Immunogenicity of COVID-19 adsorbed inactivated vaccine (CoronaVac) and additional doses of mRNA BNT162b2 vaccine in immunocompromised adults compared with immunocompetent persons.

Inactivated COVID-19 vaccines data in immunocompromised individuals are scarce. This trial assessed the immunogenicity of two CoronaVac doses and additional BNT162b2 mRNA vaccine doses in immunocompromised (IC) and immunocompetent (H) individuals. Adults with solid organ transplant (SOT), hematopoietic stem cell transplant, cancer, inborn immunity errors or rheumatic diseases were included in the IC group. Immunocompetent adults were used as control group for comparison. Participants received two CoronaVac doses within a 28-day interval. IC received two additional BNT162b2 doses and H received a third BNT162b2 dose (booster). Blood samples were collected at baseline, 28 days after each dose, pre-booster and at the trial end. We used three serological tests to detect antibodies to SARS-CoV-2 nucleocapsid (N), trimeric spike (S), and receptor binding domain (RBD). Outcomes included seroconversion rates (SCR), geometric mean titers (GMT) and GMT ratio (GMTR). A total of 241 IC and 100 H adults participated in the study. After two CoronaVac doses, IC had lower SCR than H: anti-N, 33.3% vs 79%; anti-S, 33.8% vs 86%, and anti-RBD, 48.5% vs 85%, respectively. IC also showed lower GMT than H: anti-N, 2.3 vs 15.1; anti-S, 58.8 vs 213.2 BAU/mL; and anti-RBD, 22.4 vs 168.0 U/mL, respectively. After the 3rd and 4th BNT162b2 doses, IC had significant anti-S and anti-RBD seroconversion, but still lower than H after the 3rd dose. After boosting, GMT increased in IC, but remained lower than in the H group. CoronaVac two-dose schedule immunogenicity was lower in IC than in H. BNT162b2 heterologous booster enhanced immune response in both groups.

Contextualizing and optimizing novel strategies to improve the latent TB continuum of care: Insights from people living with HIV and health care providers in Brazil.

Tuberculosis (TB) causes 1 in 3 deaths among people living with HIV (PLHIV). Diagnosing and treating latent tuberculosis infection (LTBI) is critical to reducing TB incidence and mortality. Blood-based screening tests (e.g., QuantiFERON-TB Gold Plus (QFT+)) and shorter-course TB preventive therapy (TPT) regimens such as 3HP (3 months weekly isoniazid-rifapentine) hold significant promise to improve TB outcomes. We qualitatively explored barriers and solutions to optimizing QFT+ and 3HP among PLHIV in three cities in Brazil. We conducted 110 in-depth interviews with PLHIV, health care providers (HCP) and key informants (KI). Content analysis was conducted including the use of case summaries and comparison of themes across populations and contexts. LTBI screening and treatment practices were dependent on HCP's perceptions of whether they were critical to improving TB outcomes. Many HCP lacked a strong understanding of LTBI and perceived the current TPT regimen as complicated. HCP reported that LTBI screening and treatment were constrained by clinic staffing challenges. While PLHIV generally expressed willingness to consider any test or treatment that doctors recommended, they indicated HCP rarely discussed LTBI and TPT. TB testing and treatment requests were constrained by structural factors including financial and food insecurity, difficulties leaving work for appointments, stigma and family responsibilities. QFT+ and 3HP were viewed by all participants as tools that could significantly improve the LTBI cascade by avoiding complexities of TB skin tests and longer LTBI treatment courses. QFT+ and 3HP were perceived to have challenges, including the potential to increase workload on over-burdened health systems if not implemented alongside improved supply chains, staffing, and training, and follow-up initiatives. Multi-level interventions that increase understanding of the importance of LTBI and TPT among HCP, improve patient-provider communication, and streamline clinic-level operations related to QFT+ and 3HP are needed to optimize their impact among PLHIV and reduce TB mortality.

Improving the continuum of care monitoring in Brazilian HIV healthcare services: An implementation science approach.

OBJECTIVE: To evaluate the impact of an intervention improving the continuum of care monitoring (CCM) within HIV public healthcare services in São Paulo, Brazil, and implementing a clinical monitoring system. This system identified three patient groups prioritized for additional care engagement: (1) individuals diagnosed with HIV, but not receiving treatment (the treatment gap group); (2) individuals receiving treatment for >6 months with a detectable viral load (the virologic failure group); and (3) patients lost to follow-up (LTFU). METHODS: The implementation strategies included three training sessions, covering system logistics, case discussions, and development of maintenance goals. These strategies were conducted within 30 HIV public healthcare services (May 2019 to April 2020). After each training session, professionals shared their experiences with CCM at regional meetings. Before and after the intervention, providers were invited to answer 23 items from the normalization process theory questionnaire (online) to understand contextual factors. The mean item scores were compared using the Mann-Whitney U test. The RE-AIM implementation science framework (evaluating reach, effectiveness, adoption, implementation, and maintenance) was used to evaluate the integration of the CCM. RESULTS: In the study, 47 (19.3%) of 243 patients with a treatment gap initiated treatment, 456 (49.1%) of 928 patients with virologic failure achieved suppression, and 700 of 1552 (45.1%) LTFU patients restarted treatment. Strategies for the search and reengagement of patients were developed and shared. Providers recognized the positive effects of CCM on their work and how it modified existing activities (3.7 vs. 4.4, p<0.0001, and 3.9 vs. 4.1, p<0.05); 27 (90%) centers developed plans to sustain routine CCM. CONCLUSION: Implementing CCM helped identify patients requiring more intensive attention. This intervention led to changes in providers' perceptions of CCM and care and management processes, which increased the number of patients engaged across the care continuum and improved outcomes.

