Neurodevelopmental outcomes of neonatal non-epileptic paroxysmal events: a prospective study.

AIM: To report on psychomotor development and outcomes in term born neonates with non-epileptic paroxysmal events (NEPEs). METHOD: From October 2017 to March 2019 we enrolled 38 consecutive term born neonates (22 males, 16 females; aged between 0-28d), born at the University Hospital San Marco in Catania, Italy, with NEPEs. We performed the Hammersmith Neonatal Neurological Examination scale (at enrolment), the Hammersmith Infant Neurological Examination (HINE) scale (at age 3, 6, 9, and 12mo), and the Griffiths scale (at age 12mo). RESULTS: The age at onset of first paroxysmal manifestations ranged from birth to 4 days. We recorded a suboptimal global score in 18 out of 38 patients at enrolment and in 10 out of 38 patients at age 3 months (>70% of these infants were male); all events disappeared within 6 months of life. At age 6, 9, and 12 months, all infants scored within normal values on the HINE and Griffiths scale. INTERPRETATION: Patients with NEPEs achieve neurodevelopment optimal scores within their first year of life. WHAT THIS PAPER ADDS: Neonates experiencing non-epileptic paroxysmal events (NEPEs) can be examined with the Hammersmith Neonatal Neurological Examination, Hammersmith Infant Neurological Examination, and Griffiths scale at follow-up. Newborn infants with NEPEs achieve optimal scores within the first year of life.

Pyridoxine Add-On Treatment for the Control of Behavioral Adverse Effects Induced by Levetiracetam in Children: A Case-Control Prospective Study.

BACKGROUND: Few studies on adult and pediatric patients have shown pyridoxine efficacy as additional therapy for those receiving levetiracetam (LEV) to prevent and mitigate behavioral adverse effects (BAEs). OBJECTIVE: The aim of our study was to analyze the safety and efficacy of pyridoxine supplementation in the prevention of LEV adverse effects, including suicidal ideation. METHODS: This randomized, case-control trial included patients receiving LEV as monotherapy treatment. Patients were subdivided into 2 groups, according to whether they were treated with LEV only (group 1) or LEV with supplemental pyridoxine (group 2). RESULTS: In both cohorts, the most frequent BAEs were irritability/aggression followed by depression and confusion. Those patients (92%) who initiated pyridoxine after 1 month of LEV treatment did not need to change or suspend LEV ( P < 0.001), and BAE improved after 9.06 ± 3.05 days of pyridoxine supplementation. None of the patients complained of symptoms of pyridoxine toxicity, and no new adverse effects of LEV off-label were reported. CONCLUSIONS: In our study, we found pyridoxine to be safe and effective in controlling LEV-induced BAEs in children.

Human capital in the nursing management of hospitals.

OBJECTIVE: To analyze how the components of human capital are used in the nursing management of hospital organizations. METHOD: This was an exploratory and qualitative study. Data collection took place between October 2014 and May 2015 using semi-structured interviews. The data were analyzed according to content analysis. RESULTS: Twelve nurse managers participated. The components of human capital used by the nurses in personnel management were: during the hiring process, when requiring specialized education in the field and prior professional experience; when retaining talents with promotion strategies; in building capacities of professionals through support and training; and in collective work to construct processes and outcome assessment. CONCLUSION: The components of human capital need to be managed strategically with a focus on professional skills and development, with the aim of transforming individual and collective knowledge into new technology. OBJETIVO: Analisar como os componentes do capital humano são utilizados na gestão de enfermeiras em organizações hospitalares. MÉTODO: Estudo exploratório, com abordagem qualitativa. A coleta de dados ocorreu de outubro de 2014 a maio de 2015 com a utilização de entrevistas semiestruturadas. Os dados foram analisados segundo a análise de conteúdo. RESULTADOS: Participaram 12 gestoras de enfermagem. Os componentes do capital humano utilizados pelas enfermeiras na gestão de pessoas foram: no processo admissional ao utilizar como critérios para contratação a exigência de especialização na área e experiência profissional prévia; na manutenção de talentos com estratégias de promoção; na capacitação de profissionais com apoio e treinamento; e no trabalho coletivo para a construção dos processos e avaliação dos resultados. CONCLUSÃO: Os componentes do capital humano precisam ser gerenciados estrategicamente com foco nas competências e no desenvolvimento do profissional, visando transformar os conhecimentos individuais e coletivos em novas tecnologias.

