A humanização da assistência de enfermagem na perspectiva de enfermeiros da atenção primária à saúde / Humanization of nursing care: perspective of nurses working in primary health care services

Reconhecendo que a enfermagem é a maior categoria profissional atuante na assistência à saúde no Sistema Único de Saúde (SUS) e que a humanização da assistência é essencial para a qualificação dessa atenção, neste estudo investigamos a percepção dos enfermeiros quanto à humanização da assistência de enfermagem nos serviços de Atenção Primária à Saúde do SUS. Trata-se de uma pesquisa de abordadem qualitativa, envolvendo 17 enfermeiros atuantes em Unidades de Referência em Atenção Primária à Saúde (URAP) em um município da região Amazônica Ocidental Brasileira. Na perspectiva dos enfermeiros, a humanização foi identificada por conceitos coerentes com a Política Nacional de Humanização do SUS, no que diz respeito aos aspectos de resolutividade, acolhimento e integralidade da assistência, embora ainda tenham sido identificadas percepções relacionadas à visão tradicional caritativa, percepção que é subjugada pela compreensão vigente da saúde como um direito dos usuários

Associação dos níveis séricos de sFlt-1, proteína C reativa (PCR) e leptina com a histopatologia da malária placentária por Plasmodium vivax.

A malária associada à gravidez representa um grande problema de saúde pública. Atualmente, estima-se que 125 milhões de gestantes no mundo estejam expostas ao risco de contrair essa doença. A malária associada à gravidez é definida pela presença de Plasmodium spp. no sangue periférico e/ou na placenta, capaz de acarretar anemia materna, restrição do crescimento intrauterino, baixo peso ao nascer e diminuição da viabilidade fetal. No Brasil, observa-se um predomínio das infecções causadas por Plasmodium (P.) vivax, onde 95% dos casos ocorrem na Amazônia Legal. Por se tratar de uma doença de magnitude e de efeitos adversos para a mãe e o feto, é necessário a identificação de biomarcadores preditivos para um rápido diagnóstico da enfermidade. Foi realizado um estudo transversal com gestantes residentes na região do Alto Juruá (Acre). As consequências e a extensão dos efeitos da malária gestacional foram avaliadas através da coleta de dados biológicos e epidemiológicos de gestantes com ou sem infecção por P. vivax. Neste trabalho, parâmetros histológicos placentários como, agregados nucleares sinciciais, espessamento da barreira placentária e infiltrado inflamatório foram analisados quantitativamente. Para a quantificação dos biomarcadores em plasma periférico foi utilizada a técnica ELISA. Entre as alterações histológicas placentárias, se observou um aumento no número de agregados nucleares sinciciais (16,12±7,68 vs 13,93±5,96 - p<0,05) e do infiltrado inflamatório (9,4±6,0 vs 6,3±4,0 - p<0.001) em gestantes com malária. Além disso, identificou-se o espessamento da barreira placentária nessas gestantes (2,73±0,68 vs 2,53±0,51 - p<0,05). Em relação aos biomarcadores, verificou-se um aumento sérico nos níveis de sFlt-1(8796,9 vs 6414,21 pg/mL - p<0,05) e proteína C reativa (1327,13 vs 1046,12 pg/mL - p<0,05) e uma redução significativa nos níveis plasmáticos de leptina (1014,88 vs 1152,97 pg/mL - p<0,05) entre as gestantes que apresentaram infecção por P. vivax quando comparadas as gestantes não infectadas. Estes resultados indicam que as alterações geradas no ambiente placentário podem ser decorrentes de distúrbios locais e sistêmicos e que, em conjunto, contribuem para um desfecho desfavorável durante a malária gestacional e, portanto, merecem especial atenção para a implantação de estratégias preventivas e curativas no controle da malária durante a gravidez.Malaria in pregnancy is a serious public health. Currently is estimated approximately 125 million of pregnancies in the world are exposed to the risk of malaria infection. Malaria in pregnancy is characterized by the presence of Plasmodium spp. in the peripheral blood and/or the placenta, consequently maternal anaemia, intrauterine growth retardation, low birth weight and decreased foetal viability. In Brazil, it is observed a prevalence of infections caused by Plasmodium (P.) vivax, where about 95% of cases occur in the Amazon Legal. Because it is a disease of great magnitude and adverse effects to the mother and the child, it is necessary to identify biomarkers predictive for a rapid diagnosis of the disease. A cross-sectional study was carried out with pregnant women living in the Alto Juruá region (Acre). The consequences of gestational infection were evaluated through the collection of biological and epidemiological data from pregnant women with or without P. vivax infection. The work had as main histological parameters, as nuclear aggregates, placental barrier thickness and inflammatory infiltrate were increasing quantitatively. Quantification of the biomarkers in peripheral plasma was done using the ELISA technique. Histological changes were observed in a number of nuclear aggregates (16.12±7.68 vs 13.93±5.96 - p<0.05) and inflammatory infiltrate (9.4±6.0 vs 6.3±4.0 - p<0.001) in pregnant women than the last malaria. In addition, the placental barrier thickening was identified in these pregnant women (2.73±0.68 vs 2.53±0.51 - p<0.05). In relation to the biomarkers, serum levels of sFlt-1 (8796.9 vs 6414.21 pg/mL - p<0.05) and C-reactive protein (1327.13 vs 1046.12 pg/mL - p <0.05) and a significant reduction in plasma levels of leptin (1014.88 vs 1152.97 pg/mL - p<0.05) among those with P. vivax infection when compared to uninfected pregnant women. This is an indication that germ changes in the environment may be erroneous, local and systemic, and that together contribute to an unfavorable outcome during gestational malaria and that deserve special attention for the implementation of preventive and curative strategies in the control of malaria during pregnancy

Clinical outcomes of newborns at birth.

