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1.
BMC Infect Dis ; 19(1): 914, 2019 Oct 29.
Artigo em Inglês | MEDLINE | ID: mdl-31664933

RESUMO

BACKGROUND: Programmatic data on the baseline risk of tuberculosis in people living with HIV (PLHIV) are needed to evaluate long-term effectiveness of the ongoing isoniazid preventive therapy (IPT) roll-out in India. METHODS: We estimated the incidence rate and risk factors of tuberculosis disease in adult PLHIV initiating first- and second-line anti-retroviral therapy (ART) prior to widespread IPT in a public ART center in Pune, India. RESULTS: 4067 participants contributing 5205.7 person-years of follow-up on first-line ART and 871 participants contributing 1031.7 person-years of follow-up on second-line ART were included in the analysis. The incidence rate of tuberculosis was 4.39 cases (95%CI 3.86-5.00) per 100 person-years on first-line ART and 1.64 cases (95%CI 1.01-2.63) per 100 person-years on second-line ART (p < 0.001). After adjusting for competing risks, male sex (aSHR = 1.33, 95%CI 1.02-1.74, p = 0.03), urban residence (aSHR = 1.53, 95%CI 1.13-2.07, p = 0.006) and CD4+ counts < 350 cells/mm3 (aSHR = 3.06 vs CD4 > 350 cells/mm3, 95%CI 1.58-5.94, p < 0.001) at ART initiation were associated with higher risk of tuberculosis independent of ART regimen. CONCLUSION: Risk of tuberculosis was lower in PLHIV receiving second-line ART compared to first-line ART. Prioritizing IPT in PLHIV with low CD4+ counts, urban residence and in males may further mitigate the risk of tuberculosis during ART.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Antirretrovirais/uso terapêutico , Terapia Antirretroviral de Alta Atividade , Tuberculose/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/prevenção & controle , Adolescente , Adulto , Antituberculosos/uso terapêutico , Contagem de Linfócito CD4 , Feminino , Seguimentos , Humanos , Incidência , Índia/epidemiologia , Isoniazida/uso terapêutico , Perda de Seguimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Tuberculose/prevenção & controle , População Urbana , Adulto Jovem
2.
Pediatrics ; 144(4)2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31515298

RESUMO

OBJECTIVES: To examine screening practices for autism spectrum disorder (ASD), subsequent referrals, and diagnostic outcomes within a large network of primary pediatric care practices. METHODS: Rates of ASD screening with the Modified Checklist for Autism in Toddlers (M-CHAT) at 18- and 24-month well-child visits were examined among 290 primary care providers within 54 pediatric practices between June 2014 and June 2016. Demographic, referral, and diagnostic data were abstracted from the medical records for all children who failed the M-CHAT (ie, score of ≥3) at either or both visits. RESULTS: Rates of M-CHAT screening were 93% at 18 months and 82% at 24 months. Among 23 514 screens, scores of 648 (3%) were ≥3 (386 at 18 months, 262 at 24 months) among 530 unique children who failed 1 or both screenings. Among screen-failed cases, 18% received a diagnosis of ASD and 59% received ≥1 non-ASD neurodevelopmental disorder diagnosis within the follow-up period. Only 31% of children were referred to a specialist for additional evaluation. CONCLUSIONS: High rates of ASD-specific screening do not necessarily translate to increases in subsequent referrals for ASD evaluation or ASD diagnoses. Low rates of referrals and/or lack of follow-through on referrals appear to contribute to delays in children's receipt of ASD diagnoses. Additional education of primary care providers regarding the referral process after a failed ASD screening is warranted.


Assuntos
Transtorno do Espectro Autista/diagnóstico , Lista de Checagem , Pediatria/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Fatores Etários , Transtorno do Espectro Autista/epidemiologia , Pré-Escolar , Humanos , Lactente , Perda de Seguimento , Transtornos do Neurodesenvolvimento/diagnóstico , Transtornos do Neurodesenvolvimento/epidemiologia
3.
BMC Infect Dis ; 19(1): 817, 2019 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-31533661

RESUMO

BACKGROUND: The emergence of Drug-Resistance Tuberculosis (DR-TB) is an increasing global public health problem. Lost to Follow-up (LTFU) from DR-TB treatment remains a major barrier to tuberculosis epidemic control and better treatment outcome. In Ethiopia, evidences on the incidence and predictors of LTFU are scarce. Thus, this study aimed to determine the incidence and identify the predictors of LTFU among DR-TB patients. METHODS: A retrospective follow-up study was conducted among a total of 332 DR-TB patients at the University of Gondar comprehensive specialized hospital. Data were retrieved from patient records from September 2010 to December 2017 and entered in to Epi-data 4.2.0.0 and analysed using Stata14.1 software. The risk was estimated using the Nelson-Aalen cumulative hazard curve. A log-rank test was used for survival comparisons between categories of independent variables. The Gompertz regression model was fitted, and hazard ratio with a 95% confidence interval (CI) was used to measure the strength of associations. Variables with less than 0.05 p-values in the multivariable model were considered as significantly associated with LTFU. RESULTS: Among a total of 332 patient records reviewed, 206 (62.05%) were male. The median age was 30 years (Inter Quartile Range (IQR): 23-40). Forty-one (12.35%) of the participants had no history of TB treatment, while a quarter of were TB-HIV co-infected. Closely all (92.17%) of the patients had pulmonary tuberculosis. The median follow up time was 20.37 months (IQR: 11.02, 21.80). Thirty-six (10.84%) patients were lost from follow-up with an incidence rate of 6.47 (95% CI: 4.67, 8.97)/1000 Person Months (PM). Homelessness (Adjusted Hazard Ratio (AHR) =2.51, 95%CI: 1.15, 5.45) and treatment enrolment year from 2013 to 2014 (AHR = 3.25, 95% CI: 1.30, 8.13) were significant predictors of LTFU. CONCLUSION: This study indicated that LTFU among DR-TB registered patients was high in the first six months compared to subsequent months. Homelessness and year of treatment enrolment were independent predictors of LTFU, requiring more economic support to patients in order to ensure treatment completion. This result can be generalized to patients who are using DR-TB treatment in similar settings.