Magnetic Resonance Imaging in Preterm Infant: A Systematic Review on Clinical Procedure Safety.

BACKGROUND: Currently, there is no evidence that MRI produces harmful effects on premature newborns, as well as short-term and long-term safety issues regarding radiofrequency fields and loud acoustic environment, while the examination that is being performed has not been clearly investigated. MRI of the brain conducted on preterm infants should be part of the diagnostic workup, when necessary. This article is intended to evaluate the short-term safety of MRI performed in preterm infants, when required, by analyzing all vital parameters available before, during, and after the MRI procedures. METHODS: We conducted a systematic review of the literature on electronic medical databases (PubMed and ClinicalTrials.gov) following the Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included all preterm infants who underwent MRI whose clinical, hemodynamic, and respiratory parameters were reported. The quality of the included articles was assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool. RESULTS: Six studies were included with a total of 311 preterm infants. No severe adverse event, such as death, occurred during MRI procedures. Vital signs remained stable in about two-thirds of all patients. CONCLUSIONS: Given the general clinical safety of MRI, we suggest it as a tool to be used in preterm infants in Neonatal Intensive Care Units, when necessary. We further suggest the development of standard protocols to guide the use of MRI in preterm infants to maximize the clinical safety of the procedure.

Simple febrile seizures: new cut off for the duration of the crises.

BACKGROUND: Our study aimed to identify a new cut-off for febrile seizure (FS) with a good prognosis, thereby replacing the 15 min described in the standard definition of simple febrile seizure (SFS). METHODS: Our study was a retrospective observational study (from January 2018 to December 2018) on children admitted to the Pediatric emergency room of the Santobono-Pausilipon Hospital, Naples, Italy, Pediatric Unit of Latina, Rome, Italy, and Policlinico-Vittorio-Emanuele University Hospital, Catania, Italy, for fever, which developed SFS during the hospitalization. All included patients had their seizures classified as SFS according to the international criteria for epilepsy. We assumed a duration cut-off, and we analyzed the EEG results, neurological follow-up at 12 months, and the recurrence of the febrile seizures the following year. Then, with another calculation, we identify an optimal cut-off of 6 min. Finally, we divided the population into two groups: children with seizures having a duration greater than or less than 6 min. RESULTS: We found that the population with FS with a duration greater than 6 min presented EEG alteration at follow-up visits, neurological disorders, and a recurrence of FS during the following year. CONCLUSIONS: We suggest to introduce a new cut-off for the duration of FS that better represents the benign nature of a simple febrile event.

Neurophysiological monitoring in neonatal abstinence syndrome from cocaine.

INTRODUCTION: Neonatal abstinence syndrome (NAS) in a newborn is a result of the sudden discontinuation of exposure to psychotropic drugs abused by the mother during pregnancy. Since forty decades, the standardized Finnegan Neonatal Abstinence Scoring Tool (FNAST) documents the infant withdrawal, and initiate the appropriate treatment regimen, when elevated scored are reported. Whereas FNAST is successfully applied for opioids NAS, in case of other psychotropic drugs and especially cocaine, the tool is not always efficacious or predictive. METHODS: Continuous v-Electroencephalography (vEEG) provides particularly useful information about brain cortical functioning and evaluation of background activity in normal newborns. vEEG allows to properly study and identify clinical manifestations as physiological motor paroxysms, that disappear from birth to infant age in correlation with the neurological development. Due to its feature to be a non-invasive tool continuous vEEG monitoring could be used to describe some clinical manifestations and assess if they can be correlated to possible injuries in critical neonates as those exposed in utero to psychoactive drugs presenting NAS. RESULTS: An example for the potential use of such methodology is discussed in a case of NAS due to prenatal exposure to cocaine as a complementary tool for the evaluation of behavioural state and clinical and neurological signs in newborns in utero exposed to psychoactive drugs, excluding epileptic phenomena. DISCUSSION: Video-EEG recording could be considered an important and objective tool that allows the evaluation of behavioural state and clinical and neurological signs in newborns in utero exposed to psychoactive drugs and the neurophysiological definition of signs and symptoms, which cannot be evaluated by FNAST such as startles and its variability during subsequent days after birth, subclinical seizures or brain injuries.

