Incorporation, adaptation and rejection of obstetric practices during the implementation of the "Adequate Childbirth Program" in Brazilian private hospitals: a qualitative study.

BACKGROUND: The "Adequate Childbirth Program" (PPA) is a quality improvement project that aims to reduce the high rates of unnecessary cesarean section in Brazilian private hospitals. This study aimed to analyze labor and childbirth care practices after the first phase of PPA implementation. METHOD: This study uses a qualitative approach. Eight hospitals were selected. At each hospital, during the period of 5 (five) days, from July to October 2017, the research team conducted face to face interviews with doctors (n = 21) and nurses (n = 28), using semi-structured scripts. For the selection of professionals, the Snowball technique was used. The interviews were transcribed, and the data submitted to Thematic Content Analysis, using the MaxQda software. RESULTS: The three analytical dimensions of the process of change in the care model: (1) Incorporation of care practices: understood as the practices that have been included since PPA implementation; (2) Adaptation of care practices: understood as practices carried out prior to PPA implementation, but which underwent modifications with the implementation of the project; (3) Rejection of care practices: understood as those practices that were abandoned or questioned whether or not they should be carried out by hospital professionals. CONCLUSIONS: After the PPA, changes were made in hospitals and in the way, women were treated. Birth planning, prenatal hospital visits led by experts (for expecting mothers and their families), diet during labor, pharmacological analgesia for vaginal delivery, skin-to-skin contact, and breastfeeding in the first hour of life are all included. To better monitor labor and vaginal birth and to reduce CS without a clinical justification, hospitals adjusted their present practices. Finally, the professionals rejected the Kristeller maneuver since research has demonstrated that using it's harmful.

Brazil has high Cesarean Section (CS) rates, with rates far from the ideal recommended by the World Health Organization and a model of care that does not favor women's autonomy and empowerment. In 2015, a quality improvement project, called "Projeto Parto Adequado" (PPA), was implemented in Brazilian private hospitals to reduce unnecessary cesarean section, in addition to encouraging the process of natural and safe childbirth. One of the components of this project was to reorganize the model of care in hospitals to prepare professionals for humanized and safe care. The data were collected in 8 hospitals with interviews with 49 professionals, approximately two years after the beginning of the project in the hospitals. There were changes in the hospital routine and in the care of women after the project. The professionals incorporated practices such as skin-to-skin contact and breastfeeding; diet during labor; non-invasive care technologies, especially to relieve pain during labor; birth plan; pregnancy courses with guided tours in hospitals (for pregnant women and family); and analgesia for vaginal labor. There was adaptation of existing practices in hospitals to reduce CS that had no clinical indication; better monitoring of labor, favoring vaginal delivery. And finally, the professionals rejected the practice that presses the uterine fundus, for not having shown efficacy in recent studies. We can conclude that the hospitals that participated in this study have made an effort to change their obstetric model. However, specific aspects of each hospital, the organization of the health system in Brazil, and the incentive of the local administration influenced the implementation of these changes by professionals in practice.

Cooperación entre médicos del departamento de emergencias y dermatólogos por telemedicina / Cooperation between emergency department physicians and dermatologists via telemedicine

Las intercurrencias dermatológicas agudas son un motivo de consulta frecuente a las centrales de emergencias, y generalmente los médicos de atención primaria se ocupan del primer nivel de atención. Puede ser necesaria una interconsulta con expertos, aunque no siempre estén disponibles. Ante la necesidad de facilitar dicha interacción a distancia, en Julio 2022 se implementó una herramienta de teledermatología en un hospital de alta complejidad en Buenos Aires, Argentina. Este servicio se limitó a días hábiles con horario restringido, permitiendo la comunicación entre médicos del departamento de emergencias y dermatólogos, a través de WhatsApp institucional. El dermatólogo podía verificar datos de salud relacionados al paciente (ej: comorbilidades y medicación crónica) mediante revisión de la historia clínica electrónica, para decidir sobre un plan de acción. Se evaluó la perspectiva de los usuarios a través de un formulario electrónico tras 3 meses de implementación. Los resultados evidenciaron que la mayoría (85%) de los profesionales conocía la herramienta, y el 57% la había usado al menos una vez. Se obtuvo una mediana de 9 puntos (de una escala de Likert del 1 al 10) sobre la recomendación hacia otro profesional. El teletriage dermatológico resultó beneficioso y fue aceptado, tanto por médicos de guardia como por especialistas. Ante las demoras en la atención ambulatoria, ha resultado una alternativa útil para evitar derivaciones innecesarias y/o acelerar aquellas que verdaderamente lo ameritan. Sin embargo, representa una forma de comunicación informal desde el punto de vista de almacenamiento de datos. Será necesario reflexionar sobre estos tópicos pendientes de esta experiencia asistencial como legalidad, seguridad y confidencialidad (AU)

Acute skin conditions are a frequent reason for consultation in emergency departments, and primary care physicians generally handle them. They might require referrals to experts, who are not always readily available. Recognizing the need to facilitate such interactions remotely, a teledermatology triage tool was implemented in July 2022 at a high-complexity hospital in Buenos Aires, Argentina. The service was limited to business days with restricted hours, enabling communication between emergency department physicians and dermatologists through institutional WhatsApp. Dermatologists could access patient-related health data (e.g., comorbidities and chronic medication) through the electronic medical record to determine an appropriate course of action. The perspective of users was evaluated through an electronic questionnaire after three months of application. Results showed that most professionals were aware of the tool (85%), and 57% used it at least once. The median rating for recommending the tool to other professionals was 9 points (on a Likert scale from 1 to 10). Dermatological teletriage proved beneficial and was well-received by emergency physicians and specialists. In the face of delays in outpatient care, it has been a useful alternative to avoid unnecessary referrals and expedite those that are warranted. However, it represents an informal method of communication with regard to data storage. It will be necessary to rethink on improvements in pending topics such as legal limitations, security, and confidentiality of this healthcare experience (AU)

Oncology and Palliative Care Integration Model: A Cost Analysis Study in a Brazilian Hospital Setting.

