Tuberculosis among HIV-1-infected subjects in a tertiary out-patient service in São Paulo city, Brazil

TB is currently considered to be the most important infectious disease among HIV-1-infected subjects in developing countries, such as Brazil. A retrospective analysis of TB cases was performed, occurring from January 1995 to December 2010 in our cohort of 599 HIV positive patients. The primary outcome was the occurrence of active TB. Forty-one TB cases were diagnosed over this period of 16 years, among 599 HIV positive patients in an open cohort setting in the city of Sao Paulo, Brazil. All-time lowest mean CD4 T cell count at the time of TB diagnosis was 146 and 186 cells/mm³, respectively. The mean HIV viral load was 5.19 log10 copies/mL, and 59% of the patients were on HAART. TB incidence was 1.47 per 100 person-years, for a total follow-up time of 2775 person-years. The probability of surviving up to 10 years after diagnosis was 75% for TB patients as opposed to 96% for patients with other, non-TB opportunistic diseases (p = 0.03). TB can be considered a public health problem among people living with HIV in Brazil despite of the widespread use of antiretrovirals for the treatment of HIV infection/AIDS.

Risk factors for atherosclerosis in an elderly out patient population in the City of São Paulo

OBJECTIVE: To analyze in out clinic elderly patients of both sexes for the prevalence of risk factors for atherosclerosis and study their association with the complications of atherosclerosis. METHODS: Five hundred and sixteen outpatients, 152 men and 364 women, 60 years or older, were studied. The prevalences of hypertension, dyslipidemia, diabetes mellitus, cigarette smoking and obesity were determined in both sexes and compared using the chi-square test. The association between these factors and the presence of atherosclerotic complications was analyzed by logistic regression. RESULTS: The comparative analysis of the factors in both sexes showed that hypertension, total cholesterol > or = 240mg/dL, LDL-cholesterol > or = 160mg/dL, and body mass index >27.5 were more frequent among women, but HDL-cholesterol <35mg/dL and cigarette smoking were more frequent among men, and no difference occurred between sexes in relation to the frequency of triglycerides > or = 250mg/dL and diabetes mellitus. After adjustment of the variables in the regression model, we observed that in the total of elderly patients, risk factors for complications of atherosclerosis were: triglycerides > or = 250mg/dL, hypertension, and male sex. Among men, the risk factors were: LDL-cholesterol > or = 160mg/dL, diabetes mellitus, HDL-cholesterol <35mg/dL and hypertension. Among women, the risk factors were: tryglicerides > or = 250mg/dL and hypertension. CONCLUSION: The results showed that, in the elderly, the risk factors for atherosclerosis persist, but with different behaviors between men and women. The study suggests that the relative importance of the risk factors can change with the aging process.

Difficulties associated with out-patient management of drug abusers by general practitioners. A cross sectional survey of general practitioners with and without methadone patients in Switzerland

Résumé de l'article Contexte : En Suisse, les médecins de premier recours traitent la plupart des patients dépendants aux opiacés méthadone en tant que traitement de substitution. Méthode : Nous avons étudié les difficultés rencontrées dans la prise en charge des patients toxicodépendants en envoyant par poste un questionnaire d'enquête. Nous avons envoyé ce questionnaire à tous les médecins de premier recours de Suisse Romande prescrivant de la méthadone (556 médecins). Nous avons envoyé un autre questionnaire, plus court, à des médecins de premier recours du Canton de Vaud qui ne prescrivent pas de méthadone. Résultats : le taux de réponse global est de 63,3 %. La plus haute dose de méthadone donnée par les médecins de premier recours est de 120,4 mg/j (moyenne). Questionnés au sujet de l'aide qu'ils désireraient recevoir face à ces patients, les médecins de premier recours avec patients substitués par méthadone ont mentionné premièrement l'importance d'un meilleur remboursement des services prodigués. Les autres éléments demandés ont été une meilleure formation, de meilleures connaissances des pathologies psychiatriques et des groupes de discussion de cas cliniques. Les médecins sans patients sous méthadone refusent de traiter ces patients surtout pour des raisons émotionnelles et relationnelles. En conclusion : les médecins acceptant des patients sous méthadone rencontrent des difficultés relationnelles et émotionnelles. Ils désirent un meilleur remboursement pour les services prodigués.

