Tatiane da Silva Campos

Cigarette smoking among patients with chronic diseases

Tobacco dependence and chronic diseases are highly prevalent and each are top causes of morbidity and mortality in the world.[1, 2] Tobacco use is also modifiable risk factor for many chronic diseases including cardiovascular disease, diabetes, and inflammatory diseases.[3–5] In a 1999–2008 sample of U.S. citizens, 26% of diabetics smoked; younger age, less education, more alcohol consumption less physical activity, and symptoms of major depression increased their odds for smoking.[6] The prevalence of smoking among people with other chronic diseases, and with overlapping chronic diseases, is less well documented. A better understanding of comorbid tobacco use and chronic illnesses is important for higher income countries, where both are highly prevalent, and is also vital for system planning in middle income countries, where tobacco use is prevalent[2] and the incidence of chronic illness is on the rise.[1] We conducted a population-based survey of all patients attending a leading regional center for chronic conditions—Centro HIPERDIA Minas in Juiz de Fora (CHDM-JF) in the state of Minas Gerais, Brazil. CHDM-JF is a leading public secondary care facility affiliated with UFJF. It focuses on interdisciplinary treatment of diabetes, hypertension, and chronic kidney disease (CKD). This type of center is the middle link in the universal health care system in Brazil, which consists of primary, secondary, and tertiary (hospital) care facilities. All CHDM-JF patients with scheduled appointments over a 3-month period, who were older than 18 years, were eligible and invited to participate. At CHDM-JF all patients check in at a central reception area, and patients’ progress through visits with the multidisciplinary treatment team is tracked in a central location. Brazilian research assistants (RAs) screened for eligibility, explained the purpose of the study, invited eligible patients to participate, collected written consent, and verbally administered the survey. All study procedures were approved by the ethics committees at the University of Kansas Medical Center (#12787) and the Federal University of Juiz de Fora (#283/2011). The survey consisted of items from international health assessments and screenings that had been validated in Brazilian Portuguese.[7–11] Data were recorded by RAs on paper forms, double-data entered into REDCap, and downloaded into Stata for cleaning and analysis.[12, 13] Analyses included descriptive statistics, chi-square tests and t-tests. Tobacco use patterns were examined by number of chronic diseases. The percentage of patients who met Brazilian treatment guideline criteria for cessation medication was calculated. Generalized Linear Models were used for analysis comparing patient characteristics according to number of chronic diseases. The survey was conducted in 2012 and analyzed in 2013. Over the 3-month study period, nearly all eligible patients (1,584—98%) visiting the clinic participated in the survey. Smokers (N=160) had a very low level of education and high rates of depression (Table). Most were being seen for hypertension (58.8%), followed by diabetes (48.8%) and CKD (33.8%). Comorbid chronic disease was the norm: 38.1% reported they had 1, 53.1% reported they had 2, and 8.8% reported they had 3 (data not shown). Table Sample, Smoking Patterns and History, and Medication Eligibility (N =160) Patients were highly interested in quitting and most were daily but light smokers (Table). Nearly all (98.1%) lived with another smoker in the home. Although 87% had been advised to quit by a health professional in the past year, only half (56%) had been given any assistance to quit. Notably, only 6.3% received any medication in the past year. Patients with one chronic disease were significantly more interested in receiving tobacco treatment through CHDM-JF (73.8%) compared to those with two (61.2%), or three chronic illnesses (50%) (p=0.048). Most (65%) were interest in receiving treatment for tobacco dependence at CHDM-JF; interest was higher among those with 1 chronic illness (73.8%) compared to those with 2 (61.2%) or 3 (50%) (p=0.048). Most (77.5%) participants met at least one criterion for receiving cessation medication (Table). This study found that one in ten patients being treated for chronic diseases smoked cigarettes. These patients were light but daily smokers and lived with another smoker in the home. Although most had been advised to quit, very few received evidence-based tobacco treatment—consisting of counseling and medication. Interest in receiving treatment via the chronic disease clinic was lower for sicker patients—those with multiple chronic illnesses. The Brazilian context of this study is in some ways different but also similar to conditions in other countries. Brazilian treatment guidelines are evidence-based and accord with those in the U.S. and many other countries. These guidelines include identifying smokers; assessing readiness to quit; providing counseling and medication to those who are ready to quit; and scheduling follow-up.[14] Unlike the U.S., but similar to other countries, Brazil has a national strategy and public funding for provider training and the provision of counseling and medications.[15] Hence, the generalizability of these data must be weighed by each country’s smoking and treatment context, and the clinic sample. For example, the prevalence of smoking in this clinic population was approximately half of the Brazilian general population, which was 17.1% in 2008.[16, 17] However, Clair and colleagues found that tobacco use among U.S. diabetics, drawn from a nationally representative sample, was no different from the general population.[6] Interestingly, both studies found depression was prevalent among smokers with diabetes in both countries. Strengths of this study include the high response rate, use of standardized international survey items, and rigorous methods for RA training and data entry. Limitations include the brief data collection instrument, which facilitated data collection but reduced the depth of measures; and collecting data in only one clinic site, which limits generalizabilty within and outside of Brazil. These data suggest that much can be done to close the gap between simply advising patients with chronic diseases to quit—and actually helping them to do so. Tobacco dependence should be redefined as a co-occurring and highly treatable chronic disease[18–20], equal in importance to patients’ other chronic conditions. Couples treatment could be offered to patients that live with other smokers. Chronic disease care providers should employ systems that ensure routine, evidence-based tobacco treatment and address comorbidities such as co-occurring depression and alcohol use.

