Empowerment e adesão ao regime terapêutico em pessoas portadoras de diabetes

Enquadramento: A Diabetes Mellitus importante flagelo de saúde pública, contribui para um elevado índice de morbi-mortalidade, devido às complicações associadas que acarretam limitações e incapacidades para o desempenho das actividades de vida diária da pessoa com diabetes. Em consequência, a adesão ao regime terapêutico é um dos focos de atenção dos cuidados de saúde. Como ferramenta promotora duma melhor gestão na diabetes, os enfermeiros promovem o empowerment, processo através do qual a pessoa adquire conhecimentos e desenvolve competências e consequentemente um maior poder e controlo sobre a sua saúde. Objetivos: Identificar factores sociodemográficos e clínicos relacionados com os autocuidados em pessoas com diabetes; Determinar o efeito preditivo do empowerment na adesão ao regime terapêutico em pessoas com diabetes. Metodologia: Estudo descritivo realizado numa amostra não probabilística por conveniência de 150 pessoas com diabetes de ambos os sexos, com uma média de idades de 66,85±9,72 anos, casados/ em união de fato (72,7%), reformados (74,7%) e com baixa escolaridade (78,0%). A colheita de dados, foi suportada num Questionário Sociodemográfico e Clínico, na Escala de Empowerment da Diabetes (Anderson; Funnel; Fitzgerald & Marrero, 2000) e na Escala Atividades de autocuidado com a diabetes, traduzida e validada para português por Bastos & Lopes (2004). Resultados: As mulheres (4,44±0,77), os solteiros/viúvos/divorciados (4,22±0,84), os detentores de situação financeira confortável (5,02±0,62), os que ocupam os tempos livres com desporto/lazer/cultura (4,37±0,79) apresentam melhor adesão ao regime terapêutico. São ainda os indivíduos com diabetes tipo 1 (4,29±0,92), que tomam insulina (4,64±0,88), que realizam a vigilância/monitorização da glicemia e registo no Guia do Diabético (4,35±0,69), e com IMC mais elevado (r=0,548; p=0.000), que pontuaram com melhor adesão. Verificou-se também que quanto maior o empowerment, melhor a adesão ao regime terapêutico (r=0,377; p=0.000). Conclusão: Os resultados sugerem que os determinantes sociodemográficos e clínicos se relacionam de forma significativa com a adesão ao regime terapêutico e que o empowerment, a prediz de forma relevante, pelo que se impõe considerá-los no planeamento das intervenções de enfermagem/ saúde que lhe são dirigidas. Palavras-chave: Adesão ao regime terapêutico, Empowerment, Pessoas com Diabetes.ABSTRACT Background: Diabetes Mellitus is an important public health scourge, that contributes to a high rate of morbidity and mortality due to associated complications that cause limitations and disabilities to perform the activities of daily living in people with diabetes. Consequently, adherence to therapy is a focus of attention of health care. As a tool for better management in diabetes, nurses promote empowerment, process through which a person acquires knowledge and develops skills and consequently greater power and control over their health. Objectives: To identify sociodemographic and clinical factors related to self-care in people with diabetes; determine the predictive effect of empowerment on adherence to therapeutic regimen in persons with diabetes. Methods: This descriptive study in a non-probabilistic convenience sample of 150 people with diabetes in both sexes, with a mean age of 66.85 ± 9.72 years, married / in union indeed (72.7%), retired (74.7%) and with lower education (78.0%). Data collection was supported by a Clinical and Sociodemographic questionnaire, the Diabetes Empowerment Scale (Anderson; Funnel; Fitzgerald & Marrero, 2000) and Self-Care Activities Scale with diabetes, translated and validated into Portuguese by Bastos & Lopes (2004). Results: The women (4.44 ± 0.77), single / widowed / divorced (4.22 ± 0.84), holders of comfortable financial situation (5.02 ± 0.62) who occupy the time free with sports / leisure/ culture (4.37 ± 0.79), have better adherence to treatment regimen. Are still individuals with type 1 diabetes (4.29 ± 0.92), taking insulin (4.64 ± 0.88), which perform surveillance / monitoring of blood glucose and registration in Diabetic Guide (4.35 ± 0.69), and BMI (r = .548, p = .000), who scored with better adherence. It was also found that the greater the empowerment, better adherence to the therapeutic regimen (r = .377, p = .000). Conclusion: The results suggest that the clinical and sociodemographic determinants relate significantly with adherence to treatment regimen and empowerment, predicts significantly, so it is necessary to consider them in the planning of nursing interventions / health. Keywords: Adherence to treatment regimen, Empowerment, People with Diabetes

