Publications by authors named "Bianca Sakamoto Ribeiro Paiva"

68 Publications

Where do Brazilian cancer patients prefer to die? Agreement between patients and caregivers.

J Pain Symptom Manage 2022 Apr 7. Epub 2022 Apr 7.

Oncology Graduate Program (T.C.D.O.V, C.E.P., B.S.R.P.), Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Research Group on Palliative Care and Health-Related Quality of Life (GPQual) (T.C.O.V., M.A.D.O., C.E.P., B.S.R.P.), Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Researcher Support Center, Learning and Research Institute (M.A.D.O., C.E.P., B.S.R.P.), Barretos Cancer Hospital, Barretos, SP, Brazil. Electronic address:

Context: Preferred place-of-death (PPoD) is considered an important outcome for the development of appropriate models of care and for improving health policies in countries with underdeveloped palliative care (PC) OBJECTIVES: To determine the concordance between the PPoD of a sample of Brazilian seriously-ill cancer patients and their caregivers, and its associated factors under four different end-of-life (EOL) scenarios: 1) health deterioration in the overall context; 2) health deterioration with severe and uncomfortable symptoms; 3) health deterioration receiving home-based visits as needed; 4) health deterioration receiving home-based visits as needed, when suffering severe and uncomfortable symptoms METHODS: Cross-sectional study at a large Brazilian cancer center, between February 2019 and July 2021. 190 adult cancer patients and their caregivers (n = 190) were analyzed RESULTS: Patient and/or caregiver PPoD concordance for EOL scenario one: 64% vs. 43% for death at home, 22% vs. 30% for death in a PC unit, 14% vs. 27% for death in hospital. Higher patient and/or caregiver PPoD concordance was found for death in hospital (41%; 49%) in EOL scenario two, and for death at home for scenario three (77%; 74%). Agreement coefficient was moderate for scenario two (k = 0.430; P < 0.001), and fair for EOL scenarios one, three and four (k = 0.237, P < 0.001; k = 0.296, P < 0.001; k = 0.307, P < 0.001, respectively). Associated disagreement factors were: performance status (OR:3.03), self-perceived health (OR: 6.99), marital status (OR:2.92), and hospital and/or emergency room proximity (OR:4.11). The presence of relevant persons (42.3% vs. 44.2%), followed by spirituality (38.5% vs. 27.9%) and the place-of-death (14.0% vs. 18.4%), were the most important factors in the EOL, when comparing patients and care givers opinions, respectively CONCLUSION: Low agreement between patients and caregivers on PPoD was identified. EOL clinical factors and deterioration, and PC support seem to influence PPoD.
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http://dx.doi.org/10.1016/j.jpainsymman.2022.03.015DOI Listing
April 2022

HAprog: A New Prognostic Application to Assist Oncologists in Routine Care.

J Pain Symptom Manage 2022 Feb 11. Epub 2022 Feb 11.

Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital (D.D.P., B.S.R.P., C.E.P.), Barretos, Sao Paulo, Brazil; Department of Clinical Oncology, Barretos Cancer Hospital (D.D.P., C.E.P.), Barretos, Sao Paulo, Brazil; Researcher Support Centre, Learning and Research Institute, Barretos Cancer Hospital (B.S.R.P., C.E.P.), Barretos, Sao Paulo, Brazil. Electronic address:

Context: More patients are seeing palliative care (PC) earlier in the disease trajectory. The Barretos Prognostic Nomogram (BPN) was designed to fill the gap of survival prognostication for patients with advanced cancer and months of life expectancy. However, its routine use is limited by the common need for a ruler and calculator. Additionally, the BPN requires blood tests.

Objectives: The aim is to refine the BPN and to create a prognostic application (App) for use on smartphones.

Methods: This is a reanalysis of the two cohorts of advanced cancer patients (development, n=215 and validation, n=276). The variable 'metastasis' was revised (volume-site combinations) and 'KPS' replaced by 'ECOG-PS'. Prognostic variables were selected for multivariable Cox and Log-logistic parametric regression analyses; the most accurate final models were identified by backward variable elimination. Calibration and discrimination properties were evaluated in the validation sample.

Results: The 'full version' model is composed of 6 parameters: sex, locoregional disease, sites of metastasis, ECOG-PS, WBC and albumin. In the 'clinical version' model (5 variables), the variable 'antineoplastic treatment' was included and the laboratory variables were excluded. At validation, both models were well calibrated and presented adequate c-Index values (0.778 and 0.739). HAprog is a freely downloadable offline App that is used by clinicians to calculate prognosis in less than 1 minute.

Conclusion: The new models that integrate HAprog are refined prognostic tools with adequate calibration and discrimination properties. It has potential practical impact for the oncologist dealing with outpatients with advanced cancer during the decision-making process.
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http://dx.doi.org/10.1016/j.jpainsymman.2022.02.004DOI Listing
February 2022

Cross-cultural adaptation and translation of the Pediatric Intensive Care Unit-Quality of Dying and Death into Brazilian Portuguese.

Rev Bras Ter Intensiva 2022 24;33(4):592-599. Epub 2022 Jan 24.

Grupo de Pesquisas em Cuidados Paliativos e Qualidade de Vida Relacionada à Saúde, Hospital de Câncer de Barretos - Barretos (SP), Brasil.

Objectives: To translate and culturally adapt the Pediatric Intensive Care Unit-Quality of Dying and Death questionnaire into Brazilian Portuguese.

Methods: This was a cross-cultural adaptation process including conceptual, cultural, and semantic equivalence steps comprising three stages. Stage 1 involved authorization to perform the translation and cultural adaptation. Stage 2 entailed independent translation from English into Brazilian Portuguese, a synthesis of the translation, back-translation, and an expert panel. Stage 3 involved a pretest conducted with family caregivers and a multidisciplinary team.

Results: The evaluation by the expert panel resulted in an average agreement of 0.8 in relation to semantic, cultural, and conceptual equivalence. The pretests of both versions of the questionnaire showed that the participants had adequate comprehension regarding the ease of understanding the items and response options.

Conclusion: After going through the process of translation and cultural adaptation, the Pediatric Intensive Care Unit-Quality of Dying and Death caregiver and multidisciplinary team versions were considered culturally adapted, with both groups having a good understanding of the items. The questionnaires include relevant items to evaluate the process of death and dying in the intensive care setting, and suggest changes in care centered on patients and especially family caregivers, given the finitude of their children.
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http://dx.doi.org/10.5935/0103-507X.20210086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8889588PMC
January 2022

Oncology palliative care: access barriers: bibliometric study.

