Evaluación del modelo de calidad de Donabedian en base a los criterios de Chinn y Kramer / Evaluation of the Donabedian quality model based on the Chinn and Kramer criteria

INTRODUCCIÓN: La evaluación de teorías es un proceso crucial para el desarrollo del conocimiento enfermero, permite seleccionar y utilizar la teoría en función de los problemas y fenómenos del cuidado, sin embargo, es escasamente realizada, especialmente en teorías de otras disciplinas. OBJETIVO: Analizar críticamente el modelo de calidad de la atención de salud de Donabedian, a través de la propuesta metodológica de Chinn y Kramer. DESARROLLO: Se realizó un estudio descriptivo-reflexivo del componente teórico y conceptual del modelo de Donabedian, se explica el propósito, conceptos, relaciones, estructura y supuestos. Se continua con la evaluación crítica del modelo, analizada bajo los criterios de claridad, sencillez, generalidad, accesibilidad e importancia, a través de una revisión narrativa de la literatura. CONCLUSIÓN: el modelo es útil para la gestión, los procesos de mejora, evaluación de estrategias y programas. Con valor para enfermería, puesto que coinciden en el significado e importancia otorgada a la calidad de la atención, reconociendo su contribución en la implementación, desarrollo de intervenciones y mejoramiento de la salud.

NTRODUCTION: The evaluation of theories is a crucial process for the development of nursing knowledge, as it allows the selection and use of such theories to address the problems of patient care. However, it is scarcely performed, especially with theoriesfrom disciplines other than nursing. OBJECTIVE: To critically analyze the Donabedian model of health care quality, through the methodological approach of Chinn and Kramer (1999). METHODOLOGY: A descriptive-reflexive study of the theoretical and conceptualcomponent of the Donabedian model was carried out, explaining its purpose, concepts, relationships, structure, and assumptions. A critical evaluation of the model was then conducted, using the criteria of clarity, simplicity, generality, accessibility, and importance, through a narrative review of the literature. CONCLUSIONS: The model is useful for management, improvement processes, and the evaluation of strategies and programs. It is especially valuable for nursing, since it coincides with the meaning and importance given to the quality of nursing care, recognizing its contribution in the development and implementation of interventions and improvement of health.

Validação do modelo lógico operacional de uma rede nacional de bancos de alimentos: contribuição para avaliação em segurança alimentar e nutricional / Validation of the logical operational model of a national network of food banks: contribution to evaluation in food and nutritional security

Resumo Objetivo: Descrever o processo de validação do modelo lógico operacional (MLO) do Programa Mesa Brasil Sesc (MBS) para a promoção da SAN. Métodos: Trata-se de um estudo transversal e de validação de instrumento, baseado em documentos legais de SAN, por meio da técnica de consenso Delphi com painel de especialistas. Resultados: O painel para validação foi formado por 12 participantes, atores em SAN das cinco macrorregiões geográficas do país, que analisaram a pertinência e relevância das atividades, produtos, resultados e impactos dos seis componentes técnicos do MBS. Os 103 itens, distribuídos nos componentes técnicos, foram consensuados quando alcançaram mais de 85% de concordância entre os participantes, confirmados pelas análises da mediana e intervalo interquartílico. Conclusão: Esse processo proporcionou um espaço rico e horizontal de discussão sobre teoria, prática e resultados, trouxe reflexões e novas percepções sobre o MBS, e o MLO resultante é valiosa ferramenta para o desenvolvimento de estratégias de M&A, tomada de decisões e governança sobre o programa.

Objective: To describe the validation process of the logical operational model (LOM) of Mesa Brasil Sesc Program (MBS) for the promotion of FNS. Methods: This is a cross-sectional study and instrument validation, based on FNS legal documents, using the Delphi consensus technique with a team of experts. Results: The validation team was made up of 12 participants, FNS important players from the country's five geographical macro-regions, who analyzed the pertinence and relevance of the activities, products, results and impacts of the six technical components of MBS. The 103 items, distributed in the technical components, reached consensus when they reached more than 85% agreement among the participants, confirmed by the analysis of the median and interquartile range. Conclusion: This process provided a rich and horizontal discussion on theory, practice and results, brought reflections and new perceptions about MBS and the resulting LOM is a valuable tool for developing M&E strategies, decision-making and governance of the Program.

Association of Sepsis Diagnosis at Daytime and on Weekdays with Compliance with the 3-Hour Sepsis Treatment Bundles. A Multicenter Cohort Study.

