Compreendendo a lacuna entre a prática e a evolução técnico-científica do banho no leito

Trata-se de estudo qualitativo, realizado com pacientes acamados, visando compreender a experiência da pessoa dependente da enfermagem para o banho no leito e desenvolver um modelo teórico representativo dessa experiência. Utilizou-se como referencial teórico o Interacionismo Simbólico e, como referencial metodológico, a Grounded Theory. Dos resultados emergiu o fenômeno - aprendendo a avaliar a vida e a enfermagem, ao tornar-se dependente de seus cuidados para o banho no leito. Isso possibilitou identificar a categoria central - propondo um modelo assistencial de enfermagem para o banho no leito, na perspectiva do processo avaliativo do paciente, que contrapõe a evolução técnico-científica relativa ao procedimento.

Rabdomiolise e mioglobinuria: relato de caso agudo com boa evolução

Os autores registram um caso de mioglobinúria confirmada pela eletroforese de proteínas da urina. A eletromiografia revelou alterações de tipo polimiosítico. A biópsia muscular do deltóide esquerdo mostrou processo inflamatório muscular inespecífico. O tratamento instituído baseou-se em repouso, hiperhidratação e alcalinização da urina. Os autores enfatizam a importância do diagnóstico pela relativa benignidade do processo, que tende para a cura se forem superadas as sérias complicações da fase aguda, a iatrogenia medicamentosa e por procedimentos diagnósticos desnecessários no início da doença.

Pneumoencéfalo intraventricular após perfuração acidental de dura-máter. Relato de caso

BACKGROUND AND OBJECTIVES: The loss of resistance to air to identify the epidural space is widely used. However, the accidental perforation of the dura mater is one of the possible complications of this procedure, with an estimated incidence between 1% and 2%. The objective of this report was to describe the case of a patient with intraventricular pneumocephalus after the accidental perforation of the dura mater using the loss of resistance with air technique. CASE REPORT: Female patient, 26 years old, 75 kg, 1.67 m, physical status ASA I, with a 38-week pregnancy, was referred to the obstetric service for a cesarean section. Venipuncture was performed after placement of the monitoring. The patient was placed in a sitting position for administration of the epidural anesthesia. During the identification of the epidural space with the loss of resistance with air technique, an accidental perforation of the dura mater was diagnosed by observing free flow of CSF through the needle. The technique was modified to epidural anesthesia and anesthetics were administered by the needle placed in the subarachnoid space. In the first 24 hours, the patient developed headache and she was treated with caffeine, dypirone, hydration, hydrocortisone, and bed rest; despite those measures, the patient's symptoms worsened and evolved to headache in decubitus. A CT scan of the head showed the presence of pneumocephalus. After evaluation by a specialist, the patient remained under observation, with progressive improvement of the symptoms and was discharged from the hospital in the fifth day, without complications. CONCLUSIONS: Pneumocephalus after accidental perforation of the dura mater presented headache with the characteristics of headache secondary to loss of CSF, but with spontaneous resolution after the air was absorbed. Invasive measures, such as epidural blood patch, were not necessary. © Sociedade Brasileira de Anestesiologia, 2006.

Aula, repouso, aquecimento e desaquecimento vocal em professores de uma escola pública de ensino médio de Salvador - BA

Pós-graduação em Educação - FFC

Single-port retroperitoneal renal biopsy using standard urological instruments

Objective: To describe the surgical technique and initial experience with a single-port retroperitoneal renal biopsy (SPRRB).Materials and Methods: Between January and April 2013, five children underwent SPRRB in our hospital. A single 1.5 cm incision was performed under the 12th rib at mid-axillary line, and an 11 mm trocar was inserted. A nephroscope was used to identify the kidney and dissect the perirenal fat. After lower pole exposure, a laparoscopic biopsy forceps was introduced through the nephroscope working channel to collect a renal tissue sample.Results: SPRRB was successfully performed in five children. The mean operative time was 32 minutes, and mean estimated blood loss was less than 10 mL. The hospital stay of all patients was two days because they were discharged in the second postoperative day, after remaining at strict bed rest for 24 hours after the procedure. The average number of glomeruli present in the specimen was 31.Conclusion: SPRRB is a simple, safe and reliable alternative to open and videolaparoscopic approaches to surgical renal biopsy.

Interaction between dietary lipids and physical inactivity on insulin sensitivity and on intramyocellular lipids in healthy men

OBJECTIVE: To assess the effect of a possible interaction between dietary fat and physical inactivity on whole-body insulin sensitivity and intramyocellular lipids (IMCLs). RESEARCH DESIGN AND METHODS: Eight healthy male volunteers were studied on two occasions. After 2 days of an equilibrated diet and moderate physical activity, participants remained inactive (bed rest) for 60 h and consumed either a high-saturated fat (45% fat, of which approximately 60% was saturated fat [BR-HF]) or a high-carbohydrate (70% carbohydrate [BR-HCHO]) diet. To evaluate the effect of a high-fat diet alone, six of the eight volunteers were restudied after a 2-day equilibrated diet followed by 60 h on a high-saturated fat diet and controlled physical activity (PA-HF). Insulin sensitivity was measured by hyperinsulinemic-euglycemic clamp and IMCL concentrations by (1)H-magnetic resonance spectroscopy. RESULTS: Insulin-mediated glucose disposal was decreased by BR-HF condition (-24 +/- 6%, P < 0.05) but did not change with BR-HCHO (+19 +/- 10%, NS). BR-HF and BR-HCHO increased IMCL levels (+32 +/- 7%, P < 0.05 and +17 +/- 8%, P < 0.0011, respectively). Although the increase in IMCL levels with PA-HF (+31 +/- 19%, P = 0.12) was similar to that during BR-HF, insulin-mediated glucose disposal (-7 +/- 9%, NS) was not decreased. CONCLUSIONS: These data indicate that physical inactivity and a high-saturated fat diet may interact to reduce whole-body insulin sensitivity. IMCL content was influenced by dietary lipid and physical inactivity but was not directly associated with insulin resistance.

