Autolesión no suicida en población general: frecuencia y factores asociados en Paraguay

Introducción: La investigación sobre la autolesión no suicida permite aumentar la conciencia sobre este fenómeno, posibilita su detección temprana y la implementación de estrategias más eficaces en prevención y tratamiento. Esto conlleva a una reducción del sufrimiento individual, los costos económicos y el impacto en la sociedad en su totalidad. Objetivo: Determinar la frecuencia y factores asociados a autolesión no suicida en una muestra de población adulta de Paraguay. Metodología: Estudio descriptivo de asociación cruzada, de corte transversal y prospectivo. Una encuesta en línea fue difundida a través de redes sociales y aplicaciones de mensajería. Esta incluía preguntas sobre datos sociodemográficos y clínicos. La presencia de autolesiones se determinó a través de la versión en español de la escala Self-Harm Questionnaire. Se utilizó estadística descriptiva para todas las variables. Para buscar asociaciones se utilizó la prueba chi cuadrado. Resultados: Participaron 241 personas (media de edad=32±12 años, 74,7% mujeres). Se encontró una frecuencia de autolesiones de 24,5% (n=59). De estos, el 91,5% había tenido ideación suicida al menos una vez. Se encontró asociación entre el nivel de ingresos y la frecuencia de autolesiones (χ

Introduction: Research on non-suicidal self-injury raises awareness of this phenomenon, enabling the early detection and implementation of more effective strategies in prevention and treatment. This leads to a reduction in individual suffering, economic costs, and impact on society. Objective: To determine the frequency and associated factors of non-suicidal self-injury in a sample of the adult population of Paraguay. Methodology: This was a descriptive, cross-sectional, and prospective study. An online survey was disseminated through social networks and messaging applications. The survey included questions on sociodemographic and clinical data. The presence of self-injury was determined by using the Spanish version of the Self-Harm Questionnaire. Descriptive statistics were used for all the variables. The chi-square test was used to examine associations. Results: There were 241 participants (mean age=32±12 years, 74.7%female). A non-suicidal self-injury frequency of 24.5% (n=59) was observed. Of these, 91.5% reported suicidal ideation at least once. An association was found between income level and the frequency of non-suicidal self-injury (χ

Maltrato en la gestante adolescente y su efecto en el peso del recién nacido en la altura geográfica peruana, Huancayo, Perú / Abuse in adolescent pregnant women and its effect on newborn weight in the Peruvian geographical altitude, Huancayo, Peru

INTRODUCCIÓN: La violencia en la gestante está asociada a muchos factores del recién nacido, pero esto casi no se ha reportado en la altura geográfica. OBJETIVO: Determinar si existe asociación entre el maltrato en la gestante adolescente y su efecto en el peso del recién nacido en la altura geográfica peruana. MÉTODO: Estudio de cohorte retrospectiva. Se tomó la información de 855 gestantes. La variable exposición fue que hubieran sufrido violencia, lo cual se asoció al peso y otros datos del recién nacido en la ciudad de Huancayo, Perú. RESULTADOS: Según el análisis multivariado, hubo más riesgo de que el niño tuviera un peso inadecuado cuando hubo violencia física (riesgo relativo ajustado [RRa]: 1,42; intervalo de confianza del 95% [IC95%]: 1,01-2,00; p = 0,045), cuando se tuvo un parto pretérmino según Capurro (RRa: 4,90; IC95%: 2,85-8,45; p < 0,001), cuando hubo complicaciones en el parto (RRa: 2,11; IC95%: 1,25-3,61; p = 0,006) y si el abuso inició en el primer trimestre (RRa: 14,74; IC95%: 4,70-46,27; p < 0,001), el segundo (RRa: 18,72; IC95%: 5,78-60,63; p < 0,001) o el tercero (RRa: 18,87; IC95%: 4,71-75,60; p < 0,001). CONCLUSIONES: Existe asociación entre sufrir violencia física durante la gestación y el bajo peso al nacer, y también se encontró asociación con otras variables.

INTRODUCTION: Violence in the pregnant woman is associated with many newborn factors, but this has hardly been reported in the geographical altitude. OBJECTIVE: To determine whether there is an association between adolescent pregnancy abuse and its effect on newborn birth weight in high altitude Peru. METHOD: Retrospective cohort study. Information was taken from 855 pregnant women. The exposure variable was whether they had suffered gender-based violence, the exposure variable was that they had suffered violence, which was associated with the weight and other data of the newborn in Huancayo city, Peru. RESULTS: In the multivariatee analysis it was found that there was a higher risk of the child having an inadequate weight when there was physical violence (adjusted relative risk [RRa]: 1.42; 95% confidence interval [95% CI]: 1.01-2.00; p = 0.045), when there was a preterm birth according to Capurro (RRa: 4.90; 95% CI: 2.85-8.45; p < 0.001), when there were complications in childbirth (RRa: 2.11; 95% CI: 1.25-3.61; p = 0.006) and if the abuse started in the first trimester (RRa: 14.74; 95% CI: 4.70-46.27; p < 0.001), second (RRa: 18.72; 95% CI: 5.78-60.63; p < 0.001) or third (RRa: 18.87; 95% CI: 4.71-75.60; p < 0.001). CONCLUSIONS: There is an association between suffering physical violence during gestation and low birth weight, and association was also found with other variables.

Lesiones de causa externa y su relación con el alcohol en pacientes atendidos en un hospital de emergencia de Lima, Perú / External lesions and their relationship with alcohol consumption in patients attending in an emergency hospital in Lima, Peru

RESUMEN Objetivo: Describir las características demográficas, temporales y espaciales de las personas con lesiones de causa externa (LCE) y la relación con el consumo y la disponibilidad de alcohol, ocurridos en el distrito y atendidos en un hospital de emergencias. Material y métodos: Estudio descriptivo retrospectivo de personas atendidas por LCE en el Hospital de Emergencias José Casimiro Ulloa en el periodo 2014-2016 y la información de la denuncia policial por los afectados, en la comisaría del distrito. Se determinó la asociación entre las variables demográficas, temporales y espaciales con el tipo de LCE y la presencia de alcohol mediante pruebas de regresión logística. Resultados : Se encontró que era más probable la presencia de alcohol en un accidentado con LCE, cuando este era del sexo masculino en los días jueves a domingo. La contusión en una LCE en vez de una herida cortante, fue más probable cuando el accidentado era de sexo masculino, edades entre 15 a 38 años, la causa era una agresión, la ocurrencia del evento se producía entre las 00:00 a 18:00 horas, los días jueves a domingo y en los años 2014 y 2016. Geográficamente, la ocurrencia fue mayor en avenidas principales a no más de 500 metros de lugares donde se vendía y consumía licor. Conclusiones : La persona que va atenderse por lesiones de causa externa causadas como consecuencia de la violencia tiene una alta probabilidad de ser varón, además ocurren con mayor frecuencia los fines de semana y en avenidas principales en donde se puede usar un transporte público y no a más de 500 metros de lugares en donde se puede vender y consumir alcohol sin necesidad de ser residentes del distrito de ocurrencia, sin descartar que el consumo de alcohol pueda considerarse un factor de riesgo.