Rationale: Compliance with sepsis bundles is associated with better outcomes, but information to support structural actions that might improve compliance is scarce. Few studies have evaluated bundle compliance in different time periods, with conflicting results.Objectives: To evaluate the association of sepsis identification during the daytime versus during the nighttime and on weekdays versus weekends with 3-hour sepsis treatment bundle compliance.Methods: This was an observational, multicenter study including patients with sepsis admitted between 2010 and 2017 to 10 hospitals in Brazil. Our exposures of interest were daytime (7:00 a.m.-6:59 p.m.) versus nighttime (7:00 p.m.-6:59 a.m.) and weekdays (Monday 7:00 a.m.-Friday 6:59 p.m.) versus weekends (Friday 7:00 p.m.-Monday 6:59 a.m.). Our primary outcome was full compliance with the 3-hour sepsis treatment bundles. We adjusted by potential confounding factors with multivariable logistic regression models.Results: Of 11,737 patients (8,733 sepsis and 3,004 septic shock), 3-hour bundle compliance was 79.1% and hospital mortality was 24.7%. The adjusted odds ratio (adjOR) for 3-hour full bundle compliance for patients diagnosed during the daytime versus during the nighttime was 1.35 (95% confidence interval [CI], 1.23-1.49; P < 0.001) and was more pronounced in the emergency department (adjOR, 1.55; 95% CI, 1.35-1.77; P < 0.001) than in nonemergency areas (adjOR, 1.19; 95% CI, 1.04-1.37; P = 0.014). Overall, there was no association between diagnosis on the weekends versus on weekdays and 3-hour full bundle compliance (adjOR, 1.08; 95% CI, 0.98-1.19; P = 0.115), although there was an association among those diagnosed in nonemergency areas (adjOR, 1.15; 95% CI, 1.00-1.32; P = 0.047). The lower compliance observed for sepsis diagnosed during the nighttime was more evident 2 years after implementation of the quality improvement initiative.Conclusions: Compliance with sepsis bundles was associated with the moment of sepsis diagnosis. The place of diagnosis and the time from campaign implementation were factors modifying this association. Our results support areas for better design of quality improvement initiatives to mitigate the influence of the period of sepsis diagnosis on treatment compliance.

A time-series analysis of therapeutic alliance, interventions, and client's clinical status in an evidence-based single-case study: Evidence for establishing change mechanisms in psychotherapy.

OBJECTIVE: The goal of this study was to analyze the time-series of alliance, interventions, and client's post-sessions clinical status, to establish if alliance and adherence to cognitive-behavioral interventions preceded improvement in psychotherapy Method: A single-case study of a complete Cognitive-Behavioral treatment of a 27-year-old male diagnosed with Generalized Anxiety Disorder treatment was conducted. Alliance, adherence to cognitive-behavioral interventions, and client's therapeutic condition were assessed every two sessions during the entire treatment. RESULTS: After controlling for the effect of autocorrelations, the transfer functions showed that alliance predicted client's clinical condition with a lag of two sessions throughout the entire treatment. However, the inverse relationship was not observed. CONCLUSIONS: Results support the hypothesis of a time-lagged association between alliance and subsequent client's changes in their clinical condition in single case of a cognitive-behavioral treatment.

Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results.

BACKGROUND: Public hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality. METHODS: We conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance. RESULTS: We included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle. CONCLUSIONS: Quality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle.

Análise do nursing activities score na perspectiva do processo de trabalho / Analysis of nursing activities score in the perspective of the work process

In the nursing, the use of instruments of evaluation of the work process is of extreme relevance, especially those that if consider to measure its loads.The objective of this study was to reflect on the use of an instrument of this type.Theoretician-reflexive constructed from the structure of the Nursing Activities Score (NAS), using references theoreticians and the dialog with other studies of literature is about an assay on the process of work of the nursing.The application of these instruments to the work object, that is the patient interned in the unit of intensive therapy, refers to the product of the work of the nursing, that is, the given care.This, in turn, is not limited only to the complete healing of the health of the patient, but it encloses the result of each one of the employed and contemplated interventions in the one NAS. The ones for 24 hours.NAS, therefore, it is important for the analysis of the quality of the given work, therefore it displays the value of the work of the nursing, and the individual and social representation of the product of this work − the care.