BMJ Support Palliat Care 2021 Dec 31. Epub 2021 Dec 31.

Hospital de Câncer de Barretos, Barretos, São Paulo, Brazil

Objective: To perform a bibliometric analysis of studies that evaluated the barriers to access to cancer palliative care (PC).

Methods: This was a bibliometric review using MEDLINE; EMBASE; Web Of Science; LILACS and the Cochrane Library. A search was conducted with the terms Barriers, Palliative Care and Cancer. Articles whose objectives targeted barriers to access to PC were considered, regardless of the year of publication. The setting is articles published from 1987 to 2020.

Results: A total of 6158 articles were identified, of which 217 were eligible for analysis. The USA and UK being the countries with the largest number of articles on the subject (n=101, n=18, respectively). After expert analysis, the barriers were grouped into nine categories.

Conclusions: Barriers related to symptom control were identified in 19% of the eligible articles, along with barriers related to health, which with 24% of occurrence in the articles, were the most frequently cited barriers. Countries which have implemented PC for some time were those with the greatest number of publications and in journals with the highest impact factors. Cross-sectional study design continues to be the most frequently used in publications.
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http://dx.doi.org/10.1136/bmjspcare-2021-003387DOI Listing
December 2021

Predictors of happiness and satisfaction with life in individuals from the Brazilian general population who use social networks: a cross-sectional study.

Cad Saude Publica 2021 10;37(12):e00164020. Epub 2021 Dec 10.

Hospital de Câncer de Barretos, Barretos, Brasil.

This study aimed to identify possible conditions associated with the perception of happiness and satisfaction with life in a sample of the Brazilian population who use social networks. This was a cross-sectional study with participants recruited online in five regions of Brazil via Facebook and WhatsApp. Data were collected from October 2015 to October 2016. The instruments used were the Pemberton Happiness Index, the Satisfaction with Life Scale, and a questionnaire regarding sociodemographic and clinical characteristics and issues potentially associated with the feeling of happiness. In total, 2,151 participants were included. A total of five variables exerted the greatest influence on higher levels of happiness and satisfaction with life in the multiple linear regression model, in the multiple logistic regression analysis, and in the decision tree model. Being satisfied with financial circumstances, having a positive self-evaluation of health, having frequent family gatherings, engaging in physical activity ≥ 3 times a week, and having no previous psychological/psychiatric diagnosis are variables that "seem" to positively influence Brazilians' perception of happiness and satisfaction with life. We identified some predictors of happiness and satisfaction with life, which were mainly related to the social activities and personal satisfaction of the participating individuals. Encouraging people to seek strategies for increasing levels of happiness and life satisfaction based on modifiable variables, such as those found, can be helpful in this context.
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http://dx.doi.org/10.1590/0102-311X00164020DOI Listing
April 2022

Prevalence of burnout and predictive factors among oncology nursing professionals: a cross-sectional study.

Sao Paulo Med J 2021 Jul-Aug;139(4):341-350

MD, PhD. Physician and Researcher, Postgraduation, Hospital de Câncer de Barretos, Barretos (SP), Brazil.

Background: Burnout is a syndrome that mostly affects professionals working in contact with patients and their caregivers. In oncology care, nursing professionals are constantly required to provide emotional support for patients and their caregivers, throughout the process of becoming ill, suffering and dying.

Objective: To evaluate the prevalence and factors associated with burnout in a sample of nursing professionals at a cancer hospital.

Design And Setting: Cross-sectional study conducted at Hospital de Câncer de Barretos.

Methods: The study population comprised 655 nursing professionals. Burnout syndrome was assessed using the Maslach Burnout Inventory Human Service Survey. Univariate analysis and binary logistic regression models were used to identify independent predictors associated with burnout.

Results: Among 304 nursing professionals included in the study, 27 (8.9%) were classified as presenting burnout according to the two-dimensional criteria, and four (1.3%) were classified based on the three-dimensional criteria. Workplace characteristics were not associated with burnout, while single marital status (odds ratio, OR = 2.695; P = 0.037), perceived workplace stressors, such as impatience with colleagues (OR = 3.996; P = 0.007) and melancholy (OR = 2.840; P = 0.021) were considered to be predictors of burnout. Nursing professionals who would choose the profession again (OR = 0.214; P = 0.001) were least likely to present burnout.

Conclusion: Perceived workplace stressors are strongly associated with burnout. Strategies focusing on restructuring of daily work processes and on activities that stimulate positive relationships are important for professionals' health because motivation to continue working in oncology nursing has a protective effect against burnout.
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http://dx.doi.org/10.1590/1516-3180.2020.0606.R1.1202021DOI Listing
October 2021

The Impact of International Research Collaborations on the Citation Metrics and the Scientific Potential of South American Palliative Care Research: Bibliometric Analysis.

Ann Glob Health 2021 03 31;87(1):32. Epub 2021 Mar 31.

Research Group on Palliative Care and Health-Related Quality of Life (GPQual), Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Background: Progress in palliative care (PC) requires scientific advances which could potentially be catalyzed by international research collaboration (IRC). It is currently not known how often IRC occurs with PC investigators in South America.

Objectives: To evaluate the percentage of South America journal articles on PC involving IRCs and the impact of these collaborations on the scientific potential the studies and on their citations.

Methods: This was a bibliometric analysis of studies published between January 1, 1998, and December 31, 2017. A search of Pubmed, Embase, Lilacs, and Web of Science (WOS) was performed using the terms "palliative care," "hospice care," "hospices" and "terminal care," combined with the name of South America countries. The scientific potential was assessed by analyzing study design, characteristics of the journal and funding. IRCs were further subdivided in internal (within South America countries) and external (with countries outside South America).

Findings: Of the 641 articles, 117 (18.2%) involved IRCs (internal: 18, 2.8%; external: 110, 17.2%). Articles with IRCs had higher median two-year citations in WOS (2 vs. 1, p < 0.001), Scopus (3 vs. 1, p < 0.001) and Google Scholar (4.5 vs. 2, p < 0.001) compared to articles without IRC. Moreover, they were more often funded (40.7% vs. 9.7%, p < 0.001), published in Pubmed-indexed (76.1% vs. 41.6%; p < 0.001) and in WOS-indexed (70.1% vs. 29.6%; p < 0.001) journals, and with study designs most often classified as clinical trial (5.1% vs. 1.0%; p = 0.002) and cohort (10.3% vs. 2.9%; p < 0.001) compared to articles without IRC.