Oxidative Stress in Preterm Infants: Overview of Current Evidence and Future Prospects.

Preterm birth (PTB), defined as parturition prior to 37 weeks of gestation, is the leading cause of morbidity and mortality in the neonatal population. The incidence and severity of complications of prematurity increase with decreasing gestational age and birthweight. The aim of this review study is to select the most current evidence on the role of oxidative stress in the onset of preterm complication prevention strategies and treatment options with pre-clinical and clinical trials. We also provide a literature review of primary and secondary studies on the role of oxidative stress in preterm infants and its eventual treatment in prematurity diseases. We conducted a systematic literature search of the Medline (Pubmed), Scholar, and ClinicalTrials.gov databases, retroactively, over a 7-year period. From an initial 777 articles identified, 25 articles were identified that met the inclusion and exclusion criteria. Of these, there were 11 literature reviews: one prospective cohort study, one experimental study, three case-control studies, three pre-clinical trials, and six clinical trials. Several biomarkers were identified as particularly promising, such as the products of the peroxidation of polyunsaturated fatty acids, those of the oxidation of phenylalanine, and the hydroxyl radicals that can attack the DNA chain. Among the most promising drugs, there are those for the prevention of neurological damage, such as melatonin, retinoid lactoferrin, and vitamin E. The microbiome also has an important role in oxidative stress. In conclusion, the most recent studies show that a strong relationship between oxidative stress and prematurity exists and that, unfortunately, there is still little therapeutic evidence reported in the literature.

Intronic Variant in CNTNAP2 Gene in a Boy With Remarkable Conduct Disorder, Minor Facial Features, Mild Intellectual Disability, and Seizures.

Introduction: Mutations in the contactin-associated protein-like 2 (CNTNAP2) gene (MIM#604569) encoding for CASPR2, a cell adhesion protein of the neurexin family, are known to be associated with autism, intellectual disability, and other neuropsychiatric disorders. A set of intronic deletions of CNTNAP2 gene has also been suggested to have a causative role in individuals with a wide phenotypic spectrum, including Pitt-Hopkins syndrome, cortical dysplasia-focal epilepsy syndrome, Tourette syndrome, language dysfunction, and abnormal behavioral manifestations. Case presentation: A 10-years-old boy was referred to the hospital with mild intellectual disability and language impairment. Moreover, the child exhibited minor facial features, epileptic seizures, and notable behavioral abnormalities including impulsivity, aggressivity, and hyperactivity suggestive of the diagnosis of disruptive, impulse-control and conduct disorder (CD). Array comparative genomic hybridization (CGH) revealed a copy number variant (CNV) deletion in the first intron of CNTNAP2 gene inherited from a healthy father. Conclusions: A comprehensive description of the phenotypic features of the child is provided, revealing a distinct and remarkable alteration of social behavior not previously reported in individuals affected by disorders related to CNTNAP2 gene disruptions. A possible causative link between the deletion of a non-coding regulatory region and the symptoms presented by the boy has been advanced.

Chromosome 15q BP3 to BP5 deletion is a likely locus for speech delay and language impairment: Report on a four-member family and an unrelated boy.