Cross-cultural adaptation of the NoMAD questionnaire to Brazilian Portuguese.

BACKGROUND: The Normalization Measure Development (NoMAD) tool is used to determine the contextual determinants in the process of implementing complex health interventions. The aim of this study is to translate and culturally adapt NoMAD to Brazilian Portuguese. METHODS: The cross-cultural adaptation was performed in five steps: 1) translation of the questionnaire into Portuguese; 2) synthesis and creation of the first version; 3) back-translation of the instrument into the source language; 4) review of the instrument by a group of experts and target professionals; and 5) pretesting. A final version of the questionnaire was answered by users of a clinical monitoring system in specialist care services for people living with HIV/AIDS, and the internal consistency of the questionnaire was assessed using Cronbach's alpha. RESULTS: The questionnaire was answered by 188 health professionals, of which 87.7% were female, and the average age was 45.2 years. For the final version of the questionnaire, Cronbach's alpha was over 0.70 for the construct's coherence (0.74), collective action (0.70), cognitive participation (0.71), and reflexive monitoring (0.81). CONCLUSION: The NoMAD questionnaire was cross-culturally adapted and can be used to evaluate the implementation of complex health care interventions.

Victims, bullies and bully-victims: prevalence and association with negative health outcomes from a cross-sectional study in São Paulo, Brazil.

OBJECTIVES: To estimate the prevalence of self-reported bullying as victims, bullies or bully-victims among 9th grade adolescents in the city of São Paulo, Brazil; to investigate association between bullying with negative health outcomes. METHODS: Cross-sectional data were obtained in 2017 from a sample of Brazilian adolescents (n = 2680) using a structured, self-administered questionnaire. Bivariate and multivariate Poisson regression were employed to assess in which extent the experience of bullying in position of victim, bully or bully-victim affects adolescents' health. RESULTS: Prevalence of bullying victimization was 18.3%, while victimization/perpetration and perpetration corresponded to 10.42% and 4.9%, respectively. Adolescents who experienced bullying victimization were more likely to present high levels of internalizing symptoms, to report self-harm, to present negative self-rated health and to use tobacco, when compared with those not involved. Bullies were more likely to use alcohol and to binge drinking. bully-victims presented a higher prevalence of all health outcomes, except for tobacco use. CONCLUSIONS: Our findings highlight the effect of bullying in adolescents' health, regardless of the position. Planned intersectoral efforts between parents, health and education systems to prevent bullying could therefore reduce negative health outcomes during adolescence.

Cross-cultural adaptation of the NoMAD questionnaire to Brazilian Portuguese

SUMMARY BACKGROUND: The Normalization Measure Development (NoMAD) tool is used to determine the contextual determinants in the process of implementing complex health interventions. The aim of this study is to translate and culturally adapt NoMAD to Brazilian Portuguese. METHODS: The cross-cultural adaptation was performed in five steps: 1) translation of the questionnaire into Portuguese; 2) synthesis and creation of the first version; 3) back-translation of the instrument into the source language; 4) review of the instrument by a group of experts and target professionals; and 5) pretesting. A final version of the questionnaire was answered by users of a clinical monitoring system in specialist care services for people living with HIV/AIDS, and the internal consistency of the questionnaire was assessed using Cronbach's alpha. RESULTS: The questionnaire was answered by 188 health professionals, of which 87.7% were female, and the average age was 45.2 years. For the final version of the questionnaire, Cronbach's alpha was over 0.70 for the construct's coherence (0.74), collective action (0.70), cognitive participation (0.71), and reflexive monitoring (0.81). CONCLUSION: The NoMAD questionnaire was cross-culturally adapted and can be used to evaluate the implementation of complex health care interventions.

