Disease Attribution to Multiple Exposures Using Aggregate Data.

BACKGROUND: Identifying which exposures cause disease and quantifying their impacts is essential in promoting and monitoring public health. When multiple exposures are involved, measuring individual contributions becomes challenging. METHODS: The authors propose a disease attribution method based on aggregate data or summary statistics of individual-level data, possibly from multiple data sources. RESULTS: Using the proposed method, the burden of disease is apportioned to the independent and interaction effects of each of its major risk factors and all the other factors as a whole. This scheme guarantees that 100% is the total share of the burden. CONCLUSION: The calculation is simple and straightforward; therefore, it is recommended for use in studies on disease burden.

Trombose: análise de conceito como subsídio teórico para qualificar a prática clínica de enfermeiros / Thrombosis: concept analysis as a theoretical contribution to qualify the clinical practice of nurses

OBJETIVO: analisar o conceito de trombose e identificar aplicações, atributos definidores, antecedentes, consequentes e referenciais empíricos. MÉTODO: análise de conceito, segundo Walker e Avant. RESULTADOS: os atributos definidores mais citados foram trombo (s), tríade de Virchow e comprometimento total/ parcial do fluxo sanguíneo. Os antecedentes mais frequentes foram câncer/uso de quimioterápicos, trombofilias e diabetes. Várias manifestações compuseram os consequentes, conforme o leito vascular comprometido. Os mais citados foram: acidente vascular cerebral ou acidente isquêmico transitório, infarto agudo do miocárdio e tromboembolismo pulmonar. Os referenciais empíricos se relacionaram a exames clínicos, testes de coagulação e escores de risco. A tomografia computadorizada foi o exame de imagem mais citado. CONCLUSÃO: a análise de conceito de trombose evidenciou o uso deste termo na literatura atual, bem como os atributos definidores, antecedentes, consequentes e referenciais empíricos. Este estudo agrega conhecimento à prática clínica de enfermeiros e pode contribuir com o refinamento dos sistemas de linguagens padronizadas.

OBJECTIVE: to analyze the concept of thrombosis and identify its applications, defining attributes, antecedents, consequences, and empirical references. METHOD: a concept analysis was carried out using Walker and Avant's framework. RESULTS: the most cited defining attributes were thrombus, Virchow's triad, and total/partial impairment of blood flow. The most frequent antecedents were cancer/chemotherapy, thrombophilia, and diabetes. Several manifestations composed the consequences, according to the compromised vascular bed. The most cited were stroke or transient ischemic attack, acute myocardial infarction, and pulmonary thromboembolism. The empirical references were related to clinical examinations, coagulation tests, and risk scores. Computed tomography was the most cited imaging test. CONCLUSION: The analysis of the thrombosis concept showed the use of this term in the current literature, its defining attributes, antecedents, consequences, and empirical references. This study adds knowledge to nurses' clinical practice and can contribute to the refinement of standardized language systems.

Caracterización clínica y terapéutica del cáncer de mama, en mujeres mayores, atendidas en un centro oncológico de Medellín ­ Colombia / Clinical and therapeutic characterization of breast cancer, in older women, attended in a cancer center in Medellin ­ Colombia

Introducción: El cáncer de mama es el cáncer más frecuente en las mujeres colombianas y más de la mitad de la incidencia la aportan las adultas mayores de 60 años. El objetivo de este estudio fue caracterizar clínicamente a un grupo de pacientes ≥ 65 años, con diagnóstico de cáncer de mama primario. Metodología: Estudio descriptivo de 188 pacientes con edad ≥ 65 años, con cáncer de mama primario, atendidas en la Fundación Colombiana de Cancerología ­ Clínica Vida, entre enero de 2017 y diciembre de 2018. Se realizó un análisis descriptivo de datos sociodemográficos, comorbilidades, características de la enfermedad y tratamiento. Resultados: La población estudiada (188) presentó una edad promedio de 73 años y en el 79.8% de ellas se reportó al menos una comorbilidad. El 76.6% tuvo enfermedad con receptor hormonal positivo. El manejo primario con cirugía se hizo en el 58.5% de las pacientes, y la mayoría fueron procedimientos conservadores de la mama (70.9%). Conclusión: Las mujeres adultas mayores tienen características del cáncer de mama que pueden diferir de las pacientes jóvenes e influir en el tratamiento que se ofrece, impactando en su pronóstico oncológico, en el pronóstico de sus comorbilidades y en la calidad de vida.