SUMMARY Objective: To describe demographic, temporal and spatial relationships of external lesions (EL) with alcohol consumption in patients attending an emergency hospital in Lima. Methods: Retrospective study of patients with EL attended at Hospital de Emergencias Casimiro Ulloa from 2014-2016 including information on police investigation. Logistic regression analysis was carried-out to evaluate association between type of EL and alcohol consumption. Results: The relationship of alcohol consumption and EL was stronger in males and from Thursday to Sunday. Contusions instead of stab wounds were more likely when the victim was male from 15-38 years of age and when had occurred from 00:00 to 18:00 from Thursdays to Sundays. EL occurred more frequently near main avenues at no more than 500 meters from alcoholic beverages were sold. Conclusions: Victims of EL are more likely to be males not necessarily living in the district where the aggression occurred, which tended to happen near main avenues close to where alcoholic beverages are offered. Alcohol consumption could not be ruled-out as a risk factors for EL.

Burnout syndrome and workplace violence among nursing staff: a cross-sectional study

ABSTRACT BACKGROUND: Among healthcare professionals, nursing workers are the most prone to becoming victims of workplace violence and present the highest burnout levels. OBJECTIVES: To investigate the association between burnout syndrome and workplace violence among nursing workers. DESIGN AND SETTING: Cross-sectional study carried out at a teaching hospital in southern Brazil. METHODS: This study involved 242 nursing workers. We collected data over a six-month period using a sociodemographic and occupational survey, the Survey Questionnaire Workplace Violence in the Health Sector and the Maslach Burnout Inventory - General Survey. For occupational violence, we selected the Survey Questionnaire Workplace Violence in the Health Sector. Burnout syndrome was evaluated using the Maslach Burnout Inventory - General Survey. The data were analyzed in the Statistical Package for the Social Sciences (SPSS). Categorical variables were described as absolute and relative frequencies and numerical variables in terms of central trend and dispersion measurements. For data analysis, we applied descriptive statistics and multiple logistic regression. RESULTS: The multiple models indicated that the workers who had experienced verbal abuse, physical violence and concern about workplace violence over the past 12 months had significantly higher chances of presenting high emotional exhaustion (P < 0.05) and depersonalization (P < 0.05) and low professional accomplishment (P < 0.05). CONCLUSION: Occurrence of violence significantly increased the chances of great emotional exhaustion and depersonalization and low professional achievement, within burnout syndrome. Therefore, workplace violence prevention strategies need to be put in place to provide workers with a safe workplace in which to conduct their activities.

Ocurrencia y factores asociados con la violencia física y psicológica a mujeres embarazadas atendidas en un hospital materno infantil / Occurrence and associated factors with physical and psychological violence on pregnant women users of a motherhood and children hospital

Resumen OBJETIVO: Estimar la ocurrencia y los factores asociados con la violencia física y psicológica ejercida a las embarazadas por parte de sus parejas. MATERIALES Y MÉTODOS: Estudio de cohorte, retrospectivo y transversal efectuado en las pacientes atendidas entre los meses de junio a noviembre de 2019 en el Hospital de la Madre y el Niño Guerrerense, México. Mediante un cuestionario electrónico (Abuse Assessment Screen), autoadministrado, se indagaron los datos sociodemográficos, de violencia física y psicológica y los antecedentes ginecoobstétricos. La estimación de factores asociados se hizo mediante razón de momios y análisis multivariado. RESULTADOS: Se reunieron 463 registros útiles para el análisis; 125 (27%) reportaron violencia psicológica y 7% (n = 32) violencia física. Los factores asociados con la violencia psicológica fueron: antecedente de este tipo de violencia en la infancia (razón de momios ajustada [RMa] 2.5; IC95%: 1.3-4.8) y antes del embarazo (RMa: 33.9; IC95%: 18.9-60.6). Los factores asociados con la violencia física fueron: antecedente de este tipo de violencia antes del embarazo (RMa: 24.6; IC95%: 10.4- 58.6) y en la infancia (RMa: 3.6; IC95%: 1.5-8.5) además, consumo de alcohol durante el embarazo (RMa: 5.5; IC95%: 1.3-24.4). Estar casada o en unión libre fue un factor protector en contra de la violencia psicológica (RMa: 0.33; IC95%: 0.11-0.97) y física (RMa: 0.29; IC95%: 0.08-0.99). CONCLUSIONES: La violencia psicológica fue mayor que la reportada para la física. Ambas se experimentaron durante los años de infancia o antes del embarazo e incrementaron el riesgo de sufrirla durante el proceso reproductivo. Las embarazadas casadas o en unión libre tuvieron menor riesgo de sufrir violencia física y psicológica.

Abstract OBJECTIVE: To estimate the occurrence and factors associated with physical and psychological violence exerted on pregnant women by their partners. MATERIALS AND METHODS: Cohort, retrospective and cross-sectional study carried out in patients attended from June to November 2019 at the Hospital de la Madre y el Niño Guerrerense, Mexico. An electronic questionnaire (Abuse Assessment Screen), self-administered, was used to inquire about sociodemographic data, physical and psychological violence and gynecological and obstetric history. The associated factors were estimated by odds ratio and multivariate analysis. RESULTS: We collected 463 records useful for analysis; 125 (27%) reported psychological violence and 7% (n = 32) physical violence. Factors associated with psychological violence were history of such violence in childhood (adjusted odds ratio [aOR] 2.5; 95%CI: 1.3-4.8) and before pregnancy (aOR: 33.9; 95%CI: 18.9-60.6). The factors associated with physical violence were history of this type of violence before pregnancy (aRI: 24.6; 95%CI: 10.4-58.6) and in childhood (aRI: 3.6; 95%CI: 1.5-8.5) and alcohol consumption during pregnancy (aRI: 5.5; 95%CI: 1.3-24.4). Being married or in union was a protective factor against psychological (RMa: 0.33; 95%CI: 0.11-0.97) and physical violence (RMa: 0.29; 95%CI: 0.08-0.99). CONCLUSIONS: Psychological violence was higher than that reported for physical violence. Both were experienced during the childhood years or before pregnancy and increased the risk of suffering it during the reproductive process. Pregnant women who were married or in union had a lower risk of suffering physical and psychological violence.