Conclusions: Studies with international research collaborations, both internal and external to South America, are more frequently cited and have characteristics with greater scientific potential than do studies without international collaborations.
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http://dx.doi.org/10.5334/aogh.3158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8015710PMC
March 2021

Characteristics of Palliative Care Publications by South American Authors in the Last 20 Years: Systematic Literature Review With Bibliometric Analysis.

J Pain Symptom Manage 2021 09 2;62(3):e177-e185. Epub 2021 Apr 2.

Oncology Graduate Program, Learning and Research Institute, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Department of Clinical Oncology, Breast and Gynecology Division, Barretos Cancer Hospital, Barretos, São Paulo, Brazil. Electronic address:

Context: Research on palliative care (PC) can be used as a direct measure to assess the level of PC development in a country or region.

Objectives: To investigate the scientific production in the field of PC in South American countries over the last two decades.

Methods: The search was performed using the terms "palliative care," "hospice care," "hospices," and "terminal care" combined with the names of South American countries in several databases. The trend in publications over time was analyzed by linear equations (R) and by calculating the annual percentage change (APC). The article citations were extracted from Web of Science (WOS), Scopus and Google Scholar, and the countries' impact factors (IFc) were calculated.

Results: Of the 4259 identified articles, 641 were included in the analysis. There was a clear increase in the number of publications over the analyzed period (R = 0.8794, APC = 14.42%). Brazil was the country with the highest number of publications (n = 389); however, after adjustments by population, GDP and number of researchers, Chile was the country with the greatest prominence, including the highest IF in WOS (4.409). Only 8.3% of publications were systematic review, clinical trial or cohort studies; only 15.4% were funded.

Conclusion: This bibliometric review identified an annual increase of 14% in the number of scientific publications by researchers from South America over the last 20 years. Although Brazil produced the most articles, Chile, had the most efficient scientific production. In general, the articles had low potential for scientific impact.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.03.017DOI Listing
September 2021

Validation of the Adolescent Barriers Questionnaire for use in Brazilian adolescents with cancer.

J Pediatr (Rio J) 2021 May-Jun;97(3):348-353. Epub 2020 Sep 6.

Hospital de Câncer de Barretos, Grupo de Pesquisa em Cuidados Paliativos e Qualidade de Vida Relacionada à Saúde (GPQual), Barretos, SP, Brazil. Electronic address:

Objective: To translate, culturally adapt, and evaluate the psychometric properties of Adolescent Barriers Questionnaire for use in Brazilian adolescents with cancer aged 12 to 18 years, based on the original American Adolescent Barriers Questionnaire which was designed to measure the extent to which adolescents with cancer have concerns about reporting pain and using analgesics.

Methods: The study analyzed the psychometric properties reliability (internal consistency and test-retest) and validity (known groups and convergent) of Adolescent Barriers Questionnaire in adolescents between 12 and 18 years of age with a diagnosis of cancer who were using or who had used analgesic medication (opioid or not) in a pediatric public health institution. It was estimated 64 adolescents as sample size and the research was conclude with 48.

Results: Results of pre-test suggest good understanding (content validity index >0.9). The internal consistency value Cronbach's α was 88%. The convergent validity values ranged between -0.400 and -0.450. Analysis of known groups showed that the instrument discriminated groups of patients with solid vs. hematologic tumors. The intraclass correlation coefficient obtained after retest was 0.863.

Conclusion: After the process of translations, validations and analysis of psychometric properties, the Brazilian Portuguese version of Adolescent Barriers Questionnaire could be considered culturally adapted, valid, and reliable for the Brazilian adolescent population with cancer aged 12 to 18 years and it can be useful in practical clinic, offering the health professionals the opportunity to understand which barriers the adolescent with cancer can encounter and offer, thus, all the support to overcome them.
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http://dx.doi.org/10.1016/j.jped.2020.06.008DOI Listing
May 2021

Influence of advance directives on reducing aggressive measures during end-of-life cancer care: A systematic review.

Palliat Support Care 2021 06;19(3):348-354

Research Group on Palliative Care and Health-Related Quality of Life (GPQual), Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Context: Although the literature recognizes the participation of patients in medical decisions as an important indicator of quality, there is a lack of consensus regarding the influence of advance directives (ADs) on reducing aggressive measures during end-of-life care involving cancer patients.

Objective: A systematic review was conducted to analyze the influence of ADs on reducing aggressive end-of-life care measures for cancer patients.

Method: We searched the Medline, Embase, Web of Science, and Lilacs databases for studies published until March 2018 using the following keywords, without language restrictions: "advance directives," "living wills," "terminal care," "palliative care," "hospice care," and "neoplasms." Article quality was assessed using study quality assessment tools from the Department of Health and Human Services (NHLBI).

Results: A total of 1,489 studies were identified; 7 met the inclusion criteria. The studies were recently published (after 2014, 71.4%). Patients with ADs were more likely to die at the site of choice (n = 3) and received less chemotherapy in the last 30 days (n = 1). ADs had no impact on intensive care unit admission (n = 1) or hospitalization (n = 1). One study found an association between ADs and referral to palliative care, but other did not find the same result.

Significance Of Results: Of the seven articles found, four demonstrated effects of ADs on the reduction in aggressive measures at the end of life of cancer patients. Heterogeneity regarding study design and results and poor methodological quality are challenges when drawing conclusions.
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http://dx.doi.org/10.1017/S1478951520000838DOI Listing
June 2021

An explorative analysis of the differences in levels of happiness between cancer patients, informal caregivers and the general population.

BMC Palliat Care 2020 Jul 11;19(1):106. Epub 2020 Jul 11.

Health-Related Quality of Life Research Group (GPQual), Learning and Research Institute, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Background: Although cancer patients experience distressing symptoms and health-related changes in their quality of life, they may report positive emotional states. The lives of informal caregivers of cancer patients may also be affected by the patient's cancer diagnosis; however, they may also find benefits in their experiences. Noticeable changes are reported in personal priorities after an oncologic diagnosis that can lead individuals to restructure their values and the way they perceive life. This study aims to assess happiness/satisfaction with life and positive and negative affect in cancer patients and informal caregivers compared with healthy people in the general population.