Patient expectations at a multicultural out-patient clinic in Switzerland.

BACKGROUND: Recognizing patient expectation is considered as an important objective for primary care physicians. A number of studies suggest that failure to identify patient expectations can lead to patient dissatisfaction with care, lack of compliance and inappropriate use of medical resources. It has been suggested that identifying patient expectations in multicultural contexts can be especially challenging. OBJECTIVES: The aim of the study was to compare health care expectations of Swiss and immigrant patients attending the out-patient clinic of a Swiss university hospital and to assess physicians' ability to identify their patients' expectations. METHODS: Over a 3-month period, all patients attending the out-patient clinic at a Swiss university hospital were requested to complete pre-consultation surveys. Their physicians were requested to complete post-consultation surveys. Outcome measures were patients' self-rated health, resort to prior home treatment, patients' expectations of the consultation, physicians' perception of their patients' expectations and agreement between patients and physicians. RESULTS: We analysed 343 questionnaires completed by patients prior to their consultation (> 50% immigrants) and 333 questionnaires completed by their physicians after the consultation. Most expectations were shared by all patients. Physicians had inaccurate perceptions of their patients' expectations, regardless of patients' origin. CONCLUSIONS: Our study found no evidence that immigrant patients' expectations differed from those of Swiss patients, nor that physicians had more difficulty identifying expectations of immigrant patients. However, physicians in our study were generally poor at identifying patients' expectations, and therefore inter-group differences may be difficult to detect. Our results point to the need to strengthen physicians' general communication skills which should then serve as a foundation for more specific, cross-cultural communication training.

Assessing feasibility and acceptability of study procedures : getting ready for implementation of national stroke guidelines in out-patient health care

BACKGROUND: Even though Swedish national guidelines for stroke care (SNGSC) have been accessible for nearly a decade access to stroke rehabilitation in out-patient health care vary considerably. In order to aid future interventions studies for implementation of SNGSC, this study assessed the feasibility and acceptability of study procedures including analysis of the context in out-patient health care settings. METHODS: The feasibility and acceptability of recruitment, observations and interviews with managers, staff and patients were assessed, as well as the feasibility of surveying health care records. RESULTS: To identify patients from the the hospitals was feasible but not from out-patient care where a need to relieve clinical staff of the recruitment process was identified. Assessing adherence to guidelines and standardized evaluations of patient outcomes through health care records was found to be feasible and suitable assessment tools to evaluate patient outcome were identified. Interviews were found to be a feasible and acceptable tool to survey the context of the health care setting. CONCLUSION: In this feasibility study a variety of qualitative and quantitative data collection procedures and measures were tested. The results indicate what can be used as a set of feasible and acceptable data collection procedures and suitable measures for studying implementation of stroke guidelines in an out-patient health care context.

TUBERCULOSIS AMONG HIV-1-INFECTED SUBJECTS IN A TERTIARY OUT-PATIENT SERVICE IN SÃO PAULO CITY, BRAZIL

TB is currently considered to be the most important infectious disease among HIV-1-infected subjects in developing countries, such as Brazil. A retrospective analysis of TB cases was performed, occurring from January 1995 to December 2010 in our cohort of 599 HIV positive patients. The primary outcome was the occurrence of active TB. Forty-one TB cases were diagnosed over this period of 16 years, among 599 HIV positive patients in an open cohort setting in the city of Sao Paulo, Brazil. All-time lowest mean CD4 T cell count at the time of TB diagnosis was 146 and 186 cells/mm3, respectively. The mean HIV viral load was 5.19 log10 copies/mL, and 59% of the patients were on HAART. TB incidence was 1.47 per 100 person-years, for a total follow-up time of 2775 person-years. The probability of surviving up to 10 years after diagnosis was 75% for TB patients as opposed to 96% for patients with other, non-TB opportunistic diseases (p = 0.03). TB can be considered a public health problem among people living with HIV in Brazil despite of the widespread use of antiretrovirals for the treatment of HIV infection/AIDS.

