Enurese noturna na adolescência: tratamento em grupo e individual

The results of a behavioral intervention program for nocturnal enuresis were compared using a national urine alarm device, applied in groups and individually, to adolescents from two Brazilian University clinics. The participants included adolescents and their parents in a program of active family participation. The participants (N=22) were behaviorally guided. Some participants were assisted in group (total N = 14; G1, N=8; G2, N=6) while eight were assisted individually (G3). Treatment success was determined following two consecutive weeks without “wet episodes” and the criterion for discharge was eight consecutive weeks without any wet episodes. The maximum length of the assistance was 40 weeks. Results in the current report focus on the analyses of the simple “wet episode” recordings, used throughout the treatment. From the assisted group, 11 participants (78.6%) succeeded and nine (64.2%) were discharged. Of those undergoing individual assistance, seven (87.5%) succeeded, and six (75%) were discharged. These differences did not reach statistical significance. The individual assistance group, within the interval of six and ten months, proved to be more efficient in promoting discharge than the group assistance service, (p=0,030 and 0,045, respectively). In the other aspects, the two types of assistance demonstrated comparable results. Missing therapeutic sessions were associated with poorer treatment performance, independently of assistance type. It is concluded that group treatment for nocturnal enuresis is feasible in university clinics, especially considering the cost/benefit relationship.Keywords: urine alarm device; enuresis; adolescence; individual assistance; group assistance. Objetivou-se comparar os resultados de um programa de intervenção comportamental para enurese noturna, tendo como recurso terapêutico o aparelho nacional de alarme de urina, aplicado, em duas clinica-escolas brasileiras, em adolescentes, em grupo e individualmente. Os participantes foram adolescentes e seus responsáveis, pela demanda de participação ativa da família. Os participantes (N=22) foram comportamentalmente orientados. Do total dos participantes 14 foram atendidos em dois grupos (G1, N=8; G2, N=6) e oito foram atendidos individualmente (G3). O critério de sucesso foi duas semanas consecutivas sem episódios enuréticos (“molhadas”) e o critério de alta, oito semanas consecutivas sem molhadas. A duração máxima do atendimento foi de 40 semanas. Utilizouse o registro simples de “molhadas”, aplicado ao longo de todo atendimento. Dos participantes do atendimento coletivo, 11 (78,6%) alcançaram sucesso e nove (64,2%) alcançaram alta. No atendimento individual, sete (87,5%) alcançaram o sucesso, e seis (75%) alcançaram alta. Essa diferença entre grupos não alcançou significância estatística. Entretanto, o atendimento individual demonstrou ser mais eficiente que o coletivo em promover a alta, quando ambos foram comparados no intervalo de seis e dez meses, (p=0,030 e 0,045, respectivamente), um resultado significante do ponto de vista estatístico. Nos demais aspectos, os dois tipos de atendimento apresentaram resultados comparáveis. Independente do tipo de atendimento, foi encontrada uma associação entre faltas e pior desempenho no tratamento. Conclui-se que o tratamento em grupo para enurese noturna na adolescência é viável, especialmente considerando-se a relação custo/benefício. Palavras-chave: aparelho de alarme; enurese; adolescência; atendimento individual; atendimento em grupo.