Background: In 2019, the São Paulo State Cancer Institute (ICESP) implemented a novel model integrating Oncology with Palliative Care specialists. We evaluated the impact of this model on healthcare resource utilization and costs. Methods: We analyzed data from all patients who passed away in February (1 month prior to implementation) and November (8 months after model implementation group) at ICESP, Brazil. Healthcare utilization data, including emergency department visits, hospital and intensive care unit admissions, chemotherapy, and radiotherapy use, were retrieved from Electronic Medical Records. Unit cost values were obtained from the administrative database. Results: A total of 198 patients who died in February and 196 in November were included in the analysis. Groups exhibited similarities in sex, age, ECOG, cancer type, previous outpatient palliative care consultations, and place of death (ward: 56.6% pre-intervention, 50% post-intervention). The mean cost per patient was US$13,226.29 pre-intervention and US$11,445.82 post-intervention (P = .007). Statistically significant differences were noted in days hospitalized in the surgical ward (227 vs 115), emergency department visits (233 vs 45), chemotherapy sessions (140 vs 26), and radiotherapy sessions (146 vs 10). Excluding outpatient treatments, the total costs for chemotherapy and radiotherapy in the last 30 days of life were US$16,924.45 pre-intervention and US$7851.65 post-intervention. Reductions were more pronounced in patients with ECOG 3-4 (P = .039). Conclusion: Our data suggests that the integration model was associated with a reduction in potentially inappropriate treatments during the last month of life, leading to decreased healthcare utilization and costs.

Explaining decisions of a light-weight deep neural network for real-time coronary artery disease classification in magnetic resonance imaging.

In certain healthcare settings, such as emergency or critical care units, where quick and accurate real-time analysis and decision-making are required, the healthcare system can leverage the power of artificial intelligence (AI) models to support decision-making and prevent complications. This paper investigates the optimization of healthcare AI models based on time complexity, hyper-parameter tuning, and XAI for a classification task. The paper highlights the significance of a lightweight convolutional neural network (CNN) for analysing and classifying Magnetic Resonance Imaging (MRI) in real-time and is compared with CNN-RandomForest (CNN-RF). The role of hyper-parameter is also examined in finding optimal configurations that enhance the model's performance while efficiently utilizing the limited computational resources. Finally, the benefits of incorporating the XAI technique (e.g. GradCAM and Layer-wise Relevance Propagation) in providing transparency and interpretable explanations of AI model predictions, fostering trust, and error/bias detection are explored. Our inference time on a MacBook laptop for 323 test images of size 100x100 is only 2.6 sec, which is merely 8 milliseconds per image while providing comparable classification accuracy with the ensemble model of CNN-RF classifiers. Using the proposed model, clinicians/cardiologists can achieve accurate and reliable results while ensuring patients' safety and answering questions imposed by the General Data Protection Regulation (GDPR). The proposed investigative study will advance the understanding and acceptance of AI systems in connected healthcare settings.

An exploration of extreme obesity and weight loss management for adults in rural, remote, and regional areas: a systematic review.

BACKGROUND: Extreme obesity is a global health issue impacting health and related health outcomes. Although extreme obesity is prevalent across all geographical settings, the condition is more common in geographically isolated locations. The success of mainstream weight loss strategies such as surgery, exercise, and dietary information within these communities remains unknown, and it is unclear if isolation facilitates or hinders treatment for weight management. AIM: This review aimed to identify common themes around weight loss and health and social impacts for extremely obese adults living in rural, remote, and regional locations. METHODS: A systematic literature review of peer-reviewed publications from May 2013 to May 2023 was undertaken and appraised using the Mixed Method Appraisal Tool (MMAT). Sequential synthesis was thematically analysed and described within a narrative account. Earlier dates were not included as initial research indicated a global surge in obesity within the early 2010s (Wang, Y., Beydoun, M. A., Min, J., Xue, H., Kaminsky, L. A., & Cheskin, L. J. (2020). Has the prevalence of overweight, obesity and central obesity levelled off in the United States? Trends, patterns, disparities, and future projections for the obesity epidemic. International Journal of Epidemiology, 49(3), 810-823) and a surge in bariatric treatments for the management of extreme obesity was noted around the same time (Mocanu, V., Dang, J. T., Sun, W., Birch, D. W., Karmali, S., & Switzer, N. J. (2020). An evaluation of the modern North American bariatric surgery landscape: current trends and predictors of procedure selection. Obesity Surgery, 30, 3064-3072). RESULTS: This review identified 13 studies that reported negative trends in extreme obesity for isolated locations linked to gender, culture, and poor mental health. Individualised and community models of weight loss support can be positive for certain demographic groups, specifically females, through the promotion of cost-effective, and locally available traditional food choices. CONCLUSION: Living with extreme obesity within geographically isolated locations and losing weight is challenging for women, Indigenous peoples, and people with low literacy and those from lower socio-economic backgrounds. Generalised advice about weight loss is often unsuccessful; however, weight loss is achievable with consumer engagement which considers the influence and impact of rurality. Further research focusing on individualised nursing models for managing morbid obesity within isolated locations is required.