'Unheard voices': Perceptions of women with mental illness on nurses screening routinely for domestic violence: A qualitative analysis / "Voces no escuchadas": Percepciones de las mujeres con enfermedades mentales sobre el cribado rutinario de la violencia doméstica por parte de las enfermeras. Un análisis cualitativo / "Vozes não ouvidas": percepções de mulheres com transtorno mental sobre o rastreamento cotidiano da violência doméstica por enfermeiras. Uma análise qualitativa

Objective. To explore women's experiences of violence and their opinion on routine screening for domestic violence by nursing professionals in mental health care settings. Methods. This qualitative narrative research design was carried out among 20 asymptomatic women with mental illness at a tertiary care centre in Bangalore, India. Results. Narrative content analysis was performed, and five dominant themes have emerged: 1. Understanding the nature and signs of violence (subtheme: Meaning of violence), 2. Abusive experiences of women with mental illness (subthemes: Physical violence, psychological violence, social violence, sexual violence and financial violence), 3. Experiences on disclosure of violence (subthemes: Identification of violence by nursing professionals, Experiences of disclosure of violence), 4. Barriers for disclosure of abuse(subthemes: Fear of consequences, the hectic schedule of nursing staff, helplessness and hopelessness, perceived poor family support). 5.Routine screening for violence by nursing professionals (subthemes: reasons for routine inquiry of violence, nature of inquiry by the nursing professionals). Conclusion. Women with mental illness were undergoing more than one form of violence, and most of the participants supported routine screening by nursing professionals. Nurses play an essential role in identifying and supporting abused women in mental health care settings.

Objetivo. Explorar las experiencias de violencia que sufren las mujeres y su opinión sobre el cribado rutinario de la violencia doméstica por parte de los profesionales de enfermería en los centros de salud mental. Métodos. Esta investigación narrativa cualitativa se llevó a cabo con 20 mujeres asintomáticas con enfermedades mentales en un centro de atención terciaria en Bangalore, India. Resultados. Se realizó un análisis de contenido narrativo y surgieron cinco temas dominantes: 1. Comprensión de la naturaleza y los signos de la violencia (subtema: Significado de la violencia), 2. Experiencias abusivas de las mujeres con enfermedades mentales (subtemas: Violencia física, violencia psicológica, violencia social, violencia sexual y violencia económica), 3. Experiencias sobre la revelación de la violencia (subtemas: Identificación de la violencia por parte de los profesionales de enfermería, Experiencias de revelación de la violencia), 4. Barreras para la revelación del abuso (subtemas: Miedo a las consecuencias, el agitado horario del personal de enfermería, impotencia y desesperanza, percepción de un escaso apoyo familiar). 5. Indagación rutinaria de la violencia por parte de los profesionales de enfermería (subtemas: razones para la indagación rutinaria de la violencia, naturaleza de la indagación por parte de los profesionales de enfermería). Conclusión. Las mujeres con enfermedades mentales sufrieron más de una forma de violencia y la mayoría de las participantes apoyó el cribado rutinario por parte de los profesionales de enfermería. Las enfermeras desempeñan un papel esencial en la identificación y en el apoyo a las mujeres maltratadas en los entornos de atención en la salud mental.

Objetivo. Explorar as experiências de violência sofrida por mulheres e sua opinião sobre o rastreamento rotineiro de violência doméstica por profissionais de enfermagem em centros de saúde mental. Métodos. Esta pesquisa narrativa qualitativa foi realizada com 20 mulheres assintomáticas com doença mental em um estabelecimento de cuidados terciários em Bangalore, Índia. Resultados. Realizou-se uma análise de conteúdo narrativo e emergiram cinco temas dominantes: 1. Compreendendo a natureza e os sinais da violência (subtópico: Significado da violência), 2. Experiências abusivas de mulheres com transtorno mental (subtópicos: Violência física, violência psicológica, violência social, violência sexual e violência econômica), 3. Experiências sobre a divulgação da violência (subtópicos: Identificação da violência por profissionais de enfermagem, Experiências da divulgação da violência), 4. Barreiras para a divulgação do abuso (subtópicos: medo das consequências, enfermagem ocupada horas de trabalho, desamparo e desesperança, percepção de pouco apoio familiar) 5. Inquérito de rotina sobre violência por profissionais de enfermagem (subtópicos: motivos de inquérito de rotina sobre violência, natureza do inquérito por profissionais de enfermagem). Conclusão. Mulheres com doença mental sofreram mais de uma forma de violência e a maioria das participantes apoiava o rastreamento de rotina pelos profissionais de enfermagem. Os enfermeiros desempenham um papel essencial na identificação e apoio às mulheres agredidas em ambientes de cuidados de saúde mental.

A qualitative study on factors associated with intimate partner violence in Colombia

Abstract Intimate partner violence (IPV) is a human rights violation and a serious global public health problem. This study investigated factors associated with IPV in female survivors in Colombia. Four focus group discussions with female survivors of IPV and 15 key informant interviews with professionals from psychological, social and legal services and community leaders were conducted in Cali and Tuluá. Participant recruitment was via purposive sampling. Transcripts were analysed manually taking a social constructivist standpoint and a content analysis approach. Factors associated with IPV were divided into four themes: cultural beliefs, jealousy, alcohol abuse, and personal history of IPV. The first theme was divided into: patriarchy, gender roles, normalisation of violence, and unawareness of rights, economic dependence, and 'men own women'. The sub-themes were all inter-related and underpinned by patriarchal values. IPV was described as a sociocultural construction formed by patriarchal values ingrained in community and societal norms and individual processes. Therefore, academia, governmental and non-governmental bodies and society are urged to together, create preventative, context specific strategies for individuals, communities and societies.

