Abuso sexual na infância e adolescência: uma leitura narrativa do impacto e dos processos conducentes à resiliência

Tese doutoramento em Psicologia (área do conhecimento em Psicologia da Justiça)A conceptualização teórica que fundamentou este estudo foi o modelo narrativo de White e Epston (1990), tendo esta investigação dois objectivos centrais: (1) compreender o impacto do abuso sexual sofrido na infância/juventude e (2) identificar os recursos que as crianças e/ou jovens abusados possuem para a sua mudança espontânea em direcção à resiliência. Ambas as dimensões foram analisadas à luz da grelha narrativa, procurando-se, num terceiro objectivo, de natureza mais teórica, avaliar a adequação e contributos do modelo narrativo para a compreensão da experiência do abuso sexual e dos processos de mudança que lhe estão associados. Para tal, foram realizadas entrevistas qualitativas em profundidade com dezasseis crianças e/ou jovens vítimas de abuso sexual, posteriormente divididos por dois grupos: crianças e/ou jovens resilientes e não resilientes. Estas entrevistas foram posteriormente submetidas a um processo de grounded analysis e a sua codificação foi validada por um juiz independente. No que se refere ao impacto, os resultados revelam uma tendência para o aumento do impacto negativo do problema após a revelação na maioria dos participantes em estudo. Especificamente, os efeitos negativos predominantes são a vergonha/estigma, a culpa e o medo. Os discursos sociais/culturais surgem também como uma variável que interfere nas significações que a vítima constrói, sendo que as crenças e estereótipos de culpabilização da vítima tendem a estar associados a maior sofrimento psicológico. Para além destes efeitos, as expectativas de justiça tornam-se particularmente relevantes para as vítimas, sendo a condenação do ofensor encarada como uma forma efectiva de validação da sua experiência abusiva. Quando analisamos as diferenças nos efeitos do abuso em função dos dois grupos de participantes entrevistados, resilientes e não resilientes, verificamos que, os participantes do grupo não resiliente reportam: a) uma forte estigmatização associada a sentimentos de diferença interpessoal; b) maior tendência para experienciar o medo como central na sua vivência do abuso; c) maior tendência para se culpabilizarem pela manutenção do segredo em relação ao abuso; d) maior percepção do abuso como uma armadilha/traição interpessoal; e) mais ansiedade face a relações futuras e receio face à homossexualidade; f) maior ambivalência face ao processo judicial, ao mesmo tempo que o consideram relevante para a validação da sua experiência abusiva.Relativamente à narrativa de mudança, globalmente, os resultados reflectem uma considerável diversidade de momentos de inovação (isto é, momentos que escapam aos efeitos e prescrições do abuso) reportados pelas vítimas. O MI mais saliente na nossa amostra é o de reflexão, enquanto os MIs de reconceptualização são aqueles que apresentam uma representação mais reduzida. De salientar que os recursos identificados pelas crianças para a mudança destacam o papel do grupo de pares, o suporte parental e familiar e o apoio dos professores. Em termos de “recursos/aliados” pessoais para a mudança, distinguem-se a revelação e o seu significado libertador, as expectativas de justiça, as crenças religiosas e a construção de novas significações para o self, que reforçam a percepção de competência pessoal e controlo. Quanto à diferenciação dos grupos resiliente e não resiliente no que diz respeito aos momentos de inovação, verificou-se que não existem diferenças significativas no que se refere à saliência dos diferentes tipos de MIs, embora tenham sido encontradas diferenças significativas relativamente à saliência dos subtipos do MI de protesto e no processo discursivo de retorno ao problema. Estes resultados no que concerne à clarificação dos processos de mudança podem estar relacionados com distintas hipóteses explicativas: a) uma elevada variabilidade intra-grupo no que se refere à frequência, diversidade e saliência dos momentos de inovação; b) uma amostra de crianças/jovens cuja capacidade para elaborar oralmente a mudança é desenvolvimentalmente distinta da dos participantes adultos; c) os discursos da rede social e judicial destas crianças, centrados nas consequências nefastas do abuso; e d) a grelha de codificação dos momentos de inovação, concebida para adultos e que poderá não ser adequada às características desenvolvimentais dos participantes. Em conclusão, o presente estudo reflecte a importância dos processos narrativos de significação, que moldam o impacto do abuso e as trajectórias destas crianças/jovens em direcção à resiliência. Sugere, ainda, indicadores importantes para a intervenção com estas vítimas, nomeadamente no que diz respeito à compreensão do impacto do abuso sexual e das formas de elaboração narrativa desta experiência que podem promover percursos mais adaptativos e preferenciais para as vítimas, tanto espontâneos como por recurso à intervenção psicoterapêutica