RESUMO INTRODUÇÃO: O questionário Normalisation Measure Development (NoMAD) tool busca identificar os fatores contextuais determinantes no processo de implementação de intervenções complexas em saúde. Este artigo tem por objetivo traduzir e adaptar culturalmente o NoMAD para o português do Brasil. MÉTODOS: A adaptação transcultural foi realizada em cinco etapas: 1-Tradução do questionário para o português; 2-Síntese e criação da primeira versão; 3-Retro-tradução do instrumento para a língua de origem; 4-Revisão por grupo de especialista e profissionais-alvo do instrumento; e 5-Pré-teste. A versão final do questionário foi respondida por usuários do sistema de monitoramento clínico em serviços de assistência especializada às pessoas vivendo com HIV/AIDS e sua consistência interna foi avaliada por meio de alpha de Cronbach. RESULTADOS: O questionário foi respondido por 188 profissionais, 87,7% eram do sexo feminino e média de idade de 45,2 anos. A versão final do questionário apresentou α de Cronbach superiores a 0.70 nos construtos coerência (0.74), ação coletiva (0.70), participação cognitiva (0,71) e monitoramento reflexivo (0.81). CONCLUSÃO: O questionário NoMAD foi adaptado transculturalmente e pode ser utilizado para avaliar a implementação de intervenções complexas no cuidado em saúde.

An intervention for the implementation of clinical monitoring in specialized care services to people living with HIV/AIDS. / Intervenção para a implementação do monitoramento clínico em serviços especializados de atenção às pessoas vivendo com HIV/aids.

The clinical monitoring of people living with HIV/AIDS (PLWHA) contributes to identifying and managing cases of individuals who have not begun treatment (gap), those experiencing treatment failure or who have abandoned treatment. This article sought to present and discuss the development of a methodology to implement the clinical monitoring of PLWHA in the services of the Brazilian Unified National Health System (SUS). The methodology used since 2014 by the CRT-STI/AIDS-Coordination of the STI/AIDS Program, São Paulo State, Brazil, was re-structured in three meetings between June and August 2018. The new methodology retained the axes of presentation of number of users in treatment failure, gap or abandonment in the participant services, as well as the discussion of individual, social and programmatic vulnerabilities. A new axis was added which directs the discussion of the possibilities of reorganizing service care flows and management practices. Additionally, the intervention started to be carried out in health services, with the participation of a higher number of professionals from the multi-professional team, discussion of cases, workflows and processes, and regional meetings to exchange clinical monitoring experiences between services. The re-structuring of the methodology contributed to a reduction in treatment gap, a reorganization of care flows and the inclusion of clinical monitoring as a management tool in services specialized in providing care to PLWHA. This methodology can be implemented by other state programs, municipalities and services, since all have access to the same information sources used in this intervention.

Intervenção para a implementação do monitoramento clínico em serviços especializados de atenção às pessoas vivendo com HIV/aids / Intervención para la implementación del monitoreo clínico en servicios especializados de atención a personas afectadas por el VIH/SIDA / An intervention for the implementation of clinical monitoring in specialized care services to people living with HIV/AIDS

O monitoramento clínico de pessoas vivendo com HIV/aids (PVHA) contribui para a identificação e gestão de caso das pessoas sem início de tratamento (gap), em falha terapêutica e em abandono de tratamento. O objetivo deste artigo é apresentar e discutir o desenvolvimento de uma metodologia para a implementação do monitoramento clínico das PVHA em serviços do Sistema Único de Saúde (SUS). A metodologia utilizada desde 2014 pelo Centro de Referência e Treinamento DST/AIDS-SP-Coordenação do Programa Estadual de IST/AIDS do Estado de São Paulo, Brasil, foi reestruturada em três reuniões, no período de junho a agosto de 2018. Foram mantidos os eixos de apresentação do número de usuários com falha terapêutica, em gap e em abandono de tratamento nos serviços participantes, e a discussão de vulnerabilidades individuais, sociais e programáticas. Foi adicionado um novo eixo que direciona a discussão das possibilidades de reorganização de fluxos assistenciais e práticas gerenciais do serviço. Adicionalmente, a intervenção passou a ser feita nos serviços de saúde, com a participação de um número maior de profissionais da equipe multiprofissional, discussão de casos, fluxos e processos de trabalho e encontros regionais para a troca de experiências em monitoramento clínico entre os serviços. A reestruturação da metodologia contribuiu para a diminuição do gap de tratamento, reorganização de fluxos assistenciais e inclusão do monitoramento clínico como ferramenta de gestão nos serviços de assistência especializada às PVHA. Essa metodologia pode ser implementada por outros programas estaduais, municípios e serviços, uma vez que todos têm acesso às mesmas fontes de informação usadas nesta intervenção.

El monitoreo clínico de personas afectadas por el VIH/SIDA (PVHA) contribuye a la identificación y gestión de caso de personas sin inicio de tratamiento (gap), con fallos en la parte terapéutica y abandono del tratamiento. El objetivo de este artículo es presentar y discutir el desarrollo de una metodología para la implementación del monitoreo clínico de las PVHA en servicios del Sistema Único de Salud (SUS). La metodología utilizada desde 2014 por el CRT-ETS/SIDA-Coordinación del Programa Estatal de ETS/SIDA del Estado de São Paulo, Brasil, fue reestructurada en tres reuniones, durante el período de junio a agosto de 2018. Se mantuvieron los ejes de presentación del número de usuarios con fallos en la parte terapéutica, gap y con abandono de tratamiento en los servicios participantes estudiados, así como la discusión de vulnerabilidades individuales, sociales y programáticas. Se añadió un nuevo eje que vertebra la discusión sobre las posibilidades de reorganización de los flujos asistenciales y prácticas de gestión del servicio. Asimismo, la intervención pasó a realizarse en los servicios de salud, con la participación de un mayor número de profesionales del equipo multiprofesional, discusión de casos, flujos y procesos de trabajo, así como encuentros regionales para el intercambio de experiencias en el monitoreo clínico entre los servicios. La reestructuración de la metodología contribuyó a la disminución del gap en el tratamiento, la reorganización de flujos asistenciales, así como la inclusión del monitoreo clínico como herramienta de gestión en los servicios de asistencia especializada a las PVHA. Esta metodología puede ser implementada en otros programas estatales, municipios y servicios, ya que todos tienen acceso a las mismas fuentes de información usadas en esta intervención.