Introduction: Breast cancer is the most frequent cancer in Colombian women and more than half of the incidence is contributed by adults over 60 years of age. The objective of this study was to clinically characterize a group of patients ≥ 65 years of age, diagnosed with primary breast cancer. Methodology: Descriptive study of 188 patients aged ≥ 65 years, with primary breast cancer, treated at the Colombian Cancer Foundation - Clínica Vida, between January 2017 and December 2018. A descriptive analysis of sociodemographic data, comorbidities, characteristics of the disease and treatment. Results: The studied population (188) had an average age of 73 years and in 79.8% of them at least one comorbidity was reported. 76.6% had hormone receptor positive disease. The primary manage-ment with surgery was done in 58.5% of the patients, and the majority were breast-conserving proce-dures (70.9%). Conclusion: Older women have characteristics of breast cancer that may differ from young pa-tients. This may influence the treatment offered, impacting on their oncological prognosis, on the prognosis of their comorbidities and on the quality of life.

The impact of disease characteristics on multiple sclerosis patients' quality of life / 한국역학회지

OBJECTIVES: The aim of this study was to assess the quality of life (QoL) of patients with multiple sclerosis (MS), and to investigate the effects of characteristics of MS such as disease course, severity, and relapses on patients' QoL.METHODS: This was a cross-sectional study, in which 171 patients were enrolled. Health-related QoL was assessed using the Persian version of the Multiple Sclerosis Quality of Life-54 questionnaire. To measure patients' disability status, we used the Expanded Disability Status Scale. Other variables included in the study were disease course and relapses of the disease.RESULTS: The average scores for patients' physical and mental QoL were 60.9±22.3 and 59.5±21.4, respectively. In a bivariate analysis, disease course, severity of the disease, and relapses were significantly associated with the physical and mental health composite scores. In a hierarchal regression analysis, disease course, severity of the disease, and relapses were responsible for 38 and 16% of the variance in physical and mental QoL, respectively. It was also observed that relapses were a strong predictor of both physical and mental QoL.CONCLUSIONS: Our results showed that disease characteristics significantly affected both dimensions of QoL. It is therefore suggested that health care providers should be aware of these characteristics of MS to more successfully improve MS patients' QoL.

The impact of disease characteristics on multiple sclerosis patients' quality of life / 한국역학회지

OBJECTIVES: The aim of this study was to assess the quality of life (QoL) of patients with multiple sclerosis (MS), and to investigate the effects of characteristics of MS such as disease course, severity, and relapses on patients' QoL. METHODS: This was a cross-sectional study, in which 171 patients were enrolled. Health-related QoL was assessed using the Persian version of the Multiple Sclerosis Quality of Life-54 questionnaire. To measure patients' disability status, we used the Expanded Disability Status Scale. Other variables included in the study were disease course and relapses of the disease. RESULTS: The average scores for patients' physical and mental QoL were 60.9±22.3 and 59.5±21.4, respectively. In a bivariate analysis, disease course, severity of the disease, and relapses were significantly associated with the physical and mental health composite scores. In a hierarchal regression analysis, disease course, severity of the disease, and relapses were responsible for 38 and 16% of the variance in physical and mental QoL, respectively. It was also observed that relapses were a strong predictor of both physical and mental QoL. CONCLUSIONS: Our results showed that disease characteristics significantly affected both dimensions of QoL. It is therefore suggested that health care providers should be aware of these characteristics of MS to more successfully improve MS patients' QoL.

