Factores psicosociales y adherencia al tratamiento antirretroviral en niños con infección perinatal por VIH-1 / Psychosocial factors and adherence to antiretroviral therapy in children with perinatal HIV-1 infection

Introducción: Con la incorporación de los tratamientos antirretrovirales de alta eficacia (HAART) el pronóstico de los niños con infección perinatal por VIH-1 ha mejorado sustancialmente. A fin de evaluar los factores psicosociales que podrían asociarse con la adherencia, hemos analizado entre otros la presencia de depresión y sucesos de vida. Métodos: Estudio prospectivo. Se incluyeron niños entre 7 y 12 años con infección perinatal por VIH-1 con tratamiento antirretroviral, en seguimiento en el Hospital Garrahan. Resultados: se incorporaron 79 niños, 51% eran mujeres, 94% vivían con sus familias de origen y 6% vivían con familia adoptiva; 60% tenían uno o ambos padres fallecidos. El inventario de depresión infantil (CDI) arrojó que un 39% presentaron síntomas depresivos. La población estudiada presentó un alto porcentaje de sucesos de vida estresantes. El 80% experimentó entre uno y ocho sucesos de vida no deseados. El suceso de vida que se observó con mayor frecuencia estaba relacionado con el estado de salud de sus padres. La adherencia resultó muy buena en el 43%. En la variable “tipo de familia” se observó una tendencia de asociación con adherencia: el 69% de los niños de familias ensambladas tenían muy buena adherencia vs. 23% de aquellos que vivían con familia ampliada (p=0,051). La autoeficacia de los padres en el manejo de la medicación del niño estuvo asociada con menores dificultades con los regímenes de tratamiento (p=0,008), mientras que con el conocimiento del diagnóstico se observó sólo una tendencia (p= 0,08). No hubo asociación entre depresión y sucesos de vida y la con adherencia. Conclusiones: El estudio revela que aproximadamente el 40% de los niños presenta puntajes indicativos de depresión y un elevado número de eventos estresantes de vida. Se remarca la necesidad de evaluar y brindar apoyo al entorno familiar para optimizar la adherencia de los niños infectados por VIH.

Factores psicosociales y adherencia al tratamiento antirretroviral en niños con infección perinatal por VIH-1 / Psychosocial factors and adherence to antiretroviral therapy in children with perinatal HIV-1 infection

Introducción: Con la incorporación de los tratamientos antirretrovirales de alta eficacia (HAART) el pronóstico de los niños con infección perinatal por VIH-1 ha mejorado sustancialmente. A fin de evaluar los factores psicosociales que podrían asociarse con la adherencia, hemos analizado entre otros la presencia de depresión y sucesos de vida. Métodos: Estudio prospectivo. Se incluyeron niños entre 7 y 12 años con infección perinatal por VIH-1 con tratamiento antirretroviral, en seguimiento en el Hospital Garrahan. Resultados: se incorporaron 79 niños, 51% eran mujeres, 94% vivían con sus familias de origen y 6% vivían con familia adoptiva; 60% tenían uno o ambos padres fallecidos. El inventario de depresión infantil (CDI) arrojó que un 39% presentaron síntomas depresivos. La población estudiada presentó un alto porcentaje de sucesos de vida estresantes. El 80% experimentó entre uno y ocho sucesos de vida no deseados. El suceso de vida que se observó con mayor frecuencia estaba relacionado con el estado de salud de sus padres. La adherencia resultó muy buena en el 43%. En la variable ôtipo de familiaö se observó una tendencia de asociación con adherencia: el 69% de los niños de familias ensambladas tenían muy buena adherencia vs. 23% de aquellos que vivían con familia ampliada (p=0,051). La autoeficacia de los padres en el manejo de la medicación del niño estuvo asociada con menores dificultades con los regímenes de tratamiento (p=0,008), mientras que con el conocimiento del diagnóstico se observó sólo una tendencia (p= 0,08). No hubo asociación entre depresión y sucesos de vida y la con adherencia. Conclusiones: El estudio revela que aproximadamente el 40% de los niños presenta puntajes indicativos de depresión y un elevado número de eventos estresantes de vida. Se remarca la necesidad de evaluar y brindar apoyo al entorno familiar para optimizar la adherencia de los niños infectados por VIH. (AU)

Successful use of problem-based learning in a third-year pediatric clerkship.