Organização da atenção primária à saúde de municípios de São Paulo, Brasil: modelo de atenção e coerência com as diretrizes do Sistema Único de Saúde / Organización de la atención primaria de salud de municipios de São Paulo, Brasil: modelo de atención y coherencia con las directrices del Sistema Único de Salud / Primary health care organization in municipalities of São Paulo, Brazil: a model of care aligned with the Brazilian Unified National Health System's guidelines

Resumo: Este trabalho tem como objetivo analisar os principais padrões de organização das redes municipais de serviços de atenção primária à saúde (APS) e avaliá-los segundo os indicadores de interface entre gestão e gerenciamento local. Trata-se de pesquisa avaliativa que analisou 461 municípios de São Paulo, Brasil, que participaram do Inquérito de Avaliação da Qualidade de Serviços de Atenção Básica (QualiAB) em 2017/2018, classificados segundo a composição dos arranjos organizacionais de 2.472 serviços de APS. Para avaliar os padrões identificados, foram selecionados oito indicadores de gestão e gerenciamento local. Os resultados apontam dois grupos de municípios: homogêneos, com serviços de um mesmo arranjo (43,6%); e heterogêneos, com diferentes arranjos (56,4%). Os grupos foram subdivididos em sete padrões que variaram entre homogêneo-tradicional, homogêneo-Estratégia Saúde da Família, homogêneo-misto e diferentes combinações no grupo heterogêneo. Todos os indicadores apontaram diferenças significativas entre os grupos (p < 0,001), com destaque para o grupo homogêneo-tradicional, com padrão organizacional distante do modelo desejado para uma APS abrangente e resolutiva, enquanto aqueles com unidades de saúde da família (USF), e com unidades básicas com agentes comunitários de saúde e/ou equipes de saúde da família (UBS/USF) demonstraram um padrão mais aproximado desse modelo - com ações de planejamento e avaliação comprometidos com a realidade local e com a qualificação do trabalho. Discute-se a importância das políticas implementadas pela gestão federal e estadual e seu poder de indução na definição do modelo de atenção à saúde na APS dos municípios.

Resumen: El trabajo tiene el objetivo de analizar los principales patrones de organización de las redes municipales de servicios de atención primaria de salud (APS) y evaluarlos conforme los indicadores de interfaz entre la dirección y gestión local. Se trata de una investigación evaluativa que analizó 461 municipios de São Paulo, Brasil, que participaron de la Encuesta de Evaluación de la Calidad de los Servicios de Atención Primaria (QualiAB) en 2017/2018, clasificados según la composición de los arreglos organizativos de 2.472 servicios de APS. Para evaluar los patrones identificados, se seleccionaron ocho indicadores de dirección y gestión local. Los resultados indican dos grupos de municipios: homogéneos, con servicios de un mismo arreglo (43,6%) e heterogéneos, con arreglos diferentes (56,4%). Los grupos se subdividieron en siete patrones que iban desde homogéneo-tradicional, homogéneo-Estrategia de Salud de la Familia, homogéneo-mixto y diferentes combinaciones en el grupo heterogéneo. Todos los indicadores señalaron diferencias significativas entre los grupos (p < 0,001), con destaque para el grupo homogéneo-tradicional, con patrón organizativo alejado del modelo deseado para una APS completa y resolutiva, mientras aquellos con unidades de salud de la familia (USF), y con unidades básicas con agentes comunitarios de salud y/o equipos de salud de la familia (UBS/USF) demostraron un patrón más cercano a este modelo -con acciones de planificación y evaluación comprometidas con la realidad local y con la calificación del trabajo. Se discute la importancia de las políticas implementadas por la gestión federal y la gestión estatal y su poder de inducción para definir el modelo de atención a la salud en la APS de los municipios.

Abstract: This study analyzes the main organization patterns used by primary health care (PHC) services in municipal networks and evaluates them according to indicators of local management-administration interface. Evaluative research analyzed 461 municipalities in São Paulo, Brazil, that participated in the Primary Care Services Quality Assessment Survey (QualiAB) in 2017/2018, classified according to the organizational arrangements composition of 2,472 PHC services. Eight indicators of local management and administration were selected to evaluate the identified patterns. Results indicate two groups of municipalities: homogeneous, with services presenting the same arrangement (43.6%); and heterogeneous, with different arrangements (56.4%). These were subdivided into seven patterns that ranged from homogeneous-traditional, homogeneous-Family Health Strategy, homogeneous-mixed, and different combinations in the heterogeneous group. All indicators showed significant differences between groups (p < 0.001), especially the homogeneous-traditional group, which presented an organizational pattern far from the desired model of a comprehensive and problem-solving PHC. Those integrated with family health units (FHU) and basic health units with community health workers and/or family health teams (BHU/FHU) showed a pattern closer to a comprehensive model - with planning and evaluation actions committed to the local reality and qualification of care. Implementation of federal and state policies are essential for defining the PHC health care model adopted by municipalities.

