The (in)visible Brazilians: A perspective review on the need for brain health and dementia research with Brazilian immigrants in the United States.

Introduction: The Brazilian population in the United States (U.S.), a Latinx subgroup, is rapidly growing and aging but remains underrepresented in U.S. health research. In addition to group-specific genetic and environmental risks, Brazilian immigrants and their offspring in the U.S. likely have cumulative risks for health inequities.It is estimated that 71% of Brazilian immigrants in the U.S. are undocumented, which may limit healthcare access/utilization. Furthermore, mental health is reported as a health priority by Brazilian immigrants in the U.S., and there is a lack of research on Alzheimer's disease and related dementia (AD/ADRD) in this population. Methods: We reviewed the scientific literature using traditional (e.g., PubMed) sources and databases generated by U.S. and Brazilian governments, as well as international organizations, and press articles. Results: This perspective review lists recommendations for researchers, health providers, and policymakers to promote greater inclusion of U.S. Brazilian populations in health research and care. The review identifies research areas in need of attention to address health inequities and promote mental/brain health in Brazilian immigrants and their offspring living in the U.S. These research areas are: 1) epidemiological studies to map the prevalence and incidence of mental/brain health conditions; 2) research on aging and AD/ADRD risk factors among Brazilian populations in the U.S.; and 3) the need for greater representation of U.S-residing Brazilian population in other relevant research areas involving genetics, neuropathology, and clinical trials. Conclusions: The recommendation and research efforts proposed should help to pave the way for the development of community-engagement research and to promote mental/brain health education, improvement of mental/brain health and AD/ADRD services, and the development of culturally-informed intervention to the U.S.-residing Brazilian communities. HIGHLIGHTS: The Brazilian population in the United States is growing but is underrepresented in U.S. health research.Approximately 71% of Brazilian immigrants in the United States are undocumented, with an increased risk for health inequities.Mental health is reported as a central health priority by Brazilian immigrants in the United States.There is a lack of research on Alzheimer's disease and other dementias (ADRD) in Brazilian immigrants in the United States.Epidemiological research is needed to map the prevalence/incidence of mental health conditions and ADRD risk factors among Brazilian immigrants in the United States.

2022 EULAR points to consider for remote care in rheumatic and musculoskeletal diseases.

BACKGROUND: Remote care and telehealth have the potential to expand healthcare access, and the COVID-19 pandemic has called for alternative solutions to conventional face-to-face follow-up and monitoring. However, guidance is needed on the integration of telehealth into clinical care of people with rheumatic and musculoskeletal diseases (RMD). OBJECTIVE: To develop EULAR points to consider (PtC) for the development, prioritisation and implementation of telehealth for people with RMD. METHODS: A multidisciplinary EULAR task force (TF) of 30 members from 14 European countries was established, and the EULAR standardised operating procedures for development of PtC were followed. A systematic literature review was conducted to support the TF in formulating the PtC. The level of agreement among the TF was established by anonymous online voting. RESULTS: Four overarching principles and nine PtC were formulated. The use of telehealth should be tailored to patient's needs and preferences. The healthcare team should have adequate equipment and training and have telecommunication skills. Telehealth can be used in screening for RMD as preassessment in the referral process, for disease monitoring and regulation of medication dosages and in some non-pharmacological interventions. People with RMD should be offered training in using telehealth, and barriers should be resolved whenever possible.The level of agreement to each statement ranged from 8.5 to 9.8/10. CONCLUSION: The PtC have identified areas where telehealth could improve quality of care and increase healthcare access. Knowing about drivers and barriers of telehealth is a prerequisite to successfully establish remote care approaches in rheumatologic clinical practice.

Learning needs assessment for multi-stakeholder implementation science training in LMIC settings: findings and recommendations.