OBJECTIVE: To determine the effect of changing from lectures to a problem-based learning (PBL) curriculum on student knowledge accrual and satisfaction with the didactic portion of a clerkship. DESIGN: Study of cohorts before and after PBL introduction and in comparison with unchanged medicine clerkship. SETTING: Third-year pediatric clerkship at 5 clinical sites. PARTICIPANTS: The PBL curriculum was introduced in the 1996 academic year. The 2 classes before the intervention served as historic controls (n = 319), whereas the 2 classes after PBL served as the intervention group (n = 320). INTERVENTION: Small groups of students worked through 6 PBL cases representing common pediatric illnesses. MAIN OUTCOME MEASURES: Knowledge was assessed with the pediatric and internal medicine subject examination of the National Board of Medical Examiners (NBME); student satisfaction was assessed by an anonymous end-of-rotation questionnaire. RESULTS: Scores on the pediatric subject examination improved significantly from means of 69.2 and 70.0 in the historic control group to 73.6 and 74.2 in the PBL cohort (P <.01). Scores on the internal medicine subject exam during the same time periods remained unchanged until the second year after the change (69.1 and 70.2, respectively, before the change; 70.1 and 72.4, respectively, after the change). Analysis of variance results indicated a significant increase in pediatric subject examination scores associated with the introduction of PBL (P <.01). Overall student satisfaction with the pre-PBL lecture series was 3.3, whereas PBL sessions received a score of 4.3. CONCLUSION: Use of PBL in a clinical clerkship was associated with higher scores on the NBME subject examination and increased student satisfaction. These results should encourage the use of PBL during the clinical years.

Linking frontline work and state-of-the-art knowledge: a community exchange system.

When challenged by complex medical and social conditions, local providers must participate in information exchanges, resource sharing, continuing education, and service coordination. A community exchange system, flexible enough to share and adapt new knowledge, and able to provide continuing multidisciplinary training and education across different practice settings, was established for the prevention and treatment of HIV/AIDS in East Harlem, New York City. The HIV/AIDS community exchange system supports linkages among disciplines within a medical center, communication among the local community-based organizations, and networks between the two settings. The system, as a model, is applicable to complex socio-medical problems such as diabetes, substance abuse, violence, tuberculosis, or geriatrics.

A community-based approach to HIV case management: systematizing the unmanageable.

This article presents an analysis and typology of community-based care for a young Hispanic mother with acquired immune deficiency syndrome (AIDS). It develops a conceptual framework that examines retrospectively the needs generated by AIDS over time, the appropriateness of the services, and an assessment of the interventions. Community-based case management can effectively address some of the diverse and changing needs of AIDS patients and their families, such as bridging service gaps and fortifying patient and system strengths while minimizing their weaknesses. Community-based case managers may also be better equipped than hospital case managers to work with difficult patients and coordinate community- and hospital-based care. Conclusions are presented regarding the definition and implementation of community-based, culturally sensitive, family-centered human immunodeficiency virus case management, as well as the importance and difficulty of developing relationships among the family, health care providers, and institutions within the community.

Community medicine: its contribution to the social science of medicine.

The Division of Behavioral Sciences operates today in a social climate different from that in its formative years. The federal agencies created specifically to stimulate and support social research have been cut back severely over the past two decades, and in some instances have been eliminated. The official policy of the National Institute of Mental Health, once the main source of support for both training and research in social science in medicine, has changed to a much narrower biomedical focus. On the other hand, there are more social scientists engaged in integral roles both locally at Mount Sinai, at medical institutions nationally, and internationally (25-26). Further, reassertion of the importance for medical education of social science specifically, and of behavioral sciences more broadly defined, has been endorsed in the strongest terms by both the Association of American Medical Colleges and the National Board of Medical Examiners (27). Also, the published literature now incorporates what we in the Division of Behavioral Sciences judge to be a richer intellectual contribution to the field than ever before (28). Perhaps most important, funding for health services research and epidemiological studies has been increased in recent federal budgets. Therefore, the division is planning for expansion of both its research and education, perceiving the future as a challenge continuous with challenges of the past: finding new ways to understand the relation between social factors and the problems of health and illness.

The community as a strategic site for refining high perinatal risk assessments and interventions.

This paper describes a community-based agency's approach to reducing perinatal risk among populations at high medical, familial and environmental risk. Following a descriptive analysis of 96 families enrolled in a maternal outreach program, a case study illustrates how client-sensitive strategies are applied to successfully engage a traumatized population. The intensity and duration of the interventions, the extensive outreach efforts to the family and the dedication and commitment of the staff are not easily replicated but invaluable in helping providers and researchers understand to what extent the impact of severe deprivations and risk can be mediated and potential damage to the newborn prevented. The paper concludes that community-based agencies in partnership with social and clinical researchers from a tertiary care setting provide the key for developing more effective, integrated perinatal care by virtue of the critical density of hard-to-reach patients who can be followed by providers and clinical researchers.