COVID-19 y cronicidad. Una oportunidad de reinventar los servicios de Medicina Física y Rehabilitación / COVID-19 and chronic diseases. An opportunity to reinvent the services of Physical Medicine and Rehabilitation

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O papel dos Agentes Comunitários de Saúde no enfrentamento da COVID-19: parte 2

O Debate Virtual do Conass de sexta-feira (04/09), às 17 horas dará continuidade à temática do papel dos Agentes Comunitários de Saúde (ACS), abordando questões como o monitoramento dos sintomáticos respiratórios; o suporte às famílias por meio de grupos de Watshapp; cadastramento por telefone; viabilização de consultas via web/teleconferência; avisos da gestão para os grupos de ACS; o agendamento de agendamento de consultas; entre outras. Os ACSs integram as Equipes de Atenção Primária à Saúde (APS), atuantes na promoção, prevenção e controle de agravos neste momento de pandemia. Trata-se de um trabalho fundamental para auxiliar na contenção da transmissão do vírus, difundindo informações adequadas e apoiando a identificação e a vigilância ativa para o cuidado das pessoas e grupos de risco no seu território, orientando tanto sobre as medidas de prevenção (como proceder e onde procurar ajuda em situações de casos suspeitos e/ou confirmados ou diante do agravamento de saúde); quanto para a continuidade do cuidado das pessoas que têm condições crônicas (que pode ficar comprometido pelo medo do contágio e pelas regras de distanciamento social). Diante desse cenário, o Conass e o Conasems sistematizaram diversos documentos com o objetivo de fornecer informações a respeito do tema e auxiliar na reorganização do processo de trabalho destes profissionais na pandemia, tanto na unidade de saúde, como na comunidade. Este encontro virtual dará continuidade ao debate ocorrido no dia 21 de agosto e contará com a participação da coordenadora da Atenção Primária à Saúde e da Rede de Atenção à Saúde de Caucaia/CE, Vilalba Carlos Lima Martins Bezerra; da presidente do Conselho Municipal de Saúde e do Conselho Local de Saúde da Unidade de Atenção aos Programas de Saúde (UAPS) Ametista (Caucaia/Ceará), Maria Irene Filha de Sousa; da Agente Comunitária de Saúde (UAPS Caucaia/CE), Francisca Célia Rodrigues Lima; e da assessora técnica do Conasems, Marcela Alvarenga. A mediação do debate será feita pela assessora técnica do Conass, Maria José Evangelista. Perguntas poderão ser enviadas pelo www.conass.org.br/participe O debate será transmitido pelo Portal do Conass: www.conass.org.br e pelo canal do Conselho no YouTube: www.youtube.com/conassoficial.

Facing multimorbidity in the precision medicine era.

The clinical picture of multimorbidity is heterogeneous and it is characterized by great complexity. Precision medicine is an innovative approach to provide personalized care focused on individual characteristics and to deliver the right treatments, at the right time, to the right person. The precision medicine approach, which represents an epochal change in the field of chronic diseases, has been poorly implemented in patients with multimorbidity. Several factors can limit this application. First, the precision medicine approach has been successfully applied in the treatment of mono-factorial diseases while multimorbidity is multifactorial. Second, there is lack of understanding of risk factors in the development and evolution of multimorbidity. Third, precision medicine is mainly focused on understanding genetic aspects of diseases and neglects other characteristics contributing to the definition of individual profiles. Finally, individual pathways may lead to the development of different multimorbidity phenotypes. A possible solution to simplify the application of precision medicine to this condition is to reduce its complexity and to find homogeneous patterns of chronic diseases that may work as targets of preventive and therapeutic strategies. This approach can lead to better understanding how these factors interact at individual level and to define interventions that might target multimorbidity.

Laboratório de Inovação Coletânea

É um vídeo de quase 13 minutos com a compilação de todo trabalho desenvolvido pelo Laboratório.