Enuresis in adolescence: behavioral intervention case study

Um relato de caso de tratamento em terapia cognitivo-comportamental de dois adolescentes que apresentavam enurese noturna é descrito. Um padrão usual de intervenção clínica cognitivo-comportamental foi empregado tendo o aparelho de alarme de urina brasileiro como adjunto terapêutico. Primeiro, uma avaliação comportamental foi desenvolvida através de entrevista com o adolescente e com os familiares, aplicação de inventários e automonitoria das molhadas noturnas para construção de uma linha de base do controle urinário. Depois, foram processadas sessões individuais com os adolescentes e seus familiares. As sessões terapêuticas foram semanais, para o participante e seus pais, separadamente. Os questionários aplicados ao início e final do trabalho foram: o CBCL (Child Behavior Checklist, Achenbach, 1991), a Escala de Intolerância (Morgan & Young, 1975), o Formulário de Avaliação de Enurese (Blackwell, 1989), a Entrevista Semi-Estruturada de Butler (1987). O registro de freqüência de molhadas foi obtido durante todo o tratamento. Utilizou-se o treino familiar em resolução de problemas, do modelo triádico de atendimento comportamental, considerando-se diversas variáveis cognitivas além das dificuldades específicas do adolescente. A freqüência inicial de “molhadas à noite” caiu de 3-4 vezes por semana para zero, ao cabo de oito semanas. O critério de alta de oito semanas consecutivas sem molhadas noturnas foi alcançado para os dois adolescentes. Os resultados indicam a utilidade desta metodologia como um potente instrumento para atender adolescentes com essa queixa.Palavra-chave: aparelho de alarme; enurese; adolescência. This describes a case study report on cognitive-behavioral therapy of two adolescents with nocturnal enuresis. The treatment followed the usual pattern of cognitive- behavioral intervention, using a Brazilian designed urine alarm device as a therapeutic adjunct. Firstly a behavioral assessment was conducted of interviews with the adolescent and with his/her parents, application of inventories and self-monitoring of wet nights in order to define a urine control baseline. Secondly, therapeutic sessions on cognitive behavioral orientation were developed individually and on a weekly basis, for both participants (adolescent and his parents, separately interviewed). The applied questionnaires at the beginning and at the end of the study were the CBCL (Child Behavior Checklist, Achenbach, 1991), the Scale of Intolerance (Morgan & Young, 1975), the Blackwell (1989) Form to evaluate enuresis (Blackwell, 1989), and Semi-Structured Interview of Butler (1987). Self monitory of wet nights was followed during treatment. Parent training on resolution of the problem was selected as a model for cognitive-behavioral intervention and several cognitive variables besides the adolescent’s specific difficulties were focused upon. The frequency of wet nights fell from 3 to 4 per week to zero, after eight weeks. The criterion of eight consecutive weeks without wet nights was reached by both adolescents. The results show the usefulness of this methodology as a powerful instrument to help adolescents with this particular problem.Keywords: urine alarm device; enuresis; adolescence

The effect of the behavioral treatment for enuresis on other behavior problems

O objetivo do estudo foi investigar o efeito do tratamento para enurese sobre os escores de outros problemas de comportamento. Foram coletadas as informações de 97 prontuários de crianças e adolescentes atendidos no período de 2002 a 2006 em uma clínica-escola de psicologia, em programa específico para enurese com uso do alarme de urina. Os dados sobre problemas de comportamento foram avaliados por meio do Child Behavior Checklist, respondido pelas mães antes e depois do tratamento. Foi encontrada uma redução significativa nos escores de problemas de comportamento, independentemente do sucesso ou não no tratamento para enurese.This work aimed to investigate the treatment effect for enuresis on other behavior problems' scores. Clinical records of 97 enuretic children and adolescents, receiving urine alarm treatment in a university clinic center from 2002 to 2006, were analyzed. Behavior problems' data were assessed through the Child Behavior Checklist, filled by the mothers at the beginning and at the end of the treatment. Results indicate a significant reduction on behavior problems' scores at the end of treatment, despite of enuresis treatment outcome.FAPESPCNP

Both “illness and temptation of the enemy”: melancholy, the medieval patient and the writings of King Duarte of Portugal (r. 1433–38)

Recent historians have rehabilitated King Duarte of Portugal, previously maligned and neglected, as an astute ruler and philosopher. There is still a tendency, however, to view Duarte as a depressive or a hypochondriac, due to his own description of his melancholy in his advice book, the Loyal Counselor. This paper reassesses Duarte's writings, drawing on key approaches in the history of medicine, such as narrative medicine and the history of the patient. It is important to take Duarte's views on his condition seriously, placing them in the medical and theological contexts of his time and avoiding modern retrospective diagnosis. Duarte's writings can be used to explore the impact of plague, doubt and death on the life of a well-educated and conscientious late-medieval ruler

A supervisão pela internet para o tratamento comportamental da enurese com aparelho nacional de alarme