Análisis evolutivo del concepto de adaptación a la diabetes tipo 2 / Evolutionary Analysis of the Concept of Adaptation to Type 2 Diabetes / Análise evolutiva do conceito de adaptação à diabete tipo 2

El concepto de adaptación tiene diferentes aplicaciones y acepciones. En personas que viven con diabetes tipo 2 (DT2) se asocia con la observancia del tratamiento y el control glucémico. Es utilizado frecuentemente en la literatura de salud, pero no está claro qué significa en personas que viven con esta enfermedad, por lo que el propósito de esta investigación fue analizar el concepto de adaptación a la DT2. Metodología: se utilizó el método de análisis evolutivo de concepto de Rodgers. Los datos se codificaron por autor, 16 en total, palabras clave, hallazgos, antecedentes, atributos y consecuencias, conceptos relativos y sustitutos. La guía del análisis respondió a tres preguntas: ¿cómo define el concepto el autor? ¿Qué características o atributos se establecen? ¿Qué idea da el autor acerca del concepto? Resultados: el concepto de adaptación muestra atributos que permiten definirlo como un proceso que se presenta en tres fases: reacción, asimilación y respuesta. Los antecedentes corresponden a conductas previas al proceso, los resultados incluyen desafíos y cambios. Conclusiones: los atributos, los antecedentes y las consecuencias ofrecen guías para la investigación; es necesario ampliar el estudio en el contexto del hogar, la familia, el trabajo y el hospital.

The concept of adaptation has different applications and meanings. In persons who live with type 2 diabetes (T2D), it is associated with treatment adherence and glycemic control. It is used frequently in health literature, but it is unclear what it means to those living with the disease. Accordingly, the purpose of this study was to analyze the concept of adaptation to T2D. Method: Rogers' evolutionary concept analysis was the method used. The data were coded by author (16 in total), key words, findings, antecedents, attributes, consequences, and surrogate and relative concepts. The analysis guide answered three questions: How the author defines the concept? What features or attributes are established? What idea does the author provide about the concept? Findings: The concept of adaptation has attributes that enable it to be defined as a process that occurs in three phases: reaction, assimilation and response. The antecedents pertain to preprocess behavior, while the results include challenges and changes. Conclusions: The attributes, antecedents and consequences offer guidelines for research. It is necessary to broaden this research to include the context of home, family, work and the hospital.

O conceito de adaptação tem diferentes aplicações e acepções. Em pessoas que vivem com diabete tipo 2 (DT2), se associa com a observância do tratamento e o controle glicêmico. É utilizado frequentemente na literatura de saúde, mas não está claro o que significa em pessoas que vivem com essa doença; por isso, o propósito desta pesquisa foi analisar o conceito de adaptação à DT2. Metodología: utilizou-se o método de análise evolutiva de conceito de Rodgers. Os dados se codificaram por autor (16 em total), palavras-chave, antecedentes, atributos e consequências, conceitos relativos e substitutos. O guia da análise respondeu a três perguntas: como o autor define o conceito? Que características ou atributos são estabelecidos? Que ideia o autor dá sobre o conceito? Resultados: o conceito de adoção mostra atributos que permitem defini-lo como um processo que se apresenta em três fases: reação, assimilação e resposta. Os antecedentes correspondem a condutas prévias ao processo; os resultados incluem desafios e mudanças. Conclusões: os atributos, os antecedentes e as consequências oferecem guias para a pesquisa. É necessário ampliar o estudo no contexto do lar, da família, do trabalho e do hospital.

The Social and Clinical Characteristics of Patients on Antiretroviral Therapy who are 'Lost to Follow-up' in KwaZulu-Natal; South Africa: a Prospective Study

A significant proportion of those initiating antiretroviral treatment (ART) for HIV infection are lost to follow-up. Causes (including HIV symptoms; quality of life; depression; herbal treatment and alcohol use) for discontinuing ART follow-up in predominantly rural resource-limited settings are not well understood. This is a prospective study of the treatment-naive patients recruited from three (one urban; one-semi-urban and one rural) public hospitals in Uthukela health district in KwaZulu-Natal from October 2007 to February 2008. The aim of this study was to investigate predictors of loss to follow-up or all caused attrition from an ART programme within a cohort followed up for over 12 months. A total of 735 patients (217 men and 518 women) prior to initiating ART completed a baseline questionnaire and 6- and 12-months' follow-up. At 12-months follow-up 557 (75.9) individuals continued active ART; 177 (24.1) were all cause attrition; there were 82 deaths (13.8); 58 (7.9) transfers; 7 (1.0) refused participation; 8 (1.1) were not yet on ART and 22 (3.0) could not be traced. Death by 12-months of follow-up was associated with lower CD4 cell counts (risk ratio; RR=2.05; confidence intervals; CI=1.20 - 3.49) and higher depression levels (RR=1.05; CI=1.01 - 1.09) at baseline assessment. The high early mortality rates indicate that patients are enrolling into ART programmes with far too advanced immunodeficiency; median CD4 cell counts 119 (IQR=59 - 163). Causes of late access to the ART programme; such as delays in health care access (delayed health care seeking); health system delays; or inappropriate treatment criteria; need to be addressed. Differences in health status (lower CD4 cell counts and higher depression scores) should be taken into account when initiating patients on ART. Treating depression at ART initiation is recommended to improve treatment outcome

