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O objetivo deste estudo foi refletir sobre os efeitos da não adesão ao tratamento para a equipe de saúde e sobre as ações/reações da equipe que podem causar a não adesão ao tratamento. A amostra foi composta por 10 profissionais de saúde. O instrumento de coleta de dados foi uma entrevista semiestruturada. O material coletado foi submetido à análise temática, e discussão foi baseada na psicanálise. Como resultado, verificou-se que os profissionais relacionaram a não adesão às carências percebidas nos pacientes. Também foi identificada a presença de um ciclo de encaminhamentos, o qual, por vezes, significava uma tentativa de eliminar um incômodo (a não adesão), mas, em contrapartida, o causava. Verificou-se também a presença de confusão entre cuidado e controle, produzindo relações permeadas por desconfiança, verificação e correção. Percebeu-se, ainda, relação entre não adesão e frustração, seja porque o tratamento é insuficiente para evitar o sofrimento do paciente, seja pelo desconforto advindo da não cooperação do paciente. Ao final, como efeitos para a equipe, evidenciou-se a presença de profissionais envolvidos por um discurso de frustração, desvalorização e impotência. Como efeitos da equipe, verificou-se que profissionais também podem produzir aquilo de que se queixam, pelos lugares subjetivos que delineiam e cristalizam. A partir disso, problematiza-se o sentido que a não adesão pode assumir, e é importante considerá-la como um sinal que pode revelar os percalços (e as possíveis resoluções) do contrato relacional entre paciente e equipe.(AU)

The objective of this study was to reflect about the effects of non-adherence to the treatment for the health team and about the actions/reactions of the team that may can cause the non-adherence to the treatment. The sample consisted of 10 health professionals. The data collection instrument was a semi-structured interview. The material collected was submitted to thematic analysis, and the discussion was based on psychoanalysis. As a result, it was verified that the professionals related non-adherence to needs perceived on patients. The presence of a referral cycle was also identified, which, sometimes, meant an attempt to eliminate a nuisance (the non-adherence) but, instead, caused it. It was also verified the presence of confusion between care and control, producing relations permeated by distrust, verification, and correction. The link between non-adherence and frustration was also observed, either due to the treatment being insufficient to avoid the suffering of the patient; or by the discomfort from the non-cooperation of the patient. At the end, as effects for the team, professionals involved by a discourse of frustration, devaluation, and impotence were evidenced. As effects of the team, it has been found that professionals can also produce what they complain about, by the subjective places that were delineate and crystallize. Thus, we problematize the meaning non-adherence may assume, and considering it a signal that can reveal the mishaps (and possible resolutions) of the relational contract between patient and team is important.(AU)

El objetivo de este estudio fue reflexionar sobre los efectos de la no adherencia al tratamiento para el equipo de salud y sobre las acciones/reacciones del equipo que pueden causar la no adherencia al tratamiento. La muestra estuvo conformada por diez profesionales de la salud. El instrumento de recolección de datos fue una entrevista semiestructurada. El material recolectado fue sometido a análisis temático, y se utilizó el psicoanálisis para discutir el material. El resultado constató que los profesionales entendieron la no adherencia como una carencia/necesidad de los pacientes. También se identificó la presencia de un ciclo de derivación, que a veces significó un intento de eliminar una molestia (falta de adherencia), pero que puede generar el problema. También se verificó la presencia de confusión entre cuidado y control, produciendo relaciones permeadas de desconfianza, verificación y corrección. También se observó el vínculo entre la no adherencia y la frustración, ya sea porque el tratamiento es insuficiente para evitar el sufrimiento del paciente o por la incomodidad que produce la falta de cooperación del paciente. Al final, como efectos para el equipo, se evidenciaron profesionales envueltos por la frustración, la devaluación y la impotencia. Como efectos del equipo, se constató que los profesionales también pueden producir lo que quejan desde los lugares subjetivos que fueron delineados y cristalizados. Así se discute el sentido que puede asumir la no adherencia, y es importante considerarla como señal de los percances (y posibles resoluciones) del contrato relacional entre paciente y equipo.(AU)

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SUMMARY OBJECTIVE: A significant problem that compels clinicians in the conventional treatment of hypoparathyroidism is patients' non-adherence to treatment. This study aimed to evaluate the effects of adequate Ca intake with dietary recommendations among hypoparathyroidism patients who persistently use Ca supplementation irregularly on plasma Ca and phosphate levels. METHODS: This prospective, randomized, controlled study was conducted on patients diagnosed with chronic hypoparathyroidism who persistently interrupt Ca supplementation therapy and therefore have a hypocalcemic course. Patients with a total daily Ca intake below 800 mg were randomized. All patients were advised to keep the doses of active vitamin D and Ca supplements they were currently using. The patients in the study group (n=32) were advised to consume 1,000-1,200 mg of Ca daily, and the patients in the control group (n=35) were advised to continue their diet according to their daily habits. After 12 weeks of follow-up, the patients' laboratory values were compared between groups to assess treatment goals. RESULTS: The mean of the total Ca level was 8.56±0.36 mg/dL in the study group and was found to be significantly higher than that in the control group, which was 7.67±0.48 mg/dL (p<0.001). The mean serum phosphate and serum Ca-P product levels were significantly higher in the study group (p<0.001) but did not exceed the safe upper limits in any patient. CONCLUSION: A suitable increase in dietary Ca intake could effectively control hypocalcemia in patients with hypoparathyroidism who persistently interrupt the recommended calcium supplementation.