Assuntos
Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Adulto , Etiópia/epidemiologia , Feminino , Hospitais Especializados , Humanos , Incidência , Perda de Seguimento , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Análise de Regressão , Estudos Retrospectivos , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Adulto Jovem
4.
BMC Infect Dis ; 19(Suppl 1): 788, 2019 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-31526372

RESUMO

BACKGROUND: Since 2001 the South African guidelines to improve child health and prevent vertical HIV transmission recommended frequent infant follow-up with HIV testing at 18 months postpartum. We sought to understand non-attendance at scheduled follow-up study visits up to 18 months, and for the 18-month infant HIV test amongst a nationally representative sample of HIV exposed uninfected (HEU) infants from a high HIV-prevalence African setting. METHODS: Secondary analysis of data drawn from a nationally representative observational cohort study (conducted during October 2012 to September 2014) of HEU infants and their primary caregivers was undertaken. Participants were eligible (N = 2650) if they were 4-8 weeks old and HEU at enrolment. All enrolled infants were followed up every 3 months up to 18 months. Each follow-up visit was scheduled to coincide with each child's routine health visit, where possible. The denominator at each time point comprised HEU infants who were alive and HIV-free at the previous visit. We assessed baseline maternal and early HIV care characteristics associated with the frequency of 'Missed visits' (MV-frequency), using a negative binomial regression model adjusting for the follow-up time in the study, and associated with missed visits at 18 months (18-month MV) using a logistic regression model. RESULTS: The proportion of eligible infants with MV was lowest at 3 months (32.7%) and 18 months (31.0%) and highest at 12 months (37.6%). HIV-positive mothers not on triple antiretroviral therapy (ART) by 6-weeks postpartum had a significantly increased occurrence rate of 'MV-frequency' (adjusted incidence rate ratio, 1.2 (95% confidence interval (CI), 1.1-1.4), p < 0.0001). Compared to those mothers with ART, these mothers also increased the risk of '18-month-MV' (adjusted odds ratio, 1.3 (CI, 1.1-1.6), p = 0.006). Unknown infant nevirapine-intake status increased the rate of 'MV-frequency' (p = 0.02). Mothers > 24 years had a significantly reduced rate of 'MV-frequency' (p ≤ 0.01) and risk of '18-month-MV' (p < 0.01) compared to younger women. Shorter travel time to health facility lowered the occurrence of 'MV-frequency' (p ≤ 0.004). CONCLUSION: Late initiation of maternal ART and infant prophylaxis under the Option- A policy and extended travel time to clinics (measured at 6 weeks postpartum), contributed to higher postnatal MV rates. Mothers older than 24 years had lower MV rates. Targeted interventions may be needed during the current PMTCT Option B+ (lifelong ART to pregnant and lactating women at HIV diagnosis) to circumvent these risk factors and reduce missed visits during HIV-care.


Assuntos
Sorodiagnóstico da AIDS , Saúde da Criança , Infecções por HIV/diagnóstico , HIV/imunologia , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Perda de Seguimento , Cuidado Pós-Natal/métodos , Adolescente , Adulto , Terapia Antirretroviral de Alta Atividade , Estudos Transversais , Feminino , Seguimentos , Infecções por HIV/tratamento farmacológico , Instalações de Saúde , Humanos , Lactente , Recém-Nascido , Lactação , Pessoa de Meia-Idade , Mães/educação , Cuidado Pós-Natal/economia , Período Pós-Parto , Gravidez , Fatores de Risco , África do Sul , Inquéritos e Questionários , Viagem , Adulto Jovem
5.
BMC Infect Dis ; 19(Suppl 1): 790, 2019 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-31526376

RESUMO

BACKGROUND: Loss to follow-up after a positive infant HIV diagnosis negates the potential benefits of robust policies recommending immediate triple antiretroviral therapy initiation in HIV positive infants. Whilst the diagnosis and follow-up of HIV positive infants in urban, specialized settings is easier to institutionalize, there is little information about access to care amongst HIV positive children diagnosed at primary health care clinic level. We sought to understand the characteristics of HIV positive children diagnosed with HIV infection at primary health care level, across all provinces of South Africa, their attendance at study-specific exit interviews and their reported uptake of HIV-related care. The latter could serve as a marker of knowledge, access or disclosure. METHODS: Secondary analysis of data gathered about HIV positive children, participating in an HIV-exposed infant national observational cohort study between October 2012 and September 2014, was undertaken. HIV infected children were identified by total nucleic acid polymerase chain reaction using standardized procedures in a nationally accredited central laboratory. Descriptive analyses were conducted on the HIV positive infant population, who were treated as a case series in this analysis. Data from interviews conducted at baseline (six-weeks post-delivery) and on study exit (the first visit following infant HIV positive diagnosis) were analysed. RESULTS: Of the 2878 HIV exposed infants identified at 6 weeks, 1803 (62.2%), 1709, 1673, 1660, 1680 and 1794 were see at 3, 6, 9, 12, 15 and 18 months respectively. In total, 101 tested HIV positive (67 at 6 weeks, and 34 postnatally). Most (76%) HIV positive infants were born to single mothers with a mean age of 26 years and an education level above grade 7 (76%). Although only 33.7% of pregnancies were planned, 83% of mothers reported receiving antiretroviral drugs to prevent MTCT. Of the 44 mothers with a documented recent CD4 cell count, the median was 346.8 cell/mm3. Four mothers (4.0%) self-reported having had TB. Only 59 (58.4%) HIV positive infants returned for an exit interview after their HIV diagnosis; there were no statistically significant differences in baseline characteristics between HIV positive infants who returned for an exit interview and those who did not. Amongst HIV positive infants who returned for an exit interview, only two HIV positive infants (3.4%) were reportedly receiving triple antiretroviral therapy (ART). If we assume that all HIV positive children who did not return for their exit interview received ART, then ART uptake amongst these HIV positive children < 18 months would be 43.6%. CONCLUSIONS: Early ART uptake amongst children aged 15 months and below was low. This raises questions about timely, early paediatric ART uptake amongst HIV positive children diagnosed in primary health care settings. Qualitative work is needed to understand low and delayed paediatric ART uptake in young children, and more work is needed to measure progress with infant ART initiation at primary care level since 2014.