BACKGROUND: Deletions in chromosome 15q13 have been reported both in healthy people and individuals with a wide range of behavioral and neuropsychiatric disturbances. Six main breakpoint (BP) subregions (BP1-BP6) are mapped to the 15q13 region and three further embedded BP regions (BP3-BP5). The deletion at BP4-BP5 is the rearrangement most frequently observed compared to other known deletions in BP3-BP5 and BP3-BP4 regions. Deletions of each of these three regions have previously been implicated in a variable range of clinical phenotypes, including minor dysmorphism, developmental delay/intellectual disability, epilepsy, autism spectrum disorders, behavioral disturbances, and speech disorders. Of note, no overt clinical difference among each group of BP region deletions has been recorded so far. METHODS: We report on a four-member family plus an additional unrelated boy affected by a BP3-BP5 deletion that presented with typical clinical signs including speech delay and language impairment. A review of the clinical features associated with the three main groups of BP regions (BP4-BP5, BP3-BP5, and BP3-BP4) deletions is reported. RESULTS: Array-CGH analysis revealed in the mother (case 1) and in her three children (cases 2, 3, and 4), as well as in the unrelated boy (case 5), the following rearrangement: arr (hg19) 15q13.1-q13.3 (29.213.402-32.510.863) x1. CONCLUSION: This report, along with other recent observations, suggests the hypothesis that the BP region comprised between BP3 and BP5 in chromosome 15q13 is involved in several brain human dysfunctions, including impairment of the language development and, its deletion, may be directly or indirectly responsible for the speech delay and language deficit in the affected individuals.

Tele-monitoring in paediatric and young home-ventilated neuromuscular patients: A multicentre case-control trial.

INTRODUCTION: Tele-monitoring (TM) has proved effective in the home management of adult ventilator-dependent neuromuscular disease (NMD) patients. We aimed to evaluate a 2-year longitudinal multicentre TM trial designed for young ventilated NMD patients in terms of feasibility, home management of exacerbations and caregivers' burden. METHODS: The TM trial protocol included patients' weekly scheduled overnight home-recording of SpO2, heart rate and ventilation and their transmission to each TM centre the following morning. Overnight data were reviewed by non-physicians and calls to families made to assess clinical condition. If clinical conditions (assessed by a scoring system) or overnight parameters worsened, either unscheduled transmissions or calls were activated and managed by non-physicians or medical team according to severity. Hospitalisations were compared with those of TM patients prior to TM start and with those of age-disease-severity-matched controls. Scores from the Caregiver Burden Inventory (CBI) questionnaire pre- and post-TM were compared. RESULTS: Forty-eight patients were enrolled, 30 males, median age 16.4 years (interquartile range (IQR) 8.9-22.1), median ventilation/day 10.5 h (IQR 8-16). Exacerbations in TM patients did not differ (59 versus 53; p = 0.15) from controls. Hospitalisations were significantly reduced in TM patients when compared with those prior to TM (11 versus 24, p = 0.04) and to controls (11 versus 21, p = 0.03). Median hospitalisation length was significantly lower in TM patients than controls (6 versus 7 days, p = 0.03). Caregivers satisfaction was excellent whereas no significant changes in CBI were seen (32.5 versus 35.5, p = 0.06). DISCUSSION: TM was effective in improving the home management of respiratory exacerbations in young ventilated NMD patients and overall well tolerated.

Child and adolescent violence: oral story of women who attempted suicide.

OBJECTIVE: To unveil expressions of intrafamily violence experienced in childhood and/or adolescence by women who attempted suicide. METHOD: This is a study with a qualitative approach based on Oral Story. Participants were ten women with a history of suicide attempt, who experienced intrafamily violence in childhood and/or adolescence. The research was carried out at the Center for the Study and Prevention of Suicide, linked to a Toxicological Information Center in the city of Salvador, Bahia, Brazil. RESULTS: From the orality of women, the study allowed the emergence of the following representative categories of intrafamily abuse experienced in childhood and/or adolescence: psychological violence, rejection, neglect, physical violence and sexual violence. FINAL CONSIDERATIONS: The study alerts to intrafamily violence as an aggravation related to suicidal behavior, offering elements that help in the identification of their expressions, which will raise awareness to suicidal behavior and consequently suicide prevention.

Electrocardiographic Evaluation in Patients With Spinal Muscular Atrophy: A Case-Control Study.