[Local treatment of chronic skin wounds in a Swiss out-patient wound centre 2010]

In Switzerland around 30,000 patients suffer from chronic skin wounds. Appropriate topical wound care along with treatment of the causes of the wounds enables to heal a lot of these patients and to avoid secondary disease such as infections. Thereby, the final goal of wound care is stable reepithelisation. Based on experience with chronic leg ulcers mainly in our out-patient wound centre, we give a survey of the wound dressings we actually use and discuss their wound-phase adapted application. Furthermore, we address the two tissue engineering products reimbursed in Switzerland, Apligraf and EpiDex, as well as the biological matrix product Oasis. The crucial question, which treatment options will be offered in future to the wound patients by our health regulatory and insurance systems, is open to debate.

Prospective surveillance of varicella-zoster virus infections in an out-patient setting in Switzerland

Limited data are available on the clinical impact of varicella in the ambulatory setting. Our goal was to determine real-life data on the clinical outcomes, medical management, and resource utilization in patients with varicella in Switzerland, a country without a universal immunization program against varicella. A total of 236 patients (222 = 94% primarily healthy individuals) with a clinical diagnosis of varicella were recruited by pediatricians and general practitioners. Age range of patients was 0-47 years with a median of 5 years. The great majority of patients (179 = 76%) were patients were single cases and in the remaining 102 patients a total of 112 further cases of varicella occurred in their households. Of these, 17 (15%) were primary cases, 18 (16%) were co-primary cases, 75 (67%) were secondary cases, and 2 cases (2%) were not directly linked to the index case. A total of 29 complications were observed in 26 (11%) of 236 patients, none of them with a known underlying disease and all subsided without apparent sequelae. All complications occurred in children under 12 years of age. In conclusion, this study describes the spectrum of varicella in an out-patient setting with a sizeable rate of complications and raises the question of the value of prophylactic immunization.

Hospital - Out-patient clinic. Sept. 5, 1951 - Construction shot

University of Michigan News Service photo. On verso: U. Hosp. new

Patient/carers' recollection of medicines related information from an out-patient clinic appointment

AIM: To identify what medicines related information children/young people or their parents/carers are able to recall following an out-patient clinic appointment. METHOD: A convenience sample of patients' prescribed at least one new long-term (>6 weeks) medicine were recruited from a single UK paediatric hospital out-patient pharmacy. A face-to-face semi-structured questionnaire was administered to participants when they presented with their prescription. The questionnaire included the following themes: names of the medicines, therapeutic indication, dose regimen, duration of treatment and adverse effects.The results were analysed using Microsoft Excel 2013. RESULTS: One hundred participants consented and were included in the study. One hundred and forty-five medicines were prescribed in total. Participants were able to recall the names of 96 (66%) medicines and were aware of the therapeutic indication for 142 (97.9%) medicines. The dose regimen was accurately described for 120 (82.8%) medicines with the duration of treatment known for 132 (91%). Participants mentioned that they had been advised about side effects for 44 (30.3%) medicines. Specific counselling points recommended by the BNFc1, were either omitted or not recalled by participants for the following systemic treatments: cetirizine (1), chlorphenamine (1), desmopressin (2), hydroxyzine (2), itraconazole (1), piroxicam (2), methotrexate (1), stiripentol (1) and topiramate (1). CONCLUSION: Following an out-patient consultation, where a new medicine is prescribed, children and their parents/carers are usually able to recall the indication, dose regimen and duration of treatment. Few were able to recall, or were told about, possible adverse effects. This may include some important drug specific effects that require vigilance during treatment.Patients, along with families and carers, should be involved in the decision to prescribe a medicine.2 This includes a discussion about the benefits of the medicine on the patient's condition and possible adverse effects.2 Treatment side effects have been shown to be a factor in treatment non-adherence in paediatric long-term medical conditions.3 Practitioners should explain to patients, and their family members or carers where appropriate, how to identify and report medicines-related patient safety incidents.4 However, this study suggests that medical staff may not be comfortable discussing the adverse effects of medicines with patients or their parents/carers.Further research in to the shared decision making process in the paediatric out-patient clinic when a new long-term medicine is prescribed is required to further support medicines adherence and the patient safety agenda.

