Heart-lung interactions with different ventilatory settings during acute lung injury and hypovolaemia: an experimental study

Background. The functional haemodynamic variables pulse pressure variation (PPV), stroke volume variation (SVV), and systolic pressure variation (SPV) are widely used to assess haemodynamic status. However, it is not known how these perform during acute lung injury (ALI). This study evaluated the effects of different ventilatory strategies on haemodynamic parameters in pigs with ALI during normovolaemia and hypovolaemia. Methods. Eight anaesthetized Agroceres pigs [40 (1.9) kg] were instrumented with pulmonary artery, PiCCO, and arterial catheters and ventilated. Three ventilatory settings were randomly assigned for 10 min each: tidal volume (VT) 15 ml kg(-1) and PEEP 5 cm H(2)O, VT 8 ml kg(-1) and PEEP 13 cm H(2)O, or VT 6 ml kg(-1) and PEEP 13 cm H(2)O. Data were collected at each setting at baseline, after ALI (lung lavage+Tween 1.5%), and ALI with hypovolaemia (haemorrhage to 30% of estimated blood volume). Results. At baseline, high VT increased PPV, SVV, and SPV (P < 0.05 for all). During ALI, high VT significantly increased PPV and SVV [(P = 0.002 and P = 0.008) respectively.]. After ALI with hypovolaemia, ventilation at VT 6 ml kg(-1) and PEEP 13 cm H(2)O decreased the accuracy of functional haemodynamic variables to predict hypovolaemia, with the exception of PPV (area under the curve 0.875). The parameters obtained by PiCCO were less influenced by ventilatory changes. Conclusions. VT is the ventilatory parameter which influences functional haemodynamics the most. During ventilation with low VT and high PEEP, most functional variables are less able to accurately predict hypovolaemia secondary to haemorrhage, with the exception of PPV.

Influence of ventilatory settings on static and functional haemodynamic parameters during experimental hypovolaemia

Background and objective The influence of ventilatory settings on static and functional haemodynamic parameters during mechanical ventilation is not completely known. The purpose of this study was to evaluate the effect of positive end-expiratory pressure, tidal volume and inspiratory to expiratory time ratio variations on haemodynamic parameters during haemorrhage and after transfusion of shed blood. Methods Ten anaesthetized pigs were instrumented and mechanically ventilated with a tidal volume of 8 ml kg(-1), a positive end-expiratory pressure of 5 cmH(2)O and an inspiratory to expiratory ratio of 1 : 2. Then, they were submitted in a random order to different ventilatory settings (tidal volume 16 ml kg(-1), positive end-expiratory pressure 15 cmH(2)O or inspiratory to expiratory time ratio 2: 1). Functional and static haemodynamic parameters (central venous pressure, pulmonary artery occlusion pressure, right ventricular end-diastolic volume and pulse pressure variation) were evaluated at baseline, during hypovolaemia (withdrawal of 20% of estimated blood volume) and after an infusion of withdrawn blood (posttransfusion). Results During baseline, a positive end-expiratory pressure of 15cmH(2)O significantly increased pulmonary artery occlusion pressure from 14.6 +/- 1.6 mmHg to 17.4 +/- 1.7 mmHg (P<0.001) and pulse pressure variation from 15.8 +/- 8.5% to 25.3 +/- 9.5% (P<0.001). High tidal volume increased pulse pressure variation from 15.8 8.5% to 31.6 +/- 10.4% (P<0.001), and an inspiratory to expiratory time ratio of 2: 1 significantly increased only central venous pressure. During hypovolaemia, high positive end-expiratory pressure influenced all studied variables, and high tidal volume strongly increased pulse pressure variation (40.5 +/- 12.4% pre vs. 84.2 +/- 19.1 % post, P<0.001). The inversion of the inspiratory to expiratory time ratio only slightly increased filling pressures during hypovolaemia, without without affecting pulse pressure variation or right ventricle end-diastolic volume. Conclusion We concluded that pulse pressure variation measurement is influenced by cyclic variations in intrathoracic pressure, such as those caused by augmentations in tidal volume. The increase in mean airway pressure caused by positive end-expiratory pressure affects cardiac filling pressures and also pulse pressure variation, although to a lesser extent. Inversion of the inspiratory to expiratory time ratio does not induce significant changes in static and functional haemodynamic parameters. Eur J Anaesthesiol 26:66-72 (c) 2009 European Society of Anaesthesiology.