O desafio das condições crônicas e como respondê-lo: análise numa perspectiva internacional

Apresentação realizada no I Seminário Internacional de Atenção às Condições Crônicas, pelo diretor do Instituto Vasco de Inovação Sanitária, Roberto Nuño Solinis. Belo Horizonte, 11 de novembro de 2014

Models and Studies of Aging: Executive Summary of a Report from the U13 Conference Series.

The American Geriatrics Society convened a conference in Bethesda, Maryland, to explore models and studies of aging. This was the second of three conferences, supported by a U13 grant from the National Institute on Aging, to aid recipients of Grants for Early Medical/Surgical Specialists Transition to Aging Research (GEMSSTAR) in integrating geriatrics into their specialties. Recognizing that aging is the largest risk factor for multiple chronic diseases and age-related loss of resilience, the conference organizers focused scientific sessions on how targeting age-related mechanisms can delay, prevent, or reverse geriatric syndromes, age-related chronic diseases, and loss of resilience. The rationale for studying models of aging as well as study designs, strategies, and challenges of studying human aging were reviewed. This article provides a summary of the full conference report, Models and Studies of Aging: Report from the U13 Conference Series, and summarizes key take-home messages that were designed to support GEMSSTAR awardees in developing their research careers focused on aging research (see supplementary text for the full report). J Am Geriatr Soc 67:428-433, 2019.

Integration of chronic disease prevention and management services into primary care (PR1MaC): findings from an embedded qualitative study.

BACKGROUND: The PR1MaC study was conducted to evaluate the integration of Chronic Disease Prevention and Management services into primary care practices and was reported effective. The aim of this study was to further explore the effects of the PR1MaC intervention on patients and their family. METHODS: We conducted a qualitative study embedded in a randomized controlled trial. The trial was implemented in eight primary health care practices in the Saguenay region, Quebec, Canada. The interdisciplinary patient-centred team-based intervention included self-management support and a motivational approach. We conducted focus groups and semi-directed individual interviews with patients, family members and healthcare professionals. RESULTS: Perceived positive effects can be grouped into six major themes: awareness, improved knowledge, improved motivation and empowerment, adoption of healthy behaviours, improvement of health status and improvement of quality of life. On the negative side, some participants reported lack of sustainability of newly acquired benefits in the months following the intervention. CONCLUSIONS: Integrating chronic disease prevention and management services into primary care settings had impacts on patients and their family members. These findings are consistent with findings that were reported in the quantitative study. Further studies should address longterm sustainabilility in terms of benefits for the patients. TRIAL REGISTRATION: ClinicalTrials.gov, no.: NCT01319656 .

Hacia la elaboración de una guía de salud para adultos con síndrome de Down / No disponible

Los adultos con síndrome de Down representan una población especial que necesita guías clínicas que aborden su atención médica. La calidad de los actuales datos, necesarios para informar esas guías clínicas, no ha sido revisada hasta ahora. Mediante la base de datos PubMed de la Biblioteca Nacional de Medicina (USA), hemos identificado 18 artículos con evaluación previa de expertos, que tratan de las condiciones médicas comórbidas que aparecen en los adultos con síndrome de Down. Se clasificó la calidad de los datos aportados y se identificaron los fallos de análisis. El número de adultos participantes en esos estudios y el diseño de los estudios clínicos fueron diferentes según el problema médico considerado, y a menudo fueron insuficientes para responder a preguntas clave. Ofrecemos datos sobre la enfermedad tiroidea, enfermedad de la columna cervical, trastornos de audición, sobrepeso/obesidad, apnea del sueño, cardiopatía congénita y osteopenia-osteoporosis. Cuando las evidencias son escasas se demuestra que existen carencias masivas en nuestro conocimiento clínico de estas personas médicamente complejas. Será preciso profundizar en el conocimiento clínico para poder disponer deguías seguras que nos permitan avanzar en la atención médica a los adultos