<p>Clinical outcomes of newborns at birth.</p

Map showing the geographic location of Cruzeiro do Sul, Acre State, Brazilian Amazon.

<p>Cruzeiro do Sul has an estimated population of 82,075 inhabitants. The map also indicates Rio Branco, the capital of Acre state.</p

Baseline characteristics of mothers at delivery.

<p>Baseline characteristics of mothers at delivery.</p

Impact of malaria on birth weight at term according to gravidity.

<p>Tukey boxplots show the effect of gravidity on the weight of newborns from malaria-infected women (A), and on newborns from women infected according with <i>Plasmodium</i> species (B). The bottom and the top of the box are the first and third quartiles, the line inside the box is the median, and the whiskers represent the lowest and the highest data within 1.5 IQR of the first and upper quartiles. The line indicates the cut-off of low birth weight. Differences between each group were examined with Mann-Whitney or Kruskal-Wallis test with a Dunn’s post hoc test. (A) P—NI x Infec (p<0.0001); M—NI x Infec (p<0.0001); NI- P x M (p<0.0001); and Infec—P x M (p = 0.0004). (B) P—NI x Pv (p = 0.0001); NI x Pf (p = 0.0003); M—NI x Pv (p = 0.0009); NI x Pf (p<0.0001); NI x Mix (p = 0.003); Pv x Pf (p = 0.025); Pv—P x M (p = 0.0009). P, primigravida; M, multigravida; NI, non-infected pregnant women; Infec, infected pregnant women; Pv, <i>P</i>. <i>vivax</i>-infection; Pf, <i>P</i>. <i>falciparum</i>-infection; Mix, mixed-infection.</p

Flowchart detailing exclusion criteria applied to the evaluation of the enrolled maternal-child pairs.

<p><i>P</i>. <i>vivax infected mothers—one or more infections only by P</i>. <i>vivax; P</i>. <i>falciparum infected mothers—one or more infections only by P</i>. <i>falciparum;</i> Mixed infection—<i>P</i>. <i>vivax</i>- and <i>P</i>. <i>falciparum</i>-infection occurring at the same time and/or at different times during pregnancy.</p

Forest plot of the odds ratio for prematurity in newborns from women infected during pregnancy compared to babies from non-infected women, according to <i>Plasmodium</i> species.

<p>Each model adjusting for maternal age, gravidity and years of formal education (less than 4 years). Mixed infection (<i>P</i>. <i>vivax</i> and <i>P</i>. <i>falciparum</i>-infection). p values were estimated through logistic regression methods. n, number of events; N, total number in each group; CI, confidence interval. Prematurity was defined as birth <37 weeks’ gestation; very preterm birth was defined as birth between ≥28 and <32 weeks’ gestation, and late preterm birth was defined as birth between ≥32 and <37 weeks’ gestation.</p

Malaria during pregnancy and newborn outcome in an unstable transmission area in Brazil: A population-based record linkage study

<div><p>Background</p><p>Malaria in pregnancy (MiP) is one of the major causes of mortality and morbidity in tropical regions, causing maternal anemia, intrauterine growth retardation, preterm birth, and low birth weight (LBW). The integration of the information systems on pregnancy and malaria could prove to be a useful method of improved decision making for better maternal-child health.</p><p>Methods</p><p>A population-based observational study acquired information retrospectively from all live births that occurred between 2006 and 2014 in Cruzeiro do Sul (Acre, Brazil). Social and clinical data of the mother and newborn was extracted from the Information System of Live Births. Malaria episodes information was obtained from the Brazilian Epidemiological Surveillance Information System Malaria. A deterministic record linkage was performed to assess malaria impact on pregnancy.</p><p>Results</p><p>The studied population presented a malaria incidence of 8.9% (1283 pregnant women infected), of which 63.9% infected by <i>Plasmodium (P</i>.<i>) vivax</i>. Reduction of newborn birth weight at term (small for gestational age (SGA) and LBW) has been found associated with <i>P</i>. <i>vivax</i> infection during pregnancy (SGA—OR 1.24, 95% CI 1.02–1.52, p = 0.035; term LBW—OR 1.39, 95% CI 1.03–1.88, p = 0.033). Additionally, <i>P</i>. <i>falciparum</i> infection during pregnancy has been found to be associated with preterm births (OR 1.54, 95% CI 1.09–2.18, p = 0.016), which is related with late preterm births (OR 1.59, 95% CI 1.11–2.27, p = 0.011).</p><p>Conclusions</p><p>Despite the decrease of malaria cases during the evaluation period and regardless of <i>Plasmodium</i> species, we present evidence of the deleterious effects of MiP in a low transmission area in the Amazonian region.</p></div

Time-series of gestational malaria cases between 2006–2014.

<p>(A) Number of gestational malaria cases per species, (B) mean birth weight of newborns from non-infected and infected women during pregnancy.</p