The clinical monitoring of people living with HIV/AIDS (PLWHA) contributes to identifying and managing cases of individuals who have not begun treatment (gap), those experiencing treatment failure or who have abandoned treatment. This article sought to present and discuss the development of a methodology to implement the clinical monitoring of PLWHA in the services of the Brazilian Unified National Health System (SUS). The methodology used since 2014 by the CRT-STI/AIDS-Coordination of the STI/AIDS Program, São Paulo State, Brazil, was re-structured in three meetings between June and August 2018. The new methodology retained the axes of presentation of number of users in treatment failure, gap or abandonment in the participant services, as well as the discussion of individual, social and programmatic vulnerabilities. A new axis was added which directs the discussion of the possibilities of reorganizing service care flows and management practices. Additionally, the intervention started to be carried out in health services, with the participation of a higher number of professionals from the multi-professional team, discussion of cases, workflows and processes, and regional meetings to exchange clinical monitoring experiences between services. The re-structuring of the methodology contributed to a reduction in treatment gap, a reorganization of care flows and the inclusion of clinical monitoring as a management tool in services specialized in providing care to PLWHA. This methodology can be implemented by other state programs, municipalities and services, since all have access to the same information sources used in this intervention.

The QualiRede intervention: improving the performance of care continuum in HIV, congenital syphilis, and hepatitis C in health regions.

INTRODUCTION: Care continuum models have supported recent strategies against sexually transmitted diseases, such as HIV and Hepatitis C (HCV). METHODS: HIV, HCV, and congenital syphilis care continuum models were developed, including all stages of care, from promotion/prevention to clinical control/cure. The models supported the intervention QualiRede, developed by a University-Brazilian National Health System (SUS) partnership focused on managers and other professionals from six priority health regions in São Paulo and Santa Catarina. Indicators were selected for each stage of the care continuum from the SUS information systems and from the Qualiaids and QualiAB facility's process evaluation questionnaires. The indicators acted as the technical basis of two workshops with professionals and managers in each region: the first one to identify problems and to create a Regional Technical Group; and the second one to design action plans for improving regional performance. RESULTS: The indicators are available at www.qualirede.org. The workshops took place in the regions of Alto Tietê, Baixada Santista, Grande ABC, and Registro (São Paulo) and of Foz do Rio Itajaí (Santa Catarina), which resulted in regional action plans in São Paulo, but not in Santa Catarina. A lack of awareness was observed regarding the new HIV and HCV protocols, as well as an incipient use of indicators in routine practices. CONCLUSION: Improving the performance of the care continuum requires appropriation of performance indicators and coordination of care flows at local, regional, and state levels of management.

The QualiRede intervention: improving the performance of care continuum in HIV, congenital syphilis, and hepatitis C in health regions / A intervenção QualiRede: melhoria do desempenho do contínuo do cuidado em HIV, sífilis congênita e hepatite C em regiões de saúde

ABSTRACT Introduction: Care continuum models have supported recent strategies against sexually transmitted diseases, such as HIV and Hepatitis C (HCV). Methods: HIV, HCV, and congenital syphilis care continuum models were developed, including all stages of care, from promotion/prevention to clinical control/cure. The models supported the intervention QualiRede, developed by a University-Brazilian National Health System (SUS) partnership focused on managers and other professionals from six priority health regions in São Paulo and Santa Catarina. Indicators were selected for each stage of the care continuum from the SUS information systems and from the Qualiaids and QualiAB facility's process evaluation questionnaires. The indicators acted as the technical basis of two workshops with professionals and managers in each region: the first one to identify problems and to create a Regional Technical Group; and the second one to design action plans for improving regional performance. Results: The indicators are available at www.qualirede.org. The workshops took place in the regions of Alto Tietê, Baixada Santista, Grande ABC, and Registro (São Paulo) and of Foz do Rio Itajaí (Santa Catarina), which resulted in regional action plans in São Paulo, but not in Santa Catarina. A lack of awareness was observed regarding the new HIV and HCV protocols, as well as an incipient use of indicators in routine practices. Conclusion: Improving the performance of the care continuum requires appropriation of performance indicators and coordination of care flows at local, regional, and state levels of management.