Adults with Down syndrome (DS) represent a unique population who are in need of clinical guidelines to address their medical care. The quality of existing evidence needed to inform clinical guidelines has not been previously reviewed. Using the National Library of Medicine (NLM) database PubMed, we have identified 18 peer reviewed articles that addressed co-occurring medical conditions in adults with DS. The quality of available evidence was then graded and knowledge gaps were identified. The number of participating adults and the design of clinical studies varied by condition and were often inadequate for answering all of our key questions. We provide data on thyroid disease, cervical spine disease, hearing impairment, overweight-obesity, sleep apnea, congenital heart disease, and osteopenia-osteoporosis. Minimal evidence demonstrates massive gaps in our clinical knowledge that compromises clinical decision making and management of these medically complex individuals. The development of evidence-based clinical guidance will require an expanded clinical knowledge-base in order to move forward

Cómo transformar el concepto de fragilidad en intervenciones eficientes: transversalidad y liderazgo de la geriatría / How to transform the concept of frailty into efficient interventions: transversality and leadership of geriatrics

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Estimating multimorbidity prevalence with the Canadian Chronic Disease Surveillance System. / Estimation de la prévalence de la multimorbidité au moyen du Système canadien de surveillance des maladies chroniques.

INTRODUCTION: The Public Health Agency of Canada's Canadian Chronic Disease Surveillance System (CCDSS) uses a validated, standardized methodology to estimate prevalence of individual chronic diseases, such as diabetes. Expansion of the CCDSS for surveillance of multimorbidity, the co-occurrence of two or more chronic diseases, could better inform health promotion and disease prevention. The objective of this study was to assess the feasibility of using the CCDSS to estimate multimorbidity prevalence. METHODS: We used administrative health data from seven provinces and three territories and five validated chronic conditions (i.e. cardiovascular disease, respiratory disease, mental illness, hypertension and diabetes) to estimate multimorbidity prevalence. We produced age-standardized (using Canada's 1991 population) and age-specific estimates for two multimorbidity definitions: (1) two or more conditions, and (2) three or more conditions from the five validated conditions, by sex, fiscal year and geography. RESULTS: Among Canadians aged 40 years and over in the fiscal year 2011/12, the prevalence of two or more and three or more chronic conditions was 26.5% and 10.2%, respectively, which is comparable to other estimates based on administrative health data. The increase in multimorbidity prevalence with increasing age was similar across provinces. The difference in prevalence for males and females varied by province and territory. We observed substantial variation in estimates over time. Results were consistent for the two definitions of multimorbidity. CONCLUSION: The CCDSS methodology can produce comparative estimates of multimorbidity prevalence across provinces and territories, but there are challenges in using it to estimate temporal trends. Further expansion of the CCDSS in the number and breadth of validated case definitions will improve the accuracy of multimorbidity surveillance for the Canadian population.

INTRODUCTION: Le Système canadien de surveillance des maladies chroniques (SCSMC) de l'Agence de la santé publique du Canada utilise une méthode validée et normalisée pour estimer la prévalence des maladies chroniques, par exemple le diabète. L'élargissement de la portée du SCSMC pour inclure la surveillance de la multimorbidité et de la présence concomitante de deux maladies chroniques ou plus pourrait mieux guider la promotion de la santé et la prévention des maladies. L'objectif de notre étude était de déterminer s'il était possible de recourir au SCSMC pour estimer la prévalence de la multimorbidité. MÉTHODOLOGIE: Nous avons utilisé les données administratives sur la santé de sept provinces et de trois territoires portant sur cinq affections chroniques validées (maladies cardiovasculaires, maladies respiratoires, maladies mentales, hypertension et diabète) pour estimer la prévalence de la multimorbidité. Nous avons produit des estimations normalisées selon l'âge et spécifiques selon l'âge (à l'aide des données démographiques canadiennes de 1991) pour deux définitions de la multimorbidité, soit deux affections ou plus ou trois affections ou plus sur les cinq affections validées, selon le sexe, la période et la zone géographique. RÉSULTATS: Au cours de l'exercice 2011-2012, la prévalence d'au moins deux et d'au moins trois affections chroniques chez les Canadiens de 40 ans ou plus se situait à respectivement 26,5 % et 10,2 %, ce qui est comparable à d'autres estimations faites à partir des données administratives sur la santé. L'augmentation de la prévalence de la multimorbidité avec l'âge était similaire dans toutes les provinces. Les différences de prévalence entre hommes et femmes variaient selon les provinces et territoires. Nous avons également observé une variation importante des estimations au fil des années. Les résultats obtenus étaient comparables pour les deux définitions de la multimorbidité. CONCLUSION: La méthodologie du SCSMC permet de produire des estimations comparatives de la prévalence de la multimorbidité dans l'ensemble des provinces et des territoires, mais son utilisation pour estimer les variations temporelles pose des difficultés. L'augmentation du nombre et de la portée des définitions de cas validées dans le SCSMC permettra d'améliorer l'exactitude de la surveillance de la multimorbidité auprès de la population canadienne.