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Introducción: La histoplasmosis diseminada es la forma de presentación más frecuente de esta micosis endémica en pacientes de sida. La esplenomegalia consecuente es muy frecuente, pero generalmente no es masiva. Objetivo: Describir un caso no frecuente de esplenomegalia masiva por histoplasmosis diseminada en un paciente de sida. Caso clínico: Se presenta el caso de un paciente de sida diagnosticado hacía 14 años. Desde entonces cumplió tratamiento antirretroviral en forma irregular. Tuvo un primer evento de esta micosis 10 años atrás. En esa ocasión, tuvo tratamiento antimicótico por 4 meses sin continuar con profilaxis secundaria. Inició con síntomas sugestivos de reactivación de la enfermedad 6 meses después. Se mantuvo sintomático en forma recurrente por todos esos años y acudió en fecha actual en estadio avanzado con linfadenopatías grandes y hepatoesplenomegalia masiva. Se confirmó el diagnóstico mediante biopsia ganglionar y se impuso tratamiento antimicótico, con lo cual los síntomas desaparecieron y hubo una reducción ostensible de los órganos que estaban aumentados de tamaño. Conclusión: La esplenomegalia masiva puede presentarse en esta enfermedad. En este caso debe haber sido originada por el largo periodo de reactivación, a su vez determinado por el estado de inmunodepresión oscilante, ya muy avanzado en el momento de su presentación, por la irregularidad del tratamiento antirretroviral y la falta de profilaxis secundaria de la micosis(AU)

Introduction: Disseminated histoplasmosis is the most frequent form of presentation of this endemic mycosis in AIDS patients. Splenomegaly commonly occurs as a consequence of it, but it is not usually massive. Objective: To describe an uncommon case of massive splenomegaly caused by disseminated histoplasmosis in an AIDS patient. Clinical case: The case of an AIDS patient diagnosed 14 years ago is presented. Since diagnosis, the patient has been under antiretroviral treatment irregularly. The first event of this mycosis was 10 years ago. In that occasion, antimitotic treatment was prescribed for four months without secondary prophylaxis. Six months later, symptoms suggestive of reactivation of the disease started. The patient remained symptomatic on a recurrent basis over these years, and attended recently to the hospital in an advanced stage of the disease with large lymphadenopathies and massive hepatosplenomegaly. Diagnostic was confirmed by node biopsy, and antimycotic treatment was indicated, resulting in the resolution of the symptoms and an evident reduction of the enlarged organs. Conclusions: Massive splenomegaly can be present in this disease. In this case, it should have been originated due to a long reactivation period which was determined by the varying and advanced immunosuppressed state, the irregularity with the antiretroviral treatment, and the lack of secondary prophylaxis for the mycosis(AU)

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Humans have been using fire for hundreds of millennia, creating an ancestral expansion toward the nocturnal niche. The new adaptive challenges faced at night were recurrent enough to amplify existing psychological variation in our species. Night-time is dangerous and mysterious, so it selects for individuals with higher tendencies for paranoia, risk-taking, and sociability (because of security in numbers). During night-time, individuals are generally tired and show decreased self-control and increased impulsive behaviors. The lower visibility during night-time favors the partial concealment of identity and opens more opportunities for disinhibition of self-interested behaviors. Indeed, individuals with an evening-oriented chronotype are more paranoid, risk-taking, extraverted, impulsive, promiscuous, and have higher antisocial personality traits. However, under some circumstances, such as respiratory pandemics, the psychobehavioral traits favored by the nocturnal niche might be counter-productive, increasing contagion rates of a disease that can evade the behavioral immune system because its disease cues are often nonexistent or mild. The eveningness epidemiological liability hypothesis presented here suggests that during the COVID-19 pandemic, the evening-oriented psychobehavioral profile can have collectively harmful consequences: there is a clash of core tendencies between the nocturnal chronotype and the recent viral transmission-mitigating safety guidelines and rules. The pandemic safety protocols disrupt much normal social activity, particularly at night when making new social contacts is desired. The SARS-CoV-2 virus is contagious even in presymptomatic and asymptomatic individuals, which enables it to mostly evade our evolved contagious disease avoidance mechanisms. A growing body of research has indirectly shown that individual traits interfering with social distancing and anti-contagion measures are related to those of the nocturnal chronotype. Indeed, some of the social contexts that have been identified as superspreading events occur at night, such as in restaurants, bars, and nightclubs. Furthermore, nocturnal environmental conditions favor the survival of the SARS-CoV-2 virus much longer than daytime conditions. We compare the eveningness epidemiological liability hypothesis with other factors related to non-compliance with pandemic safety protocols, namely sex, age, and life history. Although there is not yet a direct link between the nocturnal chronotype and non-compliance with pandemic safety protocols, security measures and future empirical research should take this crucial evolutionary mismatch and adaptive metaproblem into account, and focus on how to avoid nocturnal individuals becoming superspreaders, offering secure alternatives for nocturnal social activities.

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The goal of the current study was to investigate the socio-demographic, psychiatric, and criminological characteristics of female violent offenders with mental disorders involuntarily committed to a forensic psychiatric hospital. The present study was a population-based retrospective case series including all female offenders with mental disorders found not guilty by reason of insanity by the criminal courts in the state of Rio de Janeiro, Brazil, and involuntarily committed to a forensic psychiatric facility (n = 27). Patients were assessed with Structured Clinical Interview for DSM-IV Axis I Disorders and the Positive and Negative Syndrome Scale. We found that most offenders were Afro-Brazilian, uneducated unmarried women. Schizophrenia with active psychotic symptoms was the most common clinical condition. Relatives were the frequent victims of aggressive behavior. Most patients had already been diagnosed with a mental disorder and placed under psychiatric treatment, but poor adherence and treatment dropout were common. Violent behavior in psychiatrically ill female patients is associated with a specific socio-demographic and clinical profile and is thus potentially amenable to prevention particularly if the mental health and social services are to provide the much-needed support for economically, socially, and psychologically vulnerable women.