Resumo A violência por parceiro íntimo (VPI) é uma violação dos direitos humanos e um grave problema de saúde pública global. Este estudo investigou fatores associados à VPI em mulheres sobreviventes na Colômbia. Quatro discussões de grupos focais com mulheres sobreviventes de VPI e 15 entrevistas com informantes-chave com profissionais de serviços sócio-médico-legais foram realizadas usando amostragem intencional nas cidades de Cali e Tuluá. As transcrições foram analisadas manualmente, sob um ponto de vista construtivista social e uma abordagem de análise de conteúdo. Os fatores associados à VPI foram divididos em 4 temas: crenças culturais, ciúmes, abuso de álcool e história pessoal da VPI. O primeiro tema foi dividido em: patriarcado, papéis de gênero, normalização da violência, desconhecimento de direitos, dependência econômica e 'homens possuem mulheres'. VPI foi descrita como uma construção sociocultural formada por valores patriarcais e processos individuais. A VPI é causada por uma complexa interação de diferentes fatores nos níveis do indivíduo, relacionamentos, comunidade e social. Os órgãos governamentais e não governamentais e a sociedade são instados a criar juntos estratégias preventivas e específicas no contexto.

Effect of physical and sexual violence during childhood and/or adolescence on the development of menstrual related mood disorders: A systematic review and meta-analysis / Efecto de la violencia física y sexual durante la infancia y/o la adolescencia en el desarrollo de trastornos del estado de ánimo relacionados con la menstruación: Una revisión sistemática y metaanálisis

Abstract Background Abuse in early life stages has been proposed as an etiological risk factor for developing menstrually-related mood disorders (MRMDs). Objetive To evaluate whether there is a relation between the occurrence of physical and/or sexual violence in childhood and/or adolescence and the development of MRMDs in adulthood. Method A systematic search was conducted in PubMed, Web of Science, and ScienceDirect, with the route ("Premenstrual Syndrome"[Mesh]) OR ("Premenstrual Dysphoric Disorder"[MeSH]) AND ("Violence"[Mesh]) / ("menstrually-related mood disorders" AND "abuse"). Fifty-four articles were initially reviewed and 32 were excluded based on the criteria. Twenty-two articles were thoroughly reviewed. Finally, five articles (publication years 2014, 2013, 2012, 2007, and 2003) were included in the systematic review and submitted to a meta-analysis. Results Results indicate that having been exposed to physical and/or sexual violence in childhood and/or adolescence increases 1.99 times the risk of experiencing MRMDs in adulthood in comparison with women who did not experience that type of violence (odds ratio [OR] = 1.99; 95% confidence interval [1.58, 2.51]). Discussion and conclusion The present work provides evidence that a woman who experienced violence through physical and/or sexual abuse during childhood and/or adolescence has a greater risk of developing MRMDs in adulthood.

Resumen Antecedentes El abuso en las etapas tempranas de la vida se ha propuesto como un factor de riesgo etiológico para desarrollar trastornos del estado de ánimo relacionados con la menstruación (TEARM). Objetivo Evaluar si existe una relación entre la ocurrencia de violencia física y/o sexual en la infancia y/o la adolescencia y el desarrollo de MRMD en la edad adulta. Método Se realizó una búsqueda sistemática en PubMed, Web of Science y ScienceDirect con la ruta ("Premenstrual Syndrome"[Mesh]) OR ("Premenstrual Dysphoric Disorder"[MeSH]) AND ("Violence"[Mesh]) / ("menstrually-related mood disorders" AND "abuse"). Cincuenta y cuatro artículos fueron revisados inicialmente y 32 fueron excluidos con base en los criterios establecidos. Veintidós artículos fueron revisados exhaustivamente. Por último, se incluyeron cinco artículos (años de publicación 2014, 2013, 2012, 2007 y 2003) en la revisión sistemática, y cinco de ellos fueron sometidos a un metaanálisis. Resultados Los resultados indican que haber estado expuesta a violencia física y/o sexual en la niñez y/o la adolescencia aumenta 1.99 veces el riesgo de experimentar TEARM en la edad adulta en comparación con las mujeres que no experimentaron ese tipo de violencia (odds ratio [OR] = 1.99; intervalo de confianza del 95% [1.58-2.51]). Discusión y conclusión El presente trabajo aporta evidencia de que una mujer que experimentó violencia por abuso físico y/o sexual durante la niñez y/o la adolescencia tiene un mayor riesgo de desarrollar TEARM en la edad adulta.

Frecuencia del maltrato y homicidio infantil en Medellín (Colombia)

RESUMEN Introducción: El maltrato y el homicidio infantil se destacan dentro del espectro de la violencia intrafamiliar por las consecuencias severas que generan en la salud, el desarrollo socioeconómico de una región y en la calidad de vida de los menores y sus familiares. Objetivo: Caracterizar el maltrato físico, sexual y los homicidios ejercidos hacia los niños y niñas menores de doce años, ocurridos en el contexto familiar en Medellín, Colombia, durante 2010-2015. Metodología: Estudio descriptivo, retrospectivo y transversal. Se realizó un análisis estadístico descriptivo de la ocurrencia de los eventos violentos intrafamiliares en menores de doce años atendidos por el Instituto Nacional de Medicina Legal y Ciencias Forenses en la ciudad de Medellín. Resultados: Se reportaron 3 519 casos de maltrato físico y sexual infligido a menores de doce años dentro del contexto familiar. 56,9 % de los hechos corresponden a maltrato sexual, siendo las mujeres las principales víctimas de este tipo de abuso; por su parte los hombres fueron los más afectados por maltrato físico. Los menores entre los seis y once años son los más maltratados. Se reportaron nueve casos de homicidio, de los cuales siete fueron cometidos contra mujeres y cinco de estos fueron perpetrados por el padrastro de las víctimas. Conclusiones: El maltrato infantil intrafamiliar ha sido un problema persistente en la ciudad de Medellín, y esto lo demuestra el alto número de casos registrados. No obstante, aunque los reportes de homicidio infantil han sido pocos, no se deben subestimar dada la importancia y las grandes consecuencias que esto presenta para la sociedad.