Na enfermagem, a utilização de instrumentos de avaliação do processo de trabalho é de extrema relevância, especialmente aqueles que se propõem a mensurar suas cargas. O objetivo deste estudo foi refletir sobre a utilização de um instrumento deste tipo. Trata-se de um ensaio teórico-reflexivo construído a partir da estrutura do Nursing Activities Score (NAS), utilizando referenciais teóricos e o diálogo com outros estudos da literatura sobre o processo de trabalho da enfermagem. A aplicação destes instrumentos ao objeto de trabalho, que é o paciente internado na unidade de terapia intensiva, tange ao produto do trabalho da enfermagem, ou seja, o cuidado prestado. Este, por sua vez, não se limita apenas ao completo restabelecimento da saúde do paciente, mas abrange o resultado de cada uma das intervenções empregadas e contempladas no NAS por 24 horas. O NAS, portanto, é importante para a análise da qualidade do trabalho prestado, pois expõe o valor do trabalho da enfermagem, e a representação individual e social do produto deste trabalho − o cuidado.

Challenges Faced in Translating the Benefits of Surfactant Replacement Therapy to a Resource-Limited Setting.

Aim To determine the challenges, if any, in translating the benefits of surfactant replacement therapy (SRT) to a resource-limited setting. Method This was a retrospective descriptive study comparing the outcome of 75 cases who received surfactant and 69 controls who did not at the University Hospital of the West Indies during the period 2001 to 2011. Descriptive analyses were performed. Statistical significance was taken at the level p < 0.05. Results Only 13% of neonates with respiratory distress syndrome received surfactant therapy. The median time of surfactant administration was 16.5 hours (interquartile range: 6-37 hours). The mean ± standard deviation time between repeat doses was 19.1 ± 14 hours. There was no difference in mortality between cases (67%) and controls (59%) (p = 0.32). However, the cases who survived were less mature (28.3 ± 2 weeks) and less clinically stable (CRIB II [Clinical Risk Index for Babies] score: 8.2 ± 3) than their controls who survived (30.0 ± 2 weeks; CRIB II score: 6.0 ± 3) (p = 0.01). There was no difference in mean gestational age or CRIB II scores between nonsurviving cases and controls. A high incidence of sepsis, pneumothoraces, and pulmonary hemorrhage was noted in both cases and controls. Conclusion SRT did not improve the overall outcome in preterm neonates treated with RDS. Challenges encountered in optimizing SRT included affordability and accessibility of surfactant, supportive equipment, and supportive therapies, as well as a high incidence of complications related to prematurity.

Disentangling the change-alliance relationship: Observational assessment of the therapeutic alliance during change and stuck episodes.

The therapeutic alliance is considered the most robust process variable associated with positive therapeutic outcome in a variety of psychotherapeutic models [Alexander, L. B., & Luborsky, L. (1986). The Penn Helping Alliance Scales. In L. S. Greenberg & W. M. Pinsoff (Eds.), The psychotherapeutic process: A research handbook (pp. 325-356). New York: Guilford Press; Horvath, A. O., Gaston, L., & Luborsky, L. (1993). The alliance as predictor of benefits of counseling and therapy. In N. Miller, L. Luborsky, J. Barber, & J. P. Docherty (Eds.), Psychodynamic treatment research: A handbook for clinical practice (pp. 247-274). New York, NY: Basic Books; Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9-16; Orlinky, D., Grawe, K., & Parks, B. (1994). Process and outcome in psychotherapy: Noch einmal. In A. Bergin & J. S. Garfield (Eds.), Handbook of psychotherapy and behaviour change (4th ed., pp. 270-378). New York, NY: Wiley and Sons]. The relationship between alliance and outcome has traditionally been studied based on measures that assess these therapy factors at a global level. However, the specific variations of the alliance process and their association with therapy segments that are relevant for change have not yet been fully examined. The present study examines the variations in the therapeutic alliance in 73 significant in-session events: 35 change and 38 stuck episodes identified through the observation of 14 short-term therapies of different theoretical orientations. Variations in the alliance were assessed using the VTAS-SF [Shelef, K., & Diamond, G. (2008). Short form of the revised Vanderbilt Therapeutic Alliance Scale: Development, reliability, and validity. Psychotherapy Research, 18, 433-443]. Nested analyses (HLM) indicate a statistically significant better quality of the alliance during change episodes.