BACKGROUND: This study aimed to show the impairment of autonomic cardiac conduction causing bradycardia and/or electrocardiographic alterations in children affected by spinal muscular atrophy type 1 and 2 (SMA 1 and 2). METHODS: We included 25 spinal muscular atrophy patients, admitted from November 2016 to May 2017. All patients underwent an electrocardiographic examination and we studied PR and QRS intervals, P-waves and QRS amplitudes, and heart rate in spinal muscular atrophy patients compared to a control group. RESULTS: In all patients, we found longer PRi and QRSi ( P < .05), lower P-wave and QRS complex amplitudes ( P < .01), and a decreased heart rate ( P < .01) with respect to controls. When we divided our patients into SMA1 and SMA2 subgroups, we found that statistical differences were maintained for P-wave and QRS complex amplitudes and heart rate, but not for PRi and QRSi with respect to controls. CONCLUSION: We suggest the hypothesis of SMN expression on cardiac tissue condition and/or autonomic cardiac conduction.

Spinal motor neuron involvement in a patient with homozygous PRUNE mutation.

In the last few years, whole exome sequencing (WES) allowed the identification of PRUNE mutations in patients featuring a complex neurological phenotype characterized by severe neurodevelopmental delay, microcephaly, epilepsy, optic atrophy, and brain or cerebellar atrophy. We describe an additional patient with homozygous PRUNE mutation who presented with spinal muscular atrophy phenotype, in addition to the already known brain developmental disorder. This novel feature expands the clinical consequences of PRUNE mutations and allow to converge PRUNE syndrome with previous descriptions of neurodevelopmental/neurodegenerative disorders linked to altered microtubule dynamics.

Pediatric Autoimmune Encephalitis.

Autoimmune (antibody mediated) encephalitis (AE) is emerging as a more common cause of pediatric encephalopathy than previously thought. The autoimmune process may be triggered by an infection, vaccine, or occult neoplasm. In the latter case, onconeural autoantibodies are directed against intracellular neuronal antigens, but a recent heterogeneous group of encephalitic syndromes has been found not to have underlying tumor but is associated with autoantibodies to the neuronal surface or synaptic antigens. Neuropsychiatric symptoms are very common in autoimmune encephalopathy; as a result, affected children may be initially present to psychiatrists. Neurological features are movement disorders, seizures, altered conscious level, and cognitive regression. Hypoventilation and autonomic features may be an aspect. Inflammatory findings in the cerebrospinal fluid may be present but are relatively nonspecific. Magnetic resonance imaging (MRI) may also demonstrate abnormalities that provide clues for diagnosis, particularly on fluid-attenuated inversion recovery or T2-weighted images. AE is well responsive to immune therapy, with prompt diagnosis and treatment strongly beneficial. Patients with paraneoplastic encephalitis are more refractory to treatment compared to those in whom no malignancy is identified. Herein, the authors present an update of literature data on the clinical presentation, laboratory and imaging findings, therapy, and outcomes for the most common autoimmune encephalitides.

The Gut-brain Axis: A New Pathogenic View of Neurologic Symptoms - Description of a Pediatric Case.

Recent literature data have given emphasis to the relationship between gastrointestinal (GI) disorders and neurologic diseases, underlying a new pathogenic pathway: The so-called "gut-brain axis." Herein, authors report a case of a 10-month-old male infant, admitted for drug-resistant epilepsy, associated with irritable behavior and GI discomfort, secondary to cow's milk protein allergy. Seizures were described by parents as upward eye movements that were mostly deviated to the right and were associated with slight extension of his neck. They were infrequent at first, but had increased gradually during the course of 3 days (up to 15-20 times/day). No anticonvulsant therapy was effective. Only a cow's milk protein-free diet, accidentally started during a gastroenteritis episode, was effective in stopping seizures. Our case underlines the peculiar vulnerability of the blood-brain barrier under 1 year of age, for which children of this age group experience neurologic manifestations during episodes of systemic inflammation.

Biological Drugs in Guillain-Barré Syndrome: An Update.