Determinantes da qualidade de vida nos utentes das unidades de média duração e reabilitação

A Rede Nacional de Cuidados Integrados (RNCCI) é um projecto recente, tendo como objectivo geral a prestação de cuidados continuados integrados a pessoas que, independentemente da idade, se encontrem em situação de dependência. Compreende diferentes tipologias de internamento (UC, UMDR, ULDM e UCP), mas principalmente as que se pretendem estudar, são as Unidades de Média Duração e Reabilitação. Com a implementação de um Modelo de Gestão da Doença Crónica, que é a RNCCI, envolvendo parceiros, colaboradores e uma articulação na prestação de cuidados multidisciplinares, pretende-se que contribua e concretize a resposta às reais necessidades em cuidados crónicos, visando a dignidade, o conforto e a qualidade de vida, mesmo em situações irrecuperáveis. A compreensão do universo qualidade de vida dos utentes internados na RNCCI, constitui um campo de investigação, que só terá significado se for estudado no seu contexto histórico, social e cultural, à dimensão regional e pessoal de cada um que vive e sente. A dimensão subjectiva da percepção do suporte social é a que proporciona maior ou menor nível de satisfação, variável que melhor explica os resultados de saúde. A saúde mental é um equilíbrio dinâmico que resulta da interacção do indivíduo com o meio envolvente, as suas características orgânicas e os seus antecedentes pessoais e familiares. O suporte social, a saúde mental e a qualidade de vida são conceitos fortemente interdependentes. No contexto dos serviços de reabilitação, é o conceito de qualidade de vida que parece ser mais sensível às intervenções das equipas multidisciplinares. QVRS abrange mais do que ganho de saúde isoladamente, estando também implícitos a prevenção, o atraso da deterioração e a melhoria da função. É um sentimento que se partilha, e do qual emerge a questão central deste estudo: Qual a Qualidade de Vida Relacionada com a Saúde das pessoas com Doença Crónica Incapacitante e Dependente internadas nas Unidades de Média Duração e Reabilitação da Região Centro? Objectivos: Face a esta problemática, a presente investigação pretende avaliar a Percepção da Qualidade de Vida da pessoa com Doença Crónica Incapacitante e Dependente, e identificar os factores sócio demográficos, clínicos, psicológicos e situacionais que influenciam os domínios da qualidade de vida, da saúde mental e do suporte social dos utentes internados nas UMDR da Região Centro. Metodologia: Em termos metodológicos, o presente estudo é considerado quantitativo, não experimental, descritivo, analítico, correlacional, retrospectivo e transversal. Foram incluídos os utentes portadores de doenças crónicas, internados em nove UMDR da região Centro (45% do número total de unidades), no período de 01 de Dezembro 2009 a 28 de Fevereiro 2010, abrangendo o momento da admissão e/ou com pelo menos 60 dias de internamento. Os instrumentos de recolha de dados utilizados neste estudo foram, Questionário de caracterização sócio demográfica, Questionário do estado de saúde do Medical Outcomes Study, referido como SF-36, Escala de Satisfação com o Suporte Social (ESSS) e o Inventário de Saúde Mental, conhecido como MHI. O Questionário foi aplicado junto de uma amostra que totalizou 46 utentes, correspondendo a 28 observações na primeira avaliação (admissão) e à segunda avaliação com 32 observações (.≥60dias). Resultados: Através da análise dos dados destaca-se que, 57,0% dos inquiridos são do género feminino; 72,00% provém do meio rural; 67,45% tem idade acima dos 70 anos; 50,00% são casados; 50,00% vive com a esposa/marido; 36.90% residem no distrito da Guarda; 76,10% possui o 1º ciclo de escolaridade; 91,30% é reformado; 54,35% referem rendimento mensal entre 250 e 400€; 34,80% recebem visitas semanalmente; 45,60% com diagnóstico de doenças do aparelho circulatório; a média de internamento centra-se nos 49,78 dias. Relativamente à colheita de dados, verifica-se que 36,90% dos utentes são da UMDR de Gouveia; 30,45% inquiridos na admissão; 39,10% com ≥60 dias da admissão; 30,45% na condição de admissão e ≥60 dias de internamento. Constata-se que a média da qualidade de vida global varia entre os momentos avaliativos (109,93 versus 118,91); a média da qualidade de saúde mental global (139,82 versus 138,94); a média da satisfação com o suporte social global (36,25 versus 36,50). A consistência interna do questionário foi avaliada através do alfa Cronbach (0,892), o que indica uma medida de boa fiabilidade. Conclusões: Conclui-se ainda, que os inquiridos na admissão, valorizam a componente saúde física em 38,68 e a componente de saúde mental com 71,25. Os utentes com ≥60 dias de internamento apresentam na componente saúde física, média 41,00, e na componente saúde mental a média 77,91. Obteve-se que o distress psicológico (MHIDIST) tem 82,29 de média e o bem-estar psicológico (MHIBEST) apresenta média igual a 57,54, no momento da admissão. No segundo momento avaliativo o MHIDIST é igual a 86,22 e o MHIBEST apresenta 52,72 de média. A satisfação com o suporte social global não apresenta diferenças significativas entre os dois momentos de avaliação. A qualidade de vida global apresenta relação com as variáveis sócio demográficas (género, proveniência, coabitação, habilitações académicas), e variável situacional (suporte social). Em relação à qualidade de saúde mental global, verifica-se que esta apresenta relação com as variáveis sócio demográficas (género e coabitação), variável situacional (frequênciade visitas) e tempo de internamento. Confirma-se que, as variáveis sócio demográficas (idade, rendimento mensal, situação profissional) influenciam a satisfação com o suporte social. Na análise comparativa dos resultados obtidos do grupo inquirido nos dois momentos de avaliação (14 utentes), constata-se que não existe relação com a qualidade de vida global, qualidade de saúde mental e satisfação com o suporte social. Facto este, que pode estar relacionado com o número reduzido da amostra, pois se duplicasse seria muito provável que já houvesse diferenças significativas. Embora os resultados tenham revelado alguns determinantes preditores da qualidade de vida