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Epilepsy is one of the most prevalent serious neurological diseases. It is unique, being the only severe and disabling neurological disease that is fully treatable in the majority of cases, but on the other hand, associated with stigma, prejudice and discriminatory practices, which negatively impact people's everyday life in important areas, such as access to education, employment, marriage and social integration. For centuries, people with epilepsy (PWE) were stigmatized in all societies, with the consequences of prejudice and discrimination adding to the medical burden of the disease. Myths and misconceptions about this disease still occur, mostly in low-resources settings, however, in many industrialized countries, the knowledge regarding epilepsy is still limited in the population. The stigma is perceived as a negative attribute that is undesirable for the community to which the individual belongs. PWE are intrinsically undervalued, both by themselves ("felt stigma") and by the others. Actual discrimination by peers and institutions generates what is referred to as "enacted stigma". Misconceptions, stigma and negative attitudes towards PWE dramatically decrease quality of life, affecting the most sensitive areas, such as marriage, employment and driving. The Resolution 68.28 of the World Health Assembly (2015), the WHO-ILAE-IBE Global Report "Epilepsy: a public health imperative", advocates for strengthening and implementing national policies and legislation to promote and protect the rights of PWE, reducing misconceptions about epilepsy and improving access to care. Consolidated efforts are required from different organizations, public health managers, healthcare providers, PWE and their families to work together to improve socialization and quality of life of PWE. Educational programs and awareness to support activities among the general population, health service providers and PWE are the best way to reduce all types of stigma and discrimination.

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AIMS: To explore the factors associated with adherence and non-adherence to the pharmacological treatment of patients with T1DM in primary care setting southeast Brazil. METHODS: We conducted a cross-sectional study with 158 patients attending in the primary health care in the city of Franca southeast Brazil and measure adherence to antidiabetic medication. Adherence was measure using Morisky-Green Test modified. RESULTS: The majority of patients was adherence to antidiabetic medication (63.2%). More than one third of patients were non-adherent treated pharmacologically and comorbidities most prevalent were hypertension (63.8%), dyslipidemia (43.1%) and depression (32.8%). Depression were strongest predictor OR=2.8 (1.2-6.5) of non-adherence. CONCLUSION: Depression is a factor associated with non-adherence to pharmacological treatment in patients with T1DM, and in clinical practice, screening for depression and intervention as well as pharmaceutical care may improve adherence to pharmacotherapy.

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BACKGROUND: Patients with chronic kidney diseases (CKD) on haemodialysis (HD) have high morbidity and mortality rates, which are also due to the inherent risks associated with nephropathy. Non-adherence (NA) to the different demands of the treatment can have consequences for the outcome of patients undergoing HD; nevertheless, there are still doubts about such repercussions. This study was conducted to evaluate the association between NA to conventional HD and all-cause mortality and cardiovascular mortality. METHODS: We prospectively evaluated mortality in a 6-year period in a cohort of 255 patients on HD in northeast Brazil. The evaluated parameters of NA to HD were interdialytic weight gain (IDWG) ≥ 4% of dry weight (DW), hyperphosphatemia and regular attendance at treatment, assessed as the correlation between the periods on HD completed and those prescribed. We used the Cox multivariate regression model to analyse survival and the predictors of all-cause mortality and cardiovascular mortality. RESULTS: With a median follow-up period of 1493 days and a mortality rate of 9.1 per 100 people-years, there were 87 deaths, of which 54% were cardiovascular deaths. IDWG ≥4% of DW was associated with a risk of all-cause mortality however presenting a borderline outcome for cardiovascular mortality, with hazard ratios of 2.02 (CI 95% 1.17-3.49, p = 0.012) and 2.09 (CI 95% 1.01-4.35, p = 0.047), respectively. No significant association was found between other parameters of NA and mortality. Subgroup analysis showed that for patients with IDWG ≥4% of DW, malnutrition, age and diagnosis of cardiovascular and cerebrovascular diseases were associated with higher all-cause mortality. CONCLUSIONS: IDWG ≥4% of DW was identified as an independent predictor of all-cause mortality and demonstrated a borderline outcome for cardiovascular mortality in patients on conventional HD. The occurrence of excessive IDWG in the presence of malnutrition represented a significant increase in the risk of death, indicating a subgroup of patients with a worse prognosis.

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La situación, de los factores de riesgo para la no adherencia a los tratamientos, ha sido abordada por la OMS, como un problema multifactorial. Es así, como en el caso de los niños con cáncer, siendo una enfermedad crónica no transmisible, se hace necesario intervenir a los cuidadores familiares, sobre la toma de conciencia acerca de la importancia de seguir el tratamiento y que el temor no sea un motivo para perder el contacto con el equipo de salud. Objetivo: Determinar los factores de riesgo para la no adherencia al tratamiento, de cuidadores familiares de niños con cáncer. Método: Estudio de abordaje cuantitativo, descriptivo y corte transversal, en el cual se incluyeron 110 cuidadores familiares de niños con cáncer, con edades comprendidas entre 0 y 14 años, con mínimo 3 meses de tratamiento, en el Instituto Nacional de Cancerología. Se aplicó la ficha de caracterización de pacientes con enfermedad crónica del grupo "Cuidado de Enfermería al Paciente Crónico y su familia" y el Instrumento para evaluar los Factores que Influyen en la Adherencia a los Tratamientos Farmacológicos y no Farmacológicos en Pacientes con Riesgo de Enfermedad Cardiovascular (tercera Versión). Análisis: se utilizó estadística descriptiva. Resultados El factor socioeconómico, para los cuidadores familiares, se ubicó como elemento de riesgo para la no adherencia a los tratamientos, mientras que el factor relacionado con el proveedor se encontró en el rango de ventaja para adherencia. Conclusiones: Los cuidadores familiares de niños con cáncer, presentaron comportamientos que indican que su adherencia es buena y como factor influyente los relacionados con el equipo de salud.