Body-QoL: un nuevo instrumento de evaluación de resultados desde la perspectiva del paciente en cirugía del contorno corporal estética y post bariátrica / Development and testing of an instrument to assess body shape related quality of life

Background: The assessment of patient satisfaction and quality of life after body remodeling surgery is important. Aim: To develop and assess a self-report instrument to evaluate the results of bariatric and body remodeling surgery. Material and Methods: A three phase methodology was used. In phase 1, literature was reviewed and in depth interviews to patients were carried out, creating a preliminary instrument that was applied to 1,340 patients in phase 2. In phase 3, the final assessment of the instrument was performed, applying it to 34 patients. The psychometric properties of the in instrument were evaluated. Results: The instrument has four domains (satisfaction with abdomen, sexual life, self-esteem and social life and psychological symptoms) and 20 items. Its score ranges from 20 (worst) to 100 (better). Response rate was 100 percent, internal reliability was 93 percent and test-re test concordance was 98 percent. Body shape related quality of life was significantly higher in men than in women. It decreases with age and with increasing body mass index. Patients subjected to bariatric surgery had lower scores than patients subjected to esthetic surgery. In the postoperative period, the score improved by 21.9 +/- 16.9 points...

Objetivo: La evaluación de resultados cualitativos demanda la utilización de instrumentos sistemáticos y reproducibles. No existe actualmente un instrumento para evaluación de resultados en cirugía de contorno corporal. nuestro objetivo fue desarrollar un nuevo instrumento de autoreporte de resultados desde la perspectiva del paciente (PROM) para medir calidad de vida (CdV) asociada a satisfacción corporal. Materiales y Métodos: Se siguió un diseño fase 3 estándar para la creación de un instrumento de autoreporte de resultados por el paciente; en la fase 1 se utilizó un diseño cualitativo en 45 pacientes para desarrollar un marco conceptual y crear los dominios e ítems de la escala preliminar. En la fase 2, se condujo una evaluación de la población a gran escala en 1.340 pacientes a fin de reducir los ítems y dominios. En la fase 3, se realizó una evaluación final del instrumento desarrollado en 34 pacientes. La evaluación estadística incluyó análisis de factores, RASCH y regresión multivariada. Las propiedades psicométricas medidas fueron la confiabilidad interna de la escala, correlaciones item-test, item-retest y correlación test-retest. Resultados: El instrumento desarrollado consta de 4 dominios (Satisfacción con el abdomen, vida sexual, autoestima-vida social y síntomas psicológicos) y 20 ítems en total. El puntaje puede variar entre 20 (peor) y 100 (mejor). La tasa de respuesta fue 100%, confiabilidad interna 93,3%, concordancia test-retest 97,7%. La calidad de vida (CdV) asociada a imagen corporal fue superior en hombres que en mujeres (p < 0,001) y disminuye con la edad (p = 0,004) e incremento del IMC (p < 0,001). Los pacientes de cirugía de contorno corporal post bariátrica, puntuaron menos que los pacientes de estética en todos los dominios del instrumento Body-QoL (p < 0,001). En el postoperatorio el puntaje mejoró un promedio de 21,9 ± 16,9 (tamaño efecto 1,8, p < 0,001)...

Designing and implementing a socioeconomic intervention to enhance TB control: operational evidence from the CRESIPT project in Peru.

BACKGROUND: Cash transfers are key interventions in the World Health Organisation's post-2015 global TB policy. However, evidence guiding TB-specific cash transfer implementation is limited. We designed, implemented and refined a novel TB-specific socioeconomic intervention that included cash transfers, which aimed to support TB prevention and cure in resource-constrained shantytowns in Lima, Peru for: the Community Randomized Evaluation of a Socioeconomic Intervention to Prevent TB (CRESIPT) project. METHODS: Newly-diagnosed TB patients from study-site healthposts were eligible to receive the intervention consisting of economic and social support. Economic support was provided to patient households through cash transfers on meeting the following conditions: screening for TB in household contacts and MDR TB in patients; adhering to TB treatment and chemoprophylaxis; and engaging with CRESIPT social support (household visits and community meetings). To evaluate project acceptability, quantitative and qualitative feedback was collected using a mixed-methods approach during formative activities. Formative activities included consultations, focus group discussions and questionnaires conducted with the project team, project participants, civil society and stakeholders. RESULTS: Over 7 months, 135 randomly-selected patients and their 647 household contacts were recruited from 32 impoverished shantytown communities. Of 1299 potential cash transfers, 964 (74 %) were achieved, 259 (19 %) were not achieved, and 76 (7 %) were yet to be achieved. Of those achieved, 885/964 (92 %) were achieved optimally and 79/964 (8 %) sub-optimally. Key project successes were identified during 135 formative activities and included: strong multi-sectorial collaboration; generation of new evidence for TB-specific cash transfer; and the project being perceived as patient-centred and empowering. Challenges included: participant confidence being eroded through cash transfer delays, hidden account-charges and stigma; access to the initial bank-provider being limited; and conditions requiring participation of all TB-affected household members (e.g. community meetings) being hard to achieve. Refinements were made to improve project acceptability and future impact: the initial bank-provider was changed; conditional and unconditional cash transfers were combined; cash transfer sums were increased to a locally-appropriate, evidence-based amount; and cash transfer size varied according to patient household size to maximally reduce mitigation of TB-related costs and be more responsive to household needs. CONCLUSIONS: A novel TB-specific socioeconomic intervention including conditional cash transfers has been designed, implemented, refined and is ready for impact assessment, including by the CRESIPT project. The lessons learnt during this research will inform policy-makers and decision-makers for future implementation of related interventions.

