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2.
Lancet ; 391(10134): 2019-2027, 2018 05 19.
Artigo em Inglês | MEDLINE | ID: mdl-29864018

RESUMO

BACKGROUND: Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels. METHODS: We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month. FINDINGS: We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14-1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12-1·72) irrespective of other patient and service characteristics. INTERPRETATION: Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes. FUNDING: Chest, Heart and Stroke Scotland.


Assuntos
Padrões de Prática Médica , Acidente Vascular Cerebral/terapia , Idoso , Estudos de Casos e Controles , Países Desenvolvidos , Países em Desenvolvimento , Medicina Baseada em Evidências , Feminino , Acesso aos Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados da Assistência ao Paciente , Pobreza , Inquéritos e Questionários , Análise de Sobrevida , Resultado do Tratamento
3.
J Am Coll Cardiol ; 70(18): 2290-2303, 2017 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-29073958

RESUMO

Early-career academic cardiologists, who many believe are an important component of the future of cardiovascular care, face myriad challenges. The Early Career Section Academic Working Group of the American College of Cardiology, with senior leadership support, assessed the progress of this cohort from 2013 to 2016 with a global perspective. Data consisted of accessing National Heart, Lung, and Blood Institute public information, data from the American Heart Association and international organizations, and a membership-wide survey. Although the National Heart, Lung, and Blood Institute increased funding of career development grants, only a small number of early-career American College of Cardiology members have benefited as funding of the entire cohort has decreased. Personal motivation, institutional support, and collaborators continued to be positive influential factors. Surprisingly, mentoring ceased to correlate positively with obtaining external grants. The totality of findings suggests that the status of early-career academic cardiologists remains challenging; therefore, the authors recommend a set of attainable solutions.


Assuntos
Cardiologistas/educação , Cardiologia/educação , Escolha da Profissão , Mentores/educação , Cardiologistas/economia , Cardiologistas/tendências , Cardiologia/economia , Cardiologia/tendências , Humanos , Apoio à Pesquisa como Assunto/economia , Apoio à Pesquisa como Assunto/tendências
4.
Br J Cancer ; 117(3): 439-449, 2017 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-28641316

RESUMO

BACKGROUND: Rurality and distance from cancer treatment centres have been shown to negatively impact cancer outcomes, but the mechanisms remain obscure. METHODS: We analysed the impact of travel time to key healthcare facilities and mainland/island residency on the cancer diagnostic pathway (treatment within 62 days of referral, and within 31 days of diagnosis) and 1-year mortality using a data-linkage study with 12 339 patients. RESULTS: After controlling for important confounders, mainland patients with more than 60 min of travelling time to their cancer treatment centre ((OR 1.42; 95% CI 1.25-1.61) and island dwellers (OR 1.32; 95% CI 1.09-1.59) were more likely to commence cancer treatment within 62 days of general practitioner (GP) referral and within 31 days of their cancer diagnosis compared with those living within 15 min. Island-dweller patients were more likely to have their diagnosis and treatment started on the same or next day (OR 1.72; 95% CI 1.31-2.25). Increased travelling time to a cancer treatment centre was associated with increased mortality to 1 year (30-59 min (HR 1.21; 95% CI 1.05-1.41), >60 min (HR 1.18; 95% CI 1.03-1.36), island dweller (HR 1.17; 95% CI 0.97-1.41). CONCLUSIONS: Island dwelling and greater mainland travel burden was associated with more rapid cancer diagnosis and treatment following GP referral even after adjustment for advanced disease; however, these patients also experienced a survival disadvantage compared with those living nearer. Cancer services may need to be better configured to suit the different needs of dispersed populations.


