Guest Editorial: Some population perspectives on chronic kidney disease

In this issue of Advances in Chronic Kidney Disease, emphasis is placed on populationbased perspectives on kidney and related chronic diseases and their risk factors. The articles remind us that we must expand our views, break down specialty barriers, work on improved primary care models and prevention modalities, and think in terms of wholeof- person and whole-of-community, rather than in organ-specific approaches.

Epidemiologia e saúde bucal coletiva: um caminhar compartilhado.

The public health dentistry is a way to bring oral health to Brazilian National Health System (SUS) and vice-versa. Thus, the epidemiology, in this context, it is one of the most important allies. In this article we intend to discuss the "shared walkway" between epidemiology and public health dentistry, through two views: first, we analyzed the efforts to establish methodological models for oral health sectional studies and the possibilities to construct a national data base. Second, we discussed how this knowledge has been transformed in a qualified scientific production presented in meetings and papers, which reflects, at the same time, about the contribution of this process in the consolidation of public health dentistry field. We concluded that this "shared walkway" was (and still is), influenced by political aspects, which, in different moments, leads to an improvement of public health dentistry. The oral health epidemiology has been established as a knowledge area, with regard to the scientific production in Brazil. At the same time, provide a tool that contributes to make oral health care models more appropriate to National Health System principles and, in other hand, make better the discussions about the social determinants of oral diseases.

Epidemiologia e saúde bucal coletiva: um caminhar compartilhado.

The public health dentistry is a way to bring oral health to Brazilian National Health System (SUS) and vice-versa. Thus, the epidemiology, in this context, it is one of the most important allies. In this article we intend to discuss the "shared walkway" between epidemiology and public health dentistry, through two views: first, we analyzed the efforts to establish methodological models for oral health sectional studies and the possibilities to construct a national data base. Second, we discussed how this knowledge has been transformed in a qualified scientific production presented in meetings and papers, which reflects, at the same time, about the contribution of this process in the consolidation of public health dentistry field. We concluded that this "shared walkway" was (and still is), influenced by political aspects, which, in different moments, leads to an improvement of public health dentistry. The oral health epidemiology has been established as a knowledge area, with regard to the scientific production in Brazil. At the same time, provide a tool that contributes to make oral health care models more appropriate to National Health System principles and, in other hand, make better the discussions about the social determinants of oral diseases.

A organização da demanda em serviços públicos de saúde bucal: universalidade, eqüidade e integralidade em saúde bucal coletiva

RONCALLI, Angelo Giuseppe. A organização da demanda em serviços públicos de saúde bucal: universalidade, eqüidade e integralidade em Saúde Bucal Coletiva. raçatuba, 2000. 238p. Tese (Doutorado em Odontologia Preventiva e Social). Faculdade de Odontologia, Universidade Estadual Paulista “Júlio de Mesquita Filho”

A organização da demanda em serviços públicos de saúde bucal: universalidade, eqüidade e integralidade em saúde bucal coletiva

RONCALLI, Angelo Giuseppe. A organização da demanda em serviços públicos de saúde bucal: universalidade, eqüidade e integralidade em Saúde Bucal Coletiva. raçatuba, 2000. 238p. Tese (Doutorado em Odontologia Preventiva e Social). Faculdade de Odontologia, Universidade Estadual Paulista “Júlio de Mesquita Filho”

Développement et pré-test d’un plan de soins de suivi pour des femmes atteintes du cancer de l’endomètre avec traitements adjuvants lors de la transition de la fin du traitement actif vers la survie au cancer