Assuntos
Antirretrovirais/uso terapêutico , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , HIV/imunologia , Cuidado Pós-Natal , Atenção Primária à Saúde , Adulto , Antirretrovirais/economia , Contagem de Linfócito CD4 , Feminino , Seguimentos , Soropositividade para HIV , Custos de Cuidados de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Lactente , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Perda de Seguimento , Masculino , Mães , Gravidez , Estudos Prospectivos , Autorrelato , África do Sul , Adulto Jovem
6.
BMC Public Health ; 19(1): 1233, 2019 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-31492117

RESUMO

BACKGROUND: Follow-up studies of infants born prematurely are essential to understand the long-term consequences of preterm birth and the efficacy of interventions delivered in the neonatal period. Retention of participants for follow-up studies, however, is challenging, with attrition rates of up to 70%. Our aim was to examine retention rates in two follow-up studies of prematurely born children and identify participant or study characteristics that were associated with higher attrition, and to discuss retention strategies with regard to the literature. METHODS: Data from children recruited at birth to one of two studies of prematurely born infants were assessed. The two studies were the United Kingdom Oscillation Study (UKOS, a randomised study comparing two modes of neonatal ventilation in infants born less than 29 weeks of gestational age (GA)), and an observational study examining the impact of viral lower respiratory tract infections in infancy in those born less than 36 weeks of GA (virus study). The UKOS participants, but not those in the virus study, had regularly been contacted throughout the follow-up period. UKOS subjects were followed up at 11 to 14 years of age and subjects in the virus study at 5-7 years of age. At follow up in both studies, pulmonary function and respiratory morbidity were assessed. Retention rates to follow-up in the two studies and baseline characteristics of those who were and were not retained were assessed. RESULTS: Retention was significantly higher in UKOS than the virus study (61% versus 35%, p < 0.0001). Subjects lost to UKOS follow up had greater deprivation scores (p < 0.001), a greater likelihood of intrauterine tobacco exposure (p = 0.001) and were more likely to be of non-white ethnicity (p < 0.001). In the virus study, those lost to follow-up had higher birth weights (p = 0.036) and were less likely to be oxygen dependent at hospital discharge (p = 0.003) or be part of a multiple birth (p = 0.048). CONCLUSIONS: Higher retention was demonstrated when there was regular contact in the follow-up period. Both social factors and initial illness severity affected the retention into follow-up studies of prematurely born infants, though these factors were not consistent across the two studies.


Assuntos
Seguimentos , Recém-Nascido Prematuro , Participação do Paciente/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Recém-Nascido , Perda de Seguimento , Masculino , Reino Unido
7.
Pan Afr Med J ; 33: 32, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31384347

RESUMO

Introduction: Antiretroviral therapy (ART) is vital for people living with HIV (PLWHIV) and a substantial number of HIV/AIDS patients still face stigmatization from family and other members of the community. Stigma could lead to poor retention in HIV care and consequently result in decreased chances of survival and increased risk of HIV transmission. The aim of this study was to determine the retention of patients in HIV care and community participation in the retention of patients in HIV care at the Muyuka Health District, South-West Region, Cameroon. Methods: This was an analytic cross-sectional retrospective study where 385 hospital records of people living with HIV (PLWHIV) enrolled in HIV care were reviewed, and we administered 348 questionnaires to community members. Data were collected and analysed using bivariate analysis and chi-square test. The Susan Rifkin's scoring method was used to measure community participation. Statistical significance was set at P-value < 0.05. Results: A total number of 112(29.1%) of people living with HIV (PLWHIV) enrolled in HIV care were retained in HIV care against 273(70.9%), who were lost to follow-up over a two year and four months period. Patients on a Zidovudine containing ART regimen were about 7 times more likely to be lost to follow-up (OR 6.92; 95% CI 1.80-26.60, P-value = 0.005). The overall community participation in the retention of adults in HIV care in the Muyuka Health District was low; mean resource allocation score = 2.43, mean leadership score = 1.0; mean organization factor score = 1.30; but the mean needs assessment score was good (4.0). Conclusion: retention of patients enrolled in HIV care, and the community participation in the retention were low. Collaborations between health care structures and community initiatives should be resourced to foster continuum of care for people living with HIV (PLWHIV).


Assuntos
Fármacos Anti-HIV/administração & dosagem , Participação da Comunidade/estatística & dados numéricos , Infecções por HIV/tratamento farmacológico , Estereotipagem , Adulto , Camarões , Estudos Transversais , Feminino , Infecções por HIV/psicologia , Humanos , Perda de Seguimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estigma Social , Inquéritos e Questionários , Adulto Jovem
8.
BMC Public Health ; 19(1): 1120, 2019 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-31416432