How to study improvement interventions: a brief overview of possible study types.

Improvement (defined broadly as purposive efforts to secure positive change) has become an increasingly important activity and field of inquiry within healthcare. This article offers an overview of possible methods for the study of improvement interventions. The choice of available designs is wide, but debates continue about how far improvement efforts can be simultaneously practical (aimed at producing change) and scientific (aimed at producing new knowledge), and whether the distinction between the practical and the scientific is a real and useful one. Quality improvement projects tend to be applied and, in some senses, self-evaluating. They are not necessarily directed at generating new knowledge, but reports of such projects if well conducted and cautious in their inferences may be of considerable value. They can be distinguished heuristically from research studies, which are motivated by and set out explicitly to test a hypothesis, or otherwise generate new knowledge, and from formal evaluations of improvement projects. We discuss variants of trial designs, quasi-experimental designs, systematic reviews, programme evaluations, process evaluations, qualitative studies, and economic evaluations. We note that designs that are better suited to the evaluation of clearly defined and static interventions may be adopted without giving sufficient attention to the challenges associated with the dynamic nature of improvement interventions and their interactions with contextual factors. Reconciling pragmatism and research rigour is highly desirable in the study of improvement. Trade-offs need to be made wisely, taking into account the objectives involved and inferences to be made.

Neonatal near miss in the Birth in Brazil survey.

This study used data from the Birth in Brazil survey, a nationwide hospital-based study of 24,197 postpartum women and their newborns, collected between February 2011 and July 2012. A three-stage cluster sampling design (hospitals, days, women) was used consisting of stratification by geographic region, type of municipality (capital or non-capital), and type of hospital financing. Logistic regression was used to identify variables that were potential predictors of neonatal mortality and neonatal near miss indicators. After testing nineteen variables, five were chosen to compose a set of neonatal near miss indicators (birth weight of less than 1,500 g, Apgar score of less than 7 in the 5th minute of life, use of mechanical ventilation, gestational age of less than 32 weeks and congenital malformations). The neonatal near miss rate in the Birth in Brazil survey was 39.2 per thousand live births, three and a half times higher than the neonatal mortality rate (11.1 per thousand). These neonatal near miss indicators were able to identify situations with a high risk of neonatal death.

Morbidade neonatal near miss na pesquisa Nascer no Brasil / Morbilidad neonatal near miss en la encuesta Nacer en Brasil / Neonatal near miss in the Birth in Brazil survey

Dados da pesquisa Nascer no Brasil, um estudo nacional de base hospitalar, incluindo 24.197 puérperas e seus recém-nascidos, de fevereiro de 2011 a julho de 2012, foram utilizados para construir um indicador de morbidade neonatal near miss. Foi utilizada amostragem por conglomerados em três estágios (hospitais, dias, mulheres), estratificada por macrorregião, tipo de município (capital ou interior) e tipo de financiamento hospitalar. Modelos de regressão logística foram utilizados para identificar as variáveis que poderiam predizer a mortalidade neonatal e compor o indicador neonatal near miss. Após serem testadas 19 variáveis, cinco foram escolhidas (peso ao nascer < 1.500g, Apgar no 5o minuto de vida < 7, uso de ventilação mecânica, idade gestacional < 32 semanas e relato de malformações congênitas). A taxa de morbidade neonatal near miss no inquérito Nascer no Brasil foi de 39,2 por mil nascidos vivos, três vezes e meia a taxa de mortalidade neonatal (11,1 por mil). O indicador de morbidade neonatal near miss foi capaz de identificar situações com alto risco de morte neonatal.