dos utentes internados nas UMDR da Região Centro, é evidente a necessidade de mudanças por parte do poder público e das instituições prestadoras de cuidados de saúde, especialmente no que diz respeito à afectação de recursos humanos, conforto, humanização dos cuidados e valorização da rede social.The National Network of Integrated Care (RNCCI) is a recent project, aimed at the integrated long-term care to people, that regardless of age, are in a situation of dependency. There are various types of hospital admissions (UC, UMDR, ULDM and UCP), but the Units of Medium-Term and Rehabilitation will be the ones researched. With the implementation of a Management Model of Chronic Illness (RNCCI), involving partners, associates and an articulation in the provision of multidisciplinary care, it is intended to contribute and materialize the response to real needs in chronic care, seeking dignity, comfort and quality of life, even in unrecoverable situations. The understanding of the universe: quality of life of admitted patients in RNCCI, is a field of inquiry that will only be meaningful if studied in its historical, social and cultural context, on a regional and personal level, according to ones’ lives and feelings. The subjective dimension of social support perception is one that provides a greater or lesser degree of satisfaction, a variable that best explains the results of health. Mental health is a dynamic equilibrium resulting from the interaction of the individual with their surroundings, their organic features and their personal and family history. Social support, mental health and quality of life are highly interdependent concepts. This concept arises a shared feeling, from which the central question of this study emerges: How is the Quality of Life Related to the Health of dependent people with disabling chronic diseases and hospitalized in Medium-Term and Rehabilitation Units of the Central Region? Purposes: In view of this problem, this research intends to assess the perception of the quality of life of dependent people with disabling chronic diseases, and identify the sociodemographic, clinical, psychological and situational factors influencing the domains of quality of life, mental health and social support for UMDR hospitalized users in the Central Region. Methodology: In terms of methodology, this is a quantitative, non experimental, descriptive, analytic, co relational, retrospective and transversal study. Patients with chronic diseases, admitted to nine UMDR the Central region (45% of the total number of units) from the 1st of December, 2009 to the 28th of February, 2010 were included, covering the time of admission and / or at least 60 days of hospitalization. The instruments for collecting data used in this study were a socio demographic questionnaire; a health status questionnaire from the Medical Outcomes Study, referred to as SF-36; the Satisfaction with Social Support Scale (ESSS); and the Mental Health Inventory, known as MHI. The questionnaire was applied with a sample totaling 46 users, corresponding to 28 observations on a first assessment (admission) and a second assessment of 32 observations (≥ 60 days). Results: By analyzing the data we highlight that 57.0% of respondents are female; 72.00% come from rural areas; 67.45% are 70 years old and over; 50.00% are married; 50.00% live with the wife / husband; 36.90% live in the district of Guarda; 76.10% attended only the first cycle of schooling; 91.30% are retired; 54.35% reported a monthly income between € 250-400; 34.80% are visited weekly; 45.60% have a cardiovascular diseases diagnosis; the average hospitalization consists on 49.78 days. For the collection of data, 36.90% of users are from UMDR de Gouveia; 30.45% responded at admission; 39.10% with ≥ 60 days of admission; 30.45% on condition of admission and ≥ 60 days of hospitalization. The overall quality of life average seems to vary between the times of evaluation (109.93 versus 118.91), the overall quality of mental health average (139.82 versus 138.94), and the average satisfaction with global social support (36.25 versus 36.50). The internal consistency of the questionnaire was assessed by Alpha Cronbach (.892), indicating a measure of good reliability. Conclusions: It is further concluded that the patients at admission value the physical health component in 38.68 and the mental health component with 71.25. Users with ≥ 60 days of hospitalization present on the physical health component an average of 41.00, and on the mental health component an average of 77.91. It was found that the psychological distress (MHIDIST) has a 82.29 average and psychological well-being (MHIBEST) presents an average of 57.54 at the time of admission. In the second evaluation stage, MHIDIST is equal to 86.22 and MHIBEST presents an average of 52.72. Satisfaction with the overall social support did not differ significantly between the two periods. The overall quality of life is correlated with the social demographic variables (gender, origin, cohabitation, educational qualifications), and situational variable (social support). Regarding the quality of the overall mental health, it appears that this is correlated with the social demographic variables (gender and cohabitation), situational variable (frequency of visits) and time of admission. It is confirmed that the social demographic variables (age, monthly income, employment status) influence satisfaction with social support. In the results’ comparative analysis of the surveyed group in both periods (14 users), it appears that there is no relation to the overall quality of life, quality of mental health and satisfaction with social support. This may be related to the small sample size, since if we doubled the result, we would very likely be able to see significant differences among them. Although the results have revealed some crucial quality of life predictors of UMDR users, hospitalized in the Central Region, there is a clear that the public authorities and institutions providing health care need to undergo some changes, especially what concerns the allocation of human resources, comfort, care humanization and the appreciation of the social network

