A importância dos fatores sociais em transtornosmentais graves na atenção primária de saúde.

Exportado OPUSMade available in DSpace on 2019-08-14T14:18:07Z (GMT). No. of bitstreams: 1 disserta__o___bruno_drummond.pdf: 1721904 bytes, checksum: 0b216d2bb21d5c11ea285f5700387187 (MD5) Previous issue date: 19Introdução: Os transtornos mentais graves, particularmente aqueles com situações de risco, apresentam complexidade em sua evolução clínica. Tal complexidade, na atenção primária de saúde, está relacionada com os fatores sociais. A importância de fatores sociais,principalmente rede e apoio social, tem sido valorizada na estratégia de tratamento de transtornos mentais graves. Deste modo é preciso conhecer, na atenção primária de saúde, os transtornos mentais e os fatores sociais. Esta dissertação tem por objetivo, em um primeiroartigo, descrever o perfil clínico epidemiológico dos transtornos mentais, priorizando os graves com situação de risco, e os equipamentos sociais disponíveis na área de referência de quatro Unidades Básicas de Saúde (UBS). Subsequentemente, avaliar em um segundo artigo, os fatores sociais associados, principalmente rede e apoio social, aos transtornos mentais graves com situações de risco. Método: Inicialmente foi realizado um estudo descritivo de portadores de transtornos mentais (que apresentam ou não situações de risco), das situações de risco no grupo de transtornos mentais graves e de equipamentos sociais disponíveis. Após levantamento de 853 prontuários em quatro UBS, fez-se estatística descritiva, qui-quadrado e mapeamento da área estudada. Posteriormente, fez-se um estudo descritivo e comparativoentre os grupos que apresentam situações de risco (transtornos mentais graves TMG) ou não (outros transtornos mentais OTM), em relação aos fatores sociais: rede, apoio, estilo, condições de vida e variáveis socio-demográficas. Foram aplicados questionários, em umaamostra de 240 usuários atendidos pela saúde mental, nas quatro UBS. Fez-se estatística descritiva, análise univariada e regressão logística binária. Resultados: Encontrou-se 72% da amostra são de OTM, com predomínio do sexo feminino e de transtornos de ansiedade. Poroutro lado, nos 28% de TMG, predominam as psicoses funcionais e orgânicas, embora com elevada proporção de transtornos neuróticos graves. As situações de risco de maior proporção foram: co-morbidade neurológica (42%) e internação psiquiátrica (33%). A rede apresenta 37projetos sociais, distribuídos por 31 equipamentos, em sete tipos de atividades. No estudo comparativo, os fatores que permaneceram associados na regressão logística binária foram: ser do sexo masculino, ter somente até um parente confidente (rede social), não conseguir retornar para casa quando sai do espaço onde vive (condições de vida) e redução na dimensão afetivo da escala utilizada para medir o apoio social. Conclusões: A presença de TMG na atenção primária de saúde é importante e o fato de distingui-los por meio desituações de risco permite a inclusão, no planejamento, de transtornos neuróticos graves. A rede social é vulnerável, devido à expressiva proporção de TMG, ao número escasso de equipamentos e sua distância em relação à moradia dos usuários. Conclui-se que há urgência de políticas que visem o aumento do número de equipamentos da rede social e projetos de apoio social com participação das famílias, particularmente para os TMG com situações de risco.Introduction: Severe mental disorders, particularly those with risk situations, have a complex clinical evolution. This complexity is related to social factors in the primary health care. Social factors, mainly social network and support, play an important role in the strategy to treat severe mental disorders. Thus, it is important to know mental disorders and social factors in the primary health care. This dissertation has the purpose, in this first paper, of describing the epidemiological clinical profile of mental disorders, prioritizing the severe ones with risksituations, and the social equipments available in the referral area of four Primary Health Care Centers - PHCC. Subsequently, in a second paper, social factors, mainly social network and support, associated to severe mental disorders with risk situations. Method: First, a descriptive study of mental disorder carriers (having or not risk situations), of risk situationsin groups of severe mental disorders and of social equipment available. After the survey of 853 medical charts from four PHCCs, a descriptive statistical analysis was performed, as well as chi-square and mapping of the studied area. Then, a descriptive and comparative study was carried out between the groups which presented risk situations (severe mental disorders SMD) or not (other mental disorders OMD), regarding social factors: network, support, life style, and socio-demographic variables. Questionnaires were applied to a sample of 240 users of health mental care in the four PHCCs. Descriptive statistical analysis, as well as univariate analysis and binary logistic regression was performed. Results: Seventy-two percent of the sample was OMD, predominantly females and with anxiety disorders. On the other hand, out of the 28% of SMD, functional and organic psychoses have predominated, although with a large number of severe neurotic disorders. Risk situations with a larger proportion were: neurological comorbidity (42%) and psychiatric hospitalization (33%). Social network presents 37 social projects, distributed by 31 equipments, in seven types of activities. In thecomparative study, factors which remained associated in the binary logistic regression were: being a male, having up to one confidant relative (social network), not being able to go back home when leaving the place where they live (life conditions) and decreased affectivedimension in the scale used to measure the social support. Conclusions: The presence of SMD in primary health care is important and the fact of distinguishing them by means of risk situations, allows including severe neurotic disorders in the planning. The social network isvulnerable due to the considerable proportion of SMD regarding the scarce number of equipment and the distance between them and the users homes. In conclusion, policies are urgently needed in order to increase the number of equipments in social network and socialsupport projects with the participation of the families, particularly for SMDs with risk situations

Social factors associated with mental disorders with risk situations in the primary health care

OBJECTIVE: To evaluate patients with mental disorders, with or without risk situations, treated at primary health care (PHC) units. METHOD: A cross-sectional study was performed in samples of 240 patients living in a region of high social vulnerability in Belo Horizonte. The response variable was mental disorders with risk situations (MD-WR). The explanatory variables were gender, age, marital status, literacy, education, employment, social benefits and per capita income. Instruments from Berkman and Syme (social network), Sherbourne and Stewart (social support), adapted for Brazil, were applied. Pearson's χ2 test and binary logistic regression were used for the adjusted analyzes. RESULTS: The factors associated with MD-WR were being male (OR = 3.62; 95%CI 1.84 - 7.09); having "up to one confident relative" only (OR = 2.53; 95%CI 1.18 - 5.42); being "not able to return home" when away from their living area (OR = 3.49; 95%CI 1.40 - 8.71). The reduction in the affective dimension of the Medical Outcomes Study (MOS) scale increases the chance of MD-WR. Conclusion: The availability and access to social and support networks are lower for patients with MD-WR and need to be strengthened to promote autonomy and citizenship among its users. We conclude that there is the need of public policies to increase the availability of social networking equipment and social support projects, encouraging the participation of families

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

This was an investigator initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (UK) Professorship held by RP. The study was sponsored by Queen Mary University of London