Se utilizaron datos de la encuesta Nacer en Brasil, un estudio nacional de base hospitalaria, realizado con 24.197 madres y sus recién nacidos, recabado de febrero 2011 a julio 2012, para construir un indicador de morbilidad neonatal near miss. Se utilizó el muestreo por conglomerados en tres etapas (hospitales, días, mujeres), estratificado por microrregiones, tipo de municipio (capital o interior), y tipo de financiamiento de los hospitales. Se emplearon modelos de regresión logística para identificar las variables que podrían predecir la mortalidad neonatal y componer el indicador de morbilidad neonatal near miss. Una vez ensayadas 19 variables, cinco fueron elegidas (peso al nacer < 1.500g; Apgar a los 5 minutos de vida; < 7 ventilación mecánica; edad gestacional < 32 semanas, y reporte de malformaciones congénitas). La tasa de morbilidad neonatal near miss fue de un 30,2 por mil nacidos vivos, tres veces y media la tasa de mortalidad neonatal (11,1 por mil). El indicador de morbilidad neonatal near miss fue capaz de identificar situaciones con alto riesgo de muerte neonatal.

This study used data from the Birth in Brazil survey, a nationwide hospital-based study of 24,197 postpartum women and their newborns, collected between February 2011 and July 2012. A three-stage cluster sampling design (hospitals, days, women) was used consisting of stratification by geographic region, type of municipality (capital or non-capital), and type of hospital financing. Logistic regression was used to identify variables that were potential predictors of neonatal mortality and neonatal near miss indicators. After testing nineteen variables, five were chosen to compose a set of neonatal near miss indicators (birth weight of less than 1,500g, Apgar score of less than 7 in the 5th minute of life, use of mechanical ventilation, gestational age of less than 32 weeks and congenital malformations). The neonatal near miss rate in the Birth in Brazil survey was 39.2 per thousand live births, three and a half times higher than the neonatal mortality rate (11.1 per thousand). These neonatal near miss indicators were able to identify situations with a high risk of neonatal death.

Findings and lessons learned from a multi-partner collaboration to increase cervical cancer prevention efforts in Bolivia.

Cervical cancer is a leading cause of cancer death among women in Bolivia, where cytology based screening has not performed well due to health-systems constraints. In response, the Centers for Disease Control and Prevention and the Pan American Health Organization partnered with the Bolivian Ministry of Health and the Peruvian Cancer Institute (INEN) to build capacity in Bolivia for the use of visual inspection of the cervix with acetic acid (VIA) and cryotherapy. Four 5-day courses on basic clinical skills to perform these procedures, provide related counseling, and manage side effects and infections were conducted from September 2010 to December 2012 for 61 Bolivian nurses and physicians. Of these courses, two were conducted by Bolivian trainers that were certified through a Training-of-Trainers course taught by the INEN. Classroom didactic sessions included lectures and practice with anatomic models followed by clinical practice sessions to provide trainees with practical experience in VIA and cryotherapy. Pre- and post-training evaluations were administered to ascertain knowledge gained. Evaluation of competency was conducted during simulation exercises in the classroom and during supervised performances of procedures in clinical settings. This report summarizes findings and lessons learned that will be useful for planning the supervision and monitoring phase of this project as well as for future partnerships in the Latin American and the Caribbean region.

Relação entre a medida de independência funcional e o Core Set da Classificação Internacional de Funcionalidade, Incapacidade e Saúde para acidente vascular encefálico / The Relationship between the Functional Independence Measure and the International Classification of Functioning, Disability, and Health Core Set for stroke

Para a avaliação da funcionalidade do paciente com acidente vascular encefálico (AVE) existem diversos instrumentos, entre eles a Medida de Independência Funcional (MIF). A partir da aprovação da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) foi desenvolvido o Core Set para indivíduos com AVE, o qual passou a considerar os componentes da CIF para o entendimento da funcionalidade e da incapacidade física destas pessoas. Objetivo: foi estabelecer uma relação entre a MIF e o Core Set da CIF para pacientes com sequelas de AVE. Método: considerando as descrições das atividades da MIF e as definições das categorias da CIF, foram selecionadas as categorias do Core Set da CIF para pessoas com AVE relacionados às tarefas avaliadas pela MIF. Foi considerado o que contemplava cada atividade da MIF, a descrição detalhada e as definições de cada categoria da CIF. Foi proposta uma relação entre os indicadores quantitativos e qualitativos da CIF e as escalas e níveis de função da MIF. Estabeleceu-se uma relação inversa entre a escala da MIF e os qualificadores da CIF, pois quanto menor a escala da MIF maior o comprometimento, já para a CIF, quanto menor o qualificador menor o comprometimento. Resultados: das 130 categorias de segundo nível utilizadas no Core Set 27 (20,8%) foram relacionadas às atividades da MIF, sendo oito (29,6%) dos componentes das funções do corpo, 17 (63%) das atividades e participação e dois (7,4%) dos fatores ambientais. Para as 10 categorias que fazem parte da versão abreviada deste Core Set, apenas cinco foram relacionadas às atividades da MIF. Conclusão: o presente estudo evidenciou que a escala MIF está centrada no indivíduo, não correlacionando fatores externos que influenciam na realização das atividades. A escala CIF possui parâmetros adequados e permite uma visão biopsicossocial do indivíduo, abrangendo desde as disfunções e deficiências dos indivíduos acometidos com por AVE até a influência destes fatores nas...