BACKGROUND: Guillain-Barré Syndrome (GBS) is currently considered the most common global cause of acute flaccid paralysis. Currently, standard therapy for Guillain-Barré Syndrome includes intravenous immunoglobulin or plasma exchange. Despite medical advances regarding these treatments, many treated patients do not reach full recovery. Therefore several biological agents have attracted the attentions from researchers during the last decades, and various studies have investigated their role in Guillain-Barré Syndrome. OBJECTIVE: The present study aims to address emerging biological approaches to GBS while considering their efficiency and safety in treating the disease. MATERIALS AND METHODS: An extensive electronic literature search was conducted by two researchers from April 2016 to July 2016. Original articles, clinical trials, systematic reviews (with or without meta-analysis) and case reports were selected. Titles and abstracts of papers were screened by reviewers to determine whether they met the eligibility criteria, and full texts of the selected articles were retrieved. RESULTS: Herein authors focused on the literature data concerning emerging biological therapeutic agents, namely anti-C5 monoclonal antibody (Eculizumab), anti-C1q monoclonal antibody, anti-T cell monoclonal antibody, anti-CD2 monoclonal antibody, anti L-selectin monoclonal antibody, anti- CD20 monoclonal antibody (Rituximab), anti-CD52 monoclonal antibody (Alemtuzumab) and cytokine targets. By far, none of these agents have been approved for the treatment of GBS by FDA. CONCLUSION: Literature findings represented in current review herald promising results for using these biological targets. Current review represents a summary of what is already in regards and what progress is required to improve the immunotherapeutic approach of treating GBS via future studies.

Levetiracetam in Neonatal Seizures as First-line Treatment: A Prospective Study.

AIM OF THE STUDY: The aim of this study is to evaluate the efficacy and safety of levetiracetam (LEV) as first-line treatment of neonatal seizures. MATERIALS AND METHODS: This study was conducted in patients of Neonatal Intensive Care Unit of Santo Bambino Hospital, University of Catania, Italy, from January to August 2016. A total of 16 neonates with convulsions not associated with major syndromes, which required anticonvulsant therapy, were included and underwent IV LEV at standard doses. RESULTS: All patients responded to treatment, with a variety range of seizure resolution period (from 24 h to 15 days; mean hours: 96 ± 110.95). No patient required a second anticonvulsant therapy. Regarding safety of LEV, no major side-effects were observed. CONCLUSIONS: To our knowledge, it is one of the few studies confirming the efficiency of LEV as first-line treatment in seizures of this age group. LEV was effective in resolving seizures and was safely administered in the current study.

Condições que interferem no cuidado às mulheres em situação de violência conjugal / Condiciones que interfieren en la atención de mujeres en situación de violencia conjugal / Conditions that interfere in the care of women in situation of conjugal violence

Resumo Objetivo conhecer as condições que interferem no cuidado às mulheres em situação de violência conjugal. Métodos estudo qualitativo ancorado na Teoria Fundamentada nos Dados. Foram realizadas entrevistas, entre fevereiro e dezembro de 2019, com 31 profissionais de saúde atuantes em Unidades de Saúde da Família de um município do Nordeste brasileiro, as quais integraram um dos dois grupos amostrais (profissionais da Estratégia de Saúde da Família e Núcleo de Apoio à Saúde da Família). Resultados os elementos que interferem no cuidado à mulher em situação de violência conjugal foram representados nas categorias: Entendendo a importância da atuação profissional organizada; Reconhecendo a necessidade de preparo profissional para enfrentamento da violência conjugal; Percebendo a essencialidade do fluxo de atendimento intersetorial. Considerações finais e impactos para a prática o estudo revelou que o cuidado à mulher em situação de violência conjugal perpassa pelo preparo profissional, pela organização dos serviços de saúde e um fluxo de atendimento articulado e intersetorial. Nesse sentido, oferece subsídios que podem orientar gestores para a elaboração ações de identificação e enfrentamento da violência conjugal contra a mulher, pautadas na coparticipação e corresponsabilização das trabalhadoras da Estratégia de Saúde da Família, com fins em melhorias na assistência ofertada.