Medidas operantes de limiar auditivo em crianças com surdez pré-lingual, usuárias de implante coclear

Limiares auditivos de crianças surdas pré-linguais usuárias de implante coclear foram avaliados com estimulação elétrica em um dos eletrodos mediais. A avaliação empregou um procedimento operante do tipo go/no go para ensinar uma discriminação simples, evidenciada por uma resposta motora, entre presença e ausência do estímulo auditivo. Estabelecida a linha de base, a manipulação na intensidade do estímulo foi implementada de acordo com o método psicofísico de escada modificado, começando por uma seqüência descendente. Os sete participantes do estudo mostraram perda da precisão no responder sob controle do estímulo quando a intensidade diminuía além de um certo valor e a precisão era recuperada quando a intensidade era novamente aumentada, o que permitiu a identificação de limiares individuais. Os resultados sugerem que o método psicofísico combinado com o procedimento operante pode ser uma alternativa viável para avaliar limiar auditivo de pessoas sem linguagem em situação clínica de regulagem do implante coclear.

Desenvolvimento de capacidades e gestualidade espontânea

O objetivo deste artigo é apresentar e discutir, em uma interlocução com o pensamento winnicottiano, a potencialidade mutativa de uma modalidade de prática psicológica denominada Enquadre Clínico para Desenvolvimento de Capacidades; propõe, ainda, uma elaboração conceitual que distingue capacidades integradas e competências dissociadas. À luz de tal distinção, essa alternativa clínica pode ser compreendida como constituição de um ambiente facilitador que favorece tanto o desenvolvimento de capacidades incipientes como a integração de competências dissociadas, que passam a ser vividas transicionalmente como experiências criativas. Esse enquadre vem sendo utilizado produtivamente na forma de uma oficina voltada ao desenvolvimento da capacidade de escrever.

Analysis of mangrove forest succession, using sediment cores: a case study in the Cananéia -Iguape coastal system, São Paulo Brazil

Sediment cores are an essential tool for the analysis of the dynamics of mangrove succession. Coring was used to correlate changes in depositional environments and lateral sedimentary facies with discrete stages of forest succession at the Cananéia-Iguape Coastal System in southeastern Brazil. A local level successional pattern was examined based on four core series T1) a sediment bank; T2) a smooth cordgrass Spartina alterniflora bank; T3) an active mangrove progradation fringe dominated by Laguncularia racemosa, and; T4) a mature mangrove forest dominated by Avicennia schaueriana. Cores were macroscopically described in terms of color, texture, sedimentary structure and organic components. The base of all cores exhibited a similar pattern suggesting common vertical progressive changes in depositional conditions and subsequent successional colonization pattern throughout the forest. The progradation zone is an exposed bank, colonized by S. alterniflora. L. racemosa, replaces S. alterniflora as progradation takes place. As the substrate consolidates A. schaueriana replaces L. racemosa and attains the greatest structural development in the mature forest. Cores collected within the A. schaueriana dominated stand contained S. alterniflora fragments near the base, confirming that a smooth cordgrass habitat characterized the establishment and early seral stages. Cores provide a reliable approach to describe local-level successional sequences in dynamic settings subject to drivers operating on multiple temporal and spatial scales where spatial heterogeneity can lead to multiple equilibria and where similar successional end-points may be reached through convergent paths.

Validade e confiabilidade da versão brasileira do Índice de Capacidade para o Trabalho

OBJETIVO: Avaliar a validade e a confiabilidade da versão brasileira de índice de capacidade para o trabalho. MÉTODOS:Estudo transversal com amostra de 475 trabalhadores de empresa do setor elétrico no estado de São Paulo (dez municípios em Campinas e região), realizado em 2005. Foram avaliados os seguintes aspectos da versão brasileira do Índice de Capacidade para o Trabalho: validade de construto, por meio de análise fatorial confirmatória e da capacidade discriminante; validade de critério, correlacionado o escore do índice com medidas de saúde auto-referidas; e confiabilidade, por meio da análise da consistência interna utilizando o coeficiente alfa de Cronbach. RESULTADOS: A análise fatorial indicou três fatores do construto capacidade para o trabalho: questões relativas aos "recursos mentais" (20,6% da variância), à autopercepção da capacidade para o trabalho (18,9% da variância) e à presença de doenças e limitações decorrentes do estado de saúde (18,4% da variância). O índice discriminou os trabalhadores segundo nível de absenteísmo, identificando média estatisticamente significativa (p<0,001) entre aqueles com absenteísmo elevado (37,2 pontos) e baixo (42,3 pontos). A análise de critério mostrou correlação do índice com todas as dimensões do estado de saúde analisadas (p<0,0001). O índice apresentou boa confiabilidade com coeficiente alfa de Cronbach (0,72). CONCLUSÕES: A versão brasileira do Índice de Capacidade para o Trabalho mostrou propriedades psicométricas satisfatórias quanto à validade de construto, de critério e de confiabilidade, representando uma opção adequada para avaliação da capacidade para o trabalho em abordagens individuais e inquéritos populacionais.

