Oral health policies and decision-making process in Brazil, Colombia and Chile

Abstract Public health policies are crucial for the well-being of the general population; however, the health systems of developed countries still do not include oral health in its system. Thus, it is necessary to understand the process of decision-making in oral health policies to create opportunities for countries to achieve an overall positive health outcome, including oral health. This study aimed to identify the factors influencing the inclusion of oral health on the political agenda in Brazil, Colombia, and Chile. The study sample involved decision-makers at political, technical, and academic levels. The extracted data were analyzed using the software Maxqda® and Kingdon´s theoretical model; defining interactive variables that produce a "window of opportunity" to define the agenda and the insertion of theme in formulating public policies. The decision-making process regarding oral health is influenced by many factors like the need to improve the overall oral health of the population, identified through national epidemiological studies, and the importance of individuals in positions involving political decision-making, who advocate for oral health. Strategies were developed in partnership with the academy that focused on the health rights of the population provided by law; territorial and national programs were also developed. The inclusion and creation of oral health policies depend on actors who advocate for thematic and scientific evidence to support decision-making. A close relationship between academia and stakeholders and knowledge translation is important for the development of public policies that can be effective for health systems.

Sobrevida de Pacientes Transplantados Cardíacos com Doença de Chagas Sob Diferentes Regimes de Imunossupressores Antiproliferativos / Survival of Heart Transplant Patients with Chagas' Disease Under Different Antiproliferative Immunosuppressive Regimens

Resumo Fundamento A Doença de Chagas (DC) é uma causa importante de transplante cardíaco (TC). O principal obstáculo é a reativação da DC (RDC), normalmente associada a altas doses de imunossupressores. Estudos anteriores sugeriram uma associação do micofenolato de mofetila com aumento na RDC. No entanto, preditores de mortalidade são desconhecidos. Objetivos Identificar os fatores de risco de mortalidade em pacientes com DC após o TC e o impacto do regime antiproliferativo sobre a sobrevida. Métodos Estudo retrospectivo com pacientes chagásicos submetidos ao TC entre janeiro de 2004 e setembro de 2020, em protocolo de imunossupressão que priorizava o uso de azatioprina e sua mudança para micofenolato de mofetila em caso de rejeição. Realizamos regressão univariada para identificar preditores de mortalidade e comparamos sobrevida, rejeição, e evidência RDC entre os pacientes que usavam azatioprina, micofenolato de mofetila, e aqueles que mudaram de azatioprina para micofenolato (grupo "Mudança") após a alta. Um valor de p<0,05 foi considerado estatisticamente significativo. Resultados Foram incluídos 85 pacientes, 54,1% homens, idade mediana 49 (39-57) anos, e 91,8% com prioridade na lista de espera. Dezenove (22,4%) usavam azatioprina, 37 (43,5%) micofenolato de mofetila, e 29 (34,1%) trocaram a terapia; a sobrevida não foi diferente entre os grupos, 2,9 (1,6-5,0) x 2,9 (1,8-4,8) x 4,2 (2,0-5,0) anos, respectivamente; p=0,4. Não houve diferença na taxa de rejeição (42%, 73% e 59% respectivamente; p=0,08) ou de RDC (T. cruzi positiva na biópsia endomiocárdica 5% x 11% x 7%; p=0,7; uso benzonidazol 58% x 65% x 69%; p=0,8; PCR positiva para T. cruzi 20% x 68% x 42% respectivamente; p=0,1). Conclusões Este estudo retrospectivo com pacientes com DC e TC não mostrou diferença na sobrevida entre os diferentes regimes antiproliferativos. O uso de micofenolato de mofetila não foi associado com taxas significativamente mais altas de RDC ou rejeição do enxerto nesta coorte. Novos ensaios randomizados são necessários para abordar essa questão.

