3 research outputs found

    Atendimento clínicos com pessoas em situação de rua em prática de Saúde Coletiva e sua importância na formação médica / Clinical care with homeless people in Public Health practice and its importance in medical training

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    A prática da disciplina de Saúde Coletiva da Universidade Federal do Amazonas consisitiu em vivenciar atendimentos médicos a pessoas em situação de rua. Esta população, não raro, é negligenciada e marginalizada. Em face de raramente procurarem serviços de saúde, às vezes por desconhecerem seus direitos, vão suportando a presença dos sintomas de doenças, recorrendo à rede emergencial em último caso, com o acúmulo de vários problemas de saúde. Relatar como ao provocar encontros com pessoas em situação de rua, a intenção da Disciplina de Saúde Coletiva IV é elucidar que aprendizagem médica não se restringe apenas ao hospital. Visando à compreensão de aspectos do planejamento em saúde a prática de saúde coletiva envolveu pessoas em situações de rua. Os alunos em duplas se distribuíram em “mesas-ambulatórios” em um salão de Instituição que ampara essa população. Assim, foram orientados a escutar os relatos de saúde trazidos, como também as falas sobre o cenário psicossocial que vivem. Dessa maneira, por meio de conversas, interesse e sutilezas foram preenchidos questionários e colhidas histórias clínicas. Realizou-se também exames físicos, em que o aluno teve a oportunidade viver aspectos de semiologia médica sob supervisão. O professor foi orientador da prática, auxiliando os alunos para a tomada de conduta. Após, os atendimentos, os exames solicitados e as prescrições foram entregues ao serviço social para que os atendidos pudessem ter acesso à rede de serviço de saúde. Com tal prática, os discentes, além de terem exercitado os conhecimentos adquiridos no curso de medicina e na disciplina de Saúde Coletiva, puderam entender a realidade vivida por moradores de rua, bem como suas principais necessidades de saúde. Ademais, realizando atividades com pessoas em estado de vulnerabilidade social, puderam sensibilizar-se e perceber a importância dos princípios propostos pelo SUS. A prática com moradores de rua cumpre seu papel na formação mais humanizada e abrangente dos futuros profissionais da saúde, que devem ser comprometidos com as necessidades das populações e atentar-se, ainda mais, para as populações que vivem à margem da cidadania e, portanto, não possuem um atendimento adequado a saúde

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

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    © 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

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    © 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
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