RESUMO

BACKGROUND: Retention in care is critical for children living with HIV taking antiretroviral therapy (ART). Loss to follow-up (LTFU) is high in HIV treatment programs in resource limited settings. We estimated the cumulative incidence of LTFU and identified associated risk factors among children on ART at Livingstone Central Hospital (LCH), Zambia. METHODS: Using a retrospective cohort study design, we abstracted data from medical records of children who received ART between 2003 and 2015. Loss to follow-up was defined as no clinical and pharmacy contact for at least 90 days after the child missed their last scheduled clinical visit. Non-parametric competing risks models were used to estimate the cumulative incidence of death, LTFU and transfer. Cause-specific Cox regression was used to estimate the hazard ratios of the risk factors of LTFU. RESULTS: A total of 1039 children aged 0-15 years commenced ART at LCH between 2003 and 2015. Median duration of follow-up was 3.8 years (95% CI: 1.2-6.5), median age at ART initiation was 3.6 years (IQR: 1.3-8.6), 179 (17%) started treatment during their first year of life. At least 167 (16%) were LTFU and we traced 151 (90%). Of those we traced, 39 (26%) had died, 71 (47%) defaulted, 20 (13%) continued ART at other clinics and 21 (14%) continued treatment with gaps. The cumulative incidence of LTFU for the entire cohort was 2.7% (95% CI: 1.9-3.9) at 3 months, 4.1% (95% CI: 2.9-5.4) at 6 months and 14.1% (95% CI: 12.4-16.9) after 5 years on ART. Associated risk factors were: 1) non-disclosure of HIV status at baseline, aHR = 1.9 (1.2-2.9), 2) No phone ownership, aHR = 2.1 (1.6-2.9), 3) starting treatment between 2013 to 2015, aHR = 5.6 (2.2-14.1). CONCLUSION: Among the children LTFU mortality and default were substantially high. Children who started treatment in recent years (2013-2015) had the highest hazard of LTFU. Lack of access to a phone and non-disclosure of HIV-status to the index child was associated with higher hazards of LTFU. We recommend re-enforcement of client counselling and focused follow-up strategies using modern technology such as mobile phones as adjunct to current approaches.


Assuntos
Antirretrovirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Perda de Seguimento , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Registros Médicos , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Zâmbia/epidemiologia
9.
BMC Public Health ; 19(1): 1172, 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31455306

RESUMO

BACKGROUND: Despite an increased uptake of option B+ treatment among HIV- positive pregnant and breastfeeding women, retaining these women in care is still a major challenge. Previous studies have identified factors associated with loss to follow-up (LTFU) in HIV care, however, the perspectives from HIV-positive pregnant and breastfeeding women regarding their LTFU in option B+ needs further exploration. We explored reasons for LTFU and motivation to resume treatment among HIV-positive women initiated in option B+ in an Urban setting. METHODS: A descriptive qualitative study was conducted at three public care and treatment clinics (CTC) (Buguruni health center, Sinza hospital, and Mbagala Rangitatu health center) in Dar es Salaam, Tanzania between February and May 2017. In-depth interviews were conducted with 30 HIV-positive pregnant and breastfeeding women who were lost to follow up in the option B+ regimen. Analysis of data followed content analysis that was performed using NVivo 10 computer-assisted qualitative data analysis software. RESULTS: Eleven women were lost to follow-up and did not resume Option B+, while 19 had resumed treatment. The study indicated a struggle with long term disease amongst HIV-positive pregnant and breastfeeding women initiated in option B+ treatment. The reported reasons contributing to LTFU among these women appeared in three categories. The contribution of LTFU in the first category namely health-related factors included medication side effects and lack of disease symptoms. The second category highlighted the contribution of psychological factors such as loss of hope, fear of medication side effects and HIV-related stigma. The third category underscored the influence of socio-economic statuses such as financial constraints, lack of partner support, family conflicts, non-disclosure of HIV-positive status, and religious beliefs. Motivators to resume treatment after LTFU included support from health care providers and family members, a desire to protect the unborn child from HIV-infection and a need to maintain a healthy status. CONCLUSION: The study has highlighted the reasons for LTFU and motivation to resume treatment among women initiated in Option B+. Our results provide further evidence on the need for future interventions to focus on these factors in order to improve retention in life-long treatment.


Assuntos
Infecções por HIV/tratamento farmacológico , Perda de Seguimento , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Adulto , Aleitamento Materno , Feminino , Infecções por HIV/psicologia , Infecções por HIV/transmissão , Humanos , Lactente , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Motivação , Gravidez , Pesquisa Qualitativa , Tanzânia , Adulto Jovem
10.
BMC Health Serv Res ; 19(1): 598, 2019 Aug 23.
Artigo em Inglês | MEDLINE | ID: mdl-31443649

RESUMO

BACKGROUND: Although the prevalence of type 2 diabetes mellitus is increasing in Uganda, data on loss to follow up (LTFU) of patients in care is scanty. We aimed to estimate proportions of patients LTFU and document associated factors among patients attending a private not for profit urban diabetes clinic in Uganda. METHODS: We conducted a descriptive retrospective study between March and May 2017. We reviewed 1818 out-patient medical records of adults diagnosed with type 2 diabetes mellitus registered between July 2003 and September 2016 at St. Francis Hospital - Nsambya Diabetes clinic in Uganda. Data was extracted on: patients' registration dates, demographics, socioeconomic status, smoking, glycaemic control, type of treatment, diabetes mellitus complications and last follow-up clinic visit. LTFU was defined as missing collecting medication for six months or more from the date of last clinic visit, excluding situations of death or referral to another clinic. We used Kaplan-Meier technique to estimate time to defaulting medical care after initial registration, log-rank test to test the significance of observed differences between groups. Cox proportional hazards regression model was used to determine predictors of patients' LTFU rates in hazard ratios (HRs). RESULTS: Between July 2003 and September 2016, one thousand eight hundred eighteen patients with type 2 diabetes mellitus were followed for 4847.1 person-years. Majority of patients were female 1066/1818 (59%) and 1317/1818 (72%) had poor glycaemic control. Over the 13 years, 1690/1818 (93%) patients were LTFU, giving a LTFU rate of 34.9 patients per 100 person-years (95%CI: 33.2-36.6). LTFU was significantly higher among males, younger patients (< 45 years), smokers, patients on dual therapy, lower socioeconomic status, and those with diabetes complications like neuropathy and nephropathy. CONCLUSION: We found high proportions of patients LTFU in this diabetes clinic which warrants intervention studies targeting the identified risk factors and strengthening follow up of patients.