Abstract Background Chagas' disease (CD) is an important cause of heart transplantation (HT). The main obstacle is Chagas' disease reactivation (CDR), usually associated to high doses of immunosuppressants. Previous studies have suggested an association of mycophenolate mofetil with increased CDR. However, mortality predictors are unknown. Objectives To identify mortality risk factors in heart transplant patients with CD and the impact of antiproliferative regimen on survival. Methods Retrospective study with CD patients who underwent HT between January 2004 and September 2020, under immunosuppression protocol that prioritized azathioprine and change to mycophenolate mofetil in case of rejection. We performed univariate regression to identify mortality predictors; and compared survival, rejection and evidence of CDR between who received azathioprine, mycophenolate mofetil and those who changed from azathioprine to mycophenolate mofetil after discharge ("Change" group). A p-value < 0.05 was considered statistically significant. Results Eighty-five patients were included, 54.1% men, median age 49 (39-57) years, and 91.8% were given priority in waiting list. Nineteen (22.4%) used azathioprine, 37 (43.5%) mycophenolate mofetil and 29 (34.1%) switched therapy; survival was not different between groups, 2.9 (1.6-5.0) x 2.9 (1.8-4.8) x 4.2 (2.0-5.0) years, respectively; p=0.4. There was no difference in rejection (42%, 73% and 59% respectively; p=0.08) or in CDR (T. cruzi positive by endomyocardial biopsy 5% x 11% x 7%; p=0.7; benznidazole use 58% x 65% x 69%; p=0.8; positive PCR for T. cruzi 20% x 68% x 42% respectively; p=0.1) rates. Conclusions This retrospective study did not show difference in survival in heart transplant patients with CD receiving different antiproliferative regimens. Mycophenolate mofetil was not associated with statistically higher rates of CDR or graft rejection in this cohort. New randomized clinical trials are necessary to address this issue.

Compreensão do processo de implementação de Programas e Políticas de Saúde Bucal na América Latina / Understanding the implementation process of Oral Health Programs and Policies in Latin America

Introdução: As políticas em saúde pública são importantes para o bem-estar da população em geral, e a saúde bucal está inserida no contexto de saúde integral, desta forma os responsáveis por criarem as políticas e programas de saúde bucal são elementos chaves para a criação de políticas que visam melhorar a saúde da população de um país. Objetivos: Identificar como foi o processo de implementação das políticas de saúde bucal, no contexto do uso da evidência, agenda política e barreiras de implementação nos países envolvidos: Brasil, Colômbia e Chile. Métodos: Trata-se de um estudo qualitativo com entrevistas presenciais com atores-chaves no processo de implementação em cada país, foi realizada análise de conteúdo e os dados foram categorizados com uso do Maxqda®. Resultados: Apesar dos países apresentarem sistemas de saúde diferentes, observou-se que durante o processo de implementação das políticas de saúde, o uso da evidência científica ainda é restrito e a participação da academia mostrou-se necessária para a elaboração das políticas de saúde. Em relação ao processo de inclusão na agenda, os resultados de estudos epidemiológicos tiveram um papel indutor, além da necessidade de atores chaves que advoguem a favor do tema. A principal barreiras citada pelos países é a formação do dentista, que ainda é voltada para o atendimento clínico individual e privado. Conclusão: Os formuladores de políticas devem compreender a importância da odontologia no sistema de saúde, a academia deve se aproximar da gestão de modo a informar as políticas para ser elaborada com uso da evidência cientifica e estimular a sensibilização dos futuros profissionais para este tema.

Brazilian Oral health teams in primary care and oral cancer: Results of a national evaluation

Abstract Oral cancer is one of the most prevalent cancers in Brazil. An understanding of how public policies are implemented to address this problem can contribute to the construction of solutions. The "Programa de Melhoria do Acesso e da Qualidade" (PMAQ-AB and PMAQ-CEO) at the level of primary and secondary care are evaluations that also collect data on prevention and monitoring strategies for oral cancer. This study aimed to analyze the results of the incorporation of oral health teams to evaluate the strategies adopted by Brazil regarding the impact on the diagnosis of oral cancer. Of the 17,202 family health teams evaluated, 72.10% had oral health teams (OHT). Considering the strategies for prevention, screening, campaign, and follow-up of suspected cases, 72.27% of the campaign teams and 59.09% of the teams who accompanied suspected cases had OHT. In secondary care, more than 65% of the teams in the Southeast and South regions registered cases of oral cancer, and the referral network was more represented. The inclusion of OHT had a positive impact on campaign actions, follow-up, referral to specialists, and registration of suspected cases throughout Brazil.