Modelos explicativos em saúde coletiva: abordagem biopsicossocial e auto-organização / Explanatory models in collective health: bio-psycho-social complexity and self-organization

A complexidade do processo saúde-doença tem ensejado a proposição de uma diversidade de modelos explicativos. Fazemos uma breve revisão dessas propostas, confrontando três perspectivas: o modelo oriundo da Medicina do século XIX, a lógica da História Natural da Doença e o debate epidemiológico no contexto da Medicina Social latino-americana. Tomando-se como referência teórica a ideia de causalidade circular presente na teoria da auto-organização, propomos que os fatores causais privilegiados em cada um dos modelos explicativos acima não seriam conflitantes. Uma noção-chave para se pensar o processo de autoorganização biopsicossocial é o "efeito baldwiniano", que descreve uma relação dialética ou coevolutiva entre processos naturais e socioculturais.

The complexity of the health-disease process has elicited the postulation of a diversity of explanatory models. We make a brief review of the proposals, starting with the biomedical model derived from the 19th century medicine. This model influenced the approach on the natural history of disease, and the debate on epidemiologic models in the context of the Latin-American Social Medicine. Broadening the spectrum of the discussion, we introduce the idea of circular causality, proposed by theories of self-organizing systems. We argue that, in a transdisciplinary perspective, these explanatory models are not conflicting. A key notion to understand these classes of concomitant explanatory models is the "Baldwin Effect", describing a dialectic or coevolutionary relation between nature, social organization and culture.

Atributos psicométricos de la Parkinson’s Disease-Cognitive Rating Scale. Estudio de validación independiente / Psychometric Attriutes of the Parkinson´s disease-cognitive rating scale. An independent validation study

Objetivo. Realizar una evaluación independiente de los atributos psicométricos de la Parkinson’s Disease-CognitiveRating Scale (PD-CRS). Pacientes y métodos. Pacientes con enfermedad de Parkinson (EP) sin impedimentos para la evaluaciónrequerida. Estudio observacional, transversal, con captación de datos sociodemográficos, históricos y las siguientes evaluaciones:Scales for Outcomes in Parkinson’s Disease-Escala motora (SCOPA-Motor), estadios de Hoehn y Yahr (HY), ClinicalImpression of Severity Index for Parkinson’s Disease (CISI-PD), Minimental State Examination (MMSE), SCOPA-Cognitive(SCOPA-Cog), Non-Motor Symptoms Questionnare y PD-CRS. Se analizaron la aceptabilidad, consistencia interna, validezde constructo y precisión de la PD-CRS. Resultados. Se incluyeron 50 pacientes, con una edad media de 63,6 ± 9,3 años.El 66% eran hombres, con 9 ± 5,7 años de duración de la EP, en estadio 1 a 4 de HY. Doce pacientes (24%) presentaban datossugerentes de demencia. La puntuación de la PD-CRS fue: subescala subcortical: 60,9 ± 16,5; subescala cortical: 27,9 ±4,4; y PD-CRS total: 88,7 ± 19,8. La diferencia media-mediana fue < 10% de las puntuaciones máximas, y la puntuación totalno presentó efecto suelo ni techo. El alfa de Cronbach fue de 0,85; las correlaciones ítem-total, de 0,57 (denominación) a0,73 (memoria de trabajo), y el índice de homogeneidad de los ítems, de 0,36. La correlación con el MMSE y la SCOPA-Cogfue alta (rS = 0,53 y 0,77). La puntuación de la PD-CRS fue significativamente menor en pacientes con bajo nivel educativo ymayor gravedad de la EP según niveles de la CISI-PD, y discriminó entre pacientes dementes y no dementes (70,3 ± 26,2 frentea 94,5 ± 13; p < 0,001). El error estándar de la medida fue de 1,98. Conclusión. La PD-CRS mostró aceptabilidad, consistenciainterna, validez de constructo y precisión satisfactorias (AU)