Assuntos
Acesso aos Serviços de Saúde , Registro Médico Coordenado , Neoplasias/mortalidade , Neoplasias/terapia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Encaminhamento e Consulta , Características de Residência , Fatores de Tempo , Reino Unido/epidemiologia
5.
Br J Cancer ; 116(9): 1148-1158, 2017 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-28334728

RESUMO

BACKGROUND: People diagnosed with cancer following emergency presentation have poorer short-term survival. To what extent this signifies a missed opportunity for earlier diagnosis in primary care remains unclear as little detailed data exist on the patient/general practitioner interaction beforehand. METHODS: Analysis of primary care and regional data for 1802 cancer patients from Northeast Scotland. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) for patient and GP practice predictors of emergency presentation. Qualitative context coding of primary care interaction before emergency presentation. RESULTS: Emergency presentations equalled 20% (n=365). Twenty-eight per cent had no relevant prior GP contact. Of those with prior GP contact 30% were admitted while waiting to be seen in secondary care, and 19% were missed opportunities for earlier diagnosis. Associated predictors: no prior GP contact (OR=3.89; CI 95% 2.14-7.09); having lung (OR=23.24; 95% CI 7.92-68.21), colorectal (OR=18.49; CI 95% 6.60-51.82) and upper GI cancer (OR=18.97; CI 95% 6.08-59.23); ethnicity (OR=2.78; CI 95% 1.27-6.06). CONCLUSIONS: Our novel approach has revealed that emergency cancer presentation is more complex than previously thought. Patient delay, prolonged referral pathways and missed opportunities by GPs all contribute, but emergency presentation can also represent effective care. Resources should be used proportionately to raise public and GP awareness and improve post-referral pathways.


Assuntos
Emergências/epidemiologia , Serviço Hospitalar de Emergência , Neoplasias/diagnóstico , Neoplasias/epidemiologia , Idoso , Feminino , Clínicos Gerais , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/patologia , Atenção Primária à Saúde , Prognóstico , Escócia , Atenção Secundária à Saúde
8.
J Neurol Neurosurg Psychiatry ; 87(2): 138-43, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26285585

RESUMO

BACKGROUND: The presence of a 'weekend' effect has been shown across a range of medical conditions, but has not been consistently observed for patients with stroke. AIMS: We investigated the impact of admission time on a range of process and outcome measures after stroke. METHODS: Using routine data from National Scottish data sets (2005-2013), time of admission was categorised into weekday, weeknight and weekend/public holidays. The main process measures were swallow screen on day of admission (day 0), brain scan (day 0 or 1), aspirin (day 0 or 1), admission to stroke unit (day 0 or 1), and thrombolysis administration. After case-mix adjustment, multivariable logistic regression was used to estimate the OR for mortality and discharge to home/usual place of residence. RESULTS: There were 52,276 index stroke events. Compared to weekday, the adjusted OR (95%CI) for early stroke unit admission was 0.81 (0.77 to 0.85) for weeknight admissions and 0.64 (0.61 to 0.67) for weekend/holiday admissions; early brain scan 1.30 (0.87 to 1.94) and 1.43 (0.95 to 2.18); same day swallow screen 0.86 (0.81 to 0.91) and 0.85 (0.81 to 0.90); thrombolysis 0.85 (0.75 to 0.97) and 0.85 (0.75 to 0.97), respectively. Seven-day mortality, 30-day mortality and 30-day discharge for weekend admission compared to weekday was 1.17 (1.05 to 1.30); 1.08 (1.00 to 1.17); and 0.90 (0.85 to 0.95), respectively. CONCLUSIONS: Patients with stroke admitted out of hours and at weekends or public holidays are less likely to be managed according to current guidelines. They experience poorer short-term outcomes than those admitted during normal working hours, after correcting for known independent predictors of outcome and early mortality.


Assuntos
Acidente Vascular Cerebral/terapia , Idoso , Estudos de Coortes , Deglutição , Feminino , Guias como Assunto , Férias e Feriados , Humanos , Tempo de Internação , Masculino , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Estudos Prospectivos , Escócia/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Terapia Trombolítica/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento
10.
J Am Heart Assoc ; 4(11)2015 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-26541391