A multi-country analysis of COVID-19 hospitalizations by vaccination status

Background: Individuals vaccinated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), when infected, can still develop disease that requires hospitalization. It remains unclear whether these patients differ from hospitalized unvaccinated patients with regard to presentation, coexisting comorbidities, and outcomes. Methods: Here, we use data from an international consortium to study this question and assess whether differences between these groups are context specific. Data from 83,163 hospitalized COVID-19 patients (34,843 vaccinated, 48,320 unvaccinated) from 38 countries were analyzed. Findings: While typical symptoms were more often reported in unvaccinated patients, comorbidities, including some associated with worse prognosis in previous studies, were more common in vaccinated patients. Considerable between-country variation in both in-hospital fatality risk and vaccinated-versus-unvaccinated difference in this outcome was observed. Conclusions: These findings will inform allocation of healthcare resources in future surges as well as design of longer-term international studies to characterize changes in clinical profile of hospitalized COVID-19 patients related to vaccination history. Funding: This work was made possible by the UK Foreign, Commonwealth and Development Office and Wellcome (215091/Z/18/Z, 222410/Z/21/Z, 225288/Z/22/Z, and 220757/Z/20/Z); the Bill & Melinda Gates Foundation (OPP1209135); and the philanthropic support of the donors to the University of Oxford's COVID-19 Research Response Fund (0009109). Additional funders are listed in the "acknowledgments" section

Association of Country Income Level With the Characteristics and Outcomes of Critically Ill Patients Hospitalized With Acute Kidney Injury and COVID-19