Hegemonía en el pluralismo médico: articulaciones y relaciones en la atención, un estudio de caso / Hegemony in medical pluralism: articulations and relationships in care, a case study / Hegemonia no pluralismo médico: articulações e relações no atendimento, um estudo de caso

Este estudio tiene como objetivo describir y analizar el pluralismo médico y el tipo de relaciones de hegemonía-subalternidad entre diversas formas o saberes de atención, que se desarrollaron en el itinerario terapéutico de una padeciente de glaucoma, para mostrar el proceso articulatorio y transaccional entre distintos recursos terapéuticos, así como comprender qué elementos estructurales configuraron el itinerario y la elección terapéutica. La investigación es cualitativa, un estudio de caso en el cual se utilizó el enfoque narrativo. Para la reconstrucción de la narrativa se realizó una entrevista semiestructurada, dirigida por una guía temática previamente determinada por un conjunto de categorías apriorísticas, para posteriormente transcribir la entrevista y realizar un proceso de triangulación hermenéutica. Los resultados mostraron, en este caso, que la hegemonía en el pluralismo médico se constituyó mediante relaciones de equivalencia, así, la padeciente sustituyó el uso de medicamentos farmacológicos por terapias de medicina alternativa, no obstante, el proceso relacional de equivalencia se desarrolló en un contexto de significación biomédica, en el cual tratar o controlar la presión intraocular fue la premisa del remplazo. Asimismo, los procesos que desencadenaron la presencia de relaciones hegemónicas se constituyeron por diversos factores sociales, culturales y económicos como el desempleo, la seguridad social y el género, que desempeñaron un papel fundamental durante la búsqueda de la atención y del cuidado.

This study aims to describe and analyze the medical pluralism and the type of hegemony-subordination relation between forms of care or knowledge in the treatment of a patient with glaucoma to show the articulatory and transactional process between several therapeutic resources and understand which structural elements shaped the treatment itinerary and option. This is a qualitative research that used a narrative case study. To reconstruct the narrative, a semi-structured interview was conducted based on a thematic script previously established by a set of a priori categories to later transcribe the data and perform hermeneutic triangulation. Results showed that the hegemony in medical pluralism was based on equivalence relations, so that the patient replaced the use of pharmacological drugs with alternative medicine treatments. However, the relational process of equivalence developed itself in a context of biomedical significance, in which the treatment or control of intraocular pressure configured the substitution premise. Thus, the processes that triggered the hegemonic relations were constituted by various social, cultural, and economic factors such as unemployment, social security, and gender, which played a fundamental role during the search for care.

Este estudo visa descrever e analisar o pluralismo médico e o tipo de relação de hegemonia-subalternidade entre diversas formas de atendimento ou conhecimentos, que ocorreram no tratamento de um paciente com glaucoma, com a finalidade de mostrar o processo articulatório e transacional entre diferentes recursos terapêuticos, bem como entender quais elementos estruturais moldaram o itinerário e a opção de tratamento. Trata-se de uma pesquisa qualitativa, que utilizou um estudo de caso com abordagem narrativa. Para a reconstrução da narrativa, foi realizada uma entrevista semiestruturada, com base em um roteiro temático previamente estabelecido por um conjunto de categorias a priori, para posteriormente transcrever os dados e realizar a triangulação hermenêutica. Os resultados mostraram que a hegemonia no pluralismo médico esteve baseada em relações de equivalência, de modo que o paciente substituiu o uso de medicamentos farmacológicos por tratamentos da medicina alternativa; no entanto, o processo relacional de equivalência desenvolveu-se em um contexto de significância biomédica, na qual o tratamento ou controle da pressão intraocular foi a premissa para a substituição. Desse modo, os processos que desencadearam a presença de relações hegemônicas foram constituídos por fatores sociais, culturais e econômicos diversos como desemprego, previdência social e gênero, os quais tiveram papel fundamental durante a busca por atendimento e cuidado.

Da Rede Cegonha à Rami: tensões entre paradigmas de atenção ao ciclo gravídico-puerperal / From the 'Rede Cegonha' to 'RAMI': tensions between paradigms of maternal and infant health care

RESUMO Em abril de 2022, o Ministério da Saúde publicou a Portaria GM/MS nº 715, que altera a Portaria de Consolidação GM/MS nº 3, de 28 de setembro de 2017, com o objetivo de instituir a Rede de Atenção à Saúde Materna e Infantil (Rami). Tendo em vista a preexistência da Rede Cegonha, também voltada a essa parcela da população, objetivou-se analisar os modelos de atenção ao ciclo gravídico-puerperal intrínsecos a cada um dos métodos de estruturação organizacional adotados. Para tanto, utilizou-se, como referencial teórico-metodológico, a pesquisa com práticas discursivas, o que possibilitou identificar os repertórios relativos a três categorias predefinidas: os sujeitos, os locais e os agentes da assistência. Na análise, puderam-se observar diferenças paradigmáticas entre as duas redes de atenção. A partir de tais distinções, concluiu-se que a Rede Cegonha está fundamentada em uma concepção de gestação e parto como eventos normais da vida sexual e reprodutiva, enquanto a Rami se estrutura por meio da ênfase no risco, propondo um modelo centrado no hospital e na figura do médico.

