"Rodas de educação permanente" na atenção básica de saúde: analisando contribuições

In 2004 the Brazilian Ministry of Health instituted the National Policy of Permanent Education as a strategy for training and developing SUS' employees. This policy states that the educational process offered to these professionals should be decentralized, ascendant and transdisciplinary. Relying on principles of meaningful learning, this policy proposed that the transformation of professional practices should be based upon critical thinking of the work process developed by the teams at the health system's units, and suggested that the states adopt Circles of Permanent Education. Taking these suggestions as a reference, the Municipal Secretary of Health of Vitória, capital city of the state of Espírito Santo, adopted this tool in its humanization and educational policy, implanting the "Circles of Permanent Education" in Primary Health Care in 2005. The guiding principles of these circles regarded three aspects of health services, namely training, management and care, and were based in white papers (National Policy of Permanent Education; the Circle Method; National Policy of Humanization). This paper presents the first evaluation of this tool, conducted by the Municipal Secretary and supported by consultants of the Ministry of Health in 2006. Results indicated that the 'Circles' represent an important collective space for discussion at the health units of Vitória's municipal network of Primary Care, and are potentially helpful in promoting participative management, the appropriation of public health policies by the workers, and in humanizing work relations.O Ministério da Saúde instituiu, em 2004, a Política Nacional de Educação Permanente em Saúde como estratégia para a formação e o desenvolvimento dos trabalhadores do SUS. Essa política propõe que os processos educativos desses profissionais se dêem de modo descentralizado, ascendente e transdisciplinar. Partindo do pressuposto da aprendizagem significativa, sugere que a transformação das práticas profissionais se baseie na reflexão crítica sobre o processo de trabalho desenvolvido pelas equipes na rede de serviços de saúde. Tomando como referência as Rodas de Educação Permanente propostas para os Pólos de Educação Permanente em Saúde dos Estados, a Secretaria Municipal de Saúde de Vitória, capital do estado do Espírito Santo, adotou esse dispositivo em sua política educacional e de humanização, implantando, em 2005, as "Rodas de Educação Permanente" na rede de Atenção Básica. Essas Rodas tinham como princípios norteadores a Política Nacional de Educação Permanente, na vertente da educação, o Método da Roda, na vertente da gestão, e a Política Nacional de Humanização na vertente do cuidado. Uma primeira avaliação desse dispositivo, conduzida pela Secretaria Municipal com apoio de consultores do Ministério da Saúde, em 2006, indicou que as "Rodas" representam um importante espaço coletivo de discussão nas unidades de saúde da rede municipal de Atenção Básica de Vitória, e apresentam um potencial para promover a gestão participativa e a apropriação das políticas de saúde pública pelos trabalhadores e humanizar as relações de trabalho

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Dengue: clinical forms and risk groups in a high incidence city in the southeastern region of Brazil Dengue: formas clínicas e grupos de risco em município de alta incidência do sudeste do Brasil

INTRODUCTION: The article describes the epidemiologic profile of dengue cases in Vitória, the capital of Espírito Santo, Brazil, from 2000 to 2009, aimed at identifying risk groups regarding the incidence and severity of the disease. METHODS: Confirmed cases of dengue among city residents during ten years were classified as dengue fever, dengue hemorrhagic fever, dengue shock syndrome and dengue with complications, and analyzed according to sex, age, race-color and education. RESULTS: The proportion of dengue cases was highest among women aged 20 to 29 years-old and similar between whites and blacks. A gradual decrease occurred in the percentage of dengue cases in the population aged 15 years-old or more, in the historical series of 10 years, and a growing increase in individuals less than 15 years-old, showing statistical significance. The fatality rate ranged from zero to 0.3% for all forms of dengue and from 0.2% to 18.2% for severe forms. CONCLUSIONS: The profile of those affected by the disease in the municipality is similar to those affected in Brazil. The increasing number of cases in individuals under 15 years-old corroborates the results of recent studies in other Brazilian municipalities.<br>INTRODUÇÃO: O artigo descreve o perfil epidemiológico dos casos de dengue ocorridos no município de Vitória, capital do Estado do Espírito Santo, no período de 2000 a 2009, procurando identificar grupos de risco para a incidência e gravidade da doença. MÉTODOS: Os casos de dengue, confirmados em residentes do município no período de dez anos, foram classificados como febre da dengue, febre hemorrágica da dengue, síndrome do choque da dengue e dengue com complicações, e analisados segundo sexo, faixa etária, raça-cor e escolaridade. RESULTADOS: A proporção de casos de dengue foi maior entre mulheres, indivíduos de 20 a 29 anos, e semelhante entre brancos e afrodescendentes. Houve uma diminuição gradual do percentual de casos de dengue na população com 15 anos ou mais, na série histórica de 10 anos, e um aumento crescente em menores de 15 anos de idade, com significância estatística. A taxa de letalidade variou de zero a 0,3% para todas as formas de dengue, e de 0,2% a 18,2% para as formas graves. CONCLUSÕES: O perfil dos acometidos pela dengue no município é semelhante ao do Brasil. O aumento crescente de casos em menores de 15 anos corrobora os resultados de estudos recentes em outros municípios brasileiros