Assuntos
Diabetes Mellitus Tipo 2/terapia , Perda de Seguimento , Adulto , Idoso , Assistência Ambulatorial/estatística & dados numéricos , Instituições de Assistência Ambulatorial , Glicemia/metabolismo , Diabetes Mellitus Tipo 2/sangue , Feminino , Seguimentos , Hospitais Filantrópicos , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Classe Social , Uganda , Saúde da População Urbana , Adulto Jovem
11.
Int J Radiat Oncol Biol Phys ; 105(4): 752-759, 2019 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-31445956

RESUMO

PURPOSE: Stereotactic body radiation therapy for early stage non-small cell lung cancer is a standard of care for medically inoperable patients. Our aim was to compare Common Terminology Criteria for Adverse Events thoracic grade 3 or higher adverse events (AEs) of 30 Gy in 1 fraction (arm 1) versus 60 Gy in 3 fractions (arm 2). METHODS AND MATERIALS: This was a randomized multi-institutional, phase 2, 2-arm clinical trial. Medically inoperable patients with biopsy-proven peripheral T1/T2N0M0 non-small cell lung cancer were enrolled. Patients were randomized to arm 1 or arm 2 and stratified by performance status. The primary endpoint was Common Terminology Criteria for Adverse Events thoracic grade 3 or higher AEs. Secondary endpoints were local control (LC), progression-free survival (PFS), overall survival (OS), and quality of life. RESULTS: Between September 2008 and April 2015, 98 patients were randomized. Median follow-up was 53.8 months. Ten patients were lost to follow-up, 1 in arm 1 and 9 in arm 2. Thoracic grade 3 AEs were experienced by 8 (16%) patients on arm 1 and 6 (12%) patients on arm 2. There were no grade 4 or 5 AEs. There were no differences in LC, PFS, or OS (P = .68, .86, and .94, respectively). Arm 1 reported better social functioning (P = .006) with less dyspnea (P = .016) in follow-up at 6 months. CONCLUSIONS: This randomized phase 2 study demonstrated that 30 Gy in 1 fraction was equivalent to 60 Gy in 3 fractions in terms of toxicity, LC, PFS, and OS. Quality of life measures of social functioning and dyspnea favored single-fraction SBRT.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/radioterapia , Neoplasias Pulmonares/radioterapia , Radiocirurgia/métodos , Idoso , Carcinoma Pulmonar de Células não Pequenas/diagnóstico por imagem , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/patologia , Fracionamento da Dose de Radiação , Feminino , Humanos , Perda de Seguimento , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Masculino , Estadiamento de Neoplasias , Intervalo Livre de Progressão , Qualidade de Vida , Dosagem Radioterapêutica , Radioterapia Guiada por Imagem , Critérios de Avaliação de Resposta em Tumores Sólidos , Resultado do Tratamento
12.
BMC Public Health ; 19(1): 973, 2019 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-31331311

RESUMO

BACKGROUND: Gauteng Province has the second lowest tuberculosis (TB) incidence rate in South Africa but the greatest proportion of TB/HIV co-infection, with 68% of TB patients estimated to have HIV. TB treatment outcomes are well documented at the national and provincial level; however, knowledge gaps remain on how outcomes differ across detailed age groups. METHODS: Using data from South Africa's National Electronic TB Register (ETR), we assessed all-cause mortality and loss to follow-up (LTFU) among patients initiating treatment for TB between 01/2010 and 12/2015 in the metropolitan municipalities of Ekurhuleni Metropolitan Municipality and the City of Johannesburg in Gauteng Province. We excluded patients who were missing age, had known drug-resistance, or transferred into TB care from sites outside the two metropolitan municipalities. Among patients assigned a treatment outcome, we investigated the association between age group at treatment initiation and mortality or LTFU (treatment interruption of ≥2 months) within 10 months after treatment initiation using Cox proportional hazard models and present hazard ratios and Kaplan-Meier survival curves. RESULTS: We identified 182,890 children (<10 years), young adolescent (10-14), older adolescent (15-19), young adult (20-24), adult (25-49), and older adult (≥50) TB cases without known drug-resistance. ART coverage among HIV co-infected patients was highest for young adolescents (64.3%) and lowest for young adults (54.0%) compared to other age groups (all over 60%). Treatment success exceeded 80% in all age groups (n = 170,017). All-cause mortality increased with age. Compared to adults, young adults had an increased hazard of LTFU (20-24 vs 25-49 years; aHR 1.43 95% CI: 1.33, 1.54) while children, young adolescents, and older adults had lower hazard of LTFU. Patients with HIV on ART had a lower risk of LTFU, but greater risk of death when compared to patients without HIV. CONCLUSIONS: Young adults in urban areas of Gauteng Province experience a disproportionate burden of LTFU and low coverage of ART among co-infected patients. This group should be targeted for interventions aimed at improving clinical outcomes and retention in both TB and HIV care.


Assuntos
Tuberculose/terapia , Adolescente , Adulto , Criança , Cidades , Coinfecção/epidemiologia , Feminino , Infecções por HIV/epidemiologia , Humanos , Perda de Seguimento , Masculino , Pessoa de Meia-Idade , África do Sul/epidemiologia , Resultado do Tratamento , Tuberculose/epidemiologia , Adulto Jovem
13.
Pan Afr Med J ; 32: 216, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31312327