BACKGROUND: Despite significant progress in the field of implementation science (IS), current training programs are inadequate to meet the global need, especially in low-and middle-income countries (LMICs). Even when training opportunities exist, there is a "knowledge-practice gap," where implementation research findings are not useful to practitioners in a field designed to bridge that gap. This is a critical challenge in LMICs where complex public health issues must be addressed. This paper describes results from a formal assessment of learning needs, priority topics, and delivery methods for LMIC stakeholders. METHODS: We first reviewed a sample of articles published recently in Implementation Science to identify IS stakeholders and assigned labels and definitions for groups with similar roles. We then employed a multi-step sampling approach and a random sampling strategy to recruit participants (n = 39) for a semi-structured interview that lasted 30-60 min. Stakeholders with inputs critical to developing training curricula were prioritized and selected for interviews. We created memos from audio-recorded interviews and used a deductively created codebook to conduct thematic analysis. We calculated kappa coefficients for each memo and used validation techniques to establish rigor including incorporating feedback from reviewers and member checking. RESULTS: Participants included program managers, researchers, and physicians working in over 20 countries, primarily LMICs. The majority had over 10 years of implementation experience but fewer than 5 years of IS experience. Three main themes emerged from the data, pertaining to past experience with IS, future IS training needs, and contextual issues. Most respondents (even with formal training) described their IS knowledge as basic or minimal. Preferences for future training were heterogeneous, but findings suggest that curricula must encompass a broader set of competencies than just IS, include mentorship/apprenticeship, and center the LMIC context. CONCLUSION: While this work is the first systematic assessment of IS learning needs among LMIC stakeholders, findings reflect existing research in that current training opportunities may not meet the demand, trainings are too narrowly focused to meet the heterogeneous needs of stakeholders, and there is a need for a broader set of competencies that moves beyond only IS. Our research also demonstrates the timely and unique needs of developing appropriately scoped, accessible training and mentorship support within LMIC settings. Therefore, we propose the novel approach of intelligent swarming as a solution to help build IS capacity in LMICs through the lens of sustainability and equity.

2020 EULAR points to consider for the prevention, screening, assessment and management of non-adherence to treatment in people with rheumatic and musculoskeletal diseases for use in clinical practice.

BACKGROUND: Non-adherence to treatment could preclude reaching an optimal outcome. Thirty to 80% of patients with rheumatic and musculoskeletal diseases (RMDs) do not adhere to the agreed treatment. OBJECTIVES: The objective was to establish points to consider (PtCs) for the prevention, screening, assessment and management of non-adherence to (non-)pharmacological treatments in people with RMDs. METHODS: An EULAR task force (TF) was established, and the EULAR standardised operating procedures for the development of PtCs were followed. The TF included healthcare providers (HCPs), comprising rheumatologists, nurses, pharmacists, psychologists, physiotherapists, occupational therapists and patient-representatives from 12 European countries. A review of systematic reviews was conducted in advance to support the TF in formulating the PtCs. The level of agreement among the TF was established by anonymous online voting. RESULTS: Four overarching principles and nine PtCs were formulated. The PtCs reflect the phases of action on non-adherence. HCPs should assess and discuss adherence with patients on a regular basis and support patients to treatment adherence. As adherence is an agreed behaviour, the treatment has to be tailored to the patients' needs. The level of agreement ranged from 9.5 to 9.9 out of 10. CONCLUSIONS: These PtCs can help HCPs to support people with RMDs to be more adherent to the agreed treatment plan. The basic scheme being prevent non-adherence by bonding with the patient and building trust, overcoming structural barriers, assessing in a blame-free environment and tailoring the solution to the problem.

A case study of social vulnerability: thoughts for the promotion of health / Un estudio de caso sobre vulnerabilidad social: reflexiones para la promoción de la salud / Um estudo de caso sobre vulnerabilidade social: reflexões para a promoção da saúde

Abstract Health promotion is a set of strategies that aim to improve the quality of life of individuals and populations. Since these strategies are based on social determinants of health, it is important to identify vulnerability issues in order to explore their impact on health care. The present study describes a case study showing the perception of women on poverty as violence and social vulnerability and the impact of the same on health. A qualitative study was performed, based on content analysis. The results are presented in narrative form and address: 1) poverty as social vulnerability; 2) poverty and perceptions of violence; 3) poverty and associated health outcomes. We found that poverty was a central question of social vulnerability which can be a determinant for women's lives. It is therefore important to consider subjectivities regarding violence and social vulnerability on populations living in poverty when designing health promotion policies. Aprovação CEP-UniCesumar CAAE 72243617.7.0000.5539

Resumen La promoción de la salud es un conjunto de estrategias que apuntan a mejorar la calidad de vida de personas y poblaciones. Dado que estas se basan en determinantes sociales de la salud, es importante identificar los problemas de vulnerabilidad para explorar su impacto en la salud. El presente trabajo describe un estudio de caso que muestra la percepción de las mujeres sobre la pobreza como violencia y vulnerabilidad social y su impacto en la salud. Se realizó un estudio cualitativo, basado en el análisis de contenido. Los resultados se presentan en forma narrativa: 1) pobreza como vulnerabilidad social; 2) pobreza y percepciones de violencia; 3) pobreza y efectos en la salud asociados. Señalamos la pobreza como un problema central de vulnerabilidad social que puede ser determinante para la vida de las mujeres. Por lo tanto, en el diseño de políticas de promoción de la salud es importante considerar las subjetividades relacionadas con violencia y vulnerabilidad social en poblaciones que viven en la pobreza. Aprovação CEP-UniCesumar CAAE 72243617.7.0000.5539