La fin du traitement actif et le début de la phase de survie correspondent à une période de transition qui présente de nombreux défis pour la personne survivante au cancer, les soignants et le système de santé. La phase de survie au cancer est une phase distincte mais négligée du continuum de soins. Pour faciliter la transition de la fin du traitement actif vers la survie et optimiser la coordination des soins de suivi, la mise en place d’un plan de soins de suivi (PSS) est proposée. Le but de cette recherche est de développer, de mettre en place et d’évaluer si un plan de soins de suivi (PSS) permet de répondre aux besoins globaux, de diminuer la détresse émotionnelle et de favoriser les comportements d’autogestion de santé de femmes atteintes du cancer de l’endomètre (FACE) lors de la transition de la fin du traitement actif vers la survie au cancer. Elle comprend deux phases distinctes. La première phase visait d’abord le développement d’un plan de soins de suivi (PSS) pour des femmes atteintes du cancer de l’endomètre avec traitements adjuvants. La sélection du contenu du PSS a été faite à partir de la recension des écrits et des données recueillies lors d’entrevues individuelles avec 19 FACE, 24 professionnels de la santé travaillant avec cette clientèle et quatre gestionnaires de proximité en oncologie. Cette première phase avait également pour but la validation du contenu du PSS auprès de dix professionnels de la santé impliqués dans l’étude. La seconde phase consistait à évaluer la faisabilité, l’acceptabilité du PSS et à en pré-tester l’utilité à répondre aux besoins globaux, à diminuer la détresse émotionnelle (peur de la récidive) et à favoriser l’autogestion de santé auprès d’un groupe de 18 femmes atteintes du cancer de l’endomètre avec traitements adjuvants à la fin du traitement actif vers la survie. Sur le plan de la faisabilité, les résultats suggèrent que la mise en place du PSS comporte des défis en termes de temps, de ressources et de coordination pour l’infirmière pivot en oncologie (IPO). Concernant l’acceptabilité du PSS, les FACE le perçoivent comme un outil d’information utile qui favorise la communication avec le médecin de famille ou d’autres professionnels de la santé. Les IPO soutiennent sa valeur ajoutée à la fin du traitement et soulignent que la discussion du contenu du PSS fait ressortir des éléments de surveillance et de suivi essentiels à prendre en compte pour la phase de survie et permet de mettre l’emphase sur l’autogestion de sa santé. Pour les médecins de famille, le PSS est un outil d’information pour les survivantes qui favorise la réassurance, la communication et la continuité des soins entre professionnels de la santé. Enfin, pour ce qui est de l’utilité du PSS à répondre aux besoins globaux, les résultats suggèrent que l’ensemble des besoins sont plus satisfaits trois mois après la fin des traitements pour le groupe ayant reçu un PSS. Bien que la peur de récidive du cancer (PRC) s’améliore au suivi de trois mois pour le groupe exposé au PSS, 55% des FACE conservent un score cliniquement significatif de 13 à la sous-échelle de sévérité de peur de récidive à la fin du traitement et 42% au suivi de trois mois. Les comportements d’autogestion de santé s’améliorent entre la fin du traitement et le suivi de trois mois pour le groupe exposé un PSS. Considérant ces résultats, la démarche soutient la pertinence de mettre en place un PSS à la fin du traitement actif pour les FACE pour répondre à des besoins d’information, favoriser la communication et la continuité des soins avec les professionnels de la santé et les comportements d’autogestion de santé dans la phase de survie. Cependant, des contraintes de temps, de ressources et de coordination doivent être prises en compte pour sa mise en place dans le milieu clinique. Mots-clés : Transition, fin du traitement actif, besoins, survie au cancer, plan de soins de suivi.

Evaluation of the impact of nursing clinics in the rheumatology services

Nursing clinics in rheumatology (NCRs) are organisational care models that provide care centred within the scope of a nurse’s abilities. To analyse the impact of NCR in the rheumatology services, national multicenter observational prospective cohort studied 1-year follow-up, comparing patients attending rheumatology services with and without NCR. NCR was defined by the presence of: (1) office itself; (2) at least one dedicated nurse; and (3) its own appointment schedule. Variables included were (baseline, 6 and 12 months): (a) test to evaluate clinical activity of the disease, research and training, infrastructure of unit and resources of NCR and (b) tests to evaluate socio-demographics, work productivity (WPAI), use of services and treatments and quality of life. A total of 393 rheumatoid arthritis and ankylosing spondylitis patients were included: 181 NCR and 212 not NCR, corresponding to 39 units, 21 with NCR and 18 without NCR (age 53 + 11.8 vs 56 + 13.5 years). Statistically significant differences were found in patients attended in sites without NCR, at some of the visits (baseline, 6 or 12 months), for the following parameters: higher CRP level (5.9 mg/l ± 8.3 vs 4.8 mg/l ± 7.8; p < 0.005), global disease evaluation by the patient (3.6 ± 2.3 vs 3.1 ± 2.4), physician (2.9 ± 2.1 vs 2.3 ± 2.1; p < 0.05), use of primary care consultations (2.7 ± 5.4 vs 1.4 ± 2.3; p < 0.001) and worse work productivity. The presence of NCR in the rheumatology services contributes to improve some clinical outcomes, a lower frequency of primary care consultations and better work productivity of patients with rheumatic diseases.

Modelo de gestión para la atención integral de pacientes con enfermedades huérfanas o raras en Colombia