ABSTRACT In April 2022, the Ministry of Health published the Ordinance No 715, aiming to establish the new Maternal and Infant Health Care Network (RAMI). Having in mind the pre-existence of an organized network to protect and promote maternal and infant health (Rede Cegonha), we aimed to analyze the models of care intrinsic to each of them. For this purpose, we used the research with discursive practices as a theoretical-methodological framework, identifying repertoires regarding three predefined categories: subjects, places, and agents of care. In our analysis, we could observe paradigmatic differences between the two health care networks. From such distinctions, we conclude that the 'Rede Cegonha' is based on a conception of pregnancy and childbirth as normal events of sexual and reproductive life, whereas 'RAMI' is structured through an emphasis on risk, which results in a model of care centered on the doctor and the hospital as a privileged location for childbirth.

Assistance to families of children with Autism Spectrum Disorders: Perceptions of the multiprofessional team / Assistência às famílias de crianças com Transtornos do Espectro Autista: percepções da equipe multiprofissional / Asistencia a familias de niños con Trastornos del Espectro Autista: percepciones del equipo multidisciplinario

Abstract Objective: to synthesize the care provided by health professionals, at different care levels, to the families of children with Autism Spectrum Disorders. Method: a qualitative study, based on the Family-Centered Care philosophical theoretical framework and developed with 22 professionals from three multidisciplinary teams from the Health Care Network of a municipality in the state of Mato Grosso do Sul, Brazil. The data were collected through two focus groups with each team, organized with the support of the Atlas.ti 8 Qualitative Data Analysis® software and submitted to Thematic Content Analysis. Results: the findings show actions centered on specific situations, especially on the demands and needs arising from the child's care and atypical behavior. Influencing factors for family care, such as work overload and little professional experience, show the weakness of multiprofessional care and the invisibility of the family as a care unit. Conclusion: the need is highlighted to review functioning of the network for the multiprofessional care of children and their families and how such network is organized. It is recommended to offer permanent education actions that contribute to the qualification of multiprofessional teams in the care of families of children in the autism spectrum.

Resumo Objetivo: sintetizar o cuidado prestado por profissionais de saúde, nos diferentes níveis de atenção, às famílias de crianças com Transtornos do Espectro Autista. Método: estudo qualitativo, baseado no referencial teórico filosófico do Cuidado Centrado na Família, desenvolvido com 22 profissionais de três equipes multidisciplinares de serviços da Rede de Atenção à Saúde de um município do estado de Mato Grosso do Sul, Brasil. Os dados foram coletados por meio de dois grupos focais com cada equipe, organizados com apoio do software Atlas.ti 8 Qualitative Data Analysis e submetidos à Análise Temática de Conteúdo. Resultados: as descobertas mostram ações centradas em situações pontuais, principalmente nas demandas e necessidades advindas do cuidado da criança e de seu comportamento atípico. Fatores influenciadores para o cuidado à família, como a sobrecarga de trabalho e a pouca experiência profissional, evidenciam a fragilidade da assistência multiprofissional e a invisibilidade da família enquanto unidade de cuidado. Conclusão: destaca-se a necessidade de rever o funcionamento e modo como a rede para o cuidado multiprofissional da criança e sua família está organizada. Recomenda-se a oferta de ações de educação permanente que contribuam com a qualificação das equipes multiprofissionais no cuidado às famílias de crianças no espectro do autismo.

Resumen Objetivo: resumir la atención que brindan los profesionales de la salud, en los diferentes niveles de atención, a las familias de niños con Trastornos del Espectro Autista. Método: estudio cualitativo, basado en el marco teórico filosófico de la Atención Centrada en la Familia, desarrollado con 22 profesionales de tres equipos multidisciplinarios de servicios de la Red de Atención de la Salud en un municipio del estado de Mato Grosso do Sul, Brasil. Los datos fueron recolectados a través de dos grupos focales con cada equipo y organizados con la ayuda del software Atlas.ti 8 Qualitative Data Analysis ® y sometidos al Análisis de Contenido Temático. Resultados: los hallazgos muestran acciones enfocadas en situaciones específicas, principalmente en las demandas y necesidades que genera el cuidado del niño y su comportamiento atípico. Factores que influyen en la atención a la familia, como la sobrecarga de trabajo y la poca experiencia profesional, revelan las falencias que tiene la asistencia multidisciplinaria y la invisibilidad de la familia como unidad de atención. Conclusión: es necesario examinar el funcionamiento y la forma en que está organizada la red para la atención multidisciplinaria de los niños y sus familias. Se recomienda implementar acciones de educación continua que contribuyan a la capacitación de los equipos multidisciplinarios para la atención a las familias de niños con espectro autista.