Methods: A cross-sectional study with participants recruited online in five regions of Brazil through the social network site Facebook® and the application WhatsApp®. Surveys were completed using the SurveyMonkey® platform. A different sample of cancer patients and informal caregivers that was personally interviewed with the same forms was also grouped in the present analysis. Variables with p-values < 0.05 in the univariate analysis were included in linear regression models (stepwise, backward).

Results: A total of 2580 participants were included, of whom 2112 were healthy representatives of the general population, 342 were cancer patients, and 126 were informal caregivers of cancer patients. In the multivariate analysis, the cancer patients and informal caregivers were happier than the healthy people in the general population, even after controlling for age, sex, educational level, and income. The patients and caregivers had lower scores for positive affect and higher scores for negative affect.

Conclusions: Overall, the conditions related to happiness, satisfaction with life and positive affect are similar for all groups. However, cancer patients and informal caregivers report increased rates of happiness and satisfaction with life compared with theoretically healthy people, although they have lower positive affect scores and higher negative affect scores. It is suggested that cancer patients and caregivers of cancer patients experience more difficulties (suffering) on ​​a daily basis. However, given the increased difficulties, they perceive life differently, reporting that they are happier.
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http://dx.doi.org/10.1186/s12904-020-00594-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354680PMC
July 2020

Do different pedagogical conceptions result in different quality of life levels?

Rev Assoc Med Bras (1992) 2020 Mar;66(3):257-262

. Faculdade de Medicina, Universidade Federal de Juiz de Fora, Juiz de Fora, Brasil.

Objective: The present study aims to compare medical students' quality of life (QoL) at two Brazilian institutions with different pedagogical conceptions.

Methods: We studied students during the first four years of medical school at two institutions (one using active methodologies and small groups and the other using traditional lectures and large groups). We used a demographic questionnaire and the WHOQOL-BREF.

Results: 820 medical students were included. No significant differences in quality of life were found in general, nor while evaluating the course phase, except for the physical WHOQOL, which was lower for 2nd-year students at the institution with traditional lectures, even when adjusted for gender.

Conclusion: Our findings revealed that, despite having very distinct pedagogical conceptions and characteristics, there were no significant differences in medical students' QoL scores between both institutions. These results are surprising and differ from our initial hypothesis, which expected better QoL for those using more active and student-centered methods.
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http://dx.doi.org/10.1590/1806-9282.66.3.257DOI Listing
March 2020

Happiness and satisfaction with life: potential social indicators for periodic measurement in Brasil?

Rev Assoc Med Bras (1992) 2020 Mar;66(3):245-247

. Grupo de Pesquisa em Cuidados Paliativos e Qualidade de Vida Relacionada à Saúde (GPQual),Instituto de Ensino e Pesquisa, Hospital de Câncer de Barretos, Barretos, SP, Brasil.

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http://dx.doi.org/10.1590/1806-9282.66.3.245DOI Listing
March 2020

Association between multiple symptoms and quality of life of paediatric patients with cancer in Brazil: a cross-sectional study.

BMJ Open 2020 05 5;10(5):e035844. Epub 2020 May 5.

Learning and Research Institute, Barretos Cancer Hospital, Barretos, Brazil

Objectives: To identify the association of multiple symptoms and clinical characteristics on quality of life (QoL) of paediatric patients with cancer.

Design: A descriptive, cross-sectional study.

Setting: South American Children's Hospital for Cancer Treatment (Barretos, São Paulo, Brazil).

Participants: A total of 157 participants, 116 paediatric patients, diagnosed with cancer, undergoing chemotherapy treatment, between 7 and 18 years of age and 41 proxies for patients between 2 and 6 years of age.

Primary Outcome Measures: The severity and prevalence ofsymptoms were identified through the use of a culturally adapted multi-symptomscreening tool, and the influence these symptoms, in association with clinicalcharacteristics, had on the QOL of Brazilian pediatric cancer patients wasassessed.

Results: Prevalent symptoms identified by all participants were 'feeling tired' (98, 62.4%), 'feeling more or less hungry (do not feel like eating) than you usually do' (96, 61.1%), 'changes in taste (flavour of the food)' (89, 56.7%), 'throwing up or feeling like you may throw up' (77, 49%) and 'changes in how your body (visually) or face looks' (72, 45.9%). The multivariate analysis for symptom severity as reported by proxies showed that surgery (OR 0.20, 95% CI 0.04 to 0.98, p=0.047) and time of diagnosis (OR 0.14, 95% CI 0.03 to 0.66, p=0.012) were associated with a decreased OR of high severity symptoms.An analysis of the clinical characteristics associated with Pediatric Quality of Life Inventory (PedsQL) demonstrated no significant effect on QoL in any of the domains evaluated. The association between Symptom Screening in Pediatrics Tool and PedsQL in the self-report version demonstrated a significant negative influence of all symptoms on the QoL.

Conclusions: The prevalence of symptoms experienced among pediatric patients during treatment was high and significantly influenced all aspects of quality of life,especially in the emotional domain.
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http://dx.doi.org/10.1136/bmjopen-2019-035844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223154PMC
May 2020

Development of a screening tool to improve the referral of patients with breast and gynecological cancer to outpatient palliative care.

Gynecol Oncol 2020 07 30;158(1):153-157. Epub 2020 Apr 30.

Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, United States of America.

Objective: New strategies that allow timely referral to outpatient palliative care (PC) for cancer patients are sought. The authors developed a 16-item checklist tool with 3 categories of care priorities based on patients' physical functionality. To evaluate the potential clinical impact of the use of these criteria in patients with advanced breast and gynecological cancer (ABGC) seen at oncology clinics.

Methods: The study was divided into 2 phases. In Phase I, research nurse prospectively assessed the referral criteria among patients with ABGC who had not yet been referred to PC. The oncologists' (routine) referral rate was compared to the referral rate if the criteria were applied universally. In Phase II, we implemented routine screening with these referral criteria without automatic trigger. Patients not yet evaluated by PC were retrospectively evaluated regarding the rate of screening and how often they met criteria.