ABSTRACT Introduction: Child abuse and homicide are highlighted in the spectrum of intrafamily violence due to the severe consequences they generate on health, the economic and social development of a region and the quality of life of children and their families. Objective: characterize the physical and sexual abuse, and homicide exercised against children under twelve years old, occurred in the family context in Medellin Colombia, during 2010-2015. Methodology: Descriptive study, retrospective and cross-sectional. It was made a descriptive statistical analysis of the occurrence of intrafamily violent events attended by the National Institute of Legal Medicine and Forensic Sciences in Medellín. Results: 3,519 cases of physical and sexual abuse inflicted on children under twelve years old within the family context were reported. Of these, 56.9% of the events correspond to sexual abuse and women are the main victims of this type of abuse; men are the most affected in physical abuse. Children between six and eleven years old are the most vulnerable. Nine cases of homicide were reported, of which seven were committed against women and five of these were perpetrated by the victims' stepfather. Conclusions: Intrafamily child abuse is a persistent problem in Medellín, and this is demonstrated by the high cases recorded. However, there have been few cases of child homicide, this does not diminish the importance and the number should not be underestimated, because of the enormous consequences they have for society.

Características y factores asociados al maltrato percibido en internos de medicina en Perú / Characteristics and associated factors with mistreatment perception in medical interns in Peru

RESUMEN Objetivo: Determinar las características y factores asociados a la percepción de maltrato en internos de medicina del Perú. Materiales y métodos : Estudio multicéntrico, transversal y analítico. Se encuestaron a internos de medicina de dieciocho hospitales del Perú. Se aplicó una encuesta entre marzo y abril del 2016 que incluían características sociodemográficas y una escala que media la percepción de maltrato psicológico, físico y sexual. Se realizaron modelos lineales generalizados y se estimaron razones de prevalencia crudas y ajustadas (RPa) con intervalos de confianza al 95%. Resultados : Participaron 418 internos de medicina. El maltrato psicológico, físico y sexual percibido fue de 91,9%; 55,5% y 34%, respectivamente. Los factores asociados con el maltrato psicológico fueron proceder de una universidad privada (RPa:1,07; IC95%:1,01- 1,13), respecto al maltrato físico fueron la edad (RPa: 1,08; IC95%: 1,05-1,12), realizar internado en un hospital de la selva (RPa: 1,27; IC95%: 1,03-1,56) y en un hospital del Seguro Social (RPa:0,66; IC95%:0,44-0,94) y para el maltrato sexual el ser mujer (RPa:1,52; IC95%:1,15-2,01). Conclusiones : Existe una alta percepción de maltrato reportado por los internos de medicina siendo el psicológico el más frecuente. Existen diferencias en la percepción de maltrato psicológico y físico según el tipo de financiamiento de la universidad de procedencia y del hospital donde se realiza el internado. Una alta frecuencia de maltrato sexual fue reportada por mujeres luego de los tres primeros meses del internado hospitalario.

ABSTRACT Objective: To determine the characteristics and factors associated with the perception of abuse in medicine interns of Peru. Material and Methods : This is a cross-sectional multicenter and analytical study. Medicine interns from eighteen Peruvian hospitals were interviewed. A survey was administered between March and April 2016, which included socio-demographic characteristics and a scale measuring psychological and physical abuse, as well as sexual harassment perception. Generalized linear models were used and crude and adjusted prevalence rates (aPR) were estimated, with 95% confidence intervals (CI). Results: 418 medical interns participated in the study. Psychological and physical abuses were perceived by 91,9% and 55,5% of the studied population. Sexual harassment was perceived by 34% of all interviewed interns. Associated factors with psychological abuse were studied in a private university (aPR: 1.07; 95% CI: 1.01-1.13). Factors associated with physical abuse were age (aPR: 1.08; 95% IC: 1.05-1.12), performing internship in an Amazonian area hospital (aPR: 1,27; 95% CI: 1,03-1,56), and in a Social Security Hospital (aPR: 0,66; 95% CI: 0,44-0,94); and for sexual harassment, being female was the main associated factor (aPR: 1,52; 95% CI: 1,15-2,01). Conclusions: There is a high perception of abuse experienced by medicine interns, being psychological abuse the most frequent condition. There are some differences in the perception of psychological and physical abuse, according to the medical school the interns come from, as well as with respect to the healthcare facility where internship is performed. A high frequency of sexual harassment was reported by female interns after three months of having started their training period.

Exploring the determinants and outcomes of intimate partner violence during pregnancy for Guyanese women: Results from a nationally representative cross-sectional household survey / Análisis de los determinantes y las consecuencias de la violencia de pareja durante el embarazo en mujeres de Guyana: resultados de una encuesta domiciliaria transversal representativa a nivel nacional / Conhecendo os determinantes e os desfechos da violência por parceiro íntimo contra mulheres na gravidez na Guiana: resultados de uma pesquisa transversal domiciliar com representatividade nacional

ABSTRACT Objective. To determine predictors associated with physical violence during pregnancy, and to determine the relationship between exposure to intimate partner violence during pregnancy and women's health and suicide ideation in Guyana. Methods. A secondary data analysis of a cross-sectional household survey. Multivariate logistic regression models were fitted to the data to estimate the association between physical violence during pregnancy, controlling partner behavior, and other predictors. Ordered logistic regression models were fitted to estimate the association between physical violence during pregnancy and women's health, and lifetime physical partner violence and overall health. Logistic regression models were fitted to estimate associations between physical violence during pregnancy and lifetime physical partner violence and overall health and suicide ideation. Results. The prevalence of lifetime physical/sexual intimate partner violence was 38.8%, current physical/sexual intimate partner violence 11.1%, and violence during pregnancy 9.2%. Controlling partner behavior was significantly and positively associated with maternal experience of physical violence during pregnancy. Experiencing physical partner violence during pregnancy, but not lifetime physical partner violence, was associated with significantly increased odds of poor overall health. Physical violence during pregnancy and lifetime physical violence were both significantly associated with increased odds of suicide ideation. Conclusions. The prevalence of violence during pregnancy in Guyana is high and is associated with adverse health outcomes. These findings suggest the need for intimate partner violence prevention, and for integrating intimate partner violence screening and treatment into antenatal care, reproductive health services, and maternal and child health programs and services to identify and treat at-risk women.