Modelo de atención sanitaria a la infancia y adolescencia en Atención Primaria. La realidad de una atención integral compartida / Health Care Model for Children and Adolescents in Primary Care. The reality of shared comprehensive care

En la actualidad, el modelo de asistencia sanitaria a la población infantojuvenil en Atención Primaria es variable en todo el territorio nacional. La Atención Primaria es el primer contacto del paciente pediátrico y su familia, atención que mayoritariamente recaía sobre el pediatra y que debe ser abordada de forma integral por las categorías profesionales implicadas en la promoción, educación para la salud y atención integral del menor, como son el pediatra, la enfermería pediátrica y la enfermería referente de centro educativos. El pediatra y el enfermero de Pediatría son los profesionales formados adecuadamente para atender a la población infantojuvenil en la Atención Primaria y una buena atención requiere de la interdependencia de ambos profesionales y de la cooperación con otras figuras profesionales del centro educativo y del centro de salud. Son necesarias actividades de salud comunitaria y trabajar con los activos de la comunidad para conseguir una atención sanitaria basada en la equidad y en la calidad desde una perspectiva global del niño en su naturaleza biopsicosocial. (AU)

Currently, the health care model for the paediatric and juvenile population in primary care varies throughout Spain. Primary care is the first contact for paediatric patients and their families, care that was mainly provided by paediatricians and which must be addressed in an integrated manner by the professional categories involved in the promotion, health education and comprehensive care of children, such as paediatricians, paediatric nurses and nurses in charge of educational centres. The paediatrician and the paediatric nurse are the professionals adequately trained to care for the paediatric population in primary care and good care requires the interdependence of both professionals and cooperation with other professional figures in the educational centre and the health centre. Community health activities are necessary, working with the assets of the community to achieve health care based on equity and quality from a global perspective of the child in his or her biopsychosocial nature. (AU)

From East to West: A Narrative Review of Healthcare Models in India and the United States.

The global healthcare landscape is fraught with quality, cost, equity, and innovation challenges. Despite this, successful healthcare interventions have emerged from unexpected locations. In India, the eradication of certain communicable diseases, the expansion of access to primary care, and the implementation of innovative methods such as telemedicine have demonstrated the potential for community-centered care. In the United States (US), improvements in healthcare quality, accessibility, and the utilization of medical technology, such as the incorporation of telehealth and artificial intelligence, have highlighted opportunities for technological innovation in healthcare delivery. This manuscript reviews the history and development of healthcare systems in India and the US, highlighting each system's strengths, weaknesses, lessons learned, and opportunities for improvement. By examining both systems, we strive to promote a healthcare model that incorporates lessons from each country to improve community-centered care and ultimately provide equitable access to all.

From adversity to advancement: leveraging war-tested approaches for the post-conflict reformation of the Ukrainian healthcare landscape.

The Russo-Ukrainian Conflict has had significant repercussions on Ukraine's healthcare system, resulting in civilian casualties and damage to healthcare institutions. The disruption of personnel, medical supplies, and patient transportation has created considerable challenges for healthcare services. However, there are successful approaches from comparable contexts that can serve as a catalyst for post-conflict healthcare reformation in Ukraine. Key strategies include improving healthcare accessibility for marginalized populations through standardized essential health and surgical care packages, rehabilitating damaged facilities, strengthening primary care provisions, and supporting war survivors with disabilities. By adopting these proven practices, Ukraine can strengthen its healthcare system and facilitate a sustainable recovery, contributing to the country's resilience and ensuring essential healthcare services for its population.

Telehealth service maturity model for the Brazilian scenario (TMSMM.br) / Modelo de madurez de servicios de telemedicina para el escenario brasileño (TMSMM.br) / Modelo de maturidade de serviços de telessaúde para o cenário brasileiro (TMSMM.br)

This article describes a proposed framework called Telehealth Service Maturity Model (TMSMM.br) for evaluating the current stage of telehealth centers in the Brazilian context. The steps included literature review, compilation and interpretation, data collection instrument, survey with center coordinators, model development, and evaluation process. The review resulted in 857 quality aspects for telehealth services, grouped into 12 themes with 34 topics. TMSMM.br consists of defining 3 foundational dimensions (themes, services, stages) and provides a standardized set of 200 requirements ordered across 5 thematic domains (structure, organization, user, operation and community) for 8 services (consultation, consultation, diagnosis, treatment and referral, education and training, social control and communication, healthcare network, and research, development, and innovation). TMSMM.br enables telehealth centers to identify and compare essential characteristics and their maturity stages.

Este artículo describe una propuesta de marco de referencia llamado Modelo de Madurez de Servicios de Telemedicina (TMSMM.br) para evaluar la etapa actual de los centros de telemedicina en el contexto brasileño. Las etapas incluyeron revisión de literatura, compilación e interpretación, instrumento de recolección, encuesta a coordinadores de centros, desarrollo del modelo y proceso de evaluación. La revisión resultó en 857 aspectos de calidad para servicios de telemedicina, agrupados en 12 temas con 34 tópicos. TMSMM.br consiste en la definición de 3 dimensiones estructurales (temas, servicios, etapas) y proporciona un conjunto estandarizado de 200 requisitos ordenados en 5 dominios temáticos (estructura, organización, usuario, operación y comunidad) para 8 servicios (consulta, asesoría, diagnóstico, tratamiento y remisión, educación y capacitación, control social y comunicación, red de atención de salud e investigación, desarrollo e innovación). TMSMM.br ayuda a los centros de telemedicina a identificar y comparar características esenciales y sus etapas de madurez