Results: Among the 120 patients evaluated in Phase I, oncologists referred 23 (19%) and the screening criteria identified another 82 (68%) who may benefit from PC, potentially increasing the PC referral rate by 3.2-fold. Patients would have been referred earlier using the criteria than based on oncologists' judgement (median survival 451 days vs. 178, p < 0.001). In Phase II, among the patients who were not yet receiving PC, 38.6% (97 of 251) met at least one criterion.

Conclusion: The use of referral criteria has the potential to significantly increase the number of timely palliative care referral. Further research is needed to test the implementation of these criteria.
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http://dx.doi.org/10.1016/j.ygyno.2020.04.701DOI Listing
July 2020

Missed Opportunities of Integration of Palliative Care: Frequency, Causes, and Profile of Missed Visits in an Oncologic Palliative Care Outpatient Unit.

J Pain Symptom Manage 2020 05 25;59(5):1067-1073.e1. Epub 2020 Jan 25.

Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Context: Many patients with cancer are referred to palliative care (PC) outpatient clinics but do not attend consultations, which increases the difficultly of integrating PC in a timely manner.

Objectives: To evaluate the frequency, causes, and profile of missing first-time consultations in a PC outpatient clinic.

Methods: Data from patients with advanced cancer who were scheduled for first-time visits to the PC outpatient clinic from September 2018 to August 2019 were analyzed. Missed consultation was defined as a nonperformed consultation with no prior notice of cancellation, and missed opportunity of palliative care (MOPC) was defined as a nonperformed consultation regardless of being notified in advance. The causes of the absence were identified by telephone using a standardized form. Logistic regression models were used to identify the profile of patients who have MOPC.

Results: About 1468 patients were scheduled for first-time visits to the PC outpatient clinic; missed consultation = 21.7% (n = 275) and MOPC = 32.5% (n = 478). Of the total number of patients who had MOPC, 86 (18%) were later seen in a median time (percentile p25-p75) of 29.5 days (range 7.0-66.5). The most common cause of MOPC was death before consultation (n = 92; 29.8%). Referral to PC using a standardized protocol (odds ratio 0.787; P = 0.044) and residence in distant cities (odds ratio 2.394; P < 0.001) were independently associated with MOPC.

Conclusion: Approximately one-third of patients eligible for PC miss the opportunity to be included earlier; only 18% of them are consulted later. Use of standardized referral protocols may help to reduce these absence rates.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.01.005DOI Listing
May 2020

Clinical Prediction of Survival in Advanced Cancer Outpatients: Do Experienced Physicians and With Prior Patient Evaluation Make More Accurate Predictions?

J Pain Symptom Manage 2020 01 1;59(1):e7-e10. Epub 2019 Oct 1.

Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Department of Clinical Oncology, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Researcher Support Centre, Learning and Research Institute, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

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http://dx.doi.org/10.1016/j.jpainsymman.2019.09.019DOI Listing
January 2020

Impact of Palliative Care on Quality of End-of-Life Care Among Brazilian Patients With Advanced Cancers.

J Pain Symptom Manage 2020 01 23;59(1):39-48. Epub 2019 Aug 23.

Research Group on Palliative Care and Health-Related Quality of Life (GPQual), Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Oncology Graduate Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil. Electronic address:

Context: Many patients with advanced cancer experience aggressive care during the end of life (EOL). Several studies have evaluated the benefits of palliative care (PC) on the reduction of aggressive measures; however, limited data are available about their benefit in Brazilian patients.

Objectives: To evaluate the impact of PC on the reduction of aggressive measures at the EOL.

Methods: Longitudinal study analyzed retrospectively medical records of patients who died of advanced cancer from 2010 to 2014. Data were obtained on PC referral and five quality-of-care indicators at the EOL; that is, emergency department visits, hospital admission, intensive care unit admission, use of systemic antineoplastic therapy within the last 30 days of life, and place of death in hospital as well as the use of a composite score for aggressiveness of care.

Results: Of the 1284 patients, 832 (65%) received some aggressive measures in EOL care. Over the years, there was a reduction in the aggressiveness of care (score = 0: 33.2% vs. 47.1%; P < 0.001). Patients not seen by PC received greater aggressive care compared with patients consulted by PC (score ≥1: 87.4% vs. 52.8%; P < 0.001). Early PC was associated with less chemotherapy (P = 0.001) and fewer emergency department visits (P = 0.004) in the last 30 days of life, when compared with late PC. However, there were no demonstrated benefits to significantly reduce the composite score at EOL care aggressiveness.

Conclusion: Patients with an advanced cancer consultation by PC staff received less aggressive care at the EOL when compared with patients without PC.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.08.021DOI Listing
January 2020

Symptom screening in paediatrics tool for screening multiple symptoms in Brazilian patients with cancer: a cross-sectional validation study.

BMJ Open 2019 08 2;9(8):e028149. Epub 2019 Aug 2.

Oncology Graduate Program and Research Group on Palliative Care and Health-Related Quality of Life (GPQual), Barretos Cancer Hospital, BARRETOS, Brazil

Objective: The objective of this study was to translate, culturally adapt and validate the Symptom Screening in Paediatrics Tool (SSPedi) into the Brazilian Portuguese language to be used by paediatric oncology patients in Brazil.

Design: A descriptive, cross-sectional study that follows an established methodology for translation and cultural adaptation, developed in two phases: phase I, linguistic translation and cultural adaptation of the SSPedi scale and phase II, psychometric properties evaluation.

Setting: Children's Hospital for Cancer Treatment in Latin America.

Participants: Paediatric patients between 7 and 18 years of age and proxies of patients between 2 and 6 years of age, diagnosed with cancer and undergoing chemotherapy treatment. Patients and proxies with significant neuropsychiatric disorders and/or visual impairment that prevented the ability to read were excluded.

Primary Outcome Measures: Construct validation of SSPedi using convergent validity and contrasted groups. Reliability was evaluated using Cronbach's alpha test and assessing the retest using the intraclass correlation coefficient (ICC).

Results: The psychometric properties of the symptom screening tool were evaluated using 157 participants, of which 116 were patients and 41 were proxies. Convergent validity and hypothesised correlations (Spearman's r>0.4) were confirmed for both self- and proxy-reported versions of the assessment tool. No significant differences found between the two contrasting groups. Assessment of SSPedi resulted in an internal consistency of reliability of α=0.77 (95% CI 0.70 to 0.82) for the self and α=0.81 (95% CI 0.71 to 0.88) for the proxy and overall reproducibility ICC values of (95% CI), 0.54 (0.15 to 0.77) and 0.77 (0.64 to 0.86).

