Challenges in transitioning adolescents and young adults with rheumatologic diseases to adult Care in a Developing Country - the Brazilian experience.

BACKGROUND: Transition guidelines and recommendations for developing countries are limited and best transition practices in young patients with chronic medical conditions have been poorly examined. This study evaluates transition practices from pediatric to adult rheumatology care in Brazil. METHODS: Practicing pediatric rheumatologists registered in the Brazilian Society of Rheumatology were e-surveyed with SurveyMonkey® using the Chira et al. questionnaire that had been used previously to evaluate transition practices of pediatric rheumatologists from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) in the USA and Canada. The questionnaire was modified to better address specific issues pertaining to the Brazilian health care system. RESULTS: Seventy-six of 112 (68%) pediatric rheumatologists responded. Only 13% of the respondents reported that they had a well-established transition program and only 14% were satisfied with their current transition process. Eighty percent did not use any specific tools to assess transition readiness. While 43% of respondents considered 18 as the ideal transition age, only a third effectively transitioned their patients at that age while 48% did later. Major hurdles for a successful transition cited by the respondents included emotional attachment to the patients (95%) insufficient training in transition practice (87%), lack of devoted time for transition preparation and process (80%), lack of assistance by pediatric generalists, (77%), and lack of available adult subspecialists (75%). Sixty-seven percent of respondents stated that their program would need more tools/resources to facilitate transition and 59% believed that the development of specific guidelines would be useful to standardize and help with the transition process. CONCLUSIONS: Our study demonstrates that the identified challenges pertaining to transition in Brazilian patients are similar to those reported by pediatric rheumatologists in the United States and Canada. However, the current financial economic pressures affecting Brazil's health care system may force physicians to deprioritize non emergent care such as transition. A comprehensive understanding of transition issues specific to youth in developing countries and educating not only patients but also health care providers about the importance of a seamless transition process will support the development of transition guidelines and ensure better outcomes of pediatric subspecialty patients.

Modifiable factors of vitamin D status among a Brazilian osteoporotic population attended a public outpatient clinic.

Objectives To evaluate the serum 25-hydroxyvitamin D [25(OH)D] concentration in Brazilian osteoporotic patients and the modifiable factors of vitamin D status in this population. Subjects and methods In a cross-sectional study, 363 community-dwelling patients who sought specialized medical care were evaluated between autumn and spring in São Paulo, Brazil. Serum levels of 25(OH)D and parathormone (PTH), biochemical and anthropometric measurements, and bone density scans were obtained. The group was assessed using two questionnaires: one questionnaire covered lifestyle and dietary habits, skin phototype, sun exposure, medical conditions, and levels of vitamin D supplementation (cholecalciferol); the other questionnaire assessed health-related quality-of-life. Logistic regression and a decision tree were used to assess the association between the variables and the adequacy of vitamin D status. Results The mean age of the overall sample was 67.9 ± 8.6 years, and the mean 25(OH)D concentration was 24.8 ng/mL. The prevalence of inadequate vitamin D status was high (73.3%), although 81.5% of the subjects were receiving cholecalciferol (mean dose of 8,169 IU/week). 25(OH)D was positively correlated with femoral neck bone mineral density and negatively correlated with PTH. In the multivariate analysis, the dose of cholecalciferol, engagement in physical activity and the month of the year (September) were associated with improvement in vitamin D status. Conclusions In this osteoporotic population, vitamin D supplementation of 7,000 IU/week is not enough to reach the desired 25(OH)D concentration (≥ 30 ng/mL). Engagement in physical activity and the month of the year are modifiable factors of the vitamin D status in this population.

Modifiable factors of vitamin D status among a Brazilian osteoporotic population attended a public outpatient clinic / Fatores modificáveis do status de vitamina D em uma população brasileira de osteoporóticos assistidos em um ambulatório público

Objectives To evaluate the serum 25-hydroxyvitamin D [25(OH)D] concentration in Brazilian osteoporotic patients and the modifiable factors of vitamin D status in this population. Subjects and methods In a cross-sectional study, 363 community-dwelling patients who sought specialized medical care were evaluated between autumn and spring in São Paulo, Brazil. Serum levels of 25(OH)D and parathormone (PTH), biochemical and anthropometric measurements, and bone density scans were obtained. The group was assessed using two questionnaires: one questionnaire covered lifestyle and dietary habits, skin phototype, sun exposure, medical conditions, and levels of vitamin D supplementation (cholecalciferol); the other questionnaire assessed health-related quality-of-life. Logistic regression and a decision tree were used to assess the association between the variables and the adequacy of vitamin D status. Results The mean age of the overall sample was 67.9 ± 8.6 years, and the mean 25(OH)D concentration was 24.8 ng/mL. The prevalence of inadequate vitamin D status was high (73.3%), although 81.5% of the subjects were receiving cholecalciferol (mean dose of 8,169 IU/week). 25(OH)D was positively correlated with femoral neck bone mineral density and negatively correlated with PTH. In the multivariate analysis, the dose of cholecalciferol, engagement in physical activity and the month of the year (September) were associated with improvement in vitamin D status. Conclusions In this osteoporotic population, vitamin D supplementation of 7,000 IU/week is not enough to reach the desired 25(OH)D concentration (≥ 30 ng/mL). Engagement in physical activity and the month of the year are modifiable factors of the vitamin D status in this population. .

Objetivos Avaliar a concentração sérica de 25-hidroxivitamina D [25(OH)D] em pacientes osteoporóticos brasileiros e os fatores modificáveis do status de vitamina D nesta população. Sujeitos e métodos Em um estudo transversal, 363 pacientes, residentes na comunidade, que procuravam atendimento médico especializado, foram avaliados entre o outono e a primavera, em São Paulo, Brasil. Níveis séricos de 25(OH)D e paratormônio (PTH), avaliações bioquímicas e antropométricas e exames de densitometria óssea foram obtidos. O grupo foi avaliado por meio de dois questionários: um questionário abordou estilo de vida e hábitos alimentares, fototipo de pele, exposição solar, problemas médicos e os níveis de suplementação de vitamina D (colecalciferol); o outro questionário avaliou a qualidade de vida relacionada à saúde. Regressão logística e árvore de decisão foram utilizadas para avaliar a associação entre as variáveis e a adequação do status de vitamina D. Resultados A idade média da amostra foi de 67,9 ± 8,6 anos e a concentração média de 25(OH)D foi de 24,8 ng/mL. A prevalência de um status de vitamina D inadequado foi elevada (73,3%), apesar de 81,5% dos indivíduos receberem colecalciferol (dose média de 8.169 UI/semana). 25(OH)D correlacionou-se positivamente com a densidade mineral óssea do colo de fêmur e negativamente com PTH. Nas análises multivariadas, a dose de colecalciferol, a prática de exercícios físicos e o mês do ano (setembro) foram associados com a melhora do status de vitamina D. Conclusões Nesta população osteoporótica, a suplementação de 7.000 UI/semana não é suficiente para atingir a concentração desejada ...