RESUMEN Objetivo. Determinar los factores predictivos relacionados con la violencia física durante el embarazo y determinar la relación entre la exposición a la violencia de pareja durante el embarazo y la ideación suicida y la salud de las mujeres en Guyana. Métodos. Se realizó un análisis secundario de los datos obtenidos de una encuesta domiciliaria transversal. Se adaptaron modelos multifactoriales de regresión logística a los datos para calcular la asociación entre la violencia física durante embarazo, comportamiento controlador de la pareja y otros factores predictivos. Se emplearon modelos ordenados de regresión logística para calcular la asociación entre la violencia física durante el embarazo y la salud de la mujer, y la violencia de pareja a lo largo de la vida y la salud en general. Se aplicaron modelos de regresión logística para calcular la asociación entre la violencia física durante el embarazo y la violencia de pareja a lo largo de la vida y la ideación suicida y la salud en general. Resultados. La prevalencia de la violencia física o sexual infligida por la pareja a lo largo de la vida fue 38,8%, la violencia física o sexual infligida por la pareja en la actualidad fue 11,1% y la violencia durante el embarazo fue 9,2%. El comportamiento controlador de la pareja mostró una asociación positiva y significativa con una experiencia materna de violencia física durante el embarazo. Sufrir violencia física durante el embarazo, aunque no a lo largo de la vida, se asoció significativamente con mayores probabilidades de un estado de salud general deficiente. Tanto la violencia física durante el embarazo como la violencia física a lo largo de la vida se asociaron significativamente con mayores probabilidades de ideación suicida. Conclusiones. La prevalencia de la violencia durante el embarazo en Guyana es alta y está relacionada con consecuencias adversas en materia de salud. Estos resultados ponen de manifiesto la necesidad de prevenir la violencia de pareja y de integrar su detección y tratamiento en la atención prenatal, los servicios de salud reproductiva y los programas y servicios de salud maternoinfantil para detectar y tratar a las mujeres en riesgo.

RESUMO Objetivo. Determinar as variáveis preditivas associadas à violência física contra mulheres na gravidez e avaliar a relação entre exposição à violência por parceiro íntimo na gravidez e saúde e ideação suicida em mulheres na Guiana. Métodos. Foi realizada uma análise dos dados secundários de uma pesquisa transversal domiciliar. Modelos de regressão logística multivariada foram ajustados ao conjunto de dados para estimar a associação entre violência física na gravidez, controlando-se o efeito do comportamento do parceiro e outras variáveis preditivas. Modelos de regressão logística ordinal foram ajustados para estimar a associação entre violência física na gravidez e saúde das mulheres e violência física por parceiro íntimo ao longo da vida e saúde geral. Modelos de regressão logística foram ajustados para estimar a associação entre violência física na gravidez e violência física por parceiro íntimo ao longo da vida e saúde geral e ideação suicida. Resultados. Observou-se uma prevalência de 38,8% de violência física/sexual por parceiro íntimo ao longo da vida, 11,1% de violência física/sexual por parceiro íntimo no momento presente e 9,2% de violência física/sexual na gravidez. Controlando-se o efeito do comportamento do parceiro, verificou-se uma associação positiva significativa com experiência materna de violência física na gravidez. Sofrer violência física por parceiro íntimo na gravidez, mas não violência física por parceiro íntimo ao longo da vida, foi associado a uma chance significativamente maior de saúde geral ruim. Verificou-se uma associação significativa entre violência física na gravidez e violência física ao longo da vida e uma maior chance de ideação suicida. Conclusões. A prevalência da violência contra mulheres na gravidez na Guiana é alta e está associada a desfechos de saúde adversos. Esses resultados apontam para a necessidade de prevenir a violência por parceiro íntimo e integrar a avaliação da violência por parceiro íntimo e o tratamento das mulheres aos serviços de assistência pré-natal e de saúde reprodutiva e programas e serviços de saúde materno-infantil para identificar e tratar as mulheres em risco.

Vulneración a la integridad física de personas mayores: prevalencia del maltrato y factores asociados / Violation of the Physical Integrity of the Elderly: Prevalence of Abuse and Related Factors

Resumen El envejecimiento poblacional que experimenta actualmente América Latina trae consigo retos para la sociedad, como la prevención de la vulneración a los derechos humanos y libertades de las personas mayores y la eliminación de todas las formas de maltrato. La prevalencia de maltrato físico a personas mayores fue de 4,1%. Se presentó principalmente en mujeres, personas sin pareja y con ingreso económico. Además, fue más prevalente en personas mayores con riesgo de depresión, ante cedentes de pensamientos suicidas, insatisfacción con la salud y que convivían con familias disfuncionales. Los hallazgos de esta investigación muestran como las re laciones familiares pueden ser un factor clave a la hora de abordar la problemática del maltrato; además, las graves repercusiones que generan estos hechos sobre la víctima, como afectaciones no solo a la salud física sino también mental.

Abstract The ageing population currently experienced by Latin America brings with it cha llenges for society, such as the prevention of human rights violation and freedoms of the elderly, and the elimination of all forms of abuse. The prevalence of physical abuse for the elderly was 4.1%. It was mainly presented in women, people without a partner, and with financial income. In addition, it was more prevalent in older people at risk of depression, a history of suicidal thoughts, dissatisfaction with health, and living with dysfunctional families. The findings of this research show how family re lationships can be a key factor in addressing the problem of abuse. In addition, the serious impact of these facts on the victim, such as affectations not only to physical health, but also to mental health.

Workplace violence in the health sector: validez y adaptación del instrumento al idioma español, en el contexto ecuatoriano para tipos de violencia / Workplace violence in the health sector: adaptation and validation of the questionnaire for types of violence in the ecuadorian context

Uno de los objetivos de la encuesta "Workplace Violence in the Health Sector" es investigar los factores que pueden contribuir a la violencia en el lugar de trabajo en el sector de salud en varios países del mundo para la toma de políticas públicas apropiadas. A pesar de que el inglés sea un idioma universal, en la práctica genera limitaciones para aplicarlo sobre todo en los países de América Latina. Esta investigación tiene como propósito validar el contenido, y constructo para que la encuesta se pueda aplicar en los países cuya lengua oficial es el español. Se emplearon las técnicas cualitativas y cuantitativas para validar el instrumento, con la revisión de expertos se validó la semántica e idioma. A través del el Alpha de Cronbach de 0,96 se puede aseverar la confiabilidad de este para medir la violencia de trabajo en el sector de la salud de los países de habla hispana.

The purpose of the survey "Violence in the workplace in the health sector" is to obtain information on the factors that could contribute to the workplace violence in the health sector within different countries of the world. Collecting data on the problem is therefore important of the appropriate public policy making. Despite of English is considered widely the universal language, in practice it generates limitations to apply especially in Latin American countries. This research aims to validate the content, and construction for the survey to the application in countries where Spanish is an official language. Qualitative and quantitative techniques were used to validate the questionnaire; experts review validated the semantics and language construction. The global inventory (Cronbach's alpha = 0.96) indicated good reliability to measure the workplace violence in the health sector for Spanish-speaking countries.