RESUMO Introdução: Modelos de cuidado contínuo baseiam recentes estratégias em HIV, infecções sexualmente transmissíveis e hepatite C (HCV). Métodos: Desenvolveram-se modelos de contínuo do cuidado em HIV, HCV e sífilis congênita incluindo todas as etapas da atenção, desde a promoção e a prevenção até o controle clínico/cura. O modelo baseou a intervenção QualiRede, desenvolvida em parceria entre universidade e Sistema Único de Saúde (SUS), direcionada a gestores e demais profissionais de 6 regiões de saúde prioritárias em São Paulo e Santa Catarina. Selecionaram-se indicadores para cada etapa do contínuo do cuidado, provenientes dos sistemas de informação do SUS e dos questionários de avaliação de processo Qualiaids e QualiAB. Os indicadores formaram a base técnica de duas oficinas com profissionais e gestores de cada região: a primeira para identificar problemas e formar um Grupo Técnico Regional; e a segunda para construir planos de ação e metas a fim de melhorar o desempenho regional. Resultados: Os indicadores estão disponíveis no website www.qualirede.org. As oficinas ocorreram em quatro regiões de São Paulo (Alto Tietê, Baixada Santista, Grande ABC e Registro) e uma região de Santa Catarina (Foz do Rio Itajaí), resultando em planos regionais em São Paulo, mas não em Santa Catarina. Observou-se domínio limitado dos novos protocolos para HIV e HCV e uso incipiente de indicadores na rotina dos serviços. Conclusão: Melhorar o desempenho do contínuo do cuidado exige apropriação dos indicadores de desempenho e coordenação integrada dos fluxos de atenção em todos os níveis de gestão.

Evaluation of outpatient services in the Brazilian Unified National Health System for persons living with HIV: a comparison of 2007 and 2010. / Avaliação dos serviços ambulatoriais de assistência a pessoas vivendo com HIV no Sistema Único de Saúde: estudo comparativo 2007/2010.

Health services play a crucial role in reaching the 90-90-90 target of controlling the HIV epidemic. This study evaluates the organization of Brazilian health services in improving, monitoring, and retention in HIV care and adherence support. Percentage variation (PV) was used to compare the responses by services to an evaluation questionnaire on organizational quality (Qualiaids) in 2007 and 2010. The study analyzed the 419 services that completed the questionnaire in 2007 (83.1% of respondents) and 2010 (63.6%). Management actions of retention and support although increased in the period, but remained at low rates, for example: systematic meetings for case discussion (32.7% in 2010; PV = 19.8%) and recording of missed medical appointments (35.3%; PV = 36.8%). Patient care actions related to adherence to ART remained largely exclusive to the attending physician. The supply of funds and resources from the Federal Government (medicines and specific HIV tests) remained high for the vast majority of the services (~90%). It will not be possible to achieve a significant decrease in HIV transmission as long as retention in treatment is not a priority in all the health services.

O papel dos serviços de saúde é crucial para o alcance da meta 90-90-90 de controle da epidemia do HIV. O estudo avalia a organização dos serviços brasileiros nas ações de promoção, monitoramento e suporte à retenção no seguimento e apoio ao tratamento. Foram comparadas, por meio de variação percentual (VP), as respostas dos serviços a um questionário de avaliação da qualidade organizacional (Qualiaids) em 2007 e em 2010. Analisou-se os 419 serviços que responderam ao questionário em 2007 (83,1% dos respondentes) e 2010 (63,6%). Ações gerenciais relacionadas à retenção e apoio, embora incrementadas no período, permaneceram com baixa frequência, tais como: reuniões sistemáticas para discussão de casos; (32,7% em 2010; VP = 19,8%), registro de faltas em consulta médica (35,3%; VP = 36,8%). Ações assistenciais relacionadas à adesão ao tratamento medicamentoso permanecem majoritariamente exclusivas do médico. O aporte de recursos de provisão federal - medicamentos e exames específicos para HIV - manteve-se alto para a grande maioria dos serviços (~90%). Não se alcançará decréscimo significativo da transmissão do HIV enquanto a permanência no tratamento não for prioridade de todos os serviços de assistência.

El papel de los servicios de salud es crucial para el alcance de la meta 90-90-90 de control de la epidemia de VIH. El estudio evalúa la organización de los servicios brasileños en las acciones de promoción, monitoreo y apoyo al mantenimiento del seguimiento y tratamiento. Se compararon, mediante la variación porcentual (VP), las respuestas de los servicios a un cuestionario de evaluación de la calidad organizativa (Qualiaids) en 2007 y en 2010. Se analizaron los 419 servicios que respondieron al cuestionario en 2007 (83,1% de los participantes) y 2010 (63,6%). Las acciones de gerencia, relacionadas con el mantenimiento y apoyo, aunque se incrementaron durante el período, permanecieron con baja frecuencia, tales como: reuniones sistemáticas para discusión de casos; (32,7% en 2010; VP = 19,8%), registro de faltas en consulta médica (35,3%; VP = 36,8%). Las acciones asistenciales relacionadas con la adhesión al tratamiento farmacológico continúan siendo mayoritariamente exclusivas del médico. La aportación de recursos de provisión federal -medicamentos y exámenes específicos para VIH- se mantuvo alta para la gran mayoría de los servicios (~90%). No se alcanzará un decremento significativo en la transmisión del VIH, mientras la permanencia en el tratamiento no sea una prioridad de todos los servicios de asistencia.