The Functional Independence Measure (FIM) is one of many instruments available for assessing the functionality of stroke patients. However, with the approval of the International Classification of Functioning, Disability, and Health (ICF), the Core Set that was developed for stroke patients, a new tool for understanding functionality and disability of these patients is available. Objective: to establish a relationship between the FIM and the ICF Core Set for stroke. Four researchers of different health care backgrounds, all working in the field of rehabilitation, considered the descriptions of the activities of the FIM and the definitions of the ICF categories. Method: they selected the categories of the ICF Core Set for stroke, which could be related to the tasks assessed by the FIM. Once the relationship was established, the researchers came to a consensus for the inclusion or exclusion of those categories. Results: From the 130 second-level categories used in the Core Set, 27 (20.8%) were related to the activities of FIM, eight (29.6%) regarded the bodily functions component (b), 17 (63%) concerned activity and participation (d), and two (7.4%) considered environmental factors (e). As for the 10 categories that are part of the Brief Core Set for stroke, only five were related to the activities of FIM. Conclusion: the FIM is focused on the individual, while the ICF is concerned not only with the dysfunctions and disabilities of the patient, but also considers these factors within social activities, as well as environmental influences, either as a facilitator or a barrier to functional independence.

Efficacy of a cognitive intervention program in patients with mild cognitive impairment.

BACKGROUND: Mild cognitive impairment (MCI) is a transitional state between normal aging and dementia. Identifying this condition would allow early interventions that may reduce the rate of progression to Alzheimer's disease (AD). We examined the efficacy of a six-month cognitive intervention program (CIP) in patients with MCI and to assess patients' condition at one-year follow-up. METHODS: Forty-six MCI participants assessed with neuropsychological, neurological, neuropsychiatry, and functional procedures were included in this study and followed up during a year. The sample was randomized into two subgroups: 24 participants (the "trained group") underwent the CIP during six months while 22 (control group) received no treatment. Sixteen participants dropped out of the study. The intervention focused on teaching cognitive strategies, cognitive training, and use of external aids, in sessions of two hours, twice per week for six months. Cognitive and functional measures were used as primary outcome and all were followed up at one year. RESULTS: The intervention effect (mean change from baseline) was significant (p < 0.05) on the Mini-Mental State Examination (1.74), the Clinical Dementia Rating Scale (0.14), the Boston Naming Test (2.92), block design (-13.66), matrix reasoning (-3.07), and semantic fluency (-3.071) tasks. Four patients (one trained and three controls) progressed to dementia after one year of follow-up. CONCLUSIONS: These results suggest that persons with MCI can improve their performance on cognitive and functional measures when provided with early cognitive training and it could persist in a long-term follow-up.

Transdiagnostic treatment using a unified protocol: application for patients with a range of comorbid mood and anxiety disorders / Tratamento transdiagnóstico utilizando um protocolo unificado: aplicação em pacientes com diferentes transtornos de humor e ansiedade comórbidos