Resumo A promoção da saúde é um conjunto de estratégias que visam melhorar a qualidade de vida de indivíduos e populações. Como suas estratégias estão baseadas nos determinantes sociais da saúde, é importante identificar as questões de vulnerabilidade social e seu impacto na assistência à saúde. Este é um estudo de caso sobre a percepção da mulher acerca da pobreza como violência e vulnerabilidade social e o seu impacto na saúde. Estudo qualitativo foi realizado, utilizando análise de conteúdo. Os resultados são apresentados em forma narrativa: 1) a pobreza como vulnerabilidade social; 2) pobreza e percepções de violência; 3) pobreza e desfechos de saúde associados. Conclui-se que a pobreza é uma questão central de vulnerabilidade social que pode ser determinante para a vida das mulheres. Assim, é importante considerar as subjetividades relacionadas à violência e à vulnerabilidade social de populações em situação de pobreza no desenho das políticas de promoção da saúde. Aprovação CEP-UniCesumar CAAE 72243617.7.0000.5539

Multidisciplinary Portuguese recommendations on DXA request and indication to treat in the prevention of fragility fractures.

OBJECTIVE: To establish Portuguese recommendations regarding the indication to perform DXA and to initiate medication aimed at the prevention of fragility fractures. METHODS: A multidisciplinary panel, representing the full spectrum of medical specialties and patient associations devoted to osteoporosis, as well as national experts in this field and in health economics, was gathered to developed recommendations based on available evidence and expert consensus. Recently obtained data on the Portuguese epidemiologic, economic and quality-of-life aspects of fragility fractures were used to support decisions. RESULTS: 10 recommendations were developed covering the issues of whom to investigate with DXA and whom to treat with antifracture medications. Thresholds for assessment and intervention are based on the cost-effectiveness analysis of interventions at different thresholds of ten-year probability of osteoporotic fracture, calculated with the Portuguese version of FRAX® (FRAX®Port), and taking into account Portuguese epidemiologic and economic data. Limitations of FRAX® are highlighted and guidance for appropriate adjustment is provided, when possible. CONCLUSIONS: Cost-effectiveness thresholds for DXA examination and drug intervention aiming at fragility fracture prevention are now provided for the Portuguese population. These are practical, based on national epidemiological and economic data, evidence-based and supported by a wide scope multidisciplinary panel of experts and scientific societies. Implementation of these recommendations holds great promise in assuring the most effective use of health resources in the prevention of osteoporotic fractures in Portugal.

Cost-Effectiveness of Intervention Thresholds for the Treatment of Osteoporosis Based on FRAX(®) in Portugal.

Cost-effective intervention thresholds (ITs) based on FRAX(®) were determined for Portugal. Assuming a willingness to pay (WTP) of €32,000 per quality-adjusted life years (QALYs), treatment with generic alendronate is cost effective for men and women aged 50 years or more, with 10-year probabilities for major osteoporotic fractures and hip above 8.8 and 2.5 %, respectively. The aim of the present study was to identify the 10-year probabilities of a major and hip osteoporotic fracture using FRAX(®) validated for Portugal, above which pharmacologic interventions become cost effective in the Portuguese context. A previously developed and validated state transition Markov cohort model was populated with epidemiologic, economic and quality-of-life fracture data from Portugal. Cost-effectiveness of FRAX(®)-based ITs was calculated for generic alendronate and proprietary zoledronic acid, denosumab and teriparatide were compared to "no intervention", assuming a WTP of €32,000 (two times national Gross Domestic Product per capita) per QALYs. In the Portuguese epidemiological and economic context, treatment with generic alendronate was cost effective for men and women aged 50 years or more, with 10-year probabilities at or above 8.8 % for major osteoporotic fractures and 2.5 % for hip fractures. Cost-effective threshold 10-year probabilities for major osteoporotic and hip fractures were higher for zoledronic acid (20.4 and 10.1 %), denosumab (34.9 and 10.1 %) and teriparatide (77.8 and 62.6 %), respectively. A tool is provided to perform the calculation of cost-effective ITs for different medications, according to age group and diverse levels of WTP. Cost-effective ITs, for different medications, age groups and WTP, based on 10-year probabilities of major and hip fracture probabilities calculated with FRAX are provided.

Validation of the educational needs assessment tool as a generic instrument for rheumatic diseases in seven European countries.