Conclusion: SSPedi was found to be culturally and linguistically adaptable and considered valid and reliable for use by paediatric oncology patients in Brazil. The new translated and adapted version was named SSPedi-BR.
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http://dx.doi.org/10.1136/bmjopen-2018-028149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6687019PMC
August 2019

Validation of the Brazilian version of the Shame and Stigma Scale (SSS-Br) for patients with head and neck cancers.

Palliat Support Care 2020 04;18(2):186-192

Health-Related Quality of Life Research Group (GPQual), Learning and Research Institute, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Objective: To evaluate the psychometric properties of the Brazilian version of the Shame and Stigma Scale (SSS) in a sample of patients with head and neck cancers (HNC).

Methods: This is a validation study carried out in a Brazilian cancer hospital. Patients over 18 years old who knew about their HNC diagnosis were consecutively recruited, answering the SSS, the Functional Assessment of Cancer Therapy (General and Head and Neck supplement) questionnaire, and the University of Washington Quality of Life Questionnaire. Internal consistency, test-retest procedure, convergent validity, and responsiveness analysis were the psychometric properties evaluated.

Results: A total of 122 HNC patients were included. The SSS showed appropriate internal consistency (alphas ranging from 0.71 to 0.86), test-retest reliability (higher than 0.92 with exception of the "Regret domain"), and convergent validity. The responsiveness analysis with 38 patients was able to discriminate the scores before and after prosthetic procedures.

Significance Of The Results: The Brazilian Portuguese version of the SSS may be considered a valid and reliable instrument for the evaluation of Brazilian patients with HNC. Future SSS validation studies are welcome in other developing countries in order to make cancer health providers aware of these negative feelings in their HNC patients.
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http://dx.doi.org/10.1017/S1478951519000488DOI Listing
April 2020

What Is Missing for You to Be Happy? Comparison of the Pursuit of Happiness Among Cancer Patients, Informal Caregivers, and Healthy Individuals.

J Pain Symptom Manage 2019 09 11;58(3):417-426.e4. Epub 2019 Jun 11.

Health-Related Quality of Life Research Group (GPQual), Learning and Research Institute, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Department of Clinical Oncology, Barretos Cancer Hospital, Barretos, São Paulo, Brazil. Electronic address:

Context: After cancer diagnosis, personal value priorities may change in a way that would transform such values and how life is perceived by cancer patients and their caregivers, including happiness and its pursuit.

Objectives: The objective of the study was to analyze and compare what cancer patients, informal caregivers, and healthy population believe that would make them happy.

Methods: A qualitative content analysis was performed on the responses to a single question: "What is missing for you to be happy?" Narratives of cancer patients (n = 242, face-to-face interview), informal caregivers (n = 125, face-to-face interview), and healthy participants (n = 1,671, recruited through social media, online survey) were analyzed. Word clouds were created for each group of participants. Contents were identified and frequencies were compared among participants by means of chi-square and Fisher's exact tests.

Results: Overall, participants were pursuing better health (n = 288, 14.1%), better interpersonal relationships (n = 456, 22.4%), money (n = 412, 20.2%), and work-related aspects (n = 481, 23.6%). Cancer patients and informal caregivers sought better health and cure more often than when compared to healthy people (P < 0.001). Among cancer patients, survivors' profile tended to be similar to that of the healthy population concerning what they need to be happy. Unexpectedly, "cure" (22.7%) was more frequent among participants with incurable cancer.

Conclusion: Regardless of the group they were in, participants sought happiness in what they considered to be important to their lives, but it was something they did not have at the time of the interview. Psychoeducational and cognitive-behavioral strategies focused on how to deal with life expectations among people facing cancer are awaited.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.05.023DOI Listing
September 2019

Impact of AferBio® on quality of life and chemotherapy toxicity in advanced lung cancer patients (AFERBIO study): protocol study for a phase II randomized controlled trial.

BMC Cancer 2019 Apr 25;19(1):382. Epub 2019 Apr 25.

Health-Related Quality of Life Research Group (GPQual), Learning and Research Institute, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Background: Lung cancer patients undergoing palliative chemotherapy exhibit many symptoms related to the disease, such as adverse events and infectious complications during treatment, which impacts directly their health-related quality of life (HRQOL). Nutritional status is a relevant aspect among advanced cancer patients under palliative care and food supplementation has the potential to reduce treatment-related adverse effects and improve the nutritional status. The product named AferBio® is a fermented supplement that has been described as able to provide some benefits, including the capacity to potentiate the effects of anticancer drugs, by promoting the reduction of side effects and ultimately improving HRQOL.

Methods/design: A Phase II double-blind placebo-controlled randomized clinical trial to assess the use of food supplementation with AferBio® in Stage IIIB or IV non-small cell lung cancer (NSCLC) patients beginning a second-line palliative mono-chemotherapy. The primary goal is to compare HRQOL scores between the arms of the study over time. The ten first patients included in the present study will undergo an AferBio®toxicity-testing (non-randomized phase). If no significant toxicity is found, the study will move on to the randomized phase. All patients will be randomized in blocks at a 1:1 ratio using the online tool REDCap. ECOG-PS (0-1 versus 2) criteria will be used for stratification. All patients included in the trial will be evaluated at baseline and at each chemotherapy cycle. Each evaluation will include the following: HRQOL (EORTC QLQ-C30, LC13 and IQualiV-Lung), ECOG-PS, anthropometric measurements, clinical and laboratory toxicity assessment and response evaluation.

Discussion: During palliative systemic therapy in advanced cancer patients, one of the main goals is the improvement and maintenance of HRQOL, which can be negatively affected by cancer symptoms, cancer- or treatment-related psychosocial difficulties, and chemotherapy toxicity. Thus, much research has been dedicated to the development of new and more effective and/or less toxic cancer therapies. The present study is justified by the testing of a novel food supplement that may reduce some toxicities, thus, having a potential positive impact on the HRQOL of lung cancer patients. The product in question (AferBio®) is already available for sale in Brazil, but has not yet been fully tested in cancer patients.

Trial Registration: This Trial was registered on March 19, 2018 with ClinicalTrials.gov , NCT03469063. Protocol version: 2.0 from March 26, 2018. Trial status: Patient enrollment in the study began in April, 2018.
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http://dx.doi.org/10.1186/s12885-019-5599-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6485167PMC
April 2019

Operation of a hospital palliative care service: a fourth-generation evaluation.