Estado nutricional e adequação da ingestão de energia e nutrientes em pacientes com insuficiência cardíaca

FUNDAMENTO: Maior conhecimento sobre o estado nutricional e a ingestão de energia e nutrientes é necessário para auxiliar no tratamento de pacientes com insuficiência cardíaca (IC). OBJETIVO: Verificar o estado nutricional e analisar a adequação da ingestão de energia, macro e micronutrientes de pacientes com IC em atendimento ambulatorial. MÉTODOS: Foram coletados dados antropométricos e de ingestão alimentar habitual de 125 pacientes (72% homens, 52,1±9,8 anos, IMC 26,9±4,4 kg/m²). As variáveis antropométricas foram comparadas entre os sexos, e analisou-se a adequação da ingestão de energia e nutrientes perante as recomendações. RESULTADOS: Depleção ou risco de depleção das reservas musculares estava presente em 38,4% dos pacientes (associação com sexo masculino; p < 0,0001). Em 69,6% dos casos, a ingestão média de energia foi menor que as necessidades energéticas (p < 0,0001). Entre os micronutrientes analisados, magnésio, zinco, ferro e tiamina apresentaram prevalências de inadequação importantes, e a maioria dos pacientes teve consumo de cálcio e potássio abaixo da ingestão adequada e consumo de sódio acima. CONCLUSÃO: Pacientes ambulatoriais com IC apresentam depleção de reservas musculares, com ingestão inadequada de energia e diversos nutrientes. Não se observou associação significante entre quantidade de energia proveniente da dieta habitual e o estado nutricional. O acompanhamento multiprofissional deve ser estimulado para avaliar melhor o estado geral desses pacientes.

Brazilian scientific production on pharmaceutical care from 1990 to 2009

Brazilian scientific production on pharmaceutical care was identified based on articles indexed on the Medline, Embase, Lilacs, Web of Science and International Pharmaceutical Abstracts databases. Sixty-three articles published in both national and international journals were retrieved. With regard to authors, 72.3% were from the Southeast and South Regions, and 60.8% were affiliated to public universities. In relation to the type of studies, 85.7% were descriptive, and the most frequently researched fields were community pharmacies, hospitals and primary health care units. Articles were original in 65.1% of cases, updates in 20.6%, and reviews in 7.9%. An increase in publications commenced in 2006. In 31.7% of cases, authors had adopted a bibliographical study design, 28.6% qualitative study, 23.8% intervention, and 15.9% observational study design. The most researched subjects were elderly with chronic diseases. The importance of stimulating the conducting of experimental and qualitative studies, as well as amplifying authorship affiliated with the service area, foreign authors and with research in a wide variety of practice settings were highlighted. Despite the limited quantity of articles, an increase in their number as well as in their scope and quality is expected, so as to create further knowledge that contributes to the recognition of pharmacists' actions by patient healthcare teams.

Epidemiology of leisure, transportation, occupational, and household physical activity: prevalence and associated factors

Background: To estimate the prevalence of and identify factors associated with physical activity in leisure, transportation, occupational, and household settings. Methods: This was a cross-sectional study aimed at investigating living and health conditions among the population of São Paulo, Brazil. Data on 1318 adults aged 18 to 65 years were used. To assess physical activity, the long version of the International Physical Activity Questionnaire was applied. Multivariate analysis was conducted using a hierarchical model. Results: The greatest prevalence of insufficient activity related to transportation (91.7%), followed by leisure (77.5%), occupational (68.9%), and household settings (56.7%). The variables associated with insufficient levels of physical activity in leisure were female sex, older age, low education level, nonwhite skin color, smoking, and self-reported poor health; in occupational settings were female sex, white skin color, high education level, self-reported poor health, nonsmoking, and obesity; in transportation settings were female sex; and in household settings, with male sex, separated, or widowed status and high education level. Conclusion: Physical activity in transportation and leisure settings should be encouraged. This study will serve as a reference point in monitoring different types of physical activities and implementing public physical activity policies in developing countries

Population-based multicentric survey of hepatitis B infection and risk factor differences among three regions in Brazil

This multicentric population-based study in Brazil is the first national effort to estimate the prevalence of hepatitis B (HBV) and risk factors in the capital cities of the Northeast, Central-West, and Federal Districts (2004-2005). Random multistage cluster sampling was used to select persons 13-69 years of age. Markers for HBV were tested by enzyme-linked immunosorbent assay. The HBV genotypes were determined by sequencing hepatitis B surface antigen (HBsAg). Multivariate analyses and simple catalytic model were performed. Overall, 7,881 persons were included; < 70 per cent were not vaccinated. Positivity for HBsAg was less than 1 per cent among non-vaccinated persons and genotypes A, D, and F co-circulated. The incidence of infection increased with age with similar force of infection in all regions. Males and persons having initiated sexual activity were associated with HBV infection in the two settings; healthcare jobs and prior hospitalization were risk factors in the Federal District. Our survey classified these regions as areas with HBV endemicity and highlighted the risk factors differences among the settings