Las enfermedades raras o huérfanas corresponden a aquellas con baja prevalencia en la población, y en varios países tienen una definición distinta de acuerdo con el número de pacientes que afectan en la población. La Organización Mundial de la Salud (OMS), las define como un trastorno que afecta de 650 a 1.000 personas por millón de habitantes, de las que se han identificado alrededor de 7.000. En Colombia su prevalencia es menor de 1 por cada 5.000 personas y comprenden: las enfermedades raras, las ultra-huérfanas y las olvidadas. Los pacientes con este tipo de enfermedades imponen retos a los sistemas sanitarios, pues si bien afectan a un bajo porcentaje de la población, su atención implica una alta carga económica por los costos que involucra su atención, la complejidad en su diagnóstico, tratamiento, seguimiento y rehabilitación. El abordaje de las enfermedades raras requiere un manejo interdisciplinar e intersectorial, lo que implica la organización de cada actor del sistema sanitario para su manejo a través de un modelo que abraque las dinámicas posibles entre ellos y las competencias de cada uno. Por lo anterior, y teniendo en cuenta la necesidad de formular políticas sanitarias específicas para la gestión de estas enfermedades, el presente trabajo presenta una aproximación a la formulación de un modelo de gestión para la atención integral de pacientes con enfermedades raras en Colombia. Esta investigación describe los distintos elementos y características de los modelos de gestión clínica y de las enfermedades raras a través de una revisión de literatura, en la que se incluye la descripción de los distintos actores del Sistema de Salud Colombiano, relacionados con la atención integral de estos pacientes para la documentación de un modelo de gestión integral.

Implementación de criterios de Beers en pacientes con atención domiciliaria mayores de 75 años polimedicados y la identificación de las reacciones cruzadas

Introducción: El incremento de la población geriátrica es una realidad a nivel mundial y con esto los modelos de atención domiciliaria toman gran relevancia para dar respuesta a las diferentes patologías que requieran su seguimiento. Se ha evidenciado que en dicho seguimiento, el fenómeno de la polimedicación se presenta con frecuencia, con el riesgo de generar efectos cruzados y reacciones adversas que incrementan el deterioro clínico de los pacientes. Objetivo: Determinar los posibles efectos cruzados de la Polimedicación no pertinente en pacientes mayores de 75 años con hipertensión arterial más enfermedad neurodegenerativa en atención domiciliaria de una EPS del régimen contributivo en Bogotá, con base en los criterios de Beers.

Prospective independent validation of APACHE III models in an Australian tertiary adult intensive care unit

Evaluation of the performance of the APACHE III (Acute Physiology and Chronic Health Evaluation) ICU (intensive care unit) and hospital mortality models at the Princess Alexandra Hospital, Brisbane is reported. Prospective collection of demographic, diagnostic, physiological, laboratory, admission and discharge data of 5681 consecutive eligible admissions (1 January 1995 to 1 January 2000) was conducted at the Princess Alexandra Hospital, a metropolitan Australian tertiary referral medical/surgical adult ICU. ROC (receiver operating characteristic) curve areas for the APACHE III ICU mortality and hospital mortality models demonstrated excellent discrimination. Observed ICU mortality (9.1%) was significantly overestimated by the APACHE III model adjusted for hospital characteristics (10.1%), but did not significantly differ from the prediction of the generic APACHE III model (8.6%). In contrast, observed hospital mortality (14.8%) agreed well with the prediction of the APACHE III model adjusted for hospital characteristics (14.6%), but was significantly underestimated by the unadjusted APACHE III model (13.2%). Calibration curves and goodness-of-fit analysis using Hosmer-Lemeshow statistics, demonstrated that calibration was good with the unadjusted APACHE III ICU mortality model, and the APACHE III hospital mortality model adjusted for hospital characteristics. Post hoc analysis revealed a declining annual SMR (standardized mortality rate) during the study period. This trend was present in each of the non-surgical, emergency and elective surgical diagnostic groups, and the change was temporally related to increased specialist staffing levels. This study demonstrates that the APACHE III model performs well on independent assessment in an Australian hospital. Changes observed in annual SMR using such a validated model support an hypothesis of improved survival outcomes 1995-1999.

What Belongs Where? Variable Selection for Zero-Inflated Count Models with an Application to the Demand for Health Care

This paper develops stochastic search variable selection (SSVS) for zero-inflated count models which are commonly used in health economics. This allows for either model averaging or model selection in situations with many potential regressors. The proposed techniques are applied to a data set from Germany considering the demand for health care. A package for the free statistical software environment R is provided.

Technologies of birth and models of midwifery care

This article is based on a study of a reform in the organisation of maternity services in the United Kingdom, which aimed towards developing a more woman-centred model of care. After decades of fragmentation and depersonalisation of care, associated with the shift of birth to a hospital setting, pressure by midwives and mothers prompted government review and a relatively radical turnaround in policy. However, the emergent model of care has been profoundly influenced by concepts and technologies of monitoring. The use of such technologies as ultrasound scans, electronic foetal monitoring and oxytocic augmentation of labour, generally supported by epidural anaesthesia for pain relief, have accompanied the development of a particular ecological model of birth – often called active management –, which is oriented towards the idea of an obstetric norm. Drawing on analysis of women’s narrative accounts of labour and birth, this article discusses the impact on women’s embodiment in birth, and the sources of information they use about the status of their own bodies, their labour and that of the child. It also illustrates how the impact on women’s experiences of birth may be mediated by a relational model of support, through the provision of caseload midwifery care.