RESUMO

BACKGROUND: Access to diagnostic tools like chest radiography (CXR) is challenging in resource-limited areas. Despite reduced reliance on CXR due to the need for quick clinical decisions, its usage remains prevalent in the approach to neonatal respiratory distress syndrome (NRDS). OBJECTIVES: To assess CXR's role in diagnosing and grading NRDS severity compared to current clinical features and laboratory standards. METHODS: A review of studies with NRDS diagnostic criteria was conducted across six databases (MEDLINE, EMBASE, BVS, Scopus-Elsevier, Web of Science, Cochrane) up to 3 March 2023. Independent reviewers selected studies, with discrepancies resolved by a senior reviewer. Data were organised into descriptive tables to highlight the use of CXR and clinical indicators of NRDS. RESULTS: Out of 1,686 studies screened, 23 were selected, involving a total of 2,245 newborns. All selected studies used CXR to diagnose NRDS, and 21 (91%) applied it to assess disease severity. While seven reports (30%) indicated that CXR is irreplaceable by other diagnostic tools for NRDS diagnosis, 10 studies (43%) found that alternative methods surpassed CXR in several respects, such as severity assessment, monitoring progress, predicting the need for surfactant therapy, foreseeing Continuous Positive Airway Pressure failure, anticipating intubation requirements, and aiding in differential diagnosis. CONCLUSION: CXR remains an important diagnostic tool for NRDS. Despite its continued use in scientific reports, the findings suggest that the study's outcomes may not fully reflect the current global clinical practices, especially in low-resource settings where the early NRDS approach remains a challenge for neonatal survival.Trial registration: PROSPERO number CRD42022336480.

Main findings: Access to diagnostic tools like chest radiography is challenging in resource-limited areas, yet its usage persists in the management of neonatal respiratory distress syndrome despite a decreased dependency due to the imperative for swift clinical decisions.Added knowledge: Despite its continued significance in scientific literature, the usage of chest radiography as a diagnostic tool for neonatal respiratory distress syndrome may not entirely reflect current global clinical practices, particularly in low-resource settings where early management of neonatal respiratory distress syndrome poses a challenge for neonatal survival.Global health impact for policy and action: The results underscore the necessity of guidelines for the utilisation of chest radiography to minimise unnecessary ionising radiation exposure while ensuring timely access to critical clinical information for appropriate newborn care.

Assuntos

RESUMO

BACKGROUND: Hypertension and diabetes mellitus (DM) are highly prevalent in low and middle-income countries (LMICs), and the proportion of patients with uncontrolled diseases is higher than in high-income countries. Innovative strategies are required to surpass barriers of low sources, distance and quality of health care. Our aim is to assess the uptake and effectiveness of the implementation of an integrated multidimensional strategy in the primary care setting, for the management of people with hypertension and diabetes mellitus in Brazil. METHODS: This scale up implementation study called Control of Hypertension and diAbetes in MINas Gerais (CHArMING) Project has mixed-methods, and comprehends 4 steps: (1) needs assessment, including a standardized structured questionnaire and focus groups with health care practitioners; (2) baseline period, 3 months before the implementation of the intervention; (3) cluster randomized controlled trial (RCT) with a 12-months follow-up period; and (4) a qualitative study after the end of follow-up. The cluster RCT will randomize 35 centers to intervention (n = 18) or usual care (n = 17). Patients ≥18 years old, with diagnosis of hypertension and/or DM, of 5 Brazilian cities in a resource-constrained area will be enrolled. The intervention consists of a multifaceted strategy, with a multidisciplinary approach, including telehealth tools (decision support systems, short message service, telediagnosis), continued education with an approach to issues related to the care of people with hypertension and diabetes in primary care, including pharmacological and non-pharmacological treatment and behavioral change. The project has actions focused on professionals and patients. CONCLUSIONS: This study consists of a multidimensional strategy with multidisciplinary approach using digital health to improve the control of hypertension and/or DM in the primary health care setting. We expect to provide the basis for implementing an innovative management program for hypertension and DM in Brazil, aiming to reduce the present and future burden of these diseases in Brazil and other LMICs. CLINICAL TRIAL IDENTIFIER: This study was registered in ClinicalTrials.gov. (NCT05660928).