Rev Bras Enferm 2019 Mar-Apr;72(2):383-390. Epub 2019 Apr 18.

Universidade Estadual de Maringá. Maringá-PR, Brasil.

Objective: Qualitatively evaluate the operation of a palliative care service in oncology.

Methodology: Qualitative study conducted in a service in southern Brazil based on a fourth generation evaluation. Between September 2014 and June 2015, 460 hours of operation were observed, and 45 semi-structured interviews and five negotiation meetings were conducted; data were analyzed using the constant comparative method.

Results: Potential services are: provision of outpatient palliative care, home and inpatient care provided by a multidisciplinary and support team, meeting the patient's biological, psychological, social and spiritual needs. Study limitations: ineffective communication between clinical and surgical oncology and palliative care sectors, lack of specialized training for professionals and in interpersonal relationship issues among team members.

Final Consideration: For palliative care progress in the service, some arrangements are required to enhance integrality of care.
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http://dx.doi.org/10.1590/0034-7167-2017-0848DOI Listing
June 2019

Doctor, are you healthy? A cross-sectional investigation of oncologist burnout, depression, and anxiety and an investigation of their associated factors.

BMC Cancer 2018 Oct 26;18(1):1044. Epub 2018 Oct 26.

Department of Clinical Oncology, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Purpose: Doctors who work at cancer hospitals are at high risk of developing emotional distress. This study evaluated the prevalence of burnout, anxiety, and depression in a sample of oncologists of various specialties and sought to identify how much of this distress is explained by specific pre-established characteristics.

Methods: This cross-sectional study used online surveys. Burnout was measured using the Maslach Burnout Inventory (MBI), and anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). The variables associated with p-values < 0.10 in the univariate analyses were included in blocks of hierarchical binary logistic regression models to identify the predictors of burnout, depression, and anxiety.

Results: Of the 227 physicians (response rate = 70.5%), 132 (58.1%) were identified as having burnout (high emotional exhaustion [EE] and depersonalization [DP]); furthermore, 28 (12.3%) had depression (HADS-D ≥ 11), and 44 (19.4%) had anxiety (HADS-A ≥ 11). The block of perceptions related to the workplace explained 22.4%, 7.7%, and 10.6% of the variances of burnout, depression, and anxiety, respectively. On the other hand, the outside-of-work characteristics block explained only 3.1%, 13.4%, and 3.4% of the variances of burnout, depression, and anxiety, respectively.

Conclusions: Work-related stressors are associated with burnout, but few are associated with anxiety and depression. Outside-of-work characteristics explained little of the distress reported by physicians. Strategies focused on perceptions of professional recognition and lower workloads that stimulate positive relationships between doctors and other health professionals are desirable in oncological context.
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http://dx.doi.org/10.1186/s12885-018-4964-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6203972PMC
October 2018

The Children's International Mucositis Evaluation Scale Is Valid and Reliable for the Assessment of Mucositis Among Brazilian Children With Cancer.

J Pain Symptom Manage 2018 11 25;56(5):774-780.e2. Epub 2018 Jul 25.

Research Group on Palliative Care and Health-Related Quality of Life (GPQual), Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Oncology Graduate Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil; Department of Clinical Oncology - Breast and Gynecology Division, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Background: The Children's International Mucositis Evaluation Scale (ChIMES) is considered a valid and reliable instrument for the assessment of mucositis in pediatric patients aged 0-18 years.

Objective: To perform the translation and cultural adaptation of ChIMES to Brazilian Portuguese and assess its psychometric properties.

Methods: Methods for translation and cultural adaptation were used. Other measurements obtained concomitantly for the assessment of psychometric properties included the Oral Mucositis Daily Questionnaire, a visual analog scale, the World Health Organization grading scale for mucositis, and the National Cancer Institute Common Terminology Criteria for Adverse Events toxicity scale. For test-retest analysis, patients and guardians responded to the self-report and proxy versions of ChIMES within intervals of one to seven days.

Results: Regarding internal consistency, Cronbach's alpha (α) values were 0.769 (95% CI = 0.631-0.868) and 0.879 (95% CI = 0.872-0.920) for the self-reported and proxy versions, respectively. The convergent validity criteria were met for the self-reported and proxy versions (Spearman's rho = 0.466-0.751; P < 0.001 and Spearman's rho = 0.410-0.551; P < 0.001, respectively). Test-retest reliability assessment for the total score and Items 1, 2, 3, and 4 in both versions showed an intraclass correlation coefficient of ≥0.7.

Conclusions: The Portuguese self-reported and proxy versions of ChIMES were considered to be culturally adapted, valid, and reliable for Brazilian pediatric patients ranging from an age of one month to 18 years and were named ChIMES-BR.
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http://dx.doi.org/10.1016/j.jpainsymman.2018.07.015DOI Listing
November 2018

Development and validation of a prognostic nomogram for ambulatory patients with advanced cancer.

Cancer Med 2018 Jun 1. Epub 2018 Jun 1.

Department of Palliative Care and Rehabilitation Medicine, M.D. Anderson Cancer Center, The University of Texas, Houston, TX, USA.

Predicting survival of advanced cancer patients (ACPs) is a difficult task. We aimed at developing and testing a new prognostic tool in ACPs when they were first referred to palliative care (PC). A total of 497 patients were analyzed in this study (development sample, n = 221; validation sample, n = 276). From 35 initial putative prognostic variables, 14 of them were selected for multivariable Cox regression analyses; the most accurate final model was identified by backward variable elimination. Parameters were built into a nomogram to estimate the probability of patient survival at 30, 90, and 180 days. Calibration and discrimination properties of the Barretos Prognostic Nomogram (BPN) were evaluated in the validation phase of the study. The BPN was composed of 5 parameters: sex, presence of distant metastasis, Karnofsky Performance Status (KPS), white blood cell (WBC) count, and serum albumin concentration. The C-index was 0.71. The values of the area under the curve (AUC) of the receiver operating characteristic (ROC) curve were 0.84, 0.74, and 0.74 at 30, 90, and 180 days, respectively. There were good calibration results according to the Hosmer-Lemeshow test. The median survival times were 313, 129, and 37 days for the BPN scores <25th percentile (<125), 25th to 75th percentile (125-175), and >75th percentile (>175), respectively (P < .001). The BPN is a new prognostic tool with adequate calibration and discrimination properties. It is now available to assist oncologists and palliative care physicians in estimating the survival of adult patients with advanced solid tumors.
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http://dx.doi.org/10.1002/cam4.1582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051167PMC
June 2018

The Brazilian version of Skindex-16 is a valid and reliable instrument to assess the health-related quality of life of patients with skin diseases.