RESUMO

Introduction: African studies have reported high rates of loss to follow up (LTFU) among children in HIV care and treatment centres. Factors associated with LTFU may vary across populations. Few studies have been conducted among HIV infected children in care in rural areas of Kenya. Methods: this involved children aged less than 15 years on follow up at Kangundo Level 4 Hospital HIV clinic from January 2010 to December 2015. We obtained sociodemographic and clinical information from patient files and electronic databases. Univariate and multivariate regression analyses were conducted to identify factors predictive of LTFU. Results: a total of 261 HIV-infected children were followed up. The mean age was 10.0 years (IQR, 7-13) and median CD4 count of 582cells/ul (IQR 314-984). By December 2015, 171 children (65.5%) remained in active care, 32 (12.3%) transferred out, 13 (5%) died, while 45 (17.2%) were classified as LTFU. Out of the 45 children presumed as LTFU, we traced 44 out of the 45 children (98%) and found that their actual current status was as follows: 33 of the 44 children (75.0%) had dropped out of care (true LTFU). Factors strongly predictive of LTFU included low caregiver level of education (HR 2.3, 1.9-3.9, P = 0.001), WHO stage I and II at enrolment (HR 1.6, 1.4-2.1, P = 0.05). Conclusion: LTFU of HIV infected children was common with an incidence of 32.9 per 1000 child years and occurred early in treatment and risk factors included poverty, low caregiver education, male child and early HIV disease stage.


Assuntos
Infecções por HIV/terapia , Perda de Seguimento , Cooperação do Paciente/estatística & dados numéricos , População Rural/estatística & dados numéricos , Adolescente , Instituições de Assistência Ambulatorial , Contagem de Linfócito CD4 , Cuidadores/estatística & dados numéricos , Criança , Pré-Escolar , Estudos Transversais , Escolaridade , Feminino , Seguimentos , Infecções por HIV/epidemiologia , Humanos , Lactente , Quênia , Masculino , Pobreza , Análise de Regressão , Fatores de Risco , Fatores Sexuais
14.
Infect Dis Poverty ; 8(1): 57, 2019 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-31269994

RESUMO

BACKGROUND: Mother to child transmission of hepatitis B virus (HBV) remains the most common form of HBV infection in China. Prevention of HBV vertical transmission involves timely administration of the complete hepatitis B vaccine (HepB) series and hepatitis B immunoglobulin. Post-vaccination serological testing (PVST) is utilized to determine an infant's outcome after HBV exposure and completion of HepB series. We aim to determine the frequency of compliance with a PVST testing cascade for HBV infected mothers and analyze factors associated with infant lost to follow up (LTFU). METHODS: We conducted a retrospective cohort review of previously collected data in Fujian, Jiangxi, Zhejiang and Chongqing provinces in China from 1 June 2016-31 December 2017. The study population included all HBV-exposed infants and their mothers. SAS software was used for statistical analyses. Bivariate and multivariate regression analyses (presented in odds ratio [OR] with 95% confidence intervals [CI]) were used to compare the proportional differences of factors associated with PVST not being completed. RESULTS: Among enrolled 8474 target infants, 40% of them transferred out of the study provinces without further information and 4988 were eligible for PVST. We found 20% (994) of infants were not compliant with the testing cascade: 55% of LTFU occurred because parents refused venous blood sample collection or failure of sample collection in the field, 16% transferred out after 6 months of age, and 10% of families chose to have independent, confidential PVST completed without reporting results. High PVST noncompliance rates were more likely to be from Fujian (aOR = 17.0, 95% CI: 9.7-29.9), Zhejiang (aOR = 5.7, 95% CI: 3.2-10.1) and Jiangxi (aOR = 1.9, 95% CI: 1.0-3.4), and from HBV e antigen positive mother (aOR = 1.2, 95% CI: 1.1-1.4). CONCLUSIONS: This study found that the LTFU rate reached 20% in PVST program, which was a significant problem. We recommend implementing a national electronic information system for tracking HBV at risk mother-infant pairs; encourage further research in developing a less invasive means of completing PVST, and take effective measures nationally to reduce HBV stigma. Without reducing the loss to follow up rate among infants eligible for PVST, elimination of vertical HBV transmission will be impossible.


Assuntos
Vírus da Hepatite B/fisiologia , Hepatite B/tratamento farmacológico , Cooperação do Paciente/estatística & dados numéricos , Testes Sorológicos/estatística & dados numéricos , Vacinação/estatística & dados numéricos , China , Estudos de Coortes , Feminino , Humanos , Lactente , Recém-Nascido , Perda de Seguimento , Masculino , Estudos Retrospectivos
15.
Pan Afr Med J ; 32: 159, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31308862

RESUMO

Introduction: Focus has been put on strengthening surveillance systems in high tuberculosis (TB) burden countries, like Zambia, however inadequate information on factors associated with unfavourable TB treatment outcomes is generated from the system. We determined the proportion of tuberculosis treatment outcomes and their associated factors. Methods: We defined unfavourable outcome as death, lost-to-follow-up, treatment-failure, or not-evaluated and favourable outcome as a patient cured or completed-treatment. We purposively selected a 1st level hospital, an urban-clinic and a peri-urban clinic. We abstracted data from TB treatment registers at these three health facilities, for all TB cases on treatment from 1st January to 31st December, 2015. We calculated proportions of treatment outcomes and analysed associations between unfavourable outcome and factors such as age, HIV status, health facility, and patient type, using univariate logistics regression. We used multivariable stepwise logistic regression to control for confounding and reported the adjusted odds ratios (AOR) and 95% confidence intervals (CI). Results: We included a total of 1,724 registered TB patients, from one urban clinic 694 (40%), a 1st Level Hospital 654 (38%), and one peri-urban-clinic 276 (22%). Of the total patients, 43% had unfavourable outcomes. Of the total unfavourable outcomes, were recorded as treatment-failure (0.3%), lost-to-follow-up (5%), death (9%) and not evaluated (29%). The odds of unfavourable outcome were higher among patients > 59 years (AOR=2.9, 95%CI: 1.44-5.79), relapses (AOR=1.65, 95%CI: 1.15-2.38), patients who sought treatment at the urban clinic (AOR=1.76, 95%CI:1.27-2.42) and TB/HIV co-infected patients (AOR=1.56, 95%CI:1.11-2.19). Conclusion: Unfavourable TB treatment outcomes were high in the selected facilities. We recommend special attention to TB patients who are > 59 years old, TB relapses and TB / HIV co-infected. The national TB programme should strengthen close monitoring of health facilities in increasing efforts aimed at evaluating all the outcomes. Studies are required to identify and test interventions aimed at improving treatment outcomes.