Objetivou-se verificar a viabilidade de uma proposta de aperfeiçoamento a distância para a prática psicológica no atendimento à Enurese (EN) em Serviços-escola, Unidades Básicas de Saúde e consultórios particulares, situados em diferentes regiões do país e se o tempo de experiência dos psicólogos participantes da proposta estava relacionado com algumas variáveis como: o número de contatos de supervisão, o tempo para alta dos clientes, as variações nos escores de problemas de comportamento dos clientes e da intolerância dos pais deles. Foram participantes (N=40) psicólogos de diferentes regiões do país, de ambos os sexos, divididos em dois grupos conforme sua experiência, sendo G1: menos de 10 anos (n=27) e G2: mais de 10 anos (n=13). Os participantes receberam treinamento e supervisão num programa de Educação a Distância (EAD) e atenderam crianças ou adolescentes com queixa de EN. As informações e as questões relativas ao atendimento foram comunicadas ao participante, através da internet, pela qual ele também ofereceu respostas e subsídios para sua prática. Os participantes tiveram total liberdade de consultar o supervisor quantas vezes desejassem para solucionar questões ou buscar orientação. O atendimento que desenvolveram se deu através de intervenção comportamental com uso de aparelho nacional de alarme. A Escala de Intolerância foi utilizada para avaliação dos pais, e para avaliar os filhos utilizou-se o Inventário de Comportamentos da Infância e Adolescência CBCL e o Registro simples de \"molhadas\" (descontrole enurético) ao longo do atendimento. Os resultados foram de dois tipos: dos participantes psicólogos e de seus clientes e pais. Foram comparados os números médios de contatos entre os psicólogos e o supervisor, dos dois diferentes grupos de experiência, e os escores obtidos nos instrumentos de avaliação dos clientes aplicados antes e após a intervenção, a fim de verificar a efetividade do tratamento, além do decréscimo do número de molhadas durante este. Do total de participantes, 15 concluíram o tratamento de seus clientes tendo eles atingido os critérios de sucesso e alta, dois tiveram clientes que concluíram sem sucesso, 13 descontinuaram o tratamento, quatro não conseguiram clientes e seis permanecem atendendo seus clientes que não finalizaram o tratamento ao final da coleta dessa pesquisa. O G1 atingiu alta no tratamento com uma média de 20,1 (dp=9,96) contatos para supervisão ix em 20,4 semanas(dp=5,27). O G2 alcançou alta com média de 10,0 contatos (dp=5,30) em 20,4 semanas (dp=7,13). Observou-se, nos clientes, significativa redução nos escores na escala total de problemas de comportamento dos clientes e de intolerância de seus pais em ambos os grupos de participantes após o tratamento. Os resultados deste estudo são inferiores aos obtidos no atendimento com supervisão presencial realizados no país, mas aproximam-se deles, justificando portanto o seu uso. Esses dados demonstram a viabilidade dessa modalidade de atendimentoThe objective was to examine feasibility of a distance improvement program of psychological practice in treating Enuresis (EN) in School-services, Basic Health Units, and private offices, located in different areas of the country and if the amount of experience time of the participating psychologists was in any way related to variables such as: the number of supervision contacts, time for client discharge, and intolerance of their parents. Participants were (N=40) psychologists from different regions of the country, from both genders, divided into two groups according to their experience, where G1: under 10 years (N=27), and G2: over 10 years (N=13). Participants received training and supervision in a Distance Learning program (EAD) and treated children or adolescents complaining about EN. Treatment information and related questions were made known to the participant through the internet, where answers and practice aid were also offered. Participants were totally free to consult with supervisor as many times as desired to solve issues or seek guidance. Developed treatment was performed by behavioral intervention with the use of national alarm device. Throughout treatment, the Intolerance Scale was used for parent evaluation, and the Child Behavior Checklist CBCL, as well as bedwetting Record for evaluating the children. Results were of two kinds: of participating psychologists and their clients and parents. The average number of contacts between participating psychologists and their supervisors, of the two experience groups, and pre and post treatment scores obtained in client evaluation instruments were compared in order to check treatment effectiveness, as well as the decrease in bedwetting throughout it. Of the total number of participants, 15 concluded treatment with client achieving success criteria and discharge, two had clients concluding without success, 13 discontinued treatment, four did not obtain clients, and six remained treating clients who had not finish treatment at the end of data collection for this research. G1 obtained treatment discharge with an average of 20.1 (SD=9.96) contacts for supervision in 20.4 weeks (SD=5.27). G2 obtained treatment discharge with an average of 10.0 contacts (SD=5.30) in 20.4 weeks (SD=7.13). Clients were observed to have a significant decrease in total behavior problems scale scores and parent intolerance in both groups of participants xi after treatment. Results of this study are inferior to the ones obtained in treatment with face to face supervision performed in the country, but are close, therefore justifying their use. Such data demonstrates feasibility for this treatment modalit

Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients

Background: The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. Methods: Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2: 1). Results: Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). Conclusion: Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding

Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort.

Objective:To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).Background:AL after RC resection often results in a permanent stoma.Methods:This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated.Results:This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76).Conclusions:The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies

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