OBJECTIVE: To evaluate the effectiveness of a unified cognitive-behavioral therapy protocol for group treatment of patients with a range of comorbid mood and anxiety disorders. METHODS: In this open-trial study, the unified protocol was followed for the psychotherapeutic treatment of 16 patients with comorbid mood and anxiety disorders, confirmed by the Mini International Neuropsychiatric Interview. Beck Depression and Anxiety Inventories, the World Health Organization Quality of Life evaluation instrument, and the ARIZONA scale of sexual function were used to evaluate progress in patients throughout the therapeutic process. RESULTS: All patients showed unipolar depressive disorder. Comorbidity with anxiety disorders was distributed as follows: generalized anxiety disorder, 13 (81.3%); panic disorder, 3 (18.8%); social anxiety disorder, 1 (6.3%); and post-traumatic stress disorder, 1 (6.3%). Improvement was observed in the signs and symptoms of depression (F = 78.62, p < 0.001) and anxiety (F = 19.64, p < 0.001), overall quality of life (F = 39.72, p < 0.001), physical domain (F = 28.15, p < 0.001)), psychological variables (F = 9.90, p = 0.007), social functioning (F = 36.86, p < 0.001), environmental variables (F = 27.63, p < 0.001), and sexuality (F = 13.13; p < 0.005). All parameters showed highly significant correlations (p < 0.01). CONCLUSION: An effort to establish one unified treatment protocol for a whole family of emotional disorders (primarily mood and anxiety disorders) showed benefits in the field of clinical psychology and for the treatment of patients. No other data were found in the literature describing the implementation of the unified protocol in a transdiagnostic group. Our results revealed statistically significant improvement in all variables, suggesting that the protocol proposed can become an important tool to improve quality of life, sexuality, and anxiety/depression symptoms in patients with different diagnoses

OBJETIVO: Avaliar a eficácia de um protocolo unificado de terapia cognitivo-comportamental para tratamento em grupo de pacientes com diferentes transtornos de humor e ansiedade comórbidos. MÉTODOS: Neste estudo aberto, o protocolo unificado foi seguido no tratamento psicoterápico de 16 pacientes com transtornos de humor e ansiedade comórbidos, confirmados pelo Mini International Neuropsychiatric Interview. Os Inventários de Depressão e Ansiedade de Beck, o instrumento de avaliação de qualidade de vida da Organização Mundial da Saúde e a escala ARIZONA de função sexual foram utilizados para avaliar o progresso em pacientes ao longo de todo o processo terapêutico. RESULTADOS: Todos os pacientes tinham transtorno depressivo unipolar. A comorbidade com transtornos de ansiedade apresentou a seguinte distribuição: transtorno de ansiedade generalizada, 13 (81,3%); transtorno do pânico, 3 (18,8%); fobia social, 1 (6,3%); e transtorno do estresse pós-traumático, 1 (6,3%). Foi observada melhora nos sinais e sintomas de depressão (F = 78,62, p < 0,001) e ansiedade (F = 19,64, p < 0,001), na qualidade de vida geral (F = 39,72, p < 0,001), no domínio físico (F = 28,15, p < 0,001)), em variáveis psicológicas (F = 9,90, p = 0,007), funcionamento social (F = 36,86, p < 0,001), variáveis ambientais (F = 27,63, p < 0,001) e sexualidade (F = 13,13; p < 0,005). Todos os parâmetros demonstraram correlações altamente significativas (p < 0,01). CONCLUSÃO: O esforço para estabelecer um protocolo unificado de tratamento para toda uma família de transtornos emocionais (especialmente humor e ansiedade) mostrou benefícios na área da psicologia clínica e no tratamento dos pacientes. Não foram encontrados outros dados na literatura descrevendo a implementação do protocolo unificado em um grupo transdiagnóstico. Nossos resultados revelaram uma melhora estatisticamente significativa em todas as variáveis, sugerindo que o protocolo proposto pode se tornar uma ferramenta importante para melhorar qualidade de vida, sexualidade e sintomas de ansiedade/depressão em pacientes com diferentes diagnósticos

Intraclass correlation coefficients in the Brazilian Network for Surveillance of Severe Maternal Morbidity study.

BACKGROUND: The purpose of the study was to evaluate intraclass correlation coefficients (ICC) of variables concerning personal characteristics, structure, outcome and process in the Brazilian Network for Surveillance of Severe Maternal Morbidity study conducted to identify severe maternal morbidity/near miss cases using the World Health Organization criteria. METHOD: It was a cross-sectional, multicenter study involving 27 hospitals providing care for pregnant women in Brazil. Cluster size and the mean size of the primary sampling unit were described. Estimated prevalence rates, ICC, their respective 95% confidence intervals, the design effect and the mean cluster size were presented for each variable. RESULTS: Overall, 9,555 cases of severe maternal morbidity (woman admitted with potentially life-threatening conditions, near miss events or death) were included in the study. ICC ranged from < 0.001 to 0.508, with a median of 0.035. ICC was < 0.1 for approximately 75% of the variables. For process-related variables, median ICC was 0.09, with 0.021 for those related to outcome. These findings confirm data from previous studies. Homogeneity may be considered minor, thus increasing reliability of these findings. CONCLUSIONS: These results may be used to design new cluster trials in maternal and perinatal health and to help calculate sample sizes.