The situation of the risk factors for the non-adherence to treatments has been tackled by the OMS, like a multifactorial problem. For that, as in the case of children with cancer, being a chronic non-transmissible disease, it´s necessary intervene the family Caregivers, about the awareness relating to the importance of follow the treatment and that fear is not a reason to lose the contact whit the health team. Objective: Determine the risk factors for the no adherence to treatment of family Caregivers of children with cancer. Method: Study of quantitative, descriptive and cross-section approach, in which one were include 110 family Caregivers of children with cancer, with ages between 0 and 14 year, with minimum 3 months of treatment, in the National Institute of Cancerology. The characterization card of patients with chronic disease of the group "Care of Nursing to the Chronic Patient and his family" and the Instrument to evaluate the Factors that Influence the Adherence to Pharmacological and Non-Pharmacological Treatments in Patients at Risk of Cardiovascular Disease was applied. (Third Version). Analysis: Descriptive statistics was used. Results: The socioeconomic factor for family caregivers was assign like the risk element for no adherence to treatments, while the factor related to the supplier was found in the range of advantage for adherence. Conclusions: The family Caregivers of children with cancer presented behaviors that indicate that their adherence is good and as an influential factor, the related with the health team

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Estudio de método mixto, con enfoque cualitativo, que utilizó la técnica de snowball. Realizado en Bahia, Brasil, entre enero/2014 y septiembre/2015. Objetivó identificar los factores que conducen a las personas a la no adhesión a la práctica regular de actividad física. Los resultados evidenciaron compromiso de salud, dificultad de conseguir un certificado médico, indisponibilidad por demandas familiares y baja motivación. Se concluye que estos saberes son necesarios para el delineamiento de la gestión y planeamiento en salud, en el sentido de guiar nuevas estrategias de promoción de salud, como consecuencia de los elevados índices de enfermedades crónicas no transmisibles en nuestro medio.(AU)

A mixed method study with a qualitative approach that implement the snowball technique. The study was developed in Bahia, Brazil, between January/2014 and September/2015. It was aimed at identifying the factors that lead people to non-adherence to regular physical activity. The results showed that the reasons were related to health problems, difficulty in getting a medical certificate, unavailability because of family demands and low motivation. We conclude that this knowledge is necessary for the delineation of management and planning in healthcare, in the sense of guiding new health promotion strategies as a result of high rates of chronic non-communicable diseases in our reality.(AU)

Estudo de método misto, ênfase no enfoque qualitativo, utilizou a técnica Snowball Sampling. Realizado na Bahia, Brasil, entre janeiro/2014 a setembro/2015. Objetivou averiguar os fatores que conduzem as pessoas a não adesão à prática regular de atividade física. Os resultados evidenciaram comprometimento de saúde, dificuldade de conseguir atestado médico, indisponibilidade por demandas familiares, e baixa motivação. Conclui-se que estes saberes são necessários ao delineamento, gestão e planejamento em saúde, posto as evidências do elevado índice de doenças crônicas não transmissíveis em nosso meio, no sentido de guiar-se pela via da promoção da saúde.(AU)

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Estudo de método misto, ênfase no enfoque qualitativo, utilizou a técnica Snowball Sampling. Realizado na Bahia, Brasil, entre janeiro/2014 a setembro/2015. Objetivou averiguar os fatores que conduzem as pessoas a não adesão à prática regular de atividade física. Os resultados evidenciaram comprometimento de saúde, dificuldade de conseguir atestado médico, indisponibilidade por demandas familiares, e baixa motivação. Conclui-se que estes saberes são necessários ao delineamento, gestão e planejamento em saúde, posto as evidências do elevado índice de doenças crônicas não transmissíveis em nosso meio, no sentido de guiar-se pela via da promoção da saúde.

A mixed method study with a qualitative approach that implement the snowball technique. The study was developed in Bahia, Brazil, between January/2014 and September/2015. It was aimed at identifying the factors that lead people to non-adherence to regular physical activity. The results showed that the reasons were related to health problems, difficulty in getting a medical certificate, unavailability because of family demands and low motivation. We conclude that this knowledge is necessary for the delineation of management and planning in healthcare, in the sense of guiding new health promotion strategies as a result of high rates of chronic non-communicable diseases in our reality.

Estudio de método mixto, con enfoque cualitativo, que utilizó la técnica de snowball. Realizado en Bahia, Brasil, entre enero/2014 y septiembre/2015. Objetivó identificar los factores que conducen a las personas a la no adhesión a la práctica regular de actividad física. Los resultados evidenciaron compromiso de salud, dificultad de conseguir un certificado médico, indisponibilidad por demandas familiares y baja motivación. Se concluye que estos saberes son necesarios para el delineamiento de la gestión y planeamiento en salud, en el sentido de guiar nuevas estrategias de promoción de salud, como consecuencia de los elevados índices de enfermedades crónicas no transmisibles en nuestro medio.

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Resiliência e religiosidade têm recebido importante atenção no manejo de pacientes com comorbidades crônicas; no entanto, não há nenhum estudo avaliando a resiliência em pacientes em hemodiálise e sua associação com outras dimensões psicológicas ou com a adesão ao tratamento. Este estudo avaliou a resiliência, a religiosidade sob três dimensões(organizacional, não organizacional e intrínsecos), sintomas depressivos e qualidade de vida relacionada à saúde. Os principais desfechos avaliados foram a adesão à medicação usando o Morisky Adesão à Medicação Scale-8 (MMAR-8) e o numero de sessões de diálise perdidas/abreviadas nos seis meses seguintes. Dos 208 pacientes abordados, 202 (97,1%) concordaram em participar da pesquisa. Cento e vinte e três pacientes (60,9%) eram do sexo masculino e a média de idade foi de 52,8 ± 14,8 anos de idade. O tempo médio em hemodiálise foi de 36meses (IQR, 12, 84). 82 (40,6%) pacientes obtiveram uma pontuação MMAS <6 e foram considerados como tendo "baixa adesão". No geral, a média do escore de adesão à medicação foi baixa (5,7 ± 2,1). Sobre a adesão a sessões de hemodiálise, os pacientes perderam um total de 234 sessões (1,6%) de hemodiálise. Quarenta e oito pacientes (23,7%) perderam uma média de pelo menos três sessões em seis meses. Em relação à adesão à medicação, não houve associação na análise uni ou multivariada entre as dimensões de religiosidade e o escore de MMAS. Após o ajuste, a resiliência foi positivamente associado com o escore de MMAS (coeficiente β padronizado 0,239, p = 0,016)...