Internal and external time conflicts in adolescents: sleep characteristics and interventions

Daytime fatigue and lack of sleep seem to increase throughout adolescent years. Several environmental, psychological, and biological factors have been associated with the development of sleep across adolescence. The aim of the present article is to summarize these factors and to give examples of various outcomes in sleep patterns among adolescents studied in different cultural settings. It is obvious from earlier work that many adolescents have displaced circadian rhythms and lack of adaptation to school hours due to an early school start or additional burdens for work. Several interventions have aimed to help the adaptation process by supporting sleep processes and changing scheduling, in this way promoting classroom alertness. In summary, adolescents worldwide shorten their sleep due to schoolwork hours and additional work, especially by disturbing their sleep due to circadian misalignment

Mothers’ birth care experiences in a Brazilian birth centre

Objective: to explore the reasons why women with previous hospital experience seek care at a birth centre, and their perceptions related to the care received in both settings. Design, setting and participants in-depth interviews focusing on the care experiences of 18 women who received birth care in a birth centre of the Brazilian public health system. Findings: three key themes emerged from the analysis: ‘Confrontation with strong problems in the hospital setting’, ‘Reasons to seek the birth centre’ and ‘Satisfaction related to birth centre care’. The main aspects that the mothers mentioned in the first and third themes were related to the institutional structure and system of care. Key conclusions and implications for practice mothers’ narratives suggested that their previous experience of problems in the hospital setting was the main motive for seeking care at the birth centre. The most important components of birth care were attention, meeting personal care demands and establishment of an adequate interpersonal relationship. More sensitive birthing care in the hospital setting is necessary, and this can be promoted through continuing professional education

Immediate reconstruction following breast-conserving surgery: management of the positive surgical margins and influence on secondary reconstruction

The efficacy of breast-conserving surgery for the local control of early breast cancer has been repeatedly evidenced. Although immediate reconstruction following breast-conserving surgery has been described, little information is available regarding surgical management in reoperative settings due to positive margins. We studied the influence of intraoperatively assessed and postoperatively controlled surgical margin status on the type of breast-conserving surgery and report our results regarding complications in a reoperative breast reconstruction scenario. All patients were seen by a multidisciplinary team who recommended breast-conserving surgery. According to the breast volume, ptosis and tumor size/location, the patients were also evaluated by a plastic surgeon, who recommended reconstruction with the appropriate technique. Intraoperative assessment of surgical margins was determined by histological examination of frozen sections. The mean follow-up time was 48months. Two hundred and eighteen patients (88.5 per cent ) underwent breast-conserving surgery and immediate reconstruction. Twelve (5.5 per cent ) patients had a positive tumor margin after review of the permanent section. All patients underwent re-exploration. In 1.3 per cent , a second reconstructive technique was indicated and in 2.2 per cent a skin-sparing mastectomy with total reconstruction was performed. Our findings support the important role of the intraoperative assessment of surgical margins and its interference in the selection of reconstruction techniques and negative margins; however, it will not guarantee complete excision of the tumor. Success depends on coordinated planning with the oncologic surgeon and careful intraoperative management

Epidemiology of Leisure, Transportation, Occupational, and Household Physical Activity: Prevalence and Associated Factors

Background: To estimate the prevalence of and identify factors associated with physical activity in leisure, transportation, occupational, and household settings. Methods: This was a cross-sectional study aimed at investigating living and health conditions among the population of So Paulo, Brazil. Data on 1318 adults aged 18 to 65 years were used. To assess physical activity, the long version of the International Physical Activity Questionnaire was applied. Multivariate analysis was conducted using a hierarchical model. Results: The greatest prevalence of insufficient activity related to transportation (91.7%), followed by leisure (77.5%), occupational (68.9%), and household settings (56.7%). The variables associated with insufficient levels of physical activity in leisure were female sex, older age, low education level, nonwhite skin color, smoking, and self-reported poor health; in occupational settings were female sex, white skin color, high education level, self-reported poor health, nonsmoking, and obesity; in transportation settings were female sex; and in household settings, with male sex, separated, or widowed status and high education level. Conclusion: Physical activity in transportation and leisure settings should be encouraged. This study will serve as a reference point in monitoring different types of physical activities and implementing public physical activity policies in developing countries.

Percepções dos professores quanto à inclusão de alunos com deficiência em aulas de Educação Física

The purpose of this study was to verify regular schooling teacher's attitudes toward inclusion children with disabilities in the classes. For that, 90 physical education teachers, from private and public schools, answered to a scale with 18 affirmations. It was observed by results that general tendency of teachers was negative toward inclusion. This pessimism wasn't related to teachers sex and time experience. Stronger teachers pessimism was about their lack of preparing to work with handicapped students. Teachers with less experience time showed more optimism about the benefits of all students in inclusion settings.