Avaliação dos serviços ambulatoriais de assistência a pessoas vivendo com HIV no Sistema Único de Saúde: estudo comparativo 2007/2010 / Evaluación de los servicios ambulatorios de asistencia a personas viviendo con VIH en el Sistema Único de Salud: estudio comparativo 2007/2010 / Evaluation of outpatient services in the Brazilian Unified National Health System for persons living with HIV: a comparison of 2007 and 2010

O papel dos serviços de saúde é crucial para o alcance da meta 90-90-90 de controle da epidemia do HIV. O estudo avalia a organização dos serviços brasileiros nas ações de promoção, monitoramento e suporte à retenção no seguimento e apoio ao tratamento. Foram comparadas, por meio de variação percentual (VP), as respostas dos serviços a um questionário de avaliação da qualidade organizacional (Qualiaids) em 2007 e em 2010. Analisou-se os 419 serviços que responderam ao questionário em 2007 (83,1% dos respondentes) e 2010 (63,6%). Ações gerenciais relacionadas à retenção e apoio, embora incrementadas no período, permaneceram com baixa frequência, tais como: reuniões sistemáticas para discussão de casos; (32,7% em 2010; VP = 19,8%), registro de faltas em consulta médica (35,3%; VP = 36,8%). Ações assistenciais relacionadas à adesão ao tratamento medicamentoso permanecem majoritariamente exclusivas do médico. O aporte de recursos de provisão federal - medicamentos e exames específicos para HIV - manteve-se alto para a grande maioria dos serviços (~90%). Não se alcançará decréscimo significativo da transmissão do HIV enquanto a permanência no tratamento não for prioridade de todos os serviços de assistência.

El papel de los servicios de salud es crucial para el alcance de la meta 90-90-90 de control de la epidemia de VIH. El estudio evalúa la organización de los servicios brasileños en las acciones de promoción, monitoreo y apoyo al mantenimiento del seguimiento y tratamiento. Se compararon, mediante la variación porcentual (VP), las respuestas de los servicios a un cuestionario de evaluación de la calidad organizativa (Qualiaids) en 2007 y en 2010. Se analizaron los 419 servicios que respondieron al cuestionario en 2007 (83,1% de los participantes) y 2010 (63,6%). Las acciones de gerencia, relacionadas con el mantenimiento y apoyo, aunque se incrementaron durante el período, permanecieron con baja frecuencia, tales como: reuniones sistemáticas para discusión de casos; (32,7% en 2010; VP = 19,8%), registro de faltas en consulta médica (35,3%; VP = 36,8%). Las acciones asistenciales relacionadas con la adhesión al tratamiento farmacológico continúan siendo mayoritariamente exclusivas del médico. La aportación de recursos de provisión federal -medicamentos y exámenes específicos para VIH- se mantuvo alta para la gran mayoría de los servicios (~90%). No se alcanzará un decremento significativo en la transmisión del VIH, mientras la permanencia en el tratamiento no sea una prioridad de todos los servicios de asistencia.

Health services play a crucial role in reaching the 90-90-90 target of controlling the HIV epidemic. This study evaluates the organization of Brazilian health services in improving, monitoring, and retention in HIV care and adherence support. Percentage variation (PV) was used to compare the responses by services to an evaluation questionnaire on organizational quality (Qualiaids) in 2007 and 2010. The study analyzed the 419 services that completed the questionnaire in 2007 (83.1% of respondents) and 2010 (63.6%). Management actions of retention and support although increased in the period, but remained at low rates, for example: systematic meetings for case discussion (32.7% in 2010; PV = 19.8%) and recording of missed medical appointments (35.3%; PV = 36.8%). Patient care actions related to adherence to ART remained largely exclusive to the attending physician. The supply of funds and resources from the Federal Government (medicines and specific HIV tests) remained high for the vast majority of the services (~90%). It will not be possible to achieve a significant decrease in HIV transmission as long as retention in treatment is not a priority in all the health services.

Using computed tomography enterography to evaluate patients with Crohn's disease: what impact does examiner experience have on the reproducibility of the method?

OBJECTIVE: To assess the impact that examiner experience has on the reproducibility and accuracy of computed tomography (CT) enterography in the detection of radiological signs in patients with Crohn's disease. MATERIALS AND METHODS: This was a retrospective, cross-sectional observational study involving the analysis of CT enterography scans of 20 patients with Crohn's disease. The exams were analyzed independently by two radiologists in their last year of residence (duo I) and by two abdominal imaging specialists (duo II). The interobserver agreement of each pair of examiners in identifying the main radiological signs was calculated with the kappa test. The accuracy of the examiners with less experience was quantified by using the consensus among three experienced examiners as a reference. RESULTS: Duo I and duo II obtained a similar interobserver agreement, with a moderate to good correlation, for mural hyperenhancement, parietal thickening, mural stratification, fat densification, and comb sign (kappa: 0.45-0.64). The less experienced examiners showed an accuracy > 80% for all signs, except for lymph nodes and fistula, for which it ranged from 60% to 75%. CONCLUSION: Less experienced examiners have a tendency to present a level of interobserver agreement similar to that of experienced examiners in evaluating Crohn's disease through CT enterography, as well as showing satisfactory accuracy in identifying most radiological signs of the disease.