OBJECTIVES: To validate the educational needs assessment tool (ENAT) as a generic tool for assessing the educational needs of patients with rheumatic diseases in European Countries. METHODS: A convenience sample of patients from seven European countries was included comprising the following diagnostic groups: ankylosing spondylitis, psoriatic arthritis, systemic sclerosis, systemic lupus erythematosus, osteoarthritis (OA) and fibromyalgia syndrome. Translated versions of the ENAT were completed through surveys in each country. Rasch analysis was used to assess the construct validity of the adapted ENATs including differential item functioning by culture (cross-cultural DIF). Initially, the data from each country and diagnostic group were fitted to the Rasch model separately, and then the pooled data from each diagnostic group. RESULTS: The sample comprised 3015 patients; the majority, 1996 (66.2%), were women. Patient characteristics (stratified by diagnostic group) were comparable across countries except the educational background, which was variable. In most occasions, the 39-item ENAT deviated significantly from the Rasch model expectations (item-trait interaction χ(2) p<0.05). After correction for local dependency (grouping the items into seven domains and analysing them as 'testlets'), fit to the model was satisfied (item-trait interaction χ(2) p>0.18) in all pooled disease group datasets except OA (χ(2)=99.91; p=0.002). The internal consistency in each group was high (Person Separation Index above 0.90). There was no significant DIF by person characteristics. Cross-cultural DIF was found in some items, which required adjustments. Subsequently, interval-level scales were calibrated to enable transformation of ENAT scores when required. CONCLUSIONS: The adapted ENAT is a valid tool with high internal consistency providing accurate estimation of the educational needs of people with rheumatic diseases. Cross-cultural comparison of educational needs is now possible.

[Transvaginal electrical stimulation of the pelvic floor in the treatment of stress urinary incontinence: clinical and ultrasonographic assessment]. / Eletroestimulação transvaginal do assoalho pélvico no tratamento da incontinência urinária de esforço: avaliações clínica e ultra-sonográfica.

BACKGROUND: The purpose of this study was to evaluate the efficacy of transvaginal electrical stimulation on the treatment of women with stress urinary incontinence (SUI) in selected cases. METHODS: Twenty two women with primary stress urinary incontinence diagnosed by urodynamic study were submitted to transvaginal electrical stimulation. The mean age was 49 years old (range 22 to 74). The treatment consisted of two weekly sessions of stimulation, each 20 minutes long, during 8 weeks. Women were evaluated through history, clinical and urogynecological exam, weekly registration of frequency of urinary leakage, stress test and transperineal ultrasound before and after treatment. A pulse of 700 sec. was used, frequency of 50 Hz and intensity varying from 12 to 53 mA according to the women's sensitivity. RESULTS: Eighteen of 22 subjects (81.7%) were satisfied with electrical stimulation and frequency of urinary incontinence reduced significantly (p<0.01). Stress test was negative in 77.2% of the women after treatment. Valsalva leak-point pressure was higher in 14 (63.3%) women after treatment, although not reaching statistical significance (p=0.37). Bladder neck mobility did not change significantly before and after electrical stimulation (p=0.30). CONCLUSION: Transvaginal electrical stimulation of the pelvic floor is an effective and safe treatment to women with SUI without sphincter deficiency, with significant reduction of the frequency of urinary leakage.

Eletroestimulação transvaginal do assoalho pélvico no tratamento da incontinência urinária de esforço: avaliações clínica e ultra-sonográfica / Transvaginal electrical stimulation of the pelvic floor in the treatment of stress urinary incontinence: clinical and ultrasonographic assessment

OBJETIVO: Verificar o efeito da eletroestimulação transvaginal no tratamento de mulheres com incontinência urinária de esforço (IUE) adequadamente selecionadas. MÉTODOS: Vinte e duas mulheres com IUE, diagnosticadas através de estudo urodinâmico, foram submetidas à eletroestimulação transvaginal do assoalho pélvico. A média das idades foi de 49 anos (22 a 74 anos). Foram realizadas duas sessões semanais, com duração de 20 minutos cada, durante oito semanas. Todas as mulheres foram avaliadas por anamnese, exames clínico e uroginecológico, registro semanal dos episódios de perda urinária, teste de esforço e ultra-sonografia transperineal antes e após o tratamento. Os parâmetros elétricos utilizados foram: pulso de 700 microssegundos, freqüência de 50 Hertz e intensidade com variação entre 12 e 53 miliamperes, de acordo com a sensibilidade da mulher. RESULTADOS: Consideraram-se satisfeitas com a eletroestimulação 18 mulheres (81,7 por cento), havendo redução significativa do número de perdas urinárias (p<0,01). O teste de esforço foi negativo em 77,2 por cento das mulheres após o tratamento. A pressão de perda sob esforço aumentou em 14 mulheres (64 por cento), não alcançando, entretanto, valor com significância estatística (p = 0,37). A avaliação ultra-sonográfica não demonstrou diferença significativa na mobilidade do colo vesical antes e após as sessões de eletroestimulação (p = 0,30). CONCLUSÃO: A eletroestimulação transvaginal do assoalho pélvico representou uma alternativa terapêutica efetiva e segura às mulheres com IUE sem defeito esfincteriano, com diminuição significativa dos episódios de perda urinária