Acanthosis nigricans (AN), an entity recognized since the 19th century, is a dermatopathy associated with insulin-resistant conditions, endocrinopathies, drugs, chromosome abnormalities and neoplasia. The latter, also known as malignant AN, is mostly related to abdominal neoplasms. Malignant AN occurs frequently among elderly patients. In these cases, the onset is subtle, and spreading involves the flexural regions of the body, particularly the axillae, palms, soles, and mucosa. Gastric adenocarcinoma is the most frequent associated neoplasia, but many others have been reported. Renal cell carcinoma (RCC), although already reported, is rarely associated with malignant AN. The authors report the case of a woman who was being treated for depression but presented a long-standing and marked weight loss, followed by darkening of the neck and the axillary regions. Physical examination disclosed a tumoral mass in the left flank and symmetrical, pigmented, velvety, verrucous plaques on both axillae, which is classical for AN. The diagnostic work-up disclosed a huge renal mass, which was resected and further diagnosed as a RCC. The post-operative period was uneventful and the skin alteration was evanescent at the first follow-up consultation. The authors call attention to the association of AN with RCC.
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 advance directives (Ads). Method: In our one-year observational study, from July 1, 2016, to February 28, 2017, second-year resident physicians in the medical residency program (MRPIM) applied SQ to all patients with multiple and varied chronic noncommunicable comorbidities, who were followed up at the general medicine outpatient clinic (GMOC) of a tertiary university hospital in São Paulo. The frequency of the outcome (death or nondeath within 12 months) was analyzed by correlating it with the clinical data (impact of the variables studied). Results: Eight hundred forty patients participated in the study: 6% died within one year, and there was a 24.9% prediction of death (214 patients), of which 14.9% died within one year. The correct prognosis for the subgroup of 626 patients among the residents (NPV) was 96.8% (CI = 95.4%-98.2%) and PPV = 14.9% (CI 10.1%-19, 6%), with a positive correlation between the outcomes death and the answer No to SQ, 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. The project was registered under nr: 69430117.3.000.0048, under Brazilian Federal Government Committee of Ethic in Research with humans
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