Assuntos
Antituberculosos/uso terapêutico , Programas Nacionais de Saúde/organização & administração , Vigilância da População , Tuberculose/tratamento farmacológico , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Coinfecção/epidemiologia , Feminino , Infecções por HIV/epidemiologia , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Perda de Seguimento , Masculino , Pessoa de Meia-Idade , Falha de Tratamento , Resultado do Tratamento , Tuberculose/epidemiologia , Adulto Jovem , Zâmbia/epidemiologia
16.
PLoS Med ; 16(5): e1002811, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31150380

RESUMO

BACKGROUND: Although the success of HIV treatment programs depends on retention and viral suppression, routine program monitoring of these outcomes may be incomplete. We used data from the national electronic medical record (EMR) system in Zambia to enumerate a large and regionally representative cohort of patients on treatment. We traced a random sample with unknown outcomes (lost to follow-up) to document true care status and HIV RNA levels. METHODS AND FINDINGS: On 31 July 2015, we selected facilities from 4 provinces in 12 joint strata defined by facility type and province with probability proportional to size. In each facility, we enumerated adults with at least 1 clinical encounter after treatment initiation in the previous 24 months. From this cohort, we identified lost-to-follow-up patients (defined as 90 or more days late for their last appointment), selected a random sample, and intensively reviewed their records and traced them via phone calls and in-person visits in the community. In 1 of 4 provinces, we also collected dried blood spots (DBSs) for plasma HIV RNA testing. We used inverse probability weights to incorporate sampling outcomes into Aalen-Johansen and Cox proportional hazards regression to estimate retention and viremia. We used a bias analysis approach to correct for the known inaccuracy of plasma HIV RNA levels obtained from DBSs. From a total of 64 facilities with 165,464 adults on ART, we selected 32 facilities with 104,966 patients, of whom 17,602 (17%) were lost to follow-up: Those lost to follow-up had median age 36 years, 60% were female (N = 11,241), they had median enrollment CD4 count of 220 cells/µl, and 38% had WHO stage 1 clinical disease (N = 10,690). We traced 2,892 (16%) and found updated outcomes for 2,163 (75%): 412 (19%) had died, 836 (39%) were alive and in care at their original clinic, 457 (21%) had transferred to a new clinic, 255 (12%) were alive and out of care, and 203 (9%) were alive but we were unable to determine care status. Estimates using data from the EMR only suggested that 42.7% (95% CI 38.0%-47.1%) of new ART starters and 72.3% (95% CI 71.8%-73.0%) of all ART users were retained at 2 years. After incorporating updated data through tracing, we found that 77.3% (95% CI 70.5%-84.0%) of new initiates and 91.2% (95% CI 90.5%-91.8%) of all ART users were retained (at original clinic or transferred), indicating that routine program data underestimated retention in care markedly. In Lusaka Province, HIV RNA levels greater than or equal to 1,000 copies/ml were present in 18.1% (95% CI 14.0%-22.3%) of patients in care, 71.3% (95% CI 58.2%-84.4%) of lost patients, and 24.7% (95% CI 21.0%-29.3%). The main study limitations were imperfect response rates and the use of self-reported care status. CONCLUSIONS: In this region of Zambia, routine program data underestimated retention, and the point prevalence of unsuppressed HIV RNA was high when lost patients were accounted for. Viremia was prevalent among patients who unofficially transferred: Sustained engagement remains a challenge among HIV patients in Zambia, and targeted sampling is an effective strategy to identify such gaps in the care cascade and monitor programmatic progress.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , HIV/efeitos dos fármacos , Retenção nos Cuidados , Adulto , Registros Eletrônicos de Saúde , Feminino , HIV/genética , HIV/crescimento & desenvolvimento , Infecções por HIV/diagnóstico , Infecções por HIV/mortalidade , Humanos , Perda de Seguimento , Masculino , Adesão à Medicação , Prevalência , Avaliação de Programas e Projetos de Saúde , RNA Viral/sangue , Amostragem , Fatores de Tempo , Resultado do Tratamento , Carga Viral , Zâmbia/epidemiologia
17.
Vasc Med ; 24(4): 332-338, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31195896

RESUMO

Loss to follow-up (LTF) has been associated with worse outcomes after procedures. We sought to identify differences in lower extremity peripheral vascular intervention (PVI) patients with and without LTF, and to determine if LTF impacted survival. Patients in the PVI registry of the Vascular Quality Initiative (VQI) were included (n = 39,342), where t-test and chi-squared analysis were used to compare those with and without LTF. Multivariable logistic regression was used to identify factors associated with LTF while Cox regression analysis was applied to compare survival among those with and without LTF. The overall 1-year follow-up rate was 91.6%. LTF patients were more often male, Hispanic, of black race, and had a higher rate of diabetes, coronary artery disease, congestive heart failure, and dialysis. LTF patients had a higher prevalence of critical limb ischemia, underwent popliteal or distal intervention, and were intervened upon urgently. There was also a higher rate of postoperative complications, and a lower rate of technical success for LTF patients. After controlling for center effects, the independent variables associated with LTF included male sex, age, diabetes, dialysis dependence, ASA class 3 or greater, as well as complications requiring admission. Preoperative aspirin, preadmission home living status, prior carotid intervention, and discharge aspirin were protective against LTF. Adjusted survival analysis showed decreased survival in LTF, with those returning face-to-face surviving longer than those with phone follow-up. Efforts should be focused on understanding these differences to improve follow-up rates and help improve overall survival.