OBJETIVO: Avaliar o impacto da experiência do examinador na reprodutibilidade e na acurácia de detecção de sinais radiológicos em exames de enterografia por tomografia computadorizada (entero-TC) de pacientes portadores da doença de Crohn. MATERIAIS E MÉTODOS: Análise retrospectiva de exames de entero-TC de 20 pacientes com doença de Crohn. Os exames foram analisados, independentemente, por dois radiologistas do último ano de residência (dupla I) e dois especialistas em imagem abdominal (dupla II). A concordância interobservador de cada dupla de examinadores para a identificação dos principais sinais tomográficos foi calculada pelo teste kappa. A acurácia da dupla I foi medida usando-se como referência um consenso entre três examinadores experientes. RESULTADOS: Ambas as duplas obtiveram concordância interobservador semelhante e com correlação moderada a boa para os sinais de estratificação mural, espessamento da parede, realce mucoso, densificação da gordura e sinal do pente (kappa: 0,45-0,64). Os examinadores menos experientes apresentaram acurácia superior a 80% para os sinais, exceto para linfonodos e fístula (entre 60% e 75%). CONCLUSÃO: Examinadores menos experientes têm tendência a apresentar grau de concordância entre si semelhante à de examinadores experientes na avaliação dos principais sinais tomográficos da doença de Crohn, com acurácia considerada satisfatória, para a maioria dos sinais.

Using computed tomography enterography to evaluate patients with Crohn's disease: what impact does examiner experience have on the reproducibility of the method? / Avaliação da doença de Crohn por meio da enterografia por tomografia computadorizada: qual o impacto da experiência dos examinadores na reprodutibilidade do método?

Abstract Objective: To assess the impact that examiner experience has on the reproducibility and accuracy of computed tomography (CT) enterography in the detection of radiological signs in patients with Crohn's disease. Materials and Methods: This was a retrospective, cross-sectional observational study involving the analysis of CT enterography scans of 20 patients with Crohn's disease. The exams were analyzed independently by two radiologists in their last year of residence (duo I) and by two abdominal imaging specialists (duo II). The interobserver agreement of each pair of examiners in identifying the main radiological signs was calculated with the kappa test. The accuracy of the examiners with less experience was quantified by using the consensus among three experienced examiners as a reference. Results: Duo I and duo II obtained a similar interobserver agreement, with a moderate to good correlation, for mural hyperenhancement, parietal thickening, mural stratification, fat densification, and comb sign (kappa: 0.45-0.64). The less experienced examiners showed an accuracy > 80% for all signs, except for lymph nodes and fistula, for which it ranged from 60% to 75%. Conclusion: Less experienced examiners have a tendency to present a level of interobserver agreement similar to that of experienced examiners in evaluating Crohn's disease through CT enterography, as well as showing satisfactory accuracy in identifying most radiological signs of the disease.

Resumo Objetivo: Avaliar o impacto da experiência do examinador na reprodutibilidade e na acurácia de detecção de sinais radiológicos em exames de enterografia por tomografia computadorizada (entero-TC) de pacientes portadores da doença de Crohn. Materiais e Métodos: Análise retrospectiva de exames de entero-TC de 20 pacientes com doença de Crohn. Os exames foram analisados, independentemente, por dois radiologistas do último ano de residência (dupla I) e dois especialistas em imagem abdominal (dupla II). A concordância interobservador de cada dupla de examinadores para a identificação dos principais sinais tomográficos foi calculada pelo teste kappa. A acurácia da dupla I foi medida usando-se como referência um consenso entre três examinadores experientes. Resultados: Ambas as duplas obtiveram concordância interobservador semelhante e com correlação moderada a boa para os sinais de estratificação mural, espessamento da parede, realce mucoso, densificação da gordura e sinal do pente (kappa: 0,45-0,64). Os examinadores menos experientes apresentaram acurácia superior a 80% para os sinais, exceto para linfonodos e fístula (entre 60% e 75%). Conclusão: Examinadores menos experientes têm tendência a apresentar grau de concordância entre si semelhante à de examinadores experientes na avaliação dos principais sinais tomográficos da doença de Crohn, com acurácia considerada satisfatória, para a maioria dos sinais.