Teledentistry and the Unified Health System: An Important Tool for the Resumption of Primary Health Care in the Context of the COVID-19 Pandemic

Abstract This paper describes the possibilities of using Teledentistry to expand and qualify health care in oral health care networks. WHO already recommended to its member countries, even before the pandemic, Telehealth as a strategy to improve the quality of services, especially in universal systems, as the Unified Health System (SUS). Teledentistry opens opportunities for oral health to resume the provision of various services, remotely, such as: 1) Tracking, active search, monitoring of priority users, those at risk and with systemic problems, suspicions of COVID-19 and contacts, through Telemonitation; 2) Initial listening, individual or collective educational activities, through Teleorientation; 3) Discussion of clinical cases for the definition of the opportunity / need for operative procedures, matrix support, sharing, solution of doubts among professionals and between these and teaching and research institutions, by Teleconsulting, among others. In addition to a review of Teledentistry in the context of the pandemic, we conceptualized the terms used and possibilities offered to SUS professionals, in addition to specifying the possible protocols for recording these activities to provide safe data for their monitoring and evaluation. Besides, we bring a brief discussion with promising experiences, carried out in the pre- and trans-pandemic contexts, which can be important strategies for the resumption of oral health in the post-pandemic scenario.

Exposición a la publicidad del tabaco en los puntos de venta en Argentina. Evidencias de la Encuesta Nacional de Factores de Riesgo 2013 / Exposure to point-of-sale tobacco displays in Argentina: evidence from the 2013 National Risk Factor Survey

Resumen: Objetivo: Describir las características de la población que refiere haber acudido a los puntos de venta (PV) de tabaco en relación con la percepción de la publicidad en Argentina. Material y métodos: Se analizaron datos de la Encuesta Nacional de Factores de Riesgo de 2013. Resultados: Se incluyeron 31 167 encuestados que acudieron a comercios donde venden cigarrillos en los últimos 30 días. De éstos, 54.1% dijo haber visto publicidad de cigarrillos. Los varones (RM=1.2) y los fumadores actuales (RM=1.9 vs. no fumador) tuvieron más posibilidad de percibirla. Aquéllos que refirieron estar expuestos al humo de tabaco en bares y restaurantes (RM= 1.2) tuvieron más posibilidad de ver publicidad de tabaco en los puntos de venta. Hubo un gradiente en relación con la edad: los jóvenes de 18 a 24 fueron más susceptibles a referir exposición (RM=2.8 vs >65 años). Entre los fumadores, aquéllos que percibieron publicidad refirieron con mayor frecuencia haber intentado dejar de fumar en el último año. Conclusiones: Es importante que la regulación de la publicidad en los PV sea más estricta para limitar la exposición a la publicidad, particularmente en los jóvenes.

Abstract: Objective: To describe the population that reports to have visited tobacco points of sale (POS) in Argentina and their perception of tobacco advertising. Materials and methods: We used data from the 2013 National Risk Factor Survey. Results: We included 31 167 respondents (96% of the total) who attended a store that sells cigarettes in the previous 30 days. Overall, 54.1% (67.3% of current smokers, 55.1% of former smokers and 49% of non smokers) referred having seen tobacco advertising at the POS. Males (OR=1.2) and current smokers (OR=1.9 vs. non smokers) were more likely to report having seen tobacco advertising at the POS. Those who were exposed to second hand smoke in bars and restaurants (OR=1.2) were also more likely to have seen advertising. We found that younger people (age 18 - 24) were more likely to be exposed (OR=2.8 vs older than 65). Among smokers, those who referred to have seen the advertising were more likely to have tried to quit smoking during the previous year. Conclusions: It is important to regulate advertising at the POS to limit exposure, particularly among young people.

