Frecuencia y determinantes del retraso en el diagnóstico de cáncer infantil en Argentina / Frequency and determinants of the delay in the diagnosis of cancer in children, in Argentina

En Argentina, la mortalidad por cáncer infantil es mayor que en países más desarrollados, siendo el diagnóstico tardío una de las posibles causas. Nuestro objetivo fue determinar la frecuencia de obstáculos al diagnóstico enfrentados por las familias de niños con cáncer asistidas por un Organismo No Gubernamental, y algunos factores demográficos, institucionales y médicos asociados. Se realizó un análisis retrospectivo observacional y cuantitativo del recorrido diagnóstico de los niños con cáncer asistidos por la Fundación N.D. Flexer, Argentina, entre el 1/1/2011 y el 31/12/2015. El resultado primario fue la presencia de obstáculos para acceder al diagnóstico. Se consideró que existió un obstáculo cuando tuvieron lugar consultas no orientativas, demora familiar, demora institucional, autoderivación y/o más de 30 días entre la aparición de síntomas y el diagnóstico. La frecuencia dentro de cada categoría se contrastó mediante la prueba de χ2. La influencia de distintas variables se evaluó mediante una regresión logística multivariada. De 1818 familias incluidas, 63.5% enfrentaron algún tipo de obstáculos. Resultaron moduladores negativos el diagnóstico antes del año, de tumor renal y la concurrencia a un hospital público de la Ciudad de Buenos Aires o de capital provincial como centro de primer contacto (todos p < 0.0001). Resultaron moduladores positivos el diagnóstico de tumor óseo (p = 0.009) y los centros de atención primaria (p < 0.0001) y consultorios particulares (p = 0.001) como centros de primer contacto. El principal factor no biológico asociado a la frecuencia de obstáculos al diagnóstico de cáncer infantil fue el tipo de centro de primer contacto.

In Argentina, mortality from childhood cancer is higher than in more developed countries, with late diagnosis being one of the possible causes. Our objective was to determine the frequency of barriers to diagnosis faced by families assisted by a Non-Governmental Organization, and some associated demographic, institutional and medical factors. A retrospective observational and quantitative analysis of the diagnosis pathway of children with cancer assisted by the N.D. Flexer Foundation, Argentina, between 1/1/2011 and 12/31/2015 was carried out. The primary outcome was the presence of barriers to diagnosis. It was considered that there was a barrier when there were consultations without diagnostic suspicion, family delay, institutional delay, self-derivation and/ or more than 30 days between the onset of symptoms and diagnosis. The frequency of barriers within each category was contrasted by the χ2 test. A multivariate logistic regression was used to examine its association with relevant variables. Among the 1818 families included, 63.5% faced delays/ barriers to diagnosis. Negative modulators were diagnosis at age younger than 1-year, renal tumor and first attention at a public hospital of the City of Buenos Aires or a provincial capital hospital (all p < 0.0001). Positive modulators were the diagnosis of bone tumor (p = 0.009) and first attention at a primary healthcare center (p< 0.0001) or private doctor's office (p= 0.001). The main non-biological factor associated with the possibility of facing barriers to diagnosis was the type of first contact-health institution.

Review of the missed opportunities for the prevention of vertical transmission of HIV in Brazil

OBJECTIVE: The present literature review aims to highlight gaps in the treatment of preventative mother-to-child HIV transmission and the risk factors in Brazil. METHODS: Among the 425 articles identified in SciELO and PubMed searches, 59 articles published between 1994 and 2016 were selected for reading and data extraction, and 33 articles were included in the present review. RESULTS: The rates of vertical HIV transmission described in the studies varied widely, from 1.8% to 27.8%, with a significant reduction over the years. However, recent rates were also found to be variable in different regions of Brazil, and despite the significant reduction in mother-to-child transmission, many gaps remain in prevention services. A failure to attend prenatal care is the main factor associated with the increased risk of vertical transmission of HIV, hindering early maternal diagnosis and the completion of preventative measures during the prenatal period and, often, the peripartum and postnatal periods. A small number of studies discussed the sociodemographic factors, including a low level of education for pregnant women and the inadequacies of health services, such as difficulties scheduling appointments and undertrained staff, associated with vertical transmission. As such, the current challenge is to better define the sociodemographic and infrastructural factors that increase the risk of mother-to-child transmission of HIV to provide the necessary investments to promote an earlier inclusion of these populations in prevention services. CONCLUSIONS: This review may serve as a guide for future programs to focus efforts on the prevention of vertical HIV transmission.

Pesquisa sobre vacunación y oportunidades de prevención y educación para la salud: Experiencia en una residencia pediátrica mediante el Mini-Clinical Evaluation Exercise / Vaccination status inquiry and hierarchy of prevention and health education opportunities: Experience in a Pediatric Residency using the Mini-Clinical Evaluation Exercise

Introducción. El Mini-Clinical Evaluation Exercise (Mini-CEX) es una herramienta formativa. Dentro de sus ítems, evalúa la pesquisa del estado de vacunación y la jerarquización de oportunidades de prevención. Objetivos. Determinar porcentaje de pesquisa de dichos ítems en controles de salud y demanda. Comparar desempeño entre primer y tercer año. Materiales y métodos. Análisis retrospectivo de las planillas del Mini-CEX de residentes. Resultados. Se evaluaron 119 residentes. La prevalencia de pesquisa de vacunación en controles fue 94,9% (intervalo de confianza -IC-: 91,09-98,91); en demanda, 73,1% (IC: 65,2-81; OR 5,33; IC: 2,23-12,75; p= 0,00004). La prevalencia de aprovechamiento de oportunidades en controles fue 69,8% (IC: 61,6-78); en demanda, 62,2% (IC: 53,5-70,9; OR 1,034; IC: 0,46382,306; p= 0,4673). En 32 residentes se comparó su desempeño entre primer y tercer año en demandas, sin diferencia significativa. Conclusiones. Se detectó alta prevalencia de pesquisa de vacunación y menor prevalencia de aprovechamiento de oportunidades en controles, con menor pesquisa de ambos ítems en demandas.