Este artigo descreve uma proposta de framework denominado Modelo de Maturidade de Serviços de Telessaúde (TMSMM.br) para avaliação do estágio corrente dos núcleos de telessaúde no contexto brasileiro. As etapas incluíram revisão da literatura, compilação e interpretação, instrumento de coleta, inquérito com coordenadores de núcleos, elaboração do modelo e do processo de avaliação. A revisão resultou 857 aspectos de qualidade para serviços de telessaúde, agrupados em 12 temas com 34 tópicos. TMSMM.br consiste na definição de 3 dimensões estruturantes (temas, serviços, estágios) e provê um conjunto padronizado de 200 requisitos ordenados em 5 domínios temáticos (estrutura, organização, usuário, operação e comunidade) para 8 serviços (consulta, consultoria, diagnóstico, tratamento e encaminhamento, formação e capacitação, controle social e comunicação, rede de atenção à saúde, e pesquisa, desenvolvimento e inovação). TMSMM.br colabora para que núcleos de telessaúde possam identificar e comparar características essenciais e seus estágios de maturidade.

Preferences of older adults for healthcare models designed to improve care coordination: Evidence from Western Switzerland.

Implementing innovations in care delivery in Switzerland is challenging due to the fragmented nature of the system and the specificities of the political process (i.e., direct democracy, decentralized decision-making). In this context, it is particularly important to account for population preferences when designing policies. We designed a discrete choice experiment to study population preferences for coordination-improving care models. Specifically, we assessed the relative importance of model characteristics (i.e., insurance premium, presence of care coordinator, access to specialists, use of EMR, cost-sharing for chronic patients, incentives for informal care), and predicted uptake under different policy scenarios. We accounted for heterogeneity in preferences for the status quo option using an error component logit model. Respondents attached the highest importance to the price attribute (i.e. insurance premium) (0.31, CI: 0.27- 0.36) and to the presence of a care coordinator (0.27, CI: 0.23 - 0.31). Policy scenarios showed for instance that gatekeeping would be preferred to free access to specialists if the model includes a GP or an interprofessional team as a care coordinator. Although attachment to the status quo is high in the studied population, there are potential ways to improve acceptance of alternative care models by implementation of positively valued innovations.

Parent and staff perceptions of patient and family-centred care in a Brazilian paediatric's hospital: Quantitative study.

BACKGROUND: Patient and family-centred care (PFCC) is a healthcare model has been acknowledged as the central pillar in the paediatric health care that recognizes the family's role and experience in the health care delivery. AIMS: This study investigated and compared the perception of PFCC from the perspective of staff and parents of hospitalized children and adolescents. METHODS: A quantitative and comparative cross-sectional survey was used in a convenience sample of 105 staff and 116 parents, who completed the Brazilian versions of the Perceptions of Family Centred Care-Parent and Staff questionnaires, with additional questions on their characteristics. Descriptive and analytical statistics were used, as well as the Kruskal-Wallis and Mann-Whitney tests and Spearman's correlation coefficient. RESULTS: Both parents and staff responses were positive and parents had significantly higher scores for 19 of the 20 items (p < 0.001). The item related to parental participation did not show any significant difference between the groups. CONCLUSION: The positive perception of PFCC for both groups is consistent with recommendations for expanded care that includes patient and family in healthcare settings. Parents' perception was more positive than staff perceptions of their delivery of family-centred care in hospital. The lowest score for the parent support subscale in both groups requires investigation.

Physical and psychiatric comorbidities among patients with severe mental illness as seen in Uganda.

While psychiatric and physical comorbidities in severe mental illness (SMI) have been associated with increased mortality and poor clinical outcomes, problem has received little attention in low- and middle-income countries (LMICs). This study established the prevalence of psychiatric (schizophrenia, bipolar affective disorder, and recurrent major depressive disorder) and physical (HIV/AIDS, syphilis, hypertension and obesity) comorbidities and associated factors among 1201 out-patients with SMI (schizophrenia, depression and bipolar affective disorder) attending care at two hospitals in Uganda. Participants completed an assessment battery including structured, standardised and locally translated instruments. SMIs were established using the MINI International Neuropsychiatric Interview version 7.2. We used logistic regression to determine the association between physical and psychiatric comorbidities and potential risk factors. Bipolar affective disorder was the most prevalent (66.4%) psychiatric diagnoses followed by schizophrenia (26.6%) and recurrent major depressive disorder (7.0%). Prevalence of psychiatric comorbidity was 9.1%, while physical disorder comorbidity was 42.6%. Specific comorbid physical disorders were hypertension (27.1%), obesity (13.8%), HIV/AIDS (8.2%) and syphilis (4.8%). Potentially modifiable factors independently significantly associated with psychiatric and physical comorbidities were: use of alcohol for both syphilis and hypertension comorbidities; and use of a mood stabilisers and khat in comorbidity with obesity. Only psychiatric comorbidity was positively associated with the negative outcomes of suicidality and risky sexual behaviour. The healthcare models for psychiatric care in LMICs such as Uganda should be optimised to address the high burden of psychiatric and physical comorbidities.