Situación epidemiológica de la obesidad en la Argentina / Epidemiológica I Condition of Obesity in Argentina

Introducción: La obesidad puede entenderse como el resultado de personas respondiendo normalmente al contexto obesogénico en el que se encuentran inmersas. Objetivo: Describir la situación epidemiológica de la obesidad y el sobrepeso en adultos y adolescentes en la Argentina. Material y métodos: Se estimó la prevalencia de obesidad y sobrepeso y factores asociados en adultos y estudiantes de 13 a 15 años a partir de datos de la Encuesta Nacional de Factores de Riesgo (ENFR) de enfermedades no transmisibles y de la Encuesta Mundial de Salud Escolar. Resultados: En 2013, la prevalencia de sobrepeso (37,1%) y de obesidad (20,8%) fue mayor que la observada en ediciones previas de la ENFR. Ambos indicadores fueron más frecuentes en varones y en personas de mayor edad. El nivel educativo y de ingresos se asoció en forma independiente con una prevalencia mayor de obesidad en mujeres. En adolescentes, en 2012, la prevalencia de sobrepeso fue del 22,8% y la de obesidad, del 5,9%. Esta última fue mayor en estudiantes con madres con primario incompleto (8,9% vs. 4,6% en hijos de mujeres con secundario completo, p = 0,002). Conclusiones: Son necesarias acciones multisectoriales de gran escala para frenar la tendencia en aumento de la epidemia de obesidad. Aunque la evidencia aún es escasa, se han propuesto varias estrategias poblacionales: campañas de comunicación y educación, regulación del precio de alimentos mediante subsidios o impuestos, etiquetado y advertencias sanitarias, regulación de la publicidad dirigida a niños y adolescentes, mejoras en el entorno alimentario escolar y laboral, reformulación de productos ultraprocesados, entre otros.

Principales resultados de la tercera encuesta nacional de factores de riesgo de enfermedades no trasmisibles en Argentina / Main results of the third national non-communicable disease risk factor survey in Argentina

INTRODUCCIÓN: la vigilancia de las enfermedades no transmisibles (ENT) y sus factores de riesgo es esencial para diseñar y evaluar políticas efectivas. En 2013 se realizó la tercera EncuestaNacional de Factores de Riesgo de ENT (ENFR). OBJETIVOS: Describir la prevalencia, distribución y evolución de los principales factores de riesgo de las ENT en Argentina. MÉTODOS: Se utilizó un diseño muestral probabilístico, que incluyó una población general de 18años o más en viviendas pertenecientes a ciudades de más de 5 000 habitantes. RESULTADOS: Se encuestó a 32 365 personas (tasa derespuesta: 70,7%). La prevalencia de obesidad (20,8%) y sobrepeso(37,1%) aumentó en comparación con ENFR previas (2005 y 2009). Se mantuvieron estables la hipertensión arterial (34,1%) y el colesterolelevado (29,8%). El consumo de frutas/verduras (media: dosporciones/día) continuó siendo bajo, mientras que el sedentarismo fueelevado (54,7%). El consumo de tabaco (25,1%), la exposición al humode tabaco ajeno en bares/restaurantes (23,5%), trabajo (25%) y hogar(27,6%) y la utilización de sal (17,3%) se redujeron significativamente. El 71,6%, 65,6% y 24,5% de la población diana realizó Papanicolaou, mamografía y pruebas de rastreo de cáncer de colon, respectivamente.La cobertura de salud sólo pública se vio asociada a una menor proporción de prácticas preventivas, y las personas con menor nivel educativo tuvieron peores indicadores. CONCLUSIONES: Aunque hubo una mejora en materia de consumo de tabaco y utilización de sal, es necesario intensificar las políticas para el abordaje de las ENT.