Assuntos
Perda de Seguimento , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Procedimentos Cirúrgicos Vasculares/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos
18.
Pediatr Blood Cancer ; 66(8): e27781, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31045326

RESUMO

BACKGROUND: Transition from pediatric to adult care is a period of high risk for loss to follow-up, morbidity, and mortality in adolescents and young adults (AYA) with hemoglobinopathies. The purpose of this study was to determine whether a transition program with transition navigator (TN) reduced loss to follow-up and hospitalizations and improved medication adherence and appointment attendance compared with an unstructured transfer. PROCEDURE: A retrospective observational study compared all AYA with hemoglobinopathies who turned 18 one year prior to (n = 51) and one year after (n = 61) the initiation of the transition program. Data from one year prior to last pediatric appointment and one year following first adult appointment were collected from each patient. RESULTS: The transition program with TN reduced loss to follow-up from 29% to 7% (P = 0.034). A greater proportion of patients in the transition cohort maintained or improved adherence to hydroxyurea or iron chelation to ≥4 days/week; exposure to the program was independently associated with such improvement (P = 0.047). A trend toward improvement or maintenance of ≥90% attendance to appointments was observed (P = 0.096). Frequency of hospitalization was not significantly different between the two cohorts (P = 0.985). CONCLUSIONS: A transition program with TN significantly reduced loss to follow-up, and significantly improved and maintained fair to good medication adherence. Further analysis of economic benefit and patient satisfaction will be conducted.


Assuntos
Agendamento de Consultas , Hemoglobinopatias/terapia , Perda de Seguimento , Adesão à Medicação/estatística & dados numéricos , Navegação de Pacientes/organização & administração , Transição para Assistência do Adulto/organização & administração , Transição para Assistência do Adulto/normas , Adolescente , Adulto , Criança , Feminino , Seguimentos , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Adulto Jovem
19.
J Bone Joint Surg Am ; 101(10): e44, 2019 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-31094991

RESUMO

BACKGROUND: The inclusion of low and middle-income country (LMIC) hospitals in multicenter orthopaedic trials expands the pool of eligible patients and improves the external validity of the evidence. Furthermore, promoting studies in LMIC hospitals defines the optimal treatments for low-resource settings, the conditions under which the majority of musculoskeletal injuries are treated. The objective of this study was to determine the feasibility of a randomized controlled trial comparing external fixation with intramedullary (IM) nailing in patients with an isolated open tibial fracture who presented to a regional hospital in Uganda. METHODS: From July 2016 to July 2017, skeletally mature patients who presented to a Ugandan regional hospital with an isolated Gustilo-Anderson type-II or IIIA open fracture of the tibial shaft were eligible for inclusion. The primary feasibility outcomes were the enrollment rate, the recruitment rate, and the 3 and 12-month follow-up rates. The secondary outcomes included a comparison of 3 and 12-month follow-up rates between the treatment arms and a qualitative assessment of barriers to enrollment, timely treatment, and missed follow-up. RESULTS: During the 12-month enrollment period, 37.5% (30 of 80) of eligible patients were successfully enrolled and operatively treated on the basis of their random allocation, with an enrollment rate of 2.5 patients per month. Of the 30 enrolled patients, 53% completed their 3-month follow-up appointment, and 40% completed their 1-year follow-up appointment. Rates of 1-year follow-up were significantly higher for patients receiving IM nails than for those receiving external fixation (absolute difference, 52%; 95% confidence interval [CI], 21 to 83, p < 0.01). The main reasons that patients declined to participate in the trial were preferences for treatment by traditional bonesetters and prehospital delays that were related to a disorganized referral system. Barriers to follow-up included prohibitive transportation costs and community pressure to turn to traditional forms of treatment. CONCLUSIONS: A regional hospital in Uganda can successfully enroll, randomize, and operatively treat multiple patients with an open tibial fracture each month. Patient follow-up presents substantial concerns over trial feasibility in this setting. Cultural pressure to utilize traditional treatments remains a particularly common barrier to study-participant enrollment and retention.


Assuntos
Fixação de Fratura/métodos , Fraturas Expostas/cirurgia , Fraturas da Tíbia/cirurgia , Adulto , Países em Desenvolvimento , Estudos de Viabilidade , Seguimentos , Fixação Intramedular de Fraturas , Consolidação da Fratura , Acesso aos Serviços de Saúde , Hospitais , Humanos , Perda de Seguimento , Aceitação pelo Paciente de Cuidados de Saúde , Seleção de Pacientes , Estudos Prospectivos , Resultado do Tratamento , Uganda
20.
Oncol Res Treat ; 42(6): 350-353, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30995668

RESUMO

Some chemotherapy formulations contain ethanol as a solvent which can become relevant for medical and nonmedical reasons. Only a few studies have tried to quantify the effects of ethanol in chemotherapy preparations. Furthermore, the alcohol amount highly depends on the specific formulation, with some variation among different manufacturers. Although the actual increase in blood alcohol levels after ethanol-based chemotherapies seems to be limited, the FDA recently released a warning that docetaxel may cause symptoms of alcohol intoxication. Here, we report on a patient with breast cancer who experienced a relapse of alcohol abuse after a single docetaxel infusion. We hypothesize a causal relationship with the ethanol-containing docetaxel infusion. Today, no guidelines exist for the use of ethanol-based chemotherapy, and patient consent forms do not address this matter. We conclude that physicians prescribing chemotherapy and patients should be aware of the potential risks of ethanol-containing infusions and nonethanol-based alternatives should be discussed when needed or desired by the patient. This could be facilitated by revised patient consent forms.


Assuntos
Alcoolismo/patologia , Antineoplásicos/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Docetaxel/uso terapêutico , Composição de Medicamentos , Etanol/efeitos adversos , Abstinência de Álcool , Feminino , Humanos , Perda de Seguimento , Pessoa de Meia-Idade , Pacientes Desistentes do Tratamento , Pacientes/psicologia , Médicos/psicologia , Recidiva , Resultado do Tratamento
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