RESUMO

BACKGROUND: A 1.5-day interactive forum was convened to discuss critical issues in the acquisition, analysis, and sharing of data in the field of cardiovascular and stroke science. The discussion will serve as the foundation for the American Heart Association's (AHA's) near-term and future strategies in the Big Data area. The concepts evolving from this forum may also inform other fields of medicine and science. METHODS AND RESULTS: A total of 47 participants representing stakeholders from 7 domains (patients, basic scientists, clinical investigators, population researchers, clinicians and healthcare system administrators, industry, and regulatory authorities) participated in the conference. Presentation topics included updates on data as viewed from conventional medical and nonmedical sources, building and using Big Data repositories, articulation of the goals of data sharing, and principles of responsible data sharing. Facilitated breakout sessions were conducted to examine what each of the 7 stakeholder domains wants from Big Data under ideal circumstances and the possible roles that the AHA might play in meeting their needs. Important areas that are high priorities for further study regarding Big Data include a description of the methodology of how to acquire and analyze findings, validation of the veracity of discoveries from such research, and integration into investigative and clinical care aspects of future cardiovascular and stroke medicine. Potential roles that the AHA might consider include facilitating a standards discussion (eg, tools, methodology, and appropriate data use), providing education (eg, healthcare providers, patients, investigators), and helping build an interoperable digital ecosystem in cardiovascular and stroke science. CONCLUSION: There was a consensus across stakeholder domains that Big Data holds great promise for revolutionizing the way cardiovascular and stroke research is conducted and clinical care is delivered; however, there is a clear need for the creation of a vision of how to use it to achieve the desired goals. Potential roles for the AHA center around facilitating a discussion of standards, providing education, and helping establish a cardiovascular digital ecosystem. This ecosystem should be interoperable and needs to interface with the rapidly growing digital object environment of the modern-day healthcare system.


Assuntos
Acesso à Informação , Pesquisa Biomédica/organização & administração , Cardiologia/organização & administração , Doenças Cardiovasculares , Mineração de Dados , Bases de Dados Factuais , Disseminação de Informação , Acidente Vascular Cerebral , American Heart Association , Pesquisa Biomédica/tendências , Cardiologia/tendências , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/terapia , Consenso , Comportamento Cooperativo , Mineração de Dados/tendências , Bases de Dados Factuais/tendências , Difusão de Inovações , Previsões , Humanos , Comunicação Interdisciplinar , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia , Estados Unidos
11.
Women Birth ; 28(3): 252-8, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25956972

RESUMO

PROBLEM: Parental stress in the neonatal intensive care unit (NICU) has been reported, however identifying modifiable stress factors and looking for demographic parent factors related to stress has not been well researched. AIM: This study aims to identify the most stressful elements for parents in the neonatal intensive care unit. METHODS: Parents of babies in an Australian neonatal intensive care unit (N=73) completed both the Parent Stress Scale - Neonatal Intensive Care Unit and a survey of parent and baby demographic and support experience variables (Parent Survey) over an 18-month period. FINDINGS: Older parental age, very premature birth and twin birth were significantly associated with a higher Parent Stress Scale - Neonatal Intensive Care Unit score. Having a high score in the Relationship and Parental Role scale was strongly associated with attendance at the parent support group. CONCLUSION: These results indicate the variables associated with stress and this knowledge can be used by teams within hospitals to provide better supportive emotional care for parents.


Assuntos
Estado Terminal/psicologia , Relações Pais-Filho , Pais/psicologia , Nascimento Prematuro/psicologia , Estresse Psicológico/diagnóstico , Adaptação Psicológica , Adulto , Austrália , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Masculino , Poder Familiar/psicologia , Gravidez , Inquéritos e Questionários
13.
Stroke ; 46(4): 1065-70, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25677597

RESUMO

BACKGROUND AND PURPOSE: Further research is needed to better identify the methods of evaluating processes and outcomes of stroke care. We investigated whether achieving 4 evidence-based components of a care bundle in a Scotland-wide population with ischemic stroke is associated with 30-day and 6-month outcomes. METHODS: Using national datasets, we looked at the effect of 4 standards (stroke unit entry on calendar day of admission [day 0] or day following [day 1], aspirin on day 0 or day 1, scan on day 0, and swallow screen recorded on day 0) on mortality and discharge to usual residence, at 30 days and 6 months. Data were corrected for the validated 6 simple variables, admission year, and hospital-level random effects. RESULTS: A total of 36,055 patients were included. Achieving stroke unit admission, swallow screen, and aspirin standards were associated with reduced 30-day mortality (adjusted odds ratio [95% confidence interval]: 0.82 [0.75-0.90], 0.88 [0.77-0.99], and 0.39 [0.35-0.43], respectively). Thirty-day all-cause mortality was higher when fewer standards were achieved, from 0 versus 4 (adjusted odds ratio [95% confidence interval], 2.95 [1.91-4.55]) to 3 versus 4 (adjusted odds ratio [95% confidence interval], 1.21 [1.09-1.34]). This effect persisted at 6 months. When less than the full care bundle was achieved, discharge to usual residence was less likely at 6 months (3 versus 4 standards; adjusted odds ratio [95% confidence interval], 0.91 [0.85-0.98]). CONCLUSIONS: Achieving a care bundle for ischemic stroke is associated with reduced mortality at 30 days and 6 months and increased likelihood of discharge to usual residence at 6 months.