Resumen Objetivo conocer las condiciones que interfieren en el cuidado de las mujeres en situaciones de violencia conyugal. Métodos estudio cualitativo basado en la Teoría Fundamentada en los Datos. Las entrevistas se realizaron entre febrero y diciembre de 2019 con 31 profesionales de la salud que laboran en Unidades de Salud de la Familia en un municipio del noreste de Brasil, quienes formaron parte de uno de los dos grupos de la muestra (profesionales del Centro de Estrategia de Salud de la Familia y Apoyo a la Salud de la Familia). Resultados los elementos que interfieren en el cuidado de la mujer en situación de violencia intrafamiliar fueron representados en las categorías: Comprensión de la importancia de la práctica profesional organizada; Reconociendo la necesidad de preparación profesional para enfrentar la violencia doméstica; Darse cuenta de la esencialidad del flujo de atención intersectorial. Consideraciones finales e impactos para la práctica el estudio reveló que la atención a la mujer en situación de violencia conyugal permea la preparación profesional, la organización de los servicios de salud y un flujo de atención articulado e intersectorial. En este sentido, ofrece subsidios que pueden orientar a los gestores a desarrollar acciones de identificación y enfrentamiento de la violencia conyugal contra las mujeres, basadas en la coparticipación y corresponsabilidad de los trabajadores en la Estrategia de Salud de la Familia, con el objetivo de mejorar la atención brindada.

Abstract Objective to know the conditions that interfere in the care of women in situation of marital violence. Methods a qualitative study anchored in Grounded Theory. Interviews were conducted, between February and December 2019, with 31 health professionals working in Family Health Units of a municipality in Northeastern Brazil, which integrated one of the two sample groups (professionals of the Family Health Strategy and Family Health Support Center). Results the elements that interfere in the care of women in situations of marital violence were represented in the categories: Understanding the importance of organized professional action; Recognizing the need for professional preparation to deal with marital violence; Realizing the essentiality of the flow of intersectoral care. Final considerations and impacts for practice the study revealed that the care for women in situations of marital violence goes through the professional preparation, the organization of health services and a flow of articulated and intersectoral care. In this sense, it offers subsidies that can guide managers to develop actions to identify and address marital violence against women, based on the co-participation and co-responsibility of the workers of the Family Health Strategy, in order to improve the assistance offered.

Unveiling the strategies used by women for confronting marital violence / Revelar las estrategias que utilizan las mujeres para enfrentar la violencia conyugal / Desvelando as estratégias de enfrentamento da violência conjugal utilizadas por mulheres

ABSTRACT Objective: to unveil the strategies used by women for confronting marital violence. Method: a qualitative research using the Straussian orientation of the Data Grounded Theory as a theoretical-methodological framework and two Justice Courts for Peace at Home as its scenario. Data was collected through individual interviews and analyzed in the coding process in three interdependent stages: open, axial and selective coding. Results: to elucidate the "Strategy" component, the following categories emerged: Finding support in family; Being part of groups of women in situations of violence; and Experiencing legal-police support. Conclusion: given the difficulty women find in breaking with a relationship permeated by violence, it is urgent that the professionals in various areas of care for women be prepared not only to recognize the problem but also to guide them as to the prominence of these resources for exiting from violence situation process and perhaps enable access to these one.

RESUMEN Objetivo: revelar las estrategias que utilizan las mujeres para hacer frente a la violencia conyugal. Método: investigación cualitativa en la que se utilizó la vertiente Straussiana de la Teoría Fundamentada en los Datos como referencial teórico-metodológico y que tuvo escenario dos Tribunales de Justicia para la Paz en el Hogar. Los datos se recolectaron por medio de entrevistas individuales y se los analizó en el proceso de codificación en tres etapas independientes: codificación abierta, axial y selectiva. Resultados: para elucidar el componente "Estrategia", surgieron las siguientes categorías: Encontrar apoyo en la familia; Integrarse a grupos de mujeres en situación de violencia y Recurrir al apoyo jurídico-policial. Conclusión: frente a la dificultad que tienen las mujeres en salir de una relación permeada por la violencia, urge que los profesionales de las diversas áreas de atención a las mujeres estén preparados no solo para reconocer la agresión sino también para orientarlas en cuanto a la prominencia de esos recursos para el proceso de salir de esa situación y, quizás, viabilizarles el acceso a dichos recursos.