Suspected child abuse and neglect cases in a single tertiary hospital in Malaysia - a 5-year retrospective study

@#Background: Published reports by the Social Welfare Department of Malaysia suggests that child abuse and neglect cases has been steadily increasing. There is a lack of basic data and qualitative study on child maltreatment in Malaysia. Objective: The aim is to describe the pattern and demographic features of all suspected child abuse and neglect (SCAN) cases seen in a single tertiary hospital in Malaysia over a period of five years. Methods: A retrospective descriptive review of children suspected of maltreatment, aged 0 to 18 years old who presented to the Hospital Serdang (HS), Selangor, Malaysia from January 2014 to December 2018 was done. A list of registered SCAN cases obtained from One Stop Crisis Centre (OSCC) HS census. Clinical information of patients was retrieved from the computerised database. Results: In all, there were a total of 391 SCAN cases over five years with almost a 3-fold increase in the number of cases from 2014 to 2018. Physical abuse was the most common (55%) seen followed by sexual abuse (34%) and neglect (10%). There were four deaths, all involving infants <1 year old who were physically abused by babysitters. The main perpetrator in sexual abuse were people known to the victim. Ninety-three percent of patients were neglected by their biological parents and more than 2/3rd of neglect cases occurred due to inadequate supervision. Discussion: Child maltreatment is an inevitable burden to our health system and infants are the most vulnerable group to sustain significant injuries leading to death and disabilities.

Abuse in Colombian elderly and its association with socioeconomic conditions and functionality / Maltrato en adultos mayores colombianos y su asociación con condiciones socioeconómicas y funcionalidad

Abstract Objective: To describe the presence of abuse in elderly people in Colombia and its association with socio-demographic and functional conditions. Methods: Cross-sectional and descriptive research. Data were taken from the SABE Colombia Survey, a population study, with a national representative sample of 23,694 adults aged over 60 years. Presence and type of abuse by partners or family members, members were investigated. Generalized linear models with Poisson link function were used to estimate the causes of the prevalence of abuse by area of residence, region, age, sex, dependence on activities of daily living and living arrangements. Results: 15.1% of the elderly in Colombia reported some type of abuse, and over 50% reported more than one form of abuse. Abuse proportion is greater in people who are aged 60-69, in women, people with lower levels of education, people who belong to lower socioeconomic status, people who live alone, people who live with children, and people in urban areas. The most frequent abuse form is psychological, followed by neglect and physical abuse. Dependence on basic and instrumental daily living activities increases the probabilities of suffering abuse. Conclusions: Home is a risky place for the elderly people, especially for those with functional dependence, those who belong to low socioeconomic strata and women. Results should encourage debate among researchers, professionals and decision makers on public policy about necessary actions and means to change violent family dynamics in homes with elderly people.

Resumen Objetivo: Describir la presencia de maltrato en las personas mayores en Colombia y su asociación con condiciones sociodemográficas y funcionales. Métodos: Estudio transversal y descriptivo. Se tomaron los datos de la Encuesta SABE Colombia, un estudio poblacional, con una muestra representativa a nivel nacional de 23,694 adultos mayores de 60 años. Se indagó por la presencia y tipo de maltrato, por parte de los miembros de la familia, hogar o convivientes. Se utilizaron modelos lineares generalizados con función de vínculo de Poisson para estimar las razones de prevalencia de maltrato por zona de residencia, región, edad, sexo, dependencia en actividades de la vida diaria y convivencia. Resultados: Reportaron algún tipo de maltrato el 15.1% de las personas mayores en Colombia y más de la mitad refiere más de una forma de maltrato. Hay mayor proporción de maltrato en las personas de 60-69 años, en mujeres, con menor escolaridad, quienes viven en estratos bajos, solos, con hijos y en zona urbana. El maltrato más frecuente es el psicológico, seguido de negligencia y maltrato físico. La dependencia en actividades básicas e instrumentales de la vida diaria, incrementa la probabilidad de sufrir maltrato. Conclusiones: El hogar es un lugar de riesgo para los adultos mayores, especialmente aquellos con dependencia funcional, de estratos bajos y mujeres. Los resultados deberán animar el debate entre investigadores, profesionales y tomadores de decisiones de política publica, en torno a las acciones y los medios necesarios para transformar las dinámicas familiares violentas en hogares con personas mayores.

Exploring the effect of time and sex in family and community violence from 2008 to 2014

ABSTRACT OBJECTIVE To evaluate the effect of the time and the sex of victims and perpetrators on the rates of family and community physical violence in a Brazilian municipality over seven years (2008-2014). METHODS We made a census analysis from non-fatal victims attended in the Forensic Institute of the Scientific Civil Police. The monthly and annual violence rates were calculated based on the population size of the municipality. Time series was evaluated by negative binomial regression models, based on the number of cases with population offset and considering the effect of the sex of victims and perpetrators. RESULTS A total of 3,324 cases of family and 4,634 cases of community violence were analyzed. There was a significant increase in family violence rates for female victims and male perpetrators. Family violence rates were always higher for female victims than for male and it was always lower for female perpetrators than for male (p < 0.001). There was a lower risk of community violence for male victims after 2013 and a decrease of aggression perpetrated by men over time. Men and women were similarly affected by community violence; however, the perpetrators were more frequently men. CONCLUSIONS The results indicate a trend of increasing female victims in the family violence, mainly perpetrated by men. The reduction in community violence rates could be the result of policies to reduce crime.

Experiencing Coercive Control in Female Victims of Dating Violence / 간호학회지

BACKGROUND: Dating violence refers to violence occurring between people in an intimate relationship. Forms of dating violence are often categorized into physical, psychological, and sexual violence, and most existing literature has followed this frame. However, few studies have focused on the phenomenon of living under the perpetrator's coercive control in victims of dating violence, although those experiences are known to be signs of severe forms of violence later on. PURPOSE: The purpose of this study was to explore the experiences of being coercively controlled in female victims who had experienced dating violence. METHODS: For this study, in-depth interviews were conducted with a total of 14 female victims, and all interviews were audio-recorded and transcribed. The data were analyzed using the phenomenological analysis method suggested by Colaizzi. RESULTS: Three themes were derived in chronological order: idealizing the relationship (period of potential control), facing severer tyranny (period of coercive control), and escaping from the unending trap (period of post-control). The results showed that the victims experienced perpetrators' control with specific patterns. The perpetrators' controlling behaviors were invisible, literally benevolent, at the beginning; however, severe forms of violence seemed to appear as their relationship deepened and the perpetrators failed to control the victims. CONCLUSION: Findings from this study presented vivid experiences of female victims who needed help and care. Hopefully, the results can benefit in terms of developing evidence-based prevention strategies for victims as well as assessing the risks of severe forms of dating violence, such as physical attack or murder.