Introduction: Acute kidney injury (AKI) has been identified as one of the most common and significant problems in hospitalized patients with COVID-19. However, studies examining the relationship between COVID-19 and AKI in low- and low-middle income countries (LLMIC) are lacking. Given that AKI is known to carry a higher mortality rate in these countries, it is important to understand differences in this population. Methods: This prospective, observational study examines the AKI incidence and characteristics of 32,210 patients with COVID-19 from 49 countries across all income levels who were admitted to an intensive care unit during their hospital stay. Results: Among patients with COVID-19 admitted to the intensive care unit, AKI incidence was highest in patients in LLMIC, followed by patients in upper-middle income countries (UMIC) and high-income countries (HIC) (53%, 38%, and 30%, respectively), whereas dialysis rates were lowest among patients with AKI from LLMIC and highest among those from HIC (27% vs. 45%). Patients with AKI in LLMIC had the largest proportion of community-acquired AKI (CA-AKI) and highest rate of in-hospital death (79% vs. 54% in HIC and 66% in UMIC). The association between AKI, being from LLMIC and in-hospital death persisted even after adjusting for disease severity. Conclusions: AKI is a particularly devastating complication of COVID-19 among patients from poorer nations where the gaps in accessibility and quality of healthcare delivery have a major impact on patient outcomes

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

ISARIC-COVID-19 dataset: A Prospective, Standardized, Global Dataset of Patients Hospitalized with COVID-19

The International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) COVID-19 dataset is one of the largest international databases of prospectively collected clinical data on people hospitalized with COVID-19. This dataset was compiled during the COVID-19 pandemic by a network of hospitals that collect data using the ISARIC-World Health Organization Clinical Characterization Protocol and data tools. The database includes data from more than 705,000 patients, collected in more than 60 countries and 1,500 centres worldwide. Patient data are available from acute hospital admissions with COVID-19 and outpatient follow-ups. The data include signs and symptoms, pre-existing comorbidities, vital signs, chronic and acute treatments, complications, dates of hospitalization and discharge, mortality, viral strains, vaccination status, and other data. Here, we present the dataset characteristics, explain its architecture and how to gain access, and provide tools to facilitate its use

Rare predicted loss-of-function variants of type I IFN immunity genes are associated with life-threatening COVID-19

BackgroundWe previously reported that impaired type I IFN activity, due to inborn errors of TLR3- and TLR7-dependent type I interferon (IFN) immunity or to autoantibodies against type I IFN, account for 15-20% of cases of life-threatening COVID-19 in unvaccinated patients. Therefore, the determinants of life-threatening COVID-19 remain to be identified in similar to 80% of cases.MethodsWe report here a genome-wide rare variant burden association analysis in 3269 unvaccinated patients with life-threatening COVID-19, and 1373 unvaccinated SARS-CoV-2-infected individuals without pneumonia. Among the 928 patients tested for autoantibodies against type I IFN, a quarter (234) were positive and were excluded.ResultsNo gene reached genome-wide significance. Under a recessive model, the most significant gene with at-risk variants was TLR7, with an OR of 27.68 (95%CI 1.5-528.7, P=1.1x10(-4)) for biochemically loss-of-function (bLOF) variants. We replicated the enrichment in rare predicted LOF (pLOF) variants at 13 influenza susceptibility loci involved in TLR3-dependent type I IFN immunity (OR=3.70[95%CI 1.3-8.2], P=2.1x10(-4)). This enrichment was further strengthened by (1) adding the recently reported TYK2 and TLR7 COVID-19 loci, particularly under a recessive model (OR=19.65[95%CI 2.1-2635.4], P=3.4x10(-3)), and (2) considering as pLOF branchpoint variants with potentially strong impacts on splicing among the 15 loci (OR=4.40[9%CI 2.3-8.4], P=7.7x10(-8)). Finally, the patients with pLOF/bLOF variants at these 15 loci were significantly younger (mean age [SD]=43.3 [20.3] years) than the other patients (56.0 [17.3] years; P=1.68x10(-5)).ConclusionsRare variants of TLR3- and TLR7-dependent type I IFN immunity genes can underlie life-threatening COVID-19, particularly with recessive inheritance, in patients under 60 years old

Correction: Rare predicted loss-of-function variants of type I IFN immunity genes are associated with life-threatening COVID-19

International audienc