INTRODUCTION: the surveillance of non-comunicable diseases (NCD) and their risk factors is essential to designand evaluate effective interventions. The 3rd National Risk Factor Survey of NCD (NRFS) was conducted in 2013. OBJECTIVES: To describe the prevalence, distribution and evolution of main risk factors of NCD in Argentina. METHODS: A probabilistic sampling design was used, including a general population aged 18 years orolder living in cities with more than 5 000 inhabitants. RESULTS: 32 365 people were interviewed (response rate: 70.7%). The prevalence of obesity (20.8%) and overweight (37.1%) was higher than in previous NRFS (2005-2009). Hypertension (34.1%) and high cholesterol (29.8%) prevalence remained stable. Meanconsumption of fruits and vegetables remained low (two servings/day), while physical inactivity was high (54.7%). Smoking (25.1%) and exposure to secondhand smoke in bars/restaurants (23.5%), at work (25%) and at home (27.6%) as well as the use of salt (17.3%) were reduced significantly. Among the targetpopulation, 71.6%, 65.6% and 24.5% performed Pap tests, mammograms and screening tests for colon cancer, respectively. Preventive health practices were less frequent among those with public health coverage only. People with lower education levelshad worse indicators. CONCLUSIONS: Despite the improvement in terms of smoking and salt consumption, further actions are needed to address NCDs.

Diarrea aguda en trasplantes renales y reno-pancreáticos

La diarrea es una complicación frecuente y potencialmente grave del trasplante renal. Se describen aquí, en un estudio de corte transversal, las características epidemiológicas y microbiológicas de la diarrea aguda y persistente en pacientes internados con trasplante renal o reno-páncreas. Se incluyeron 52 pacientes internados en un hospital de la Ciudad de Buenos Aires, 42 (80.8%) habían recibido un trasplante renal y 10 (19.2%) reno-páncreas. La diarrea fue el motivo de ingreso en 34 casos (65.4%). La etiología de la diarrea pudo estudiarse en 50 pacientes: en 25 (50%) no se arribó a un diagnóstico etiológico y en 18 (36%) se constató diarrea con causa microbiológica específica: 3 (6%) enfermedad por citomegalovirus, 6 (12%) diarrea atribuida a citomegalovirus, 5 (10%) a rotavirus y 4 (8%) a Clostridium difficile. En 7 (14%) la diarrea fue atribuida a fármacos (mofetil micofenolato y sirolimus). Aquellos con diarrea con causa microbiológica habían recibido recientemente inmunosupresores a altas dosis con mayor frecuencia que el resto (p = 0.048). Los pacientes con diarrea atribuida a fármacos recibían más frecuentemente mofetil micofenolato (p = 0.039). En 16 (30.8%) se realizaron modificaciones de los inmunosupresores como medida terapéutica, y a 47 (90.4%) se les indicó antibioticoterapia empírica. La mediana de duración de internación fue de 6 días y 7 pacientes (14.6%) persistieron con diarrea al quinto día. Todos tuvieron resolución de la diarrea al alta y un tercio persistió con insuficiencia renal. La información de este estudio puede servir para mejorar las medidas preventivas, diagnósticas y terapéuticas en estos pacientes.

Diarrhea is a frequent and potentially severe complication of kidney transplantation. We describe here, in a cross-sectional study, the epidemiological and microbiological characteristics of acute and persistent diarrhea in 52 inpatients with kidney and kidney-pancreas transplant in a hospital in Buenos Aires, 42 (80.8%) of whom had received a kidney and 10 (19.2%) a kidney-pancreas transplant. Diarrhea was the reason of admission of 34 cases (65.4%). The etiology could be studied in 50 patients: 25 (50%) had no etiological diagnosis of diarrhea and 18 (36%) had a specific infectious etiology: 3 (6%) cytomegalovirus disease, 6 (12%) diarrhea attributed to cytomegalovirus, 5 (10%) to rotavirus and 4 (8%) to Clostridium difficile. In 7 (14%) diarrhea was attributed to drugs (mycophenolate mofetil and sirolimus). Patients with infectious diarrhea had recently received high doses of immunosuppressive therapy more frequently than the rest (p = 0.048). Those with diarrhea attributed to drugs were more frequently on mycophenolate mofetil than the rest (p = 0.039). Empirical modification of the immunosuppressive treatment was done in 16 (30.8%) and empirical antibiotic therapy was given to 47 patients (90.4%). Median length of hospital stay was 6 days. Seven patients (14.6%) persisted with diarrhea at the fifth day of admission. At hospital discharge all cases had complete resolution of symptoms and one third persisted with kidney failure. Information provided in this study can be useful as a starting point for improving preventive, diagnostic and therapeutic measures in these patients.