Estoque domiciliar de medicamentos de pessoas assistidas por uma equipe de profissionais da Estratégia de Saúde da Família / Medications stored at home by patients cared for by Family Health Strategy professionals / Almacenamiento medicamentos de los pacients atendidos por profesionales de atención primaria de la salud

O estoque domiciliar de medicamentos é uma prática comum a muitas famílias, mas pode representar um risco à saúde. Foi realizado um estudo transversal em 100 domicílios em uma área de abrangência da Estratégia Saúde da Família (ESF) em Blumenau, SC, entre fevereiro e março de 2012. Nos domicílios visitados, 91% tinham medicamentos, sendo encontrados 737 medicamentos (média de 7,6 por domicílio). O grupo terapêutico de medicamentos mais frequente foi o dos que atuam no sistema digestivo 148 (20,1%) e o medicamento mais encontrado foi o paracetamol (48,7%). Dentre os entrevistados, 29 (31,9%) relataram descartar medicamentos no lixo comum, 12 (13,2%) não observavam o aspecto físico antes de utilizar e 74 (81,3%) tiveram acesso a medicamentos em farmácias comunitárias e ESFs. Observou-se associação entre número de medicamentos e número de pessoas no domicílio (p<0,01) e com presença de doenças crônicas (p<0,05). Pessoas com mais escolaridade armazenam mais medicamentos (p<0,001). Contudo, pessoas com baixa escolaridade utilizam mais medicamentos prescritos por médicos (p<0,001).

Many families commonly store medications at home, a practice that may pose a health risk to these individuals. A cross-sectional study of 100 households in an area covered under the Family Health Strategy (FHS) was conducted in Blumenau, SC, between February and March 2012. Among the households visited, 91% had stored drugs; 737 different medications were found (with a mean of 7.6 medications per household). The most commonly stored drugs were the ones that act on the digestive system (148 drugs, or 20.1%), and the most commonly found medication was paracetamol (48.7%). Among the respondents, 29 (31.9%) reported often having disposed of medications in the trash; 12 (13.2%) did not particularly note the drug's appearance before ingesting it; and 74 (81.3%) had access to drugs in publicly funded (community) pharmacies and primary healthcare centers. The number of drugs was associated with the number of people in the household (p < 0.01) and the presence of chronic diseases (p < 0.05). People with higher levels of education stored more drugs (p < 0.001). However, people with lower levels of education used more drugs prescribed by doctors (p < 0.001).

El almacenamiento de los medicamentos en los hogares es una práctica común para muchas familias, pero puede representar un riesgo a la salud. Un estudio transversal se llevó a cabo en 100 hogares en un área de cobertura de la Estrategia de la Salud de la Familia (ESF) en Blumenau, SC, entre febrero y marzo del 2012. En el 91% de los hogares visitados había medicinas, donde fueron encontrados 737 medicamentos (promedio de 7,6 por hogar). Los medicamentos que actúan sobre el sistema digestivo fue el grupo terapéutico más frecuente 148 (20,1%) y la medicina más encontrada fue el Paracetamol (48,7%). Entre los encuestados, 29 (31,9 %) relataron que decartaan sus medicamentos en la basura comun, 12 (13,2 %) no observaban el aspecto físico antes del uso y 74 (81,3%) tuvieron acceso a los medicamentos en las farmacias comunitarias y en la ESF. Se observó una asociación entre el número de medicamentos y el número de personas en el hogar (p<0,01) y la presencia de enfermedades crónicas (p<0,05). Las personas con más educación almacenan más drogas (p<0,001). Sin embargo las personas con bajo nivel de estudios útilizan nás medicamentos prescritos por los médicos (p<0,001).

Micoses superficiais em pacientes com Diabetes Mellitus atendidos em um ambulatório geral em Blumenau, SC / Superficial mycoses in patient with Diabetes Mellitus served in a general outpatient clinic in Blumenau, SC

O Diabetes Mellitus (DM) caracteriza-se por uma síndrome clínica de evolução crônica e degenerativa, decorrente de distúrbio na secreção e/ou ação da insulina no organismo, que determina um conjunto de alterações metabólicas, caracterizadas,principalmente, pela hiperglicemia. Os indivíduos portadores de DM são, em geral, indivíduos vulneráveis a uma série de complicações de natureza infecciosa, como os processos bacterianos, fúngicos e virais. As micoses mais frequentemente encontradas são causadas por fungos dermatófitos e leveduras do gênero Candida. O objetivo deste estudo foi analisar a frequência de infecção fúngica em portadores de DM atendidos em um ambulatório geral, em Blumenau, SC. Métodos: O diagnóstico laboratorial foi feito através de métodos tradicionais, incluindo exame micológico direto e cultura. Resultados: Constatou-se que, dentre os indivíduos avaliados, 36% apresentaram resultado positivo,sendo que, desses, 86% apresentaram lesão por Candida spp. e 14% por dermatófitos, o qual foi identificado como Trichophyton mentagrophytes na cultura. Conclusão: A maior frequência de Candida spp. pode estar relacionada à imunossupressão ocasionada pelo Diabetes Mellitus. Com este estudo, pode-se demonstrar a importância do diagnóstico laboratorial precoce das infecções fúngicas em indivíduos com Diabetes Mellitus...