Resilience and religiosity have received significant attention in the management of patientswith chronic comorbidities; however, there are no studies evaluating resilience inhemodialysis patients and its association with other psychological dimensions or treatmentadherence. This study assessed resilience, religiosity under three dimensions (organizational,non-organizational and intrinsic), depressive symptoms and health-related quality of life. Themain outcomes were medication adherence using the Morisky Medication Adherence Scale-8(MMAR) and the missing/shortened dialysis sessions in the following six months. Of 208patients approached, 202 (97.1%) agreed to participate. One hundred twenty-three patients(60.9%) were males and mean age was 52.8±14.8 years-old. The median time onhemodialysis was 36 months (IQR, 12, 84). 82 (40.6%) patients obtained a MMAS-8 score <6 and were considered as having “poor adherence”. Overall, the mean score of medicationadherence was low (5.7±2.1). About adherence to hemodialysis sessions, patients missed atotal of 234 (1.6%) hemodialysis sessions. Forty-eight patients (23.7%) missed an average ofat least three sessions in six months. Regarding adherence to medication, there was noassociation in the uni- or multivariate analysis between religiosity dimensions and MMAS-8score. After adjustment, resilience was positively associated with MMAS-8 score(standardized β coefficient 0.239, p=0.016)...

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Donor-specific anti-HLA antibodies (DSA) causing CAMR are responsible for a high proportion of long-term graft failures after RTX. We studied the prevalence of DSA in RTX children biopsied for creeping Cr, its relationship with NA, and patient and graft survival according to histopathology. Between 2008 and 2013, 92 children were biopsied at a median of 38 months post-RTX. At biopsy, the prevalence of DSA was 49% and C4d 70%. NA rate was 45%, higher in adolescents (60%). Most frequent diagnoses were CAMR (72%) and interstitial fibrosis with tubular atrophy (IFTA) (28%). Forty-five of 66 patients with CAMR (68%) had detectable DSA. Twenty-one DSA-negative patients with CAMR had histological damage (IFTA + C4d positivity). C4d was detected in 64 of 66 biopsies with CAMR. Recipients with IFTA alone had neither C4d, nor detectable DSA, and were adherent. Graft survival at five yr was 89% in patients with CAMR, 79% in those with CAMR + TCMR Banff I, 33% in those with CAMR + TCMR Banff II, and 96% in those with IFTA. ABMR and complement activation were frequent in children biopsied for creeping Cr. Recipients with DSA were more likely to be non-adherent and have CAMR or CAMR + TCMR and worse graft survival.

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O objetivo da presente revisão é apresentar de forma clara e acessível os conceitos-chave para compreensão, identificação e manejo da não adesão ao tratamento farmacológico, aplicados à realidade brasileira. Para isso conduziu-se busca por artigos científicos nas bases Scielo, Scopus e PubMed. Os artigos identificados foram selecionados por revisores independentes observando as etapas de uma revisão integrativa com síntese qualitativa dos dados. Existem diferentes termos para definir o grau em que o comportamento do paciente corresponde às orientações de saúde. As conseqüências de tal comportamento representam um importante preditor de desfechos clínicos negativos, como o aumento de mortalidade, internações e custos com saúde, e é determinado por múltiplas dimensões. Condições relacionadas a fatores socioeconômicos, a características do sistema e equipe de saúde, ao paciente, a doença e ao tratamento são condicionantes da não adesão, que pode ser intencional ou não intencional. Sua mensuração pode ser feita por métodos diretos, indiretos ou pela combinação destes de acordo com o enfoque desejado. A construção de práticas profissionais e rotinas nos serviços de saúde que sejam capazes de identificar a não adesão, rastrear seus determinantes individuais e construir estratégias de intervenção e suporte são fundamentais para o manejo desta condição, aumento da resolutividade dos serviços e, assim, da qualidade de vida dos pacientes.

The aim of this review is to discuss in a clear andaccessible way the key concepts for the understandingand management of non-adherence to pharmacologicaltreatment, in the Brazilian context. To this end, a searchwas conducted among scientific articles publishedin Scopus, Scielo and PubMed. Papers were selectedand analyzed by independent reviewers, following thestages of an integrative review involving qualitativeinterpretation of records. Various terms are usedcurrently to define the degree of correspondencebetween a patient?s behavior and the medical advicereceived. Non-adherence is determined by multipledimensions and represents an important predictor ofadverse clinical outcomes, such as increased mortality,hospitalization and health care cost. Living conditionsrelated to socioeconomic factors, characteristics of thehealth system and health care professionals in relationto the patient, the disease and its treatment can all playa part in non-adherence, which may be intentional orunintentional. It can be measured by direct, indirect ormixed methods, according to the type of enquiry. Thedevelopment of professional practices and routines in thehealth services, capable of identifying non-adherence,tracing its individual causes and building interventionand support strategies, is basic to the management ofthis situation and improvement of the services providedand patients? quality of life.