Violent victimization of the mentally ill- skeletons in the closet

Background: Mentally ill individuals are generally portrayed as being violent by society. Violence againstthe mentally ill, on the other hand is not portrayed despite its higher prevalence. It has been seen in a varietyof settings and needs to be estimated and tackled.Methodology: This study was conducted in a tertiary care centre in urban Bangalore.100 inpatients ofPsychiatry were compared with inpatients in Medicine and Surgery based on Norvold’s AbuseQuestionnaire (NorAQ) for lifetime emotional, physical and sexual abuse. Comparisons were also made onthe basis of gender.Results: A significantly higher prevalence of lifetime abuse was found in the mentally ill with differences inthe nature of abuse across gender.Conclusion: The mentally ill face significant discrimination and victimization in society which needs urgentaddressing. Variations in abuse across social scenario and gender are known to occur. More studies on thisaspect are required to guide lawmakers and mental health professionals alike.

Prevalencia de violencia física, abuso verbal y factores asociados en trabajadores/as de servicios de emergencia en establecimientos de salud públicos y privados / Verbal and physical abuse towards health care workers in emergency services

Background: One of the peculiarities of our society is the increase in violence and its repercussions in various areas. Health care is not an exemption. Aim: To determine the prevalence of physical violence, verbal abuse towards emergency service health care workers at two public and two private health centers in the province of Concepción, Chile. Material and Methods: A questionnaire for Work Violence in Health Centers, with dimensions about physical violence and verbal abuse was applied to 366 health care workers, stratified according to center and occupational categories. Results: Thirteen percent of workers perceived physical violence. Paramedical technicians had the higher risk of perceiving this type of violence. Fifty nine percent of workers perceived verbal abuse. Nurses and administrative staff had the higher risk of perceiving this type of violence. The most common offenders were patients and family. The most common form of coping with abuse was avoiding a reaction. Most of the physical and verbal aggressions were not reported or denounced. Conclusions: There is a high prevalence of verbal abuse and physical violence in emergency services, which requires measures to achieve a zero tolerance to violence in these spaces.

Assessment of physical violence against research assistants and nurses in an university hospital / Evaluación de la violencia física contra investigadores asociados y enfermeras en un hospital universitario / Avaliação da violência física contra assistentes de pesquisa e enfermeiros em um hospital universitário

Abstract: 14. The aim of this study was to determine the prevalence of physical violence and related factors among assistants and nurses. This cross-sectional study was included 166 research assistants and 209 nurses who worked at the University Hospital. The data was collected with a self-administered questionnaire. As 12.0% participants had a history of physical violence at workplace within the last 6 months. The perpetrator was a patient relative in 41 (78.8%) and the patient himself/herself in 18 (34.6%).The most common place of violence was emergency unit for the assistants and in-patient unit for the nurses. The emergency unit was observed to have a higher incidence of violence than other departments. One of every ten health care workers appears to be a victim of physical workplace violence. Between health care workers with patient/the relatives of the patient of the impact on relations the close of violence to be examined separately according to occupational groups. As a result, professional differences between nurses and doctors should be taken into consideration while investigating health violence. Each professions of healthcare have different professional practice and ethical obligations on the relationship between health care provider and patient /relatives.

Resumen: 18. El objetivo de este estudio consiste en determinar la prevalencia de la violencia física y otros factores relacionados contra investigadores asociados y enfermeras. Este estudio transversal incluyó 166 investigadores asociados y 209 enfermeras trabajadores del hospital universitario. Los datos fueron recolectados mediante un cuestionario autoadministrado. 12% de los participantes informaron de violencia física en su lugar de trabajo en los últimos seis meses. El perpetrador fue un familiar de un paciente en 41 de los casos (78,8%) y pacientes en 18 casos (34,6%). La unidad de emergencia fue el lugar más común donde ocurrió la violencia para los investigadores asociados y la unidad de pacientes para las enfermeras. Se observó que la unidad de emergencia tuvo una mayor incidencia de violencia que otras unidades. Uno de cada 10 trabajadores de la salud es víctima de violencia física en el trabajo. Se examinó separadamente, según grupos de trabajo, el impacto en las relaciones de la violencia contra trabajadores de la salud por parte de pacientes o familiares de estos. Como resultado, se aconseja tener en consideración diferencias profesionales entre médicos y enfermeras cuando se investiga la violencia en el cuidado de la salud. Cada profesión del cuidado de la salud tiene diferentes prácticas profesionales y obligaciones éticas entre el proveedor de salud y el paciente y familiares.

Resumo: 22. O objetivo deste estudo foi determinar a prevalência de violência física e fatores relacionados entre assistentes e enfermeiros/as. Este estudo transversal incluiu 166 assistentes de pesquisa e 209 enfermeiras que trabalhavam no Hospital Universitário. Os dados foram coletados através de um questionário autoaplicável. Como resultado, 12,0% participantes apresentaram um histórico de violência física no local de trabalho nos últimos 6 meses. Como autores da violência foram identificados: os familiares dos pacientes em 41 questionários (78,8%) e o paciente em si em 18 (34,6%). O local mais comum de violência foi a unidade de emergência para os assistentes de pesquisa e a unidade de internação hospitalar para os enfermeiros/as. Na unidade de emergência, observou-se que há uma maior incidência de violência do que em outros departamentos. Um de cada dez trabalhadores na área de saúde demonstra ser vítima de violência física no local de trabalho. O impacto das relações de violência entre profissionais de saúde e pacientes/familiares deve ser examinado separadamente, de acordo com cada grupo ocupacional. Como resultado, diferenças profissionais entre médicos e enfermeiros/as devem ser consideradas ao investigar violência na área da saúde. Cada profissional de saúde possui diferentes práticas profissionais e obrigações éticas na relação entre médico e paciente / familiares.