Aim. To perform an independent evaluation of the psychometric attributes of the Parkinson’s Disease-CognitiveRating Scale (PD-CRS). Patients and methods. The study involved patients with Parkinson’s disease (PD) free of any impedimentspreventing them from participating in the required evaluation. Sociodemographic and historical data were collected for use inthis observational, cross-sectional study and the following evaluations were employed: Scales for Outcomes in Parkinson’sDisease-Motor Scale (SCOPA-Motor), Hoehn and Yahr staging (HY), Clinical Impression of Severity Index for Parkinson’sDisease (CISI-PD), Minimental State Examination (MMSE), SCOPA-Cognitive (SCOPA-Cog), Non-Motor Symptoms Questionnaireand PD-CRS. Acceptability, internal consistence, construct validity and precision of the PD-CRS were analysed. Results. Thesample consisted of 50 patients, with a mean age of 63.6 ± 9.3 years. In all, 66% were males, with a history of 9 ± 5.7 yearswith PD, in HY stages 1 to 4. Twelve patients (24%) presented data suggestive of dementia. The PD-CRS score was: subcorticalsub-scale: 60.9 ± 16.5; cortical sub-scale: 27.9 ± 4.4; and total PD-CRS: 88.7 ± 19.8. The mean-median differencewas < 10% of the maximum scores and the total score showed no ceiling or floor effect. Cronbach’s alpha was 0.85; the itemtotalcorrelations ranged from 0.57 (naming) to 0.73 (working memory), and the homogeneity index of the items was 0.36.Correlation with the MMSE and the SCOPA-Cog was high (rS = 0.53 and 0.77). The PD-CRS score was significantly lower inpatients with a low level of schooling and more severe PD according to levels on the CISI-PD and distinguished betweenpatients with and without dementia (70.3 ± 26.2 versus 94.5 ± 13; p < 0.001. The standard error of the measurement was1.98. Conclusions. The levels of acceptability, internal consistence, construct validity and precision displayed by the PD-CRSwere satisfactory (AU)

Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients.

Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection among pediatric intensive care unit (ICU) patients. Empiric therapy for VAP accounts for approximately 50% of antibiotic use in pediatric ICUs. VAP is associated with an excess of 3 days of mechanical ventilation among pediatric cardiothoracic surgery patients. The attributable mortality and excess length of ICU stay for patients with VAP have not been defined in matched case control studies. VAP is associated with an estimated $30,000 in attributable cost. Surveillance for VAP is complex and usually performed using clinical definitions established by the CDC. Invasive testing via bronchoalveolar lavage increases the sensitivity and specificity of the diagnosis. The pathogenesis in children is poorly understood, but several prospective cohort studies suggest that aspiration and immunodeficiency are risk factors. Educational interventions and efforts to improve adherence to hand hygiene for children have been associated with decreased VAP rates. Studies of antibiotic cycling in pediatric patients have not consistently shown this measure to prevent colonization with multidrug-resistant gram-negative rods. More consistent and precise approaches to the diagnosis of pediatric VAP are needed to better define the attributable morbidity and mortality, pathophysiology, and appropriate interventions to prevent this disease.

Neuropeptidomics: MS applied to the discovery of novel peptides from the brain.

By comparing the proteins and peptides in diseased an normal tissues, researchers can identify differential expression patterns that may lead to biomarkers.

La construcción social de la enfermedad / Disease as a social construction

En la naturaleza, la enfermedad no existe como tal sino como un fenómeno biológico que sólo puede distinguirse porque rompe cierta secuencia de eventos que son parte de un proceso continuo. Si no está el ojo testigo del ser humano, ese fenómeno no adquiere sentido. Es el individuo y la sociedad los que otorgan el rótulo de enfermedad a determinado evento. Este rótulo es el resultado de una construcción social y como tal se describe en este artículo desde una mirada sociológica. La enfermedad se construye a través de un vínculo médico-paciente en el que se generan roles y expectativas de cumplimiento mutuo. La medicina es una respuesta de la cultura para legitimar la condición de enfermo en alguien que no puede continuar cumpliendo sus roles habituales. Hay escuelas que consideran la enfermedad como una desviación legítima en cuanto se asuma que el paciente no es responsable de su propia dolencia; si se asume responsabilidad, esa enfermedad pasa a considerarse una desviación ilegítima con una fuerte condición moral peyorativa. La enfermedad, a su vez, puede tener una significación diferente según la clase social del individuo que la padece. El médico debe ser consciente del significado social que tienen las enfermedades, ya que este conocimiento puede contribuir a que cumpla con el mayor desafío de la medicina que es ayudar al otro considerándolo, no un objeto de conocimiento, sino esencialmente un semejante.(AU)