Assuntos
Isquemia Encefálica , Avaliação de Resultados (Cuidados de Saúde)/estatística & dados numéricos , Pacotes de Assistência ao Paciente/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Acidente Vascular Cerebral , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/mortalidade , Isquemia Encefálica/terapia , Estudos de Coortes , Humanos , Masculino , Pacotes de Assistência ao Paciente/métodos , Pacotes de Assistência ao Paciente/normas , Escócia/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/terapia , Resultado do Tratamento
15.
BMC Health Serv Res ; 15: 583, 2015 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-26719156

RESUMO

BACKGROUND: In Scotland all non-obstetric, non-psychiatric acute inpatient and day case stays are recorded by an administrative hospital discharge database, the Scottish Morbidity Record (SMR01). The Scottish Stroke Care Audit (SSCA) collects data from all hospitals managing acute stroke in Scotland to support and improve quality of stroke care. The aim was to assess whether there were discrepancies between these data sources for admissions from 2010 to 2011. METHODS: Records were matched when admission dates from the two data sources were within two days of each other and if an International Classification of Diseases (ICD) code of I61, I63, I64, or G45 was in the primary or secondary diagnosis field on SMR01. We also carried out a linkage analysis followed by a case-note review within one hospital in Scotland. RESULTS: There were a total of 22 416 entries on SSCA and 22 200 entries on SMR01. The concordance between SSCA and SMR01 was 16 823. SSCA contained 5593 strokes that were not present in SMR01, whereas SMR01 contained 185 strokes that were not present in SSCA. In the case-note review the concordance was 531, with SSCA containing 157 strokes that were not present in SMR01 and SMR01 containing 32 strokes that were not present in SSCA. CONCLUSIONS: When identifying strokes, hospital administrative discharge databases should be used with caution. Our results demonstrate that SSCA most accurately represents the number of strokes occurring in Scotland. This resource is useful for determining the provision of adequate patient care, stroke services and resources, and as a tool for research.


Assuntos
Bases de Dados Factuais/normas , Registros Eletrônicos de Saúde/normas , Auditoria Médica/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Acidente Vascular Cerebral/epidemiologia , Coleta de Dados/normas , Bases de Dados Factuais/estatística & dados numéricos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Morbidade , Admissão do Paciente/estatística & dados numéricos , Escócia/epidemiologia , Acidente Vascular Cerebral/diagnóstico
16.
J Neurol Neurosurg Psychiatry ; 86(3): 314-8, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24966391

RESUMO

BACKGROUND AND AIM: Randomised trials indicate that stroke unit care reduces morbidity and mortality after stroke. Similar results have been seen in observational studies but many have not corrected for selection bias or independent predictors of outcome. We evaluated the effect of stroke unit compared with general ward care on outcomes after stroke in Scotland, adjusting for case mix by incorporating the six simple variables (SSV) model, also taking into account selection bias and stroke subtype. METHODS: We used routine data from National Scottish datasets for acute stroke patients admitted between 2005 and 2011. Patients who died within 3 days of admission were excluded from analysis. The main outcome measures were survival and discharge home. Multivariable logistic regression was used to estimate the OR for survival, and adjustment was made for the effect of the SSV model and for early mortality. Cox proportional hazards model was used to estimate the hazard of death within 365 days. RESULTS: There were 41 692 index stroke events; 79% were admitted to a stroke unit at some point during their hospital stay and 21% were cared for in a general ward. Using the SSV model, we obtained a receiver operated curve of 0.82 (SE 0.002) for mortality at 6 months. The adjusted OR for survival at 7 days was 3.11 (95% CI 2.71 to 3.56) and at 1 year 1.43 (95% CI 1.34 to 1.54) while the adjusted OR for being discharged home was 1.19 (95% CI 1.11 to 1.28) for stroke unit care. CONCLUSIONS: In routine practice, stroke unit admission is associated with a greater likelihood of discharge home and with lower mortality up to 1 year, after correcting for known independent predictors of outcome, and excluding early non-modifiable mortality.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Idoso , Causas de Morte , Grupos Diagnósticos Relacionados , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Funções Verossimilhança , Masculino , Razão de Chances , Alta do Paciente/estatística & dados numéricos , Modelos de Riscos Proporcionais , Escócia , Viés de Seleção , Acidente Vascular Cerebral/mortalidade , Análise de Sobrevida
17.
J Clin Nurs ; 23(21-22): 3156-65, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24575971