Estudio prospectivo, descriptivo y multicéntrico acerca de la infección de piel y partes blandas por Staphylococcus aureus meticilino-resistente adquirido en la comunidad (SAMRAC) / Multicentric prospective and descriptive study about community-acquired methicillin-resistant Staphylococcus aureus cutaneous and sof tissue infection (CA-MRSA)

El Staphylococus aureus meticilino-resistente adquirido en la comunidad (SAMRAC) es uno de los principales patógenos emergentes de la última década, y en algunos países es la principal causa de infecciones de piel y partes blandas. El objetivo de este estudio es describir las características epidemiológicas, clínicas y microbiológicas de las infecciones de piel y partes blandas producidas por SAMRAC en pacientes ambulatorios. Materiales y métodos. Estudio descriptivo, prospectivo, multicéntrico realizado en seis Servicios de Dermatología de la ciudad de Buenos Aires entre julio de 2008 y junio de 2009. Se incluyeron pacientes con infección de piel y partes blandas por SAMRAC documentada por cultivo. La definición de adquisición en la comunidad se basó en criterios epidemiológicos. Resultados. Se reclutaron 114 pacientes, de los cuáles 49% fueron hombres y 51 % mujeres. La media de la edad fue 27 años. El 74% recibió tratamiento con ß lactámicos previo al diagnóstico. Los forúnculos representaron la forma clínica más frecuente (59%), seguido de los abscesos (20%). El antibiótico más indicado fue trimetoprima-sulfametoxasol (68,4%).Las resistencias más frecuentes fueron eritromicina (21,7%) y clindamicina (16,2%), 6 pacientes requirieron internación, 18 pacientes presentaron recurrencias y no se registró ninguna muerte. Conclusiones. Los datos demográficos y clínicos obtenidos en este estudio son similares a los comunicados previamente. La mayoría de los pacientes recibieron tratamiento antibiótico previo, lo que denota una baja sospecha diagnóstica. El impétigo representó una forma de presentación frecuente en la población pediátrica y la celulitis sólo comprometió a mujeres. La resistencia a clindamicina fue mayor al 15%, por lo que no debería ser considerado un antibiótico de primera línea. Las infecciones de piel y partes blandas por SAMRAC son frecuentes en nuestro medio, por lo que debe considerarse en pacientes con lesiones supurativas o falta de...

Community acquired methicillin-resistant Staphylococcus aureus is oneof the main emergent pathogens of the last decade, being the fi rstcause of skin and soft tissue infections in some countries. The purposeof this study is to describe the epidemiologic, clinical, and microbiologicalcharacteristics of CA-MRSA cutaneous and soft tissue infections inan ambulatory setting.Methods. We conducted a multuicentric, prospective, descriptive studyperformed in 6 dermatology units at Buenos Aires from july 2008 to june2009. Patients with documented CA-MRSA skin and soft tissue infectionswere included. Community acquisition was defi ned based on epidemiologiccriteria.Results. We included 114 patients, of which 49% were male and 51%were female. The median age was 27 years. Seventy four percent of the patientshad received beta-lactamic antibiotic treatment prior to inclusion.The main clinical presentation were furuncules (59%) followed by abscesses( 20%). The most frequently prescribed antibiotic was trimethoprim-sulfametoxazole(68,4%). The most frequently recovered isolates were erithromicin-(21,7%) and clindamycin-resistant (16,2%). Six patients requiredhospital admission, 18 had recurrent diseases, and no death was recorded.Discussion. Demographic and clinical data obtained in this study aresimilar to those previously reported. Most of the patients had received antibiotictreatment before inclusion, which shows the low CA-MRSA clinicalsuspicious. Impetigo was fecuently observed among children, and celulitiswas exclusively observed in females. As clindamycin resistance washigher than 15%, this antibiotic should not be considered a fi rst-line treatmentoption. CA-MRSA infections were frecuently observed in our patients,therefore its diagnosis should be considered on suppurative lesionsand non responding pyodermitis (Dermatol Argent 2010;16(2):110-116).