La construcción social de la enfermedad / Disease as a social construction

En la naturaleza, la enfermedad no existe como tal sino como un fenómeno biológico que sólo puede distinguirse porque rompe cierta secuencia de eventos que son parte de un proceso continuo. Si no está el ojo testigo del ser humano, ese fenómeno no adquiere sentido. Es el individuo y la sociedad los que otorgan el rótulo de enfermedad a determinado evento. Este rótulo es el resultado de una construcción social y como tal se describe en este artículo desde una mirada sociológica. La enfermedad se construye a través de un vínculo médico-paciente en el que se generan roles y expectativas de cumplimiento mutuo. La medicina es una respuesta de la cultura para legitimar la condición de enfermo en alguien que no puede continuar cumpliendo sus roles habituales. Hay escuelas que consideran la enfermedad como una desviación legítima en cuanto se asuma que el paciente no es responsable de su propia dolencia; si se asume responsabilidad, esa enfermedad pasa a considerarse una desviación ilegítima con una fuerte condición moral peyorativa. La enfermedad, a su vez, puede tener una significación diferente según la clase social del individuo que la padece. El médico debe ser consciente del significado social que tienen las enfermedades, ya que este conocimiento puede contribuir a que cumpla con el mayor desafío de la medicina que es ayudar al otro considerándolo, no un objeto de conocimiento, sino esencialmente un semejante.

Diseño y validación de un instrumento para la evaluación de los atributos de la calidad en la clínica odontológica Santa Mónica / Design of validation of an instrument for the evaluation of the attributes of the quality in Santa Mónica dental clinic

La investigación buscaba diseñar y validar un instrumento para la evaluación de los atributos de la calidad en IPS odontológicas que se constituyera en un modelo piloto útil para instituciones similares. Se diseño el instrumento con base en las normas legales vigentes respecto al sistema Obligatorio de Garantía de Calidad (Decreto 2174 de 1996) y con base en el Modelo del Doble Propósito descrito por lovelock, 1997. El instrumento consta de dos partes: una para profesionales donde se evalúan los atributos de la calidad; y otra para usuarios donde se evalúa la satisfacción de los mismos. Consta de 44 reactivos para los profesionales y 32 reactivos para los usuarios. Se escogió una muestra de 70 profesionales y 30 usuarios de la clínica Odontológica Santa Mónica, a los cuales se les aplicó los instrumentos respectivos. Para el análisis estadístico el coeficiente alfa de cronbach para evaluar la confiabilidad de la prueba; validación por juicio de expertos, para la validez de contenido y constructo; se obtuvieron normas percentilares con base en los puntajes brutos obtenidos por los sujetos. El alfa de cronbach para la parte del instrumento aplicada a los profesionales arrojó un coeficiente de 0.6 y para la parte del instrumento aplicada a los usuarios fue de 0.8. Las tendencias hacia los atributos de la calidad fueron favorables de acuerdo con los rangos percentilares obtenidos. Se sugiere realizar posteriores evaluaciones del instrumento en diferentes IPS odontológicas, con el fin de mejorar la confiabilidad y validez del mismo.

[Diabolus, disease, and Nietzsche: considerations and interpretations]. / Diabolus, choroba i Nietzsche. Rozwazania i interpretacje.

Disease shows its dual nature: it carries suffering and pain, but also means trespassing the sluggish limits of healthy life. This trespassing confirms the distance separating man from nature and, at the same time, confirms man's spirituality. Nietzsche's disease and work support this interpretation, so precisely expressed by Thomas Mann in his novel Doctor Faustus: disease contains the diabolus of human biology and human spirituality.