Reducing occupational sitting: Workers' perspectives on participation in a multi-component intervention.

BACKGROUND: Office workers spend much of their time sitting, which is now understood to be a risk factor for several chronic diseases. This qualitative study examined participants' perspectives following their involvement in a cluster randomised controlled trial of a multi-component intervention targeting prolonged workplace sitting (Stand Up Victoria). The intervention incorporated a sit-stand workstation, individual health coaching and organisational support strategies. The aim of the study was to explore the acceptability of the intervention, barriers and facilitators to reducing workplace sitting, and perceived effects of the intervention on workplace culture, productivity and health-related outcomes. METHODS: Semi-structured interviews (n = 21 participants) and two focus groups (n = 7) were conducted with intervention participants at the conclusion of the 12 month trial and thematic analysis was used to analyse the data. Questions covered intervention acceptability, overall impact, barriers and facilitators to reducing workplace sitting, and perceived impact on productivity and workplace culture. RESULTS: Overall, participants had positive intervention experiences, perceiving that reductions in workplace sitting were associated with improved health and well-being with limited negative impact on work performance. While sit-stand workstations appeared to be the primary drivers of change, workstation design and limited suitability of standing for some job tasks and situations were perceived as barriers to their use. Social support from team leaders and other participants was perceived to facilitate behavioural changes and a shift in norms towards increased acceptance of standing in the workplace. CONCLUSIONS: Multi-component interventions to reduce workplace sitting, incorporating sit-stand workstations, are acceptable and feasible; however, supportive social and environmental conditions are required to support participant engagement. Best practice approaches to reduce workplace sitting should address the multiple levels of influence on behaviour, including factors that may act as barriers to behavioural change.

Laparoscopic Sleeve Gastrectomy Then and Now: An Updated Systematic Review of the Progress and Short-term Outcomes Over the Last 5 Years.

INTRODUCTION AND AIM: Laparoscopic sleeve gastrectomy (LSG) is considered one of the most popular bariatric surgeries of the present time. This review aimed to evaluate the progress and short-term outcomes of LSG over the last 5 years. METHODS: The systematic review of electronic databases revealed 27 relevant articles, which were carefully assessed. The data extracted from the studies were analyzed and compared with data reported by a previous review published in 2010. RESULTS: A total of 5218 patients were included in this review with a mean age of 41.1. The average preoperative body mass index (43.8±8) significantly dropped at 12 months to 30.7±3.9. The average percentage of excess weight loss at 1 year was 67.3. The mean rates of remission of diabetes mellitus, hypertension, and dyslipidemia were 81.9%, 66.5%, and 64.1%, respectively. The mean complication rate across the studies was 8.7% and the average mortality rate was 0.3%. A significant drop in postoperative body mass index, higher percentage of excess weight loss, and significantly lower overall complication rate were observed in comparison with the previous systematic review. CONCLUSIONS: LSG continues to achieve satisfactory weight loss and improvement of obesity-related comorbidities with acceptably low morbidity and mortality rates.

The effect of close postoperative follow-up on co-morbidity improvement after bariatric surgery.