Limitaciones de esfuerzos terapéuticos: Resultados de un registro prospectivo en una sala de clínica médica / Limitation of life-sustaining treatment: A prospective study developed in a clinical ward

El objetivo de este trabajo fue describir el proceso de limitación de los esfuerzos terapéuticos (LET) en los pacientes internados en una sala general. Para ello se realizó un estudio prospectivo descriptivo, desarrollado en la sala de internación general de un hospital universitario. Fueron evaluados pacientes que tuviesen alguna LET, asistidos por el servicio de clínica médica en un período de 60 días consecutivos. Durante el mismo se hospitalizaron 402 pacientes, 62 (15%) tuvieron algún tipo de LET. Este último grupo estaba compuesto por un 66% de mujeres, la mediana de edad fue de 86 años (78-90) y de la duración de hospitalización de 12 días (8-18). La mala calidad de vida fue la causa más frecuente de LET (69%). Se brindó información acerca de las limitaciones a 43 familias (69%) y 8 pacientes (13%). En la decisión participaron el médico de cabecera (50%), médicos de planta (50%), residentes (40%), la familia (42%) y los propios pacientes (11%). En 7 casos hubo constancia en la historia clínica (11%). Diecisiete pacientes (27%) con LET fallecieron durante la internación, mientras que 44 (71%) fueron dados de alta. En conclusión, la limitación de esfuerzos terapéuticos en nuestros pacientes constituyó un hecho frecuente. No se logró identificar un proceso uniforme o sistematizado para la toma de la decisión de LET. Resulta innegable la necesidad de normativas que guíen al equipo de salud en la toma de decisiones, tranquilicen a familiares y acompañen a los pacientes en sus reales necesidades.

The purpose of this study is to describe the limiting life-sustaining treatment process of patients admitted to a general ward. A prospective descriptive study was designed. The setting was the general ward of universitary hospital. Study participants were patients assisted by the internal medicine department during a 60- consecutive days period who had limitations of life sustaining treatments. During the study period, 402 patients were hospitalized, 62 (15%) of them had limitations of life support care. The median patient age of the last group was 86 years (78-90), 66% were women and the length of stay was 12 days (8-18). A low quality of life was the most frequent cause of limitation (69%). Information about the limitations was provided to 43 families (69%) and 8 patients (13%). The primary care physician participated in the decision in 50% of the cases, while the attending physician, the resident in charge, patient's family and patients themselves participated in 50%, 40%, 42% and 11% of the cases respectively. The decision of limiting life-sustaining treatments was recorded in seven patient's charts (11%). Seventeen (27%) patients with limitations died during the hospital stay while 44 (71%) were discharged. In conclusion, we found a frequent life sustaining treatment limitation in our patients. These decisions did not follow a uniform or systemized process. The need of guidelines to sort the medical and ethical challenges imposed to the medical team is undeniable.

Cuidados paliativos na insuficiência cardíaca: uma revisão da terapia medicamentosa recomendada para tratar os sintomas / Palliative care in heart faillure: a review of drugs to treat symptoms

Atualmente há um grande movimento para melhorar o final da vida dos pacientes com insuficiência cardíaca. A insuficiência cardíaca atinge 4% a 11% das pessoas com mais de 65 anos ou mais, e aproximadamente 10% dos pacientes com insuficiência cardíaca possuem a forma mais avançada da doença. Se uma condição reversível não está presente ou se o transplante cardíaco não constitui opção factível...