Assuntos

RESUMO

BACKGROUND: During the COVID-19 pandemic, telehealth was expanded without the opportunity to extensively evaluate the adopted technology's usability. OBJECTIVE: We aimed to synthesize evidence on health professionals' perceptions regarding the usability of telehealth systems in the primary care of individuals with noncommunicable diseases (NCDs; hypertension and diabetes) from the COVID-19 pandemic onward. METHODS: A systematic review was performed of clinical trials, prospective cohort studies, retrospective observational studies, and studies that used qualitative data collection and analysis methods published in English, Spanish, and Portuguese from March 2020 onward. The databases queried were MEDLINE, Embase, BIREME, IEEE Xplore, BVS, Google Scholar, and grey literature. Studies involving health professionals who used telehealth systems in primary care and managed patients with NCDs from the COVID-19 pandemic onward were considered eligible. Titles, abstracts, and full texts were reviewed. Data were extracted to provide a narrative qualitative evidence synthesis of the included articles. The risk of bias and methodological quality of the included studies were analyzed. The primary outcome was the usability of telehealth systems, while the secondary outcomes were satisfaction and the contexts in which the telehealth system was used. RESULTS: We included 11 of 417 retrieved studies, which had data from 248 health care professionals. These health care professionals were mostly doctors and nurses with prior experience in telehealth in high- and middle-income countries. Overall, 9 studies (82%) were qualitative studies and 2 (18%) were quasiexperimental or multisite trial studies. Moreover, 7 studies (64%) addressed diabetes, 1 (9%) addressed diabetes and hypertension, and 3 (27%) addressed chronic diseases. Most studies used a survey to assess usability. With a moderate confidence level, we concluded that health professionals considered the usability of telehealth systems to be good and felt comfortable and satisfied. Patients felt satisfied using telehealth. The most important predictor for using digital health technologies was ease of use. The main barriers were technological challenges, connectivity issues, low computer literacy, inability to perform complete physical examination, and lack of training. Although the usability of telehealth systems was considered good, there is a need for research that investigates factors that may influence the perceptions of telehealth usability, such as differences between private and public services; differences in the level of experience of professionals, including professional experience and experience with digital tools; and differences in gender, age groups, occupations, and settings. CONCLUSIONS: The COVID-19 pandemic has generated incredible demand for virtual care. Professionals' favorable perceptions of the usability of telehealth indicate that it can facilitate access to quality care. Although there are still challenges to telehealth, more than infrastructure challenges, the most reported challenges were related to empowering people for digital health. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42021296887; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=296887. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.21801/ppcrj.2022.82.6.

