our observational study, from July 1, 2016, to February 28, 2017, (PGY-2) in the Internal Medicine Residency Program (IMRP) applied SQ to all patients with multiple and varied chronic no communicable comorbidities, who were followed up at the general medicine outpatient clinic (GMOC) of a tertiary university hospital in São Paulo- Brazil. The frequency of the outcome (death or non-death within 12 months) was analyzed by correlating it with the clinical data (impact of the studied variables).

RESULTS

Eight hundred forty patients entered the study. Fitfty-two of them (6.2%) died within one year. PGY-2 predicted that two hundred and fourteen patients (25.5% of total) would die within a year (answer No to SQ), of which, 32 (14.9%) did so. The correct residents' prognosis for the subgroup of 626 patients (answer "Yes" to SQ) was NPV = 96.8% (CI = 95.4%-98.2%) and PPV = 14.9% (CI 10.1%-19, 6%). Answering "Yes" to SQ correlated negatively to addressing AD while the outcomes death and the answer No to SQ were positively correlated, according to the number of comorbidities.

CONCLUSION

The SQ, in addition to care, contributed to health education, communication and care planning shared by the doctor and patient.

Attitudes and intentions to smoke: a study of young Brazilian children

BACKGROUND

Children at earlier stages tend to be more susceptible towards different types of tobacco messages. These are able to influence attitudes and behaviours around smoking. This study examined how these messages are able to influence 5- and 6-year olds' attitudes about smokers and their smoking intentions.

METHODS

Researchers worked one-on-one with 5- and 6-year olds (n = 398) in Brazil. Children could attribute positive and negative characteristics to two different persons in photos as smoker/non-smoker. Children could indicate the attribute as of a smoker, a non-smoker, both or none. Children were asked also about their smoking intentions. Analysis considered parental smoking, sex, age, cigarette and alcohol brand logos, children's location and media characters from cartoons. We conducted a path analysis for a multivariate model of children's attitudes and intentions about smoking.

RESULTS

Overall, children had negative attitudes about smokers (M = -4.58, SD = 4.08) and a total of 32 (8.0%) of them reported intentions to smoke. The resulting multivariate model indicates that parental smoking is a source for a positive image of smokers, while being 6 years old, living in rural areas, being aware of alcohol brands and recognizing educational cartoons tended to be negatively correlated to children's attitudes. Further, 6 year olds were found to be less likely to have smoking intentions, while attitude about smokers was positively related with intentions. One's attitudes served as a mediator for all of the variables in the model towards smoking intentions. The path models differed for each sex.

CONCLUSION

Shaped by social and environmental influences, very young children have opinions about smokers. In turn, these attitudes significantly predict children's smoking intentions. To corroborate this research, we recommend that longitudinal designs be employed to help model why Brazilian children become smokers.

Kinetic analysis of the initial steps involved in lipoplex--cell interactions: effect of various factors that influence transfection activity

We investigated the mode of interaction of lipoplexes (DOTAP:DOPE/DNA) with HeLa cells, focusing on the analysis of the initial steps involved in the process of gene delivery. We evaluated the effect of different factors, namely the stoichiometry of cationic lipids and DNA, the presence of serum in the cell culture medium, and the incorporation of the ligand transferrin into the lipoplexes, on the extent of binding, association and fusion (lipid mixing) of the lipoplexes with the cells. Parallel experiments were performed upon cell treatment with inhibitors of endocytosis. Our results indicate that a decrease of the net charge of the complexes (upon addition of DNA) generally leads to a decrease in the extent of binding, cell association and fusion, except for the neutral complexes. Association of transferrin to the lipoplexes resulted in a significant enhancement of the interaction processes referred to above, which correlates well with the promotion of transfection observed under the same conditions. Besides triggering internalization of the complexes, transferrin was also shown to mediate fusion with the endosomal membrane. The extent of fusion of this type of complexes was reduced upon their incubation with cells in the presence of serum, suggesting that serum components limit the transferrin fusogenic properties. Results were analyzed by using a theoretical model which allowed to estimate the kinetic parameters involved in lipoplex--cell interactions. The deduced fusion and endocytosis rate constants are discussed and compared with those obtained for other biological systems. From the kinetic studies we found a twofold enhancement of the fusion rate constant (f) for the ternary lipoplexes. We also concluded that HeLa cells yield a relatively low rate of endocytosis. Overall, our results estimate the relative contribution of fusion of lipoplexes with the plasma membrane, endocytosis and fusion with the endosomal membrane to their interactions with cells, this information being of crucial importance for the development of gene therapy strategies.

Severe cat flea infestation of dairy calves in Brazil

An investigation was conducted into a severe flea infestation on dairy calves. Inspection of the dairy revealed a high infestation of Ctenocephalides felis felis on four calves and thousands of fleas in the stable where cows and calves were brought in for milking. A 3-month-old female calf was highly infested with fleas. The animal showed an evident lethargy, weight loss, as well as pale mucous membranes and dehydration. Hematological analysis revealed anemia, with 10% packed cell volume and a 1.72 x 10(6) microl(-1) erythrocyte count. Blood transfusions were performed and the flea infestation was controlled with 1% fipronil pour-on (1 ml/10 kg). The farmer was advised to treat the other calves with fipronil, remove the manure from the stable and spread 1% propoxur powder (100 g/m2) onto the floor of the stable.