Patient-perceived health-related quality of life during recovery after total hip arthroplasty – a 6-month follow-up study

Potilaiden käsitys terveyteen liittyvästä elämänlaadusta lonkan tekonivelleikkauksen jälkeisenä toipumisaikana – kuuden kuukauden seurantatutkimus Tässä kaksivaiheisessa seurantatutkimuksessa tarkasteltiin potilaiden käsitystä terveyteen liittyvästä elämänlaadusta lonkan tekonivelleikkauksen jälkeisenä toipumisaikana. Tutkimuksen ensimmäisessä vaiheessa tarkoituksena oli sekä kuvailla potilaiden kokemuksia potilaana olosta, saamastaan hoidosta ja terveyspalveluorganisaatiosta että analysoida aikaisempien tutkimusten perusteella leikkauksen tuloksia potilaan kannalta. Toisessa vaiheessa tarkoituksena oli arvioida potilaiden kokemaa elämänlaatua leikkauksen jälkeen, ja sitä vaikuttivatko primaaritulokset (fyysinen toimintakyky, kipu, ahdistus) tai taloudelliset seuraukset (potilaiden itsensämaksamat kustannukset, palvelujen käyttö) terveyteen liittyvään elämänlaatuun. Tutkimuksen tavoitteena oli löytää mahdolliset kriittiset ajankohdat tai tekijät, jotka saattavat hidastaa toipumista ja siten huonontaa potilaiden elämänlaatua. Tätä tietoa voidaan käyttää hoitotyössä kun suunnitellaan sopivaa hoitoa ja tukea toipumisajalle. Tutkimuksen ensimmäisessä vaiheessa primaarileikkaukseen tulevat potilaat (n = 17) kuvailivat teemahaastatteluissa kokemuksiaan kahdesti leikkauksen jälkeen. Haastatteluaineisto analysoitiin induktiivisella sisällönanalyysilla. Lisäksi 17 tutkimusartikkelista analysoitiin deduktiivisella sisällönanalyysilla leikkauksen tuloksia potilaalle, tuloksiin vaikuttavia tekijöitä ja käytetyt tutkimusmetodit. Toisessa vaiheessa primaari- tai revisioleikkaukseen tulevat potilaat (n = 100) arvioivat leikkauksen tuloksia kuuden kuukauden ajan leikkauksen jälkeen: terveyteen liittyvää elämänlaatua, primaarituloksia ja taloudellisia seurauksia. Aineisto kerättiin erilaisilla mittareilla: Sickness Impact Profile, Finnish Version, Stait-Trait Anxiety Inventory, ja Numeric Rating Scale. Lisäksi käytettiin tätä tutkimusta varten tehtyjä kyselylomakkeita: Fyysinen toimintakyky-mittari, Palvelujen käyttö-mittari ja Kustannusmittari. Tutkimuksen toiseen vaiheen tulokset analysoitiin tilastollisilla menetelmillä. Potilaiden terveyteen liittyvä elämänlaatu parani ja kipu lievittyi leikkauksen jälkeen ja fyysinen toimintakyky lisääntyi toipumisaikana. Positiivisista muutoksista huolimatta potilaat kokivat ahdistusta samassa määrin kuin ennen leikkaustakin. Palvelujen käyttö vaihteli toipumisajan kuluessa ja potilaiden maksamissa kustannuksissa oli suuria vaihteluita. Fyysisen toimintakyvyn lisääntyminen ja kivun lieveneminen paransivat terveyteen liittyvää elämänlaatua. Sen sijaan huonompi elämänlaatu toipumisaikana oli yhteydessä suurempaan palvelujen käyttöön, kun taas kustannuksilla ei ollut yhteyttä elämänlaatuun. Potilaiden ominaispiirteet tulisi ottaa enemmän huomioon suunniteltaessa sopivaa leikkauksenjälkeistä hoitoa ja tukea. Potilaat tarvitsevat yksilöllisiä ohjeita, sillä monet taustatekijät (esim. ikä, sukupuoli, preoperatiivinen kipu, siviilisääty, ja leikkaustyyppi) vaikuttavat toipumiseen.