Assuntos

RESUMO

BACKGROUND: Clinicians face barriers when assessing lung maturity at birth due to global inequalities. Still, strategies for testing based solely on gestational age to predict the likelihood of respiratory distress syndrome (RDS) do not offer a comprehensive approach to addressing the challenge of uncertain outcomes. We hypothesize that a noninvasive assessment of skin maturity may indicate lung maturity. OBJECTIVE: This study aimed to assess the association between a newborn's skin maturity and RDS occurrence. METHODS: We conducted a case-control nested in a prospective cohort study, a secondary endpoint of a multicenter clinical trial. The study was carried out in 5 Brazilian urban reference centers for highly complex perinatal care. Of 781 newborns from the cohort study, 640 were selected for the case-control analysis. Newborns with RDS formed the case group and newborns without RDS were the controls. All newborns with other diseases exhibiting respiratory manifestations were excluded. Skin maturity was assessed from the newborn's skin over the sole by an optical device that acquired a reflection signal through an LED sensor. The device, previously validated, measured and recorded skin reflectance. Clinical data related to respiratory outcomes were gathered from medical records during the 72-hour follow-up of the newborn, or until discharge or death, whichever occurred first. The main outcome measure was the association between skin reflectance and RDS using univariate and multivariate binary logistic regression. Additionally, we assessed the connection between skin reflectance and factors such as neonatal intensive care unit (NICU) admission and the need for ventilatory support. RESULTS: Out of 604 newborns, 470 (73.4%) were from the RDS group and 170 (26.6%) were from the control group. According to comparisons between the groups, newborns with RDS had a younger gestational age (31.6 vs 39.1 weeks, P<.001) and birth weight (1491 vs 3121 grams, P<.001) than controls. Skin reflectance was associated with RDS (odds ratio [OR] 0.982, 95% CI 0.979-0.985, R2=0.632, P<.001). This relationship remained significant when adjusted by the cofactors antenatal corticosteroid and birth weight (OR 0.994, 95% CI 0.990-0.998, R2=0.843, P<.001). Secondary outcomes also showed differences in skin reflectance. The mean difference was 0.219 (95% CI 0.200-0.238) between newborns that required ventilatory support versus those that did not and 0.223 (95% CI 0.205-0.241) between newborns that required NICU admission versus those that did not. Skin reflectance was associated with ventilatory support (OR 0.996, 95% CI 0.992-0.999, R2=0.814, P=.01) and with NICU admission (OR 0.994, 95% CI 0.990-0.998, R2=0.867, P=.004). CONCLUSIONS: Our findings present a potential marker of lung immaturity at birth using the indirect method of skin assessment. Using the RDS clinical condition and a medical device, this study demonstrated the synchrony between lung and skin maturity. TRIAL REGISTRATION: Registro Brasileiro de Ensaios Clínicos (ReBEC) RBR-3f5bm5; https://tinyurl.com/9fb7zrdb. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2018-027442.

RESUMO

BACKGROUND: The restrictions imposed by the COVID-19 pandemic reduced health service access by patients with chronic diseases. The discontinuity of care is a cause of great concern, mainly in vulnerable regions. OBJECTIVE: This study aimed to assess the impact of the COVID-19 pandemic on people with hypertension and diabetes mellitus (DM) regarding the frequency of consultations and whether their disease was kept under control. The study also aimed to develop and implement a digital solution to improve monitoring at home. METHODS: This is a multimethodological study. A quasiexperimental evaluation assessed the impact of the pandemic on the frequency of consultations and control of patients with hypertension and DM in 34 primary health care centers in 10 municipalities. Then, an implementation study developed an app with a decision support system (DSS) for community health workers (CHWs) to identify and address at-risk patients with uncontrolled hypertension or DM. An expert panel assessment evaluated feasibility, usability, and utility of the software. RESULTS: Of 5070 patients, 4810 (94.87%) had hypertension, 1371 (27.04%) had DM, and 1111 (21.91%) had both diseases. There was a significant reduction in the weekly number of consultations (107, IQR 60.0-153.0 before vs 20.0, IQR 7.0-29.0 after social restriction; P<.001). Only 15.23% (772/5070) of all patients returned for a consultation during the pandemic. Individuals with hypertension had lower systolic (120.0, IQR 120.0-140.0 mm Hg) and diastolic (80.0, IQR 80.0-80.0 mm Hg) blood pressure than those who did not return (130.0, IQR 120.0-140.0 mm Hg and 80.0, IQR 80.0-90.0 mm Hg, respectively; P<.001). Also, those who returned had a higher proportion of controlled hypertension (64.3% vs 52.8%). For DM, there were no differences in glycohemoglobin levels. Concerning the DSS, the experts agreed that the CHWs can easily incorporate it into their routines and the app can identify patients at risk and improve treatment. CONCLUSIONS: The COVID-19 pandemic caused a significant drop in the number of consultations for patients with hypertension and DM in primary care. A DSS for CHW has proved to be feasible, useful, and easily incorporated into their routines.