Introduction. The Mini-Clinical Evaluation Exercise (Mini-CEX) is a formative tool with two descriptors assessing the inquiry of vaccination status and the hierarchy of prevention opportunities. Objectives. Determine the prevalence of both items in pediatric controls and spontaneous demands. Compare the performance between first and third year of their training. Material and methods. Retrospective analysis based on trainees Mini-CEX charts. Results. There were 119 residents evaluated during their first year. The prevalence of vaccination status screening in controls was 94.9% (confidence interval -CI-: 91.09-98.91); in demands 73.1% (CI: 65.2-81; OR 5.33; CI: 2.2312.75; p 0.00004). The prevalence of prevention opportunities in controls was 69.8% (CI: 61.678); in demands 62.2% (CI: 53.5-70.9; OR 1.034; CI: 0.4638-2.306; p= 0.4673). There were 32 trainees compared between their first and third year performance in demands, without significant difference. Conclusions. We found high prevalence of vaccination inquiry and lower prevalence of hierarchization of prevention opportunities in controls, with less inquiry in demands.

Missed opportunities for earlier HIV-testing in patients with HIV infection referred to a tertiary hospital, a cross-sectional study

Introduction: In Malaysia, the prevalence of missed opportunities for HIV-testing is unknown. Missed opportunities have been linked to late diagnosis of HIV and poorer outcome for patients. We describe missed opportunities for earlier HIV-testing in newly-HIV-diagnosed patients. Methods: Cross sectional study. Adult patients diagnosed with HIV infection and had at least one medical encounter in a primary healthcare setting during three years prior to diagnosis were included. We collected data on sociodemographic characteristics, patient characteristics at diagnosis, HIV-related conditions and whether they were subjected to risk assessment and offered HIV testing during the three years prior to HIV diagnosis. Results: 65 newly HIV-diagnosed patients (male: 92.3%; Malays: 52.4%; single: 66.7%; heterosexual: 41%; homosexual 24.6%; CD4 <350 at diagnosis: 63%). 93.8% were unaware of their HIV status at diagnosis. Up to 56.9% had presented with HIV-related conditions at a primary healthcare facility during the three years prior to diagnosis. Slightly more than half were had risk assessment done and only 33.8% were offered HIV-testing. Conclusions: Missed opportunities for HIV-testing was unacceptably high with insufficient risk assessment and offering of HIV-testing. Risk assessment must be promoted and primary care physicians must be trained to recognize HIV-related conditions that will prompt them to offer HIVtesting.

Oportunidades perdidas de avaliação sorológica para a infecção pelo vírus da imunodeficiência humana na rotina de atendimento ambulatorial do Hospital Universitário de Brasília, Distrito Federal / Missed opportunities for serological evaluation of human immunodeficiency virus infection during routine outpatient care at the University Hospital of Brasilia, Federal District

Foram estudados os fatores envolvidos na oferta de sorologia para detectar a infecção pelo vírus de imunodeficiência humana, no atendimento de adultos no ambulatório do Hospital Universitário de Brasília, por meio de aplicação de questionários específicos a 53 médicos e 347 usuários. Os resultados revelaram que 96,8 por cento dos usuários identificaram como fator de risco para adquirir a infecção as relações sexuais desprotegidas e 13,6 por cento desconheciam a possibilidade de transmissão vertical. Em relação à exposição dos usuários aos fatores de risco, 88,2 por cento praticaram relações sexuais desprotegidas, 22,2 por cento tiveram diagnóstico de outras doenças de transmissão sexual e 22,2 por cento tinham recebido transfusões sangüíneas. Os fatores de risco mais questionados pelos médicos foram a prática de relações sexuais desprotegidas e o diagnóstico prévio de hepatite B ou C (35,9 por cento para ambos). Dezoito por cento dos usuários receberam oferta de testes no Hospital Universitário de Brasília; 15,8 por cento foram testados e 7,4 por cento dos indivíduos testados não tiveram acesso ao resultado. Noventa e um por cento dos médicos referiram sentir-se confortáveis ao oferecer testes e apenas 30,4 por cento oferecem-nos rotineiramente. O estudo confirma a perda de oportunidades de testagem sorológica para detectar a infecção no Hospital Universitário de Brasília e reforça a necessidade de implementar medidas para corrigir o problema.

The factors involved in the provision of serological testing to detect human immunodeficiency virus infection, for adults within the outpatient care setting at the University Hospital of Brasilia, were studied. Specific questionnaires were applied to 53 physicians and 347 users. The results showed that 96.8 percent of the users identified unprotected sexual intercourse as a risk factor for acquiring this infection and that 13.6 percent were unaware of possibility of vertical transmission. Regarding users' exposure to risk factors, 88.2 percent practiced unprotected sexual intercourse, 22.2 percent had a diagnosis of other sexually transmitted diseases and 22.2 percent had received blood transfusions. The risk factors that physicians asked about most frequently were unprotected sexual practices and previous diagnoses of hepatitis B or C (35.9 percent for each). Eighteen percent of the users had been offered tests at the University Hospital of Brasilia; 15.8 percent underwent tests and 7.4 percent of the individuals tested had not had access to the results. Ninety-one percent of the physicians said that they felt comfortable about offering tests, while only 30.4 percent offered them routinely. The study confirms that opportunities for serological testing to detect this infection at the University Hospital of Brasilia have been missed and reinforces the need to implement measures to correct this problem.