Beliefs and attitudes of profissionals about marital violence: studies with health profissionals, policemen and teachers

Este artigo apresenta um conjunto de investigações cujo objectivo foi caracterizar as crenças dos profissionais mais directamente implicados na resposta e prevenção da violência conjugal face a este fenómeno. Para tal, um instrumento de avaliação das crenças sobre a violência conjugal foi administrado a um conjunto de 226 profissionais de saúde, 85 agentes de segurança e 280 professores. Os resultados evidenciam uma tendência para a discordância moderada, nas três amostras estudadas, relativamente aos mitos e crenças legitimadoras do abuso conjugal. Subsistem, contudo, alguns mitos relacionados com a raridade do problema, a sua atribuição a causas externas e a protecção da privacidade familiar. Os sujeitos mais velhos e de sexo masculino exibem, tendencialmente, uma maior legitimação da violência.This article presents a set of three research projects that aimed to characterize the beliefs about marital violence of the professionals most directly implied in the response and prevention of this problem. A research questionnaire that evaluates beliefs about marital violence was administered to a sample of 226 health professionals, 85 law enforcement agents and 280 teachers. On the global results show a tendency to moderate disagreement with beliefs that legitimize this form of abuse. Some myths, however, persist in these samples, namely those related to the privacy of the problem, its rarity and attribution to external causes. Male and older subjects show, in general, higher levels of violence legitimization

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P < 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men

Unraveling the genetic background of individuals with a clinical familial hypercholesterolemia phenotype

Familial hypercholesterolemia (FH) is a common genetic disorder of lipid metabolism caused by pathogenic/likely pathogenic variants in LDLR, APOB, and PCSK9 genes. Variants in FH-phenocopy genes (LDLRAP1, APOE, LIPA, ABCG5, and ABCG8), polygenic hypercholesterolemia, and hyperlipoprotein (a) [Lp(a)] can also mimic a clinical FH phenotype. We aim to present a new diagnostic tool to unravel the genetic background of clinical FH phenotype. Biochemical and genetic study was performed in 1,005 individuals with clinical diagnosis of FH, referred to the Portuguese FH Study. A next-generation sequencing panel, covering eight genes and eight SNPs to determine LDL-C polygenic risk score and LPA genetic score, was validated, and used in this study. FH was genetically confirmed in 417 index cases: 408 heterozygotes and 9 homozygotes. Cascade screening increased the identification to 1,000 FH individuals, including 11 homozygotes. FH-negative individuals (phenotype positive and genotype negative) have Lp(a) >50 mg/dl (30%), high polygenic risk score (16%), other monogenic lipid metabolism disorders (1%), and heterozygous pathogenic variants in FH-phenocopy genes (2%). Heterozygous variants of uncertain significance were identified in primary genes (12%) and phenocopy genes (7%). Overall, 42% of our cohort was genetically confirmed with FH. In the remaining individuals, other causes for high LDL-C were identified in 68%. Hyper-Lp(a) or polygenic hypercholesterolemia may be the cause of the clinical FH phenotype in almost half of FH-negative individuals. A small part has pathogenic variants in ABCG5/ABCG8 in heterozygosity that can cause hypercholesterolemia and should be further investigated. This extended next-generation sequencing panel identifies individuals with FH and FH-phenocopies, allowing to personalize each person’s treatment according to the affected pathway

Characterisation of microbial attack on archaeological bone

As part of an EU funded project to investigate the factors influencing bone preservation in the archaeological record, more than 250 bones from 41 archaeological sites in five countries spanning four climatic regions were studied for diagenetic alteration. Sites were selected to cover a range of environmental conditions and archaeological contexts. Microscopic and physical (mercury intrusion porosimetry) analyses of these bones revealed that the majority (68%) had suffered microbial attack. Furthermore, significant differences were found between animal and human bone in both the state of preservation and the type of microbial attack present. These differences in preservation might result from differences in early taphonomy of the bones. © 2003 Elsevier Science Ltd. All rights reserved

Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational, observational study

Background: Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs). Methods: This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support. Results: A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83-7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97-2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14-1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25-1.30]). Conclusions: In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable

Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational, observational study

Background: Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs). Methods: This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support. Results: A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83–7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97–2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14–1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25–1.30]). Conclusions: In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable

Thrombotic and hemorrhagic complications of COVID-19 in adults hospitalized in high-income countries compared with those in adults hospitalized in low- and middle-income countries in an international registry

Background: COVID-19 has been associated with a broad range of thromboembolic, ischemic, and hemorrhagic complications (coagulopathy complications). Most studies have focused on patients with severe disease from high-income countries (HICs). Objectives: The main aims were to compare the frequency of coagulopathy complications in developing countries (low- and middle-income countries [LMICs]) with those in HICs, delineate the frequency across a range of treatment levels, and determine associations with in-hospital mortality. Methods: Adult patients enrolled in an observational, multinational registry, the International Severe Acute Respiratory and Emerging Infections COVID-19 study, between January 1, 2020, and September 15, 2021, met inclusion criteria, including admission to a hospital for laboratory-confirmed, acute COVID-19 and data on complications and survival. The advanced-treatment cohort received care, such as admission to the intensive care unit, mechanical ventilation, or inotropes or vasopressors; the basic-treatment cohort did not receive any of these interventions. Results: The study population included 495,682 patients from 52 countries, with 63% from LMICs and 85% in the basic treatment cohort. The frequency of coagulopathy complications was higher in HICs (0.76%-3.4%) than in LMICs (0.09%-1.22%). Complications were more frequent in the advanced-treatment cohort than in the basic-treatment cohort. Coagulopathy complications were associated with increased in-hospital mortality (odds ratio, 1.58; 95% CI, 1.52-1.64). The increased mortality associated with these complications was higher in LMICs (58.5%) than in HICs (35.4%). After controlling for coagulopathy complications, treatment intensity, and multiple other factors, the mortality was higher among patients in LMICs than among patients in HICs (odds ratio, 1.45; 95% CI, 1.39-1.51). Conclusion: In a large, international registry of patients hospitalized for COVID-19, coagulopathy complications were more frequent in HICs than in LMICs (developing countries). Increased mortality associated with coagulopathy complications was of a greater magnitude among patients in LMICs. Additional research is needed regarding timely diagnosis of and intervention for coagulation derangements associated with COVID-19, particularly for limited-resource settings

Characteristics and outcomes of an international cohort of 600 000 hospitalized patients with COVID-19

Background: We describe demographic features, treatments and clinical outcomes in the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) COVID-19 cohort, one of the world's largest international, standardized data sets concerning hospitalized patients. Methods: The data set analysed includes COVID-19 patients hospitalized between January 2020 and January 2022 in 52 countries. We investigated how symptoms on admission, co-morbidities, risk factors and treatments varied by age, sex and other characteristics. We used Cox regression models to investigate associations between demographics, symptoms, co-morbidities and other factors with risk of death, admission to an intensive care unit (ICU) and invasive mechanical ventilation (IMV). Results: Data were available for 689 572 patients with laboratory-confirmed (91.1%) or clinically diagnosed (8.9%) SARS-CoV-2 infection from 52 countries. Age [adjusted hazard ratio per 10 years 1.49 (95% CI 1.48, 1.49)] and male sex [1.23 (1.21, 1.24)] were associated with a higher risk of death. Rates of admission to an ICU and use of IMV increased with age up to age 60 years then dropped. Symptoms, co-morbidities and treatments varied by age and had varied associations with clinical outcomes. The case-fatality ratio varied by country partly due to differences in the clinical characteristics of recruited patients and was on average 21.5%. Conclusions: Age was the strongest determinant of risk of death, with a ∼30-fold difference between the oldest and youngest groups; each of the co-morbidities included was associated with up to an almost 2-fold increase in risk. Smoking and obesity were also associated with a higher risk of death. The size of our international database and the standardized data collection method make this study a comprehensive international description of COVID-19 clinical features. Our findings may inform strategies that involve prioritization of patients hospitalized with COVID-19 who have a higher risk of death

The value of open-source clinical science in pandemic response: lessons from ISARIC

International audienc