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A partir de la estrategia de la OMS "Alto a la Tuberculosis", se evaluó la situación en un hospital público. Objetivo primario: Contribuir con la estrategia de reducción de la tuberculosis. Objetivo secundario: a) evaluar la adherencia al tratamiento b) describir las características clínico-epidemiológicas de una población pediátrica atendida en un hospital público. Material y método: Se realizó un estudio observacional, descriptivo, transversal. Se definió: no adherencia al tratamiento, cuando un paciente no recibe los medicamentos durante un mes o más, en cualquier fase del tratamiento. Resultados: Durante los años 2008-2009, se diagnosticó tuberculosis en 30 niños. Mediana de: 56 meses (rango 1m-14 años). Indice de masculinidad: 0.87. Al ingreso 80% eran sintomáticos, 86% eran eutróficos. El foco de contagio se detectó en el 72%. La prueba tuberculínica fue positiva en el 63%. Predominó la forma pulmonar. La forma pulmonar grave se registró en 12/23 y la común o moderada 11/23. La pleural fue más frecuente entre las extrapulmonares. La radiografía de tórax mostró predominio de infiltrado unilateral sin cavidad 11/23. El rendimiento bacteriológico fue del 36,7%. En 2008 la tasa de abandono fue del 50% y en 2009 44,44%. No hubo fallecidos. Conclusiones: Existe una baja detección de casos por antecedente de contacto. No hubo diferencias entre las formas graves y las pulmonares comunes. La tuberculosis pleural predominó como forma extrapulmonar. El abandono de tratamiento fue muy alto por lo cual propusimos realizar intervenciones.(AU)

Based on the World Health Organization "Stop TB Strategy", the current situation of the Hospital Prof. Dr. A. Posadas was evaluated. Primary Objective: to contribute to the strategy for tuberculosis reduction. Secondary Objectives: a) to evaluate the adherence to treatment b) to describe clinical and epidemiological features of tuberculosis in a pediatric population at a public hospital. Materials& Method: Observational, longitudinal and retrospective study. Treatment default was defined as the period of one or more months during which a patient does not receive medications, in any phase of treatment. Results: During the years 2008 and 2009, 30 children with tuberculosis were registered. Median age was 56 months (range 1m-14 years). Masculinity Index: 0.87. At the time of the first visit, 80% did not present any symptoms and 86% presented a normal nutritional status. Contacts study was positive in 72% of the cases. Tuberculin test (PPD 2 TU) was positive = 10mm in 63% of the patients. Pulmonary TB was the predominant form of presentation. Severe pulmonary TB was recorded in 12/23 patients and mild or moderate TB, in 11/23 patients. Among the extrapulmonary forms, pleural tuberculosis was predominant. Chest X-ray: unilateral pulmonary TB with no cavity was predominant, 11/23 patients. Bacteriological diagnosis was positive in 36.7% of the patients. Outcome: in 2008, default rate was 50% and in 2009, 44.44%. There were no deceased patients. Conclusions: There is a low case detection by contact history. There were no differences in treatment outcome between severe and non severe pulmonary TB. Pleural tuberculosis was predominant as an extrapulmonary presentation. Treatment default was very high in this population; for this reason individual, particular and general interventions are suggested.(AU)

RESUMO

A partir de la alta tasa de abandono del tratamiento de la tuberculosis observada durante los años 2008-2009, se implementaron intervenciones con el fin de disminuirla. Objetivo primario: Evaluar la adherencia al tratamiento en el nuevo modelo de atención en la población pediátrica con tuberculosis atendida en un hospital público. Objetivo secundario: Describir las características clínico-epidemiológicas de la población pediátrica atendida con tuberculosis. Material y método: Diseño observacional, descriptivo, transversal. Criterios de Inclusión: Niños con diagnóstico de tuberculosis. Se utilizaron las mismas variables, definiciones, indicadores y base de datos del 1er. trabajo. Se implementaron intervenciones en lo individual, particular y general. Estas intervenciones se comenzaron a hacer en el Servicio fuera del marco del trabajo. Resultados: Hubieron 25 niños con tuberculosis. La mediana correspondió a 83 meses (rango 2 m a 15 años). 84% fueron eutróficos. Se detectó foco en el 64%. La prueba tuberculínica fue positiva en el 76%. Predominó la forma pulmonar; la común o moderada se observó en 14/25 y la grave en 7/25. La ganglionar resultó la forma extrapulmonar más frecuente. El patrón radiológico predominante fue unilateral sin cavidad 11/25. El rendimiento bacteriológico fue del 64%. En el año 2010 la tasa de abandono fue del 12%. No hubo fallecidos. Conclusiones: La mayoría de los pacientes presentó formas comunes o moderadas. La TB ganglionar predominó como forma extrapulmonar. La tasa de abandono descendió luego de la implementación del nuevo modelo de atención.(AU)

Owing to the high rates of default from tuberculosis treatment observed during 2008 - 2009, interventions were implemented with the purpose of diminishing them. Primary Objective: To make a contribution to tuberculosis treatment adherence. Secondary Objective: a) To evaluate adherence to treatment after implementing individual, particular and general interventions b) To describe clinical and epidemiological features of a pediatric population treated in a public hospital. Materials& Method: Observational, descriptive and transverse design. Inclusion criteria: Patients with tuberculosis diagnosis. The variables, definitions, indicators and database were those used in the previous reported study. Individual, particular and general interventions were implemented. These interventions were carried out outside the service frame of work. Results: 25 children presented with tuberculosis. The median age was 83 months (range 2m to 15 years). 84% presented with a normal nutritional status. Contact investigations were positive for tuberculosis infection sources in 64% of the cases. Tuberculin test was positive in 76% of the cases. Pulmonary TB was the predominant presentation form; mild or moderate pulmonary TB was observed in 14/25, and severe pulmonary TB in 7/25. The most frequent extrapulmonary sites of infection were the lymph nodes. Chest X-ray: unilateral TB with no cavity was predominant, 11/25. Bacteriological diagnosis was positive in 64% of the cases. Outcome: in 2010, 12% of the patients defaulted treatment. There were no deceased patients. Conclusions: Most of the patients presented with mild or moderate TB. Lymph node TB was the predominant extrapulmonary presentation. Default rate decreased with the implementation of the intervention.(AU)