BACKGROUND: Patients undergoing gastric bypass (RYGB) surgery require follow-up for efficacy assessment, early detection of postoperative complications, and also for management of co-morbid conditions. Recent literature shows support for improved long-term weight loss with close patient follow-up. However, attrition rates after RYGB have been reported as high as 50%. OBJECTIVE: The objective of this study was to assess the relationship between complete follow-up and improvement or remission of co-morbid conditions at 12 months after surgery. SETTING: University Hospital, United States. METHODS: Using the Bariatric Outcomes Longitudinal Database (BOLD) data set, patients with 12-month follow-up after RYGB were identified. Patients with complete follow-up were compared with patients who had missed either or both of their 3- and 6-month visits. Improvement and remission of type 2 diabetes, hypertension, and dyslipidemia were evaluated at 12-month postoperatively. RESULTS: 46,381 patients (30.6% of all RYGB patients) were identified that had follow-up with minimum 12-month data. Complete follow-up was recorded for 75.6% of this group with 12-month data. Of the 18,629 patients with type 2 diabetes at baseline, 13,498 (72.4%) and 11,287 (60.6%) had improvement and remission, respectively, at 12 months. Improvement in hypertension and dyslipidemia was noted in 17,808 (62.8%) and 11,602 (55.2%) of patients, while 13,024 (45.9%) and 9119 (43.4%) had hypertension and dyslipidemia remission, respectively. After adjusting for baseline characteristics, complete follow-up in the first year after RYGB was independently associated with a higher rate of improvement or remission of co-morbid conditions. CONCLUSION: Complete postoperative follow-up resulted in a higher rate of co-morbidity improvement and remission compared with incomplete postoperative care. Patients and practices should strive to achieve complete and long-term follow-up after RYGB surgery.

Planning for sedentary behaviour interventions: office workers' survey and focus group responses.

AIMS: As sedentary behaviour is becoming more prominent in office-based work environments, this study aimed to explore office workers' perceptions of sedentary behaviour, explore potential behavioural strategies to reduce sedentary behaviour in the workplace and identify barriers which may hamper behaviour change. METHODS: A total of 140 office workers were recruited and surveyed from the same workplace. The survey included questions regarding perceptions of the relationship between sitting time and health. Following the survey, 12 employees also participated in focus groups to identify potential sedentary behaviour intervention strategies and barriers. The responses from the survey and focus groups were thematically analysed. RESULTS: In total, 88% of all participants surveyed agreed that there was a relationship between sitting time and their health. The most prominent theme identified was musculoskeletal complaints followed by general health and weight gain or obesity. The focus groups identified that interventions targeting reducing sitting time should include education, supportive and knowledgeable managers, and a variety of behaviour change strategies to address individual preferences and barriers. CONCLUSION: Multiple behavioural strategies were identified, which appear to be appropriate for sedentary behaviour change.

Factors associated with tobacco use among patients with multiple chronic conditions.

BACKGROUND: Cigarette smoking is an important risk factor for disease onset and progression among the major chronic diseases accounting for most morbidity and mortality in the world. Our objective was to identify characteristics associated with tobacco use among patients with multiple chronic conditions (MCC). METHODS: This cross-sectional study was implemented at the Center HIPERDIA Minas Juiz de Fora, Brazil, which manages patients with high cardiovascular risk, hypertension, diabetes mellitus and chronic kidney disease. RESULTS: Of 1558 participants, 12% were current smokers; 41% former smokers and 47%, never smokers. In univariate analyses, current smoking was associated with gender, age, physical activity, alcohol use, depressive symptoms, overweight, and atherosclerosis. In multinomial analyses, multiple chronic conditions were associated with the current or previous use of tobacco; COPD and atherosclerotic disease were more prevalent among patients who were current smokers. CONCLUSIONS: Cigarette smoking was as prevalent in this high population as in the general population. Smokers had worse clinical profiles compared to former smokers or never smokers. Aggressive smoking cessation support should yield considerable health benefits and health care cost savings within patients with MCC, especially, those with high cardiovascular risk.