The Mixed Management of Patients' Medical Records: Responsibility Sharing Between the Patient and the Physician

Through this article, we propose a mixed management of patients' medical records, so as to share responsibilities between the patient and the Medical Practitioner by making Patients responsible for the validation of their administrative information, and MPs responsible for the validation of their Patients' medical information. Our proposal can be considered a solution to the main problem faced by patients, health practitioners and the authorities, namely the gathering and updating of administrative and medical data belonging to the patient in order to accurately reconstitute a patient's medical history. This method is based on two processes. The aim of the first process is to provide a patient's administrative data, in order to know where and when the patient received care (name of the health structure or health practitioner, type of care: out patient or inpatient). The aim of the second process is to provide a patient's medical information and to validate it under the accountability of the Medical Practitioner with the help of the patient if needed. During these two processes, the patient's privacy will be ensured through cryptographic hash functions like the Secure Hash Algorithm, which allows pseudonymisation of a patient's identity. The proposed Medical Record Search Engines will be able to retrieve and to provide upon a request formulated by the Medical ractitioner all the available information concerning a patient who has received care in different health structures without divulging the patient's identity. Our method can lead to improved efficiency of personal medical record management under the mixed responsibilities of the patient and the MP.

Acolhendo o acolhedor: o caminho mais curto para a humanização da assistência

INTRODUÇÃO: o acolhimento tem se constituído num potente disparador de mudanças. Este trabalho reflete a satisfação experimentada, resultante da atuação num ambiente altamente sinérgico e produtivo. OBJETIVO: implantação e implementação da assistência materno-neonatal a partir do acolhimento ao cliente interno. MÉTODO: realizou-se observação direta do cotidiano em setores distintos do Hospital Maternidade Interlagos (HMI) -SES/SP e seu Ambulatório. Foram realizadas entrevistas semi-estruturadas com dois profissionais da equipe multidisciplinar, as quais subsidiaram oficinas de humanização no ambiente hospitalar. Os profissionais foram divididos em áreas de exercício profissional, da administrativa à assistencial. RESULTADOS: ocorreu implantação do Comitê de Acolhimento e Humanização da Assistência Materno-Neonatal no Hospital Maternidade Interlagos, com participação dos líderes de acolhimento na gerência institucional, provendo melhor desempenho individual e coletivo no exercício laboral na Unidade Hospitalar

A comparison of the symptomatic profile between two consecutive depressive episodes in patients with bipolar disorder type I

Objective: To compare the variability of patterns of depressive symptoms between two consecutive depressive episodes in patients with bipolar disorder type I. Methods: Review of prospectively collected data from 136 subjects of an out-patient bipolar unit from 1997 to 2007. Binomial statistics was used for the analysis of Hamilton Depression Rating Scale (HDRS)-31 items of the first and second episodes, and the correlation of the HDRS-31 item scores of both episodes was determined using the Spearman coefficient. Results: Ten depressive symptoms showed a significant correlation between index and subsequent episodes: psychological anxiety, somatic anxiety, somatic symptoms, diurnal variation, paranoid symptoms, obsessive and compulsive symptoms, hypersomnia, loss of appetite and helplessness. Only four symptoms were stable in both statistical tests: paranoid symptoms, obsessive-compulsive symptoms, loss of appetite and hypersomnia. Conclusions: Paranoid and obsessive-compulsive symptoms, loss of appetite and hypersomnia tended to be found in successive episodes. However, the moderate correlations of the symptoms across two depressive recurrences suggested that clinical presentations in bipolar depression may not be predicted by symptom profiles presented in previous episodes.