RESUMO

A partir de la estrategia de la OMS "Alto a la Tuberculosis", se evaluó la situación en un hospital público. Objetivo primario: Contribuir con la estrategia de reducción de la tuberculosis. Objetivo secundario: a) evaluar la adherencia al tratamiento b) describir las características clínico-epidemiológicas de una población pediátrica atendida en un hospital público. Material y método: Se realizó un estudio observacional, descriptivo, transversal. Se definió: no adherencia al tratamiento, cuando un paciente no recibe los medicamentos durante un mes o más, en cualquier fase del tratamiento. Resultados: Durante los años 2008-2009, se diagnosticó tuberculosis en 30 niños. Mediana de: 56 meses (rango 1m-14 años). Índice de masculinidad: 0.87. Al ingreso 80% eran sintomáticos, 86% eran eutróficos. El foco de contagio se detectó en el 72%. La prueba tuberculínica fue positiva en el 63%. Predominó la forma pulmonar. La forma pulmonar grave se registró en 12/23 y la común o moderada 11/23. La pleural fue más frecuente entre las extrapulmonares. La radiografía de tórax mostró predominio de infiltrado unilateral sin cavidad 11/23. El rendimiento bacteriológico fue del 36,7%. En 2008 la tasa de abandono fue del 50% y en 2009 44,44%. No hubo fallecidos. Conclusiones: Existe una baja detección de casos por antecedente de contacto. No hubo diferencias entre las formas graves y las pulmonares comunes. La tuberculosis pleural predominó como forma extrapulmonar. El abandono de tratamiento fue muy alto por lo cual propusimos realizar intervenciones.

Based on the World Health Organization "Stop TB Strategy", the current situation of the Hospital Prof. Dr. A. Posadas was evaluated. Primary Objective: to contribute to the strategy for tuberculosis reduction. Secondary Objectives: a) to evaluate the adherence to treatment b) to describe clinical and epidemiological features of tuberculosis in a pediatric population at a public hospital. Materials& Method: Observational, longitudinal and retrospective study. Treatment default was defined as the period of one or more months during which a patient does not receive medications, in any phase of treatment. Results: During the years 2008 and 2009, 30 children with tuberculosis were registered. Median age was 56 months (range 1m-14 years). Masculinity Index: 0.87. At the time of the first visit, 80% did not present any symptoms and 86% presented a normal nutritional status. Contacts study was positive in 72% of the cases. Tuberculin test (PPD 2 TU) was positive = 10mm in 63% of the patients. Pulmonary TB was the predominant form of presentation. Severe pulmonary TB was recorded in 12/23 patients and mild or moderate TB, in 11/23 patients. Among the extrapulmonary forms, pleural tuberculosis was predominant. Chest X-ray: unilateral pulmonary TB with no cavity was predominant, 11/23 patients. Bacteriological diagnosis was positive in 36.7% of the patients. Outcome: in 2008, default rate was 50% and in 2009, 44.44%. There were no deceased patients. Conclusions: There is a low case detection by contact history. There were no differences in treatment outcome between severe and non severe pulmonary TB. Pleural tuberculosis was predominant as an extrapulmonary presentation. Treatment default was very high in this population; for this reason individual, particular and general interventions are suggested.

Assuntos

RESUMO

A partir de la alta tasa de abandono del tratamiento de la tuberculosis observada durante los años 2008-2009, se implementaron intervenciones con el fin de disminuirla. Objetivo primario: Evaluar la adherencia al tratamiento en el nuevo modelo de atención en la población pediátrica con tuberculosis atendida en un hospital público. Objetivo secundario: Describir las características clínico-epidemiológicas de la población pediátrica atendida con tuberculosis. Material y método: Diseño observacional, descriptivo, transversal. Criterios de Inclusión: Niños con diagnóstico de tuberculosis. Se utilizaron las mismas variables, definiciones, indicadores y base de datos del 1er. trabajo. Se implementaron intervenciones en lo individual, particular y general. Estas intervenciones se comenzaron a hacer en el Servicio fuera del marco del trabajo. Resultados: Hubieron 25 niños con tuberculosis. La mediana correspondió a 83 meses (rango 2 m a 15 años). 84% fueron eutróficos. Se detectó foco en el 64%. La prueba tuberculínica fue positiva en el 76%. Predominó la forma pulmonar; la común o moderada se observó en 14/25 y la grave en 7/25. La ganglionar resultó la forma extrapulmonar más frecuente. El patrón radiológico predominante fue unilateral sin cavidad 11/25. El rendimiento bacteriológico fue del 64%. En el año 2010 la tasa de abandono fue del 12%. No hubo fallecidos. Conclusiones: La mayoría de los pacientes presentó formas comunes o moderadas. La TB ganglionar predominó como forma extrapulmonar. La tasa de abandono descendió luego de la implementación del nuevo modelo de atención.