Depression Symptoms among Patients with Multiple Chronic Conditions

Aim: To identify depressive symptoms and biological psychosocial risk factors associated among patients with multiple chronic conditions (MCC). Methods: The study was conducted in a center for the treatment of hypertension, diabetes, and chronic kidney disease in Brazil. During three months a structured interview was conducted among patients waiting for routine visits. In the univariate analysis, descriptive statistics were performed to characterize the sample and in the bivariate analysis were used the chi-square. The risk of depression was calculated in a Prevalence Ratio with 95% confidence interval, as association measure. Variables with p<0.10 were selected for inclusion in the multivariate model, except in the case of self reported chronic disease and the elderly (60 years old or more). Results: The study population included 1.558 patients with MCC. The mean age of participants was 61.4 years (SD = 12.4), most were women (57.5%) and had low levels of education (87.3%). The most prevalent disease was hypertension (88.6%), over half of the sample (55.9%) had 2 chronic diseases, 12% were smokers, and 3.5% were heavy alcohol users. The prevalence of depressive symptoms was 33.3% and was associated with female gender, diabetes and tobacco use. Conclusion: There is a high prevalence of depressive symptoms in this population and it is associated with a number of health conditions and health behaviors, confirming the complex relationship between depressive symptoms and MCC. These data reinforce the need for screening, early diagnosis and management of depression among patients with MCC.

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.

The Caring Costs for Patients Bearing Chronic Kidney Disease (CKD), in a Non-dialytic Phase of a University Hospital / O Custo do Atendimento aos Pacientes com Doença Renal Crônica (Drc), em Fase Não Dialítica de um Hospital Universitário

O estudo tem como objetivo: identificar o custo do atendimento aos pacientes com doenca renal cronica (DRC), em fase nao dialitica de um Hospital Universitario do Rio de Janeiro. O tratamento conservador e uma modalidade terapeutica que tem objetivo acompanhar o paciente em todos os estagios da doenca. Metodos: Trata-se de um estudo de coorte retrospectivo com abordagem quantitativa e analise de custos realizado em um hospital universitario do estado do Rio de Janeiro. Resultados: Diante do estudo foram delimitados dados como idade, sexo, religiao, escolaridade, raca, renda, tipo de acesso, modo de entrada em terapia dialitica, exames, consultas e suas especialidades e medicamentos. Discussao: foi discutido ponto a ponto de cada dado observado a fim de destacarmos os custos do tratamento conservador e o aspecto benefico que esta intimamente ligado. Conclusao: Evidencia-se, entao, a necessidade de incentivar pesquisas para a tematica quando aos aspectos epidemiologicos, financeiros e clinicos.

IMPLANTAÇÃO DA CONSULTA DE ENFERMAGEM NO AMBULATÓRIO DE ATENDIMENTO AO PACIENTE RENAL EM TRATAMENTO CONSERVADOR

Universidade do Estado do Rio de Janeiro e Universidade Federal Fluminense, Enfermeira, Doutora, email: silviamarialins@gmail.com Universidade do Estado do Rio de Janeiro, Enfermeira, Doutora. Universidade do Estado do Rio de Janeiro e Universidade Federal Fluminense, Enfermeira, Doutora. Universidade do Estado do Rio de Janeiro, Enfermeira, Mestre. Universidade do Estado do Rio de Janeiro, Enfermeira, Mestre. Universidade do Estado do Rio de Janeiro, Enfermeiro, Doutor. Universidade Federal do Rio de Janeiro, Enfermeira, Doutora. Associação Brasileira de Ensino Universitário, Enfermeiro, Especialista. IMPLANTAÇÃO DA CONSULTA DE ENFERMAGEM NO AMBULATÓRIO DE ATENDIMENTO AO PACIENTE RENAL EM TRATAMENTO CONSERVADOR Lins SMSB, Silva FVC, Tavares JMAB, Campos TS, Lima VGK, Rocha RG, Broca PV, Pereira ER