As mudanças na política de atenção primária e a (in)sustentabilidade da Estratégia Saúde da Família / Changes in the primary care policy and the (un)sustainability of the Family Health Strategy

RESUMO A Atenção Primária à Saúde é um nível de atenção estratégico para a conformação de um sistema de saúde sustentável e capaz de responder a necessidades diversas. Este artigo teve como objetivo analisar a normatização federal e suas implicações para a organização das equipes de atenção primária no Brasil. Pesquisa exploratória de métodos mistos, envolvendo a análise de 25 portarias federais e de dados secundários de abrangência nacional referentes às equipes homologadas no Cadastro Nacional de Estabelecimentos de Saúde, no período de 2017 a 2021. Os resultados indicam mudanças na direcionalidade da política quanto à configuração, ao financiamento e ao credenciamento das equipes. Verificaram-se expansão das equipes de atenção primária, redução de Agentes Comunitários de Saúde e enfraquecimento do Núcleo de Apoio à Saúde da Família. Os resultados sugerem que os estímulos a outros arranjos de equipes e a flexibilização da cobertura do agente comunitário e da atuação multiprofissional comprometem a sustentabilidade do modelo de Saúde da Família no Sistema Único Saúde.

ABSTRACT Primary Health Care is a strategic level of care for forming a sustainable health system that responds to diverse needs. This article analyzed federal regulation and its implications for establishing primary care teams in Brazil. Exploratory mixed methods research involves analyzing 25 federal ordinances and secondary data of national scope referring to the teams approved in the National Register of Health Establishments from 2017 to 2021. The results indicate changes in the direction of the policy regarding the configuration, funding, and accreditation of teams. There was an expansion of primary care teams, a reduction in community health agents, and a weakening of the Family Health Support Center. The results suggest that the incentives for other team arrangements, the flexibility of the coverage of the community agent, and the multidisciplinary action compromise the sustainability of the Family Health model in the Unified Health System.

Demandas de autocuidado no parto na água: estudo qualitativo / Demandas de autocuidado en el parto en el agua: estudio cualitativo / Self-care demands in water birth: a qualitative study

Resumo Objetivo Analisar a compreensão de puérperas sobre a participação da enfermeira obstetra/obstetriz no parto na água, sob a luz da teoria do autocuidado. Métodos Estudo qualitativo por meio da técnica de análise de conteúdo com a participação de 21 mulheres portuguesas que tiveram o seu parto na água, em ambiente hospitalar. Foi utilizado, como referencial teórico o conceito de autocuidado, proposto por Dorothea Orem. Resultados Aflorou uma grande categoria "Necessidade de Autocuidado no Contexto do Parto na Água", cujas unidades de significados foram: Medo de não conseguir vivenciar o parto na água, Percepção do manejo seguro da distócia, Deconhecimento sobre a gravidade que constitui a hemorragia pós-parto e Incompetência no reparo de traumas perineais. Conclusão As participantes identificaram que a presença da enfermeira obstetra/obstetriz, trouxe segurança para que prosseguissem confiantes no modelo de parto na água. As necessidades das mulheres foram atendidas com respeito permanente pelas profissionais, o que favoreceu a autonomia das puérperas, a harmonia entre as partes e o suporte da enfermeira.

Resumen Objetivo Analizar la comprensión de puérperas sobre la participación de la enfermera obstetra/partera en el parto en el agua, bajo la perspectiva de la teoría del autocuidado. Métodos Estudio cualitativo por medio de la técnica de análisis de contenido, con la participación de 21 mujeres portuguesas que tuvieron su parto en el agua, en ambiente hospitalario. Se utilizó el concepto de autocuidado propuesto por Dorothea Orem como marco referencial teórico. Resultados Surgió una gran categoría "Necesidades de autocuidado en el contexto del parto en el agua", cuyas unidades de significado fueron: Miedo de no poder realizar el parto en el agua, Percepción del manejo seguro de la distocia, Desconocimiento sobre la gravedad que constituye la hemorragia posparto e Incompetencia en la reparación de traumas perineales. Conclusión Las participantes identificaron que la presencia de la enfermera obstetra/partera les dio seguridad para continuar con confianza con el modelo de parto en el agua. Las necesidades de las mujeres fueron atendidas con respeto permanente por parte de las profesionales, lo que favoreció la autonomía de las puérperas, la armonía entre las partes y el apoyo de la enfermera.

Abstract Objective To analyze the puerperal women's understanding about the participation of obstetric nurses/nurse-midwives in water birth, under the light of the Self-Care Deficit Theory. Methods This is a qualitative study using the content analysis technique with the participation of 21 Portuguese women who had water birth at a hospital. The concept of self-care proposed by Dorothea Orem was used as a theoretical framework. Results The mean category "Need for self-care in the context of water birth" emerged, whose meaning units were: Fear of not being able to experience water birth; Perception of dystocia safe management; Lack of knowledge about the severity of postpartum hemorrhage; and Incompetence in perineal trauma repair. Conclusion Participants identified that the presence of obstetric nurses/nurse-midwives brought security for them to continue confident in the water birth model. Women's needs were met with permanent respect by professionals, which favored puerperal women's autonomy, harmony between parties and support by nurses.

Re-examining the roles of generalists and specialists in healthcare.

Increasing workload and case complexity of a multimorbid ageing population have catalysed primary care transformation for general practitioners to meet these challenges. There is also a need to re-examine the role of hospital specialists as overly disease-centric, hospital-based specialist care is no longer sustainable. A new specialist-generalist model can maximise the potential of generalists and specialists to provide person-centred care, increase cost-effectiveness, improve appropriateness of referrals, decrease length of hospital stay and lower mortality.