RESUMO

AIMS AND OBJECTIVES: To explore the nurses' views of their role both in the neonatal intensive care unit and in the provision of interacting with, and emotionally supporting, families. BACKGROUND: The neonatal intensive care nurse has a large and complex clinical role and also a role of emotional supporter for parents in the neonatal intensive care unit. Identifying components of their role and recognising the elements within the nursery that obstruct or encourage this role can allow for modification of nurse education and peer support. DESIGN: Qualitative study based on semistructured interviews. METHODS: Nine neonatal nurses from a single neonatal intensive care unit were interviewed and the data analysed thematically using NVIVO version 10. RESULTS: Participants viewed their role as an enjoyable yet difficult one, requiring seniority, training and experience. They provided support to parents by communicating, listening, providing individualised support and by encouraging parental involvement with their baby. Constructive elements that contributed to the provision of support included a positive neonatal intensive care unit environment and providing a parent support group. More obstructive elements were a lack of physical neonatal intensive care unit space, little time available for nurse-to-parent conversation and language and cultural barriers between nurses and parents. CONCLUSION: The role of the neonatal nurse in providing emotional support is complex and requires a high level of ongoing support and education for staff, and minimisation of physical and staff-related obstructions. RELEVANCE TO CLINICAL PRACTICE: The modern neonatal intensive care unit offers complex medical and nursing services and with this care comes higher needs from both babies and their parents. Neonatal intensive care unit nurses should be supported in their roles by having peer support available in the neonatal intensive care unit and education and training in emotional support and counselling skills. The nursing staff also require a comfortable and practical physical working space in which to assist parents to be with their baby.


Assuntos
Atitude do Pessoal de Saúde , Papel do Profissional de Enfermagem , Pais/psicologia , Relações Profissional-Família , Adulto , Enfermagem Familiar , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal , Entrevistas como Assunto , Masculino , Austrália do Sul
20.
Adv Neonatal Care ; 13(6): 438-46, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24300964

RESUMO

PURPOSE: The experience of the neonatal intensive care unit (NICU) for parents can be anxiety-provoking, fearful, and distressing. To help parents cope with these overwhelming feelings, a number of interventions, including parent support groups, are typically offered. It is hoped that the provision of these groups and other forms of emotional support lessen the distressing experience for parents and lessen the anxiety of hospital discharge. This study focuses on the emotional reactions during the transition to home from the NICU for parents who participated in one such support group. METHODS: Parents were interviewed 4 to 6 months after discharge of their baby from hospital. RESULTS: Themes from these interviews included anxiety and concern about the baby's readiness for discharge, concerns about the risks of further illness and rehospitalization, and whether the parent felt prepared sufficiently to care for his or her baby at home. Recalling their time in the nursery was distressing for parents, but despite this, they identified that positive staff interactions helped them through the hardest times in the NICU. CONCLUSIONS: The support group was reported to be effective and helpful for parents. Parents often maintained social contact with other parents and recalled advice and supportive information from the group as needed. Participants recommended that the support group continue to assist other parents.


Assuntos
Ansiedade/psicologia , Terapia Intensiva Neonatal/psicologia , Poder Familiar/psicologia , Pais/psicologia , Alta do Paciente , Apoio Social , Estresse Psicológico/psicologia , Adaptação Psicológica , Adulto , Emoções , Feminino , Serviços de Assistência Domiciliar , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal , Oxigenoterapia , Relações Pais-Filho , Readmissão do Paciente , Pesquisa Qualitativa , Grupos de Autoajuda , Adulto Jovem
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