RESUMO Objetivo: desvelar as estratégias de enfrentamento da violência conjugal utilizadas por mulheres. Método: pesquisa qualitativa que se utilizou da vertente Straussiana da Teoria Fundamentada nos Dados como referencial teórico-metodológico e que teve como cenário duas Varas de Justiça pela Paz em Casa. Os dados foram coletados por meio de entrevistas individuais e analisados no processo de codificação em três etapas interdependentes: codificação aberta, axial e seletiva. Resultados: para a elucidação do componente "Estratégia", emergiram as seguintes categorias: Encontrando apoio na família; Inserindo-se em grupos de mulheres em situação de violência; e Experienciando o suporte jurídico-policial. Conclusão: diante da dificuldade feminina em romper com a relação permeada pela violência, urge que os profissionais das diversas áreas de atendimento a mulheres estejam preparados não apenas para reconhecer o agravo como também para orientá-las quanto à saliência desses recursos para o processo de saída desta situação e quiçá viabilizar o acesso a estes.

The Client Capital in Nursing Management in Hospitals / El capital del cliente en la Gestión de Enfermería en Hospitales / O Capital do Cliente na Gestão de Enfermagem em Hospitais

Abstract Objective: To analyze how the components of the client's capital are used in the management of nursing in hospitals. Method: A qualitative research carried out in five public hospitals, four private hospitals and three philanthropic hospitals in the period from October 2014 to May 2015. Data were collected through a semi-structured interview with twelve nursing managers and analyzed according to content analysis. Results: The components of the Client's Capital were used by the nurses when performing the management of the client service to promote changes and improve the service after evaluating the satisfaction of the nursing care through active systematic search, with its own evaluation tools and the ombudsman's information and in the interaction with suppliers of materials, equipment and services. Conclusion and implications for practice: The managers use managerial actions for the development of the client's capital of organizations. In order to improve them, they must evaluate the nursing care in a continuous and strategic process to satisfy the clients, throughout their trajectory in the organization, since clients are permanent sources of innovation that affect professional and organizational development and productivity.

Resumen Objetivo: Analizar cómo se utilizan los componentes de capital del cliente en la gestión de enfermería hospitalaria. Método: Investigación cualitativa, realizada en cuatro hospitales privados, cinco hospitales públicos y tres hospitales filantrópicos, de octubre de 2014 a mayo de 2015. Los datos fueron recolectados a través de entrevista semiestructurada con 12 gestoras de enfermería y analizados según el análisis de contenido. Resultados: Los componentes del Capital del Cliente fueron utilizados por las enfermeras al realizar la gestión de la atención al cliente para promover cambios y mejorar el servicio después de realizar la evaluación de la satisfacción de la atención de enfermería a través de búsqueda activa, sistemática, con instrumentos de evaluación propios e informaciones de la Oidoría y en la interacción con proveedores de materiales, equipos y servicios. Conclusión e implicaciones para la práctica: Las gestoras utilizan acciones gerenciales para el desarrollo del capital del cliente de las organizaciones. Para perfeccionarlas, deben evaluar la atención de enfermería en proceso continuo y estratégico para satisfacer a los clientes durante toda su trayectoria en la organización, una vez que los clientes son fuentes permanentes de innovación que generan impacto en el desarrollo y productividad profesional y organizacional.

Resumo Objetivo: Analisar como os componentes do capital do cliente são utilizados na gestão da enfermagem em hospitais. Método: Pesquisa qualitativa, realizada em quatro hospitais privados, cinco hospitais públicos e três hospitais filantrópicos, de outubro de 2014 a maio de 2015. Os dados foram coletados através de entrevista semiestruturada com 12 gestoras de enfermagem e analisados segundo a análise de conteúdo. Resultados: Os componentes do Capital do Cliente foram utilizados pelas enfermeiras ao realizar a gestão do atendimento ao cliente para promover mudanças e aprimorar o serviço após realizar a avaliação da satisfação do atendimento de enfermagem através de busca ativa, sistemática, com instrumentos de avaliação próprios e informações da Ouvidoria e na interação com fornecedores de materiais, equipamentos e serviços. Conclusão e implicação para a prática: As gestoras utilizam ações gerenciais para o desenvolvimento do capital do cliente das organizações. Para aperfeiçoá-las, devem avaliar o atendimento de enfermagem em processo contínuo e estratégico para satisfazer os clientes, durante toda a sua trajetória na organização, uma vez que clientes são fontes permanentes de inovação que geram impacto no desenvolvimento e produtividade profissional e organizacional.