PLoS One 2018 22;13(3):e0194492. Epub 2018 Mar 22.

Palliative Care and Health-Related Quality of Life Research Group, Barretos, Brazil.

Introduction: The aim of this study was to assess the psychometric properties of the Brazilian version of Skindex-16 in patients with various skin diseases.

Methods: Dermatologic assessments were performed for the diagnosis and classification of the severity of skin conditions. The clinical feasibility of Skindex-16 was assessed based on the time required to complete the questionnaire and the number of unanswered items. The participants (n = 110) answered the Hospital Anxiety and Depression Scale (HADS), the Dermatology Life Quality Index (DLQI) and the Skindex-16 (Portuguese/Brazil version) questionnaires. Convergent validity was assessed based on the correlation of the Skindex-16 with the DLQI and HADS subscales. Known-groups validity was assessed based on the comparison of the mild, moderate and severe disease groups using the Kruskal-Wallis test. Internal consistency was assessed using Cronbach's alpha and test-retest reproducibility using the intraclass correlation coefficient (ICC) obtained with 29 participants who answered the Skindex-16 a second time 3 to 10 days after the first assessment.

Results: The mean time to answer the questionnaire was 2 min 41 sec. Cronbach's alpha scores were 0.867, 0.930 and 0.888 for the Skindex-16 domains symptoms, emotions and functioning, respectively. The ICCs were 0.947, 0.860 and 0.843 for the Skindex-16 domains symptoms, emotions and functioning, respectively. All three Skindex-16 scales exhibited strong correlations with DLQI. Moderate correlations were found between HADS subscales and the Skindex-16 emotions domain. Known-groups validity showed differences in all three Skindex-16 domains between the mild and moderate skin disease groups (emotions: p < 0.001; symptoms: p = 0.049; functioning: p < 0.001) and between the mild and severe skin disease groups (emotions: p = 0.002; symptoms: p = 0.001; functioning: p = 0.002).

Conclusion: The Portuguese/Brazil version of Skindex-16 is a valid and reliable instrument to assess the quality of life of patients with skin diseases.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194492PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5864026PMC
July 2018

Burnout among medical students during the first years of undergraduate school: Prevalence and associated factors.

PLoS One 2018 7;13(3):e0191746. Epub 2018 Mar 7.

Research Group on Palliative Care and Health-Related Quality of Life (GPQual) -Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Objective: To evaluate the prevalence and possible factors associated with the development of burnout among medical students in the first years of undergraduate school.

Method: A cross-sectional study was conducted at the Barretos School of Health Sciences, Dr. Paulo Prata. A total of 330 students in the first four years of medical undergraduate school were invited to participate in responding to the sociodemographic and Maslach Burnout Inventory-Student Survey (MBI-SS) questionnaires. The first-year group consisted of 150 students, followed by the second-, third-, and fourth-year groups, with 60 students each.

Results: Data from 265 students who answered at least the sociodemographic questionnaire and the MBI-SS were analyzed (response rate = 80.3%). One (n = 1, 0.3%) potential participant viewed the Informed Consent Form but did not agree to participate in the study. A total of 187 students (187/265, 70.6%) presented high levels of emotional exhaustion, 140 (140/265, 52.8%) had high cynicism, and 129 (129/265, 48.7%) had low academic efficacy. The two-dimensional criterion indicated that 119 (44.9%) students experienced burnout. Based on the three-dimensional criterion, 70 students (26.4%) presented with burnout. The year with the highest frequency of affected students for both criteria was the first year (p = 0.001). Personal attributes were able to explain 11% (ΔR = 0.11) of the variability of burnout under the two-dimensional criterion and 14.4% (R2 = 0.144) under the three-dimensional criterion.

Conclusion: This study showed a high prevalence of burnout among medical students in a private school using active teaching methodologies. In the first years of graduation, students' personal attributes (optimism and self-perception of health) and school attributes (motivation and routine of the exhaustive study) were associated with higher levels of burnout. These findings reinforce the need to establish preventive measures focused on the personal attributes of first-year students, providing better performance, motivation, optimism, and empathy in the subsequent stages of the course.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191746PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841647PMC
June 2018

Factors associated with palliative care referral among patients with advanced cancers: a retrospective analysis of a large Brazilian cohort.

Support Care Cancer 2018 Jun 5;26(6):1933-1941. Epub 2018 Jan 5.

Oncology Post-Graduate Program (Stricto Sensu), Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Purpose: The purpose of the study is to estimate the proportion of patients who had access to palliative care (PC) and to identify the timing and factors associated with this access.

Methods: A retrospective longitudinal study that included patients who died of advanced cancer between the years of 2010 and 2014 was conducted. The proportion of patients who received PC consultations was compared during those years. Sociodemographic and clinical factors, the timing between first PC consultation and death (early, ≥ 3 months; late, < 3 months), and first PC consultation were assessed.

Results: Of the 1284 studied patients, 988 (76.9%) were referred to PC and 839 (65.3%) had a PC consultation. The proportion of patients who received late PC consultation increased between the years 2010 and 2014 (44.2 vs. 60.4%, p = 0.001). Multivariate analysis revealed that younger age (odds ratio (OR) = 0.98, p = 0.016) and gynecologic cancer (OR = 2.17, p = 0.011) were associated with a PC consultation. Upper gastrointestinal tract (GIT) cancer (OR = 2.42, p = 0.001) and hematologic malignancies (OR = 0.37, p = 0.001) were associated with late PC consultations. The median time interval between the first PC consultation and death was 2.66 months: timing differed significantly among cancer subtypes (p = 0.002).

Conclusion: Most patients received PC consultation before death, and the number of patients with late consultation increased throughout the study. Patients with late referrals could have received PC earlier. The current findings suggest the need to standardize the referral criteria to optimize access to PC.
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http://dx.doi.org/10.1007/s00520-017-4031-yDOI Listing
June 2018
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