Dengue: clinical forms and risk groups in a high incidence city in the southeastern region of Brazil

INTRODUCTION: The article describes the epidemiologic profile of dengue cases in Vitória, the capital of Espírito Santo, Brazil, from 2000 to 2009, aimed at identifying risk groups regarding the incidence and severity of the disease. METHODS: Confirmed cases of dengue among city residents during ten years were classified as dengue fever, dengue hemorrhagic fever, dengue shock syndrome and dengue with complications, and analyzed according to sex, age, race-color and education. RESULTS: The proportion of dengue cases was highest among women aged 20 to 29 years-old and similar between whites and blacks. A gradual decrease occurred in the percentage of dengue cases in the population aged 15 years-old or more, in the historical series of 10 years, and a growing increase in individuals less than 15 years-old, showing statistical significance. The fatality rate ranged from zero to 0.3% for all forms of dengue and from 0.2% to 18.2% for severe forms. CONCLUSIONS: The profile of those affected by the disease in the municipality is similar to those affected in Brazil. The increasing number of cases in individuals under 15 years-old corroborates the results of recent studies in other Brazilian municipalities

Encefalite anti-NMDAr associada a tumores ovarianos: estudo de casos e revisão sistemática

A encefalite anti-NMDAR associada a tumores ovarianos é uma condição neurológica rara caracterizada pela presença de anticorpos anti-receptores NMDA no sistema nervoso central, frequentemente relacionada a teratomas ovarianos. Nesse sentido, o presente estudo tem como objetivo analisar casos sobre a encefalite anti-NMDAr associada a tumores ovarianos e realizar uma revisão bibliográfica. A revisão foi conduzida por meio de buscas nas bases de dados PubMed, Cochrane Library e SciELO, usando descritores MeSH relacionados à encefalite anti-NMDAR e teratomas ovarianos, com um recorte temporal de 2013 a 2023, com artigos na língua inglesa. Foram selecionados artigos que abordavam achados clínicos, diagnóstico, tratamento e desfechos de pacientes com essa síndrome. Os achados clínicos incluíram sintomas como psicose, convulsões, movimentos involuntários e comportamento agressivo. O diagnóstico envolveu avaliação clínica, exames de imagem e detecção de anticorpos anti-NMDA. A terapia incluiu ressecção cirúrgica de teratomas, pulsoterapia de imunoglobulina intravenosa (IVIG) e corticosteroides. Todos os pacientes apresentaram recuperação completa. A compilação dos resultados revelou a eficácia da terapia, com melhora estatisticamente significativa nos sintomas e respostas clínicas após tratamento. A remoção cirúrgica dos teratomas e a terapia imunomodulatória resultaram em recuperação completa. A abordagem de tratamento combinada foi eficaz na redução da resposta autoimune. A análise dos casos também destacou a importância do diagnóstico precoce para melhores resultados. Em resumo, a encefalite anti-NMDAR associada a teratomas ovarianos é uma condição complexa, mas tratável. A abordagem terapêutica combinada, a qual inclui ressecção cirúrgica e terapia imunomoduladora, cuja dose recomendada é de 0,4 g/kg/dia por 5 dias, seguida de corticoides para reduzir a inflamação cerebral, demonstrou eficácia na recuperação completa dos pacientes

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.13Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research