Owing to the high rates of default from tuberculosis treatment observed during 2008 - 2009, interventions were implemented with the purpose of diminishing them. Primary Objective: To make a contribution to tuberculosis treatment adherence. Secondary Objective: a) To evaluate adherence to treatment after implementing individual, particular and general interventions b) To describe clinical and epidemiological features of a pediatric population treated in a public hospital. Materials& Method: Observational, descriptive and transverse design. Inclusion criteria: Patients with tuberculosis diagnosis. The variables, definitions, indicators and database were those used in the previous reported study. Individual, particular and general interventions were implemented. These interventions were carried out outside the service frame of work. Results: 25 children presented with tuberculosis. The median age was 83 months (range 2m to 15 years). 84% presented with a normal nutritional status. Contact investigations were positive for tuberculosis infection sources in 64% of the cases. Tuberculin test was positive in 76% of the cases. Pulmonary TB was the predominant presentation form; mild or moderate pulmonary TB was observed in 14/25, and severe pulmonary TB in 7/25. The most frequent extrapulmonary sites of infection were the lymph nodes. Chest X-ray: unilateral TB with no cavity was predominant, 11/25. Bacteriological diagnosis was positive in 64% of the cases. Outcome: in 2010, 12% of the patients defaulted treatment. There were no deceased patients. Conclusions: Most of the patients presented with mild or moderate TB. Lymph node TB was the predominant extrapulmonary presentation. Default rate decreased with the implementation of the intervention.

Assuntos

RESUMO

OBJECTIVE: To investigate the level of compliance with glaucoma medications in a clinic setting and the factors associated with failed compliance. METHOD: This was a prospective study done at the Glaucoma Clinic, University Hospital of the West Indies, between April and June 2005. Consecutive patients in the clinic were administered a questionnaire by the doctor. Statistical analysis was done using cross-tabulations, Chisquare (Χ²) tests and odds ratio using SPSS version 11.0. RESULTS: One hundred glaucoma patients were recruited: 63% were female; 57% of the total group was in the 61-80-year age group. Forty-seven per cent had been attending the glaucoma clinic for over 10 years. Eighty-five per cent knew their diagnosis, although only 22% understood their diagnosis. Patients who did not have a full understanding of glaucoma were more likely to be non-compliant (odds ratio 0.771 (95% CI 0.298, 1.995, p = 0.591)). Females were more likely to be compliant than males (odds ratio was 1.64 (95% CI 0.72, 3.75, p = 0.24)). Patients who were clinic attendees for less than five years duration were less compliant than those attending the glaucoma clinic for 6-10 years. The reasons for reduced compliance were financial in 44%, forgetfulness in 20% and eye-drops being unimportant in 12% of cases. The educational level of patients was not related to compliance. CONCLUSION: The level of full compliance was 50% and partial compliance 43%. There was a 7% level of non-compliance. Higher levels of compliance were seen in females, patients who understood their diagnosis and those who had no comorbid disease.

OBJETIVO: Investigar el nivel de cumplimiento de la medicación del glaucoma en el contexto de una clínica y los factores asociados con la falta del cumplimiento. MÉTODO: Se trata de un estudio prospectivo en la Clínica del Glaucoma del Hospital Universitario de West Indies, entre abril y junio de 2005. A un número de pacientes consecutivos en la clínica, les fue aplicado un cuestionario por parte de un facultativo. El análisis estadístico se realizó usando tabulaciones cruzadas y pruebas de chicuadrado (Χ2) así como el cociente de probabilidades (odds ratio) usando la versión 11.0 del SPSS. RESULTADOS: Se reclutaron cien pacientes con glaucoma, de los cuales el 63% eran hembras. El 57% de la totalidad de los pacientes se hallaba en el grupo etario de 61 a 80 años. El 47% había estado asistiendo a la clínica del glaucoma por más de 10 años. El 85% conocía su diagnóstico, aunque sólo el 22% entendía su diagnóstico. Los pacientes que no tenían plena comprensión del glaucoma eran con mayor probabilidad aquellos que no cumplían con la medicación (odds ratio 0.771 (95% CI 0.298, 1.995, p = 0.591)). Las hembras mostraron una mayor probabilidad que los varones en cuanto a cumplir con la medicación (odds ratio 1.64 (95% CI 0.72, 3.75, p = 0.24)). Los pacientes que habían asistido a la clínica por menos de cinco años, mostraban menos cumplimiento que los que habían asistido a la clínica del glaucoma por un período de 6 a 10 años. Las razones para la disminución del cumplimiento fueron problemas financieros en 44%, olvido en 20% y el considerar los colirios como no importantes en 12% de casos. El nivel educacional de los pacientes no guardaba relación con el cumplimiento. CONCLUSIÓN: El nivel de cumplimiento pleno fue de 50% y el de cumplimiento parcial 43%. Hubo un nivel de no cumplimiento de 7%. Se vieron niveles más altos de cumplimiento en las hembras, los pacientes que entendían el diagnóstico, y aquéllos que no tenían ninguna enfermedad comórbida.

Assuntos

RESUMO

Lack of information on antiretroviral drugs or the misunderstanding of available information can facilitate incorrect use of such drugs. This can result in non-adherence to the prescribed regimen, leading to a great possibility of a therapeutic failure. The aim of this study was to know which information HIV/AIDS patients, who receive their medicines at the pharmacy of a reference hospital in the northeast Brazil, have on the drugs they use, the source of this information and whether there is a need for additional information. A total of 195 HIV/AIDS patients, who were using either zidovudina + lamivudina 300+150mg (AZT+3TC), efavirenz 600mg (EFZ) or lopinavir/ritonavir 133.33/33mg (LPV/r), were interviewed. The mean age was 41 years (SD = 9.55) and 70.8 percent were males. Of the total, 55.4 percent didn't know the effect of the drug in the organism; 35.9 percent were unaware of the necessity of taking antiretroviral drugs for the rest of their lives; only 14.4 percent knew how to proceed when a dosage was missed; 22.1 percent said they could die and the same number of individuals believed in aggravation of the disease in case of treatment interruption. The majority, 68.2 percent, considered it very necessary to receive drug information. The results show that there is an apparent lack of general information among users of antiretroviral drugs, and at the same time a need for it. It is necessary that all professionals involved in the health care of the patients agree that an efficient supply of information on prescribed drugs is an ethical component of the treatment that favors and fosters its adherence.

Assuntos