Clinical predictors of prophylaxis use prior to the onset of acute venous thromboembolism in hospitalized patients SWIss Venous ThromboEmbolism Registry (SWIVTER)

BACKGROUND: We investigated clinical predictors of appropriate prophylaxis prior to the onset of venous thromboembolism (VTE). METHODS: In 14 Swiss hospitals, 567 consecutive patients (306 medical, 261 surgical) with acute VTE and hospitalization < 30 days prior to the VTE event were enrolled. RESULTS: Prophylaxis was used in 329 (58%) patients within 30 days prior to the VTE event. Among the medical patients, 146 (48%) received prophylaxis, and among the surgical patients, 183 (70%) received prophylaxis (P < 0.001). The indication for prophylaxis was present in 262 (86%) medical patients and in 217 (83%) surgical patients. Among the patients with an indication for prophylaxis, 135 (52%) of the medical patients and 165 (76%) of the surgical patients received prophylaxis (P < 0.001). Admission to the intensive care unit [odds ratio (OR) 3.28, 95% confidence interval (CI) 1.94-5.57], recent surgery (OR 2.28, 95% CI 1.51-3.44), bed rest > 3 days (OR 2.12, 95% CI 1.45-3.09), obesity (OR 2.01, 95% CI 1.03-3.90), prior deep vein thrombosis (OR 1.71, 95% CI 1.31-2.24) and prior pulmonary embolism (OR 1.54, 95% CI 1.05-2.26) were independent predictors of prophylaxis. In contrast, cancer (OR 1.06, 95% CI 0.89-1.25), age (OR 0.99, 95% CI 0.98-1.01), acute heart failure (OR 1.13, 95% CI 0.79-1.63) and acute respiratory failure (OR 1.19, 95% CI 0.89-1.59) were not predictive of prophylaxis. CONCLUSIONS: Although an indication for prophylaxis was present in most patients who suffered acute VTE, almost half did not receive any form of prophylaxis. Future efforts should focus on the improvement of prophylaxis for hospitalized patients, particularly in patients with cancer, acute heart or respiratory failure, and in the elderly.

Effects of hibernation on bone in yellow-bellied marmots

Disuse osteoporosis is a problem for people with spinal cord injury or stroke, patients confined to bed rest, and astronauts exposed to microgravity. Unlike most mammals however, bears have been shown to prevent bone loss during hibernation, a seasonal period of disuse. Similarly, studies in ground squirrels indicate preservation of whole bone strength during hibernation, though evidence suggests there may be some increased osteocytic osteolysis. Uncovering the mechanism by which these animals prevent bone loss during hibernation could lead to an improved treatment for osteoporosis in humans. Marmots are a good animal model for these studies because they are small enough to easily house in an animal facility yet still utilize intracortical remodeling like humans and bears, and unlike smaller rodents like squirrels. Marmots preserve bone mechanical and microstructural properties during hibernation. Bone mechanical and geometrical properties are not diminished in post-hibernation samples compared to pre-hibernation samples. Mineral content, measured by ash fraction, was higher in post-hibernation samples (p = 0.0003). Haversian porosity as well as remodeling cavity density were not different (p > 0.38) between pre- and post-hibernation samples. Similarly, average lacunar area, lacunar density, and lacunar porosity were all lower (p < 0.0001) in post-hibernation samples. Trabecular thickness was larger in posthibernation samples (p = 0.0058). Bone volume fraction was not different between groups, but approached significance (p = 0.0725). Further studies in marmots and other hibernators could help uncover the mechanism that allows hibernators to prevent disuse osteoporosis during hibernation.

Exploration of the role of serum factors in maintaining bone mass during hibernation in black bears

Disuse osteoporosis is a condition in which reduced mechanical loading (e.g. bed-rest, immobilization, or paralysis) results in unbalanced bone turnover. The American black bear is a unique, naturally occurring model for the prevention of disuse osteoporosis. Bears remain mostly inactive for up to half a year of hibernation annually, yet they do not lose bone mechanical strength or structural properties throughout hibernation. The long-term goal of this study is to determine the biological mechanism through which bears maintain bone during hibernation. This mechanism could pinpoint new signaling pathway targets for the development of drugs for osteoporosis prevention. In this study, bone specific alkaline phosphatase (BSALP), a marker of osteoblast activity, and tartrate resistant acid phosphatase (TRACP), a marker of osteoclast number, were quantified in the serum of hibernating and active black bears. BSALP and TRACP decreased during hibernation, suggesting a balanced reduction in bone turnover. This decrease in BSALP and TRACP were correlated positively to serum adiponectin and inversely to serum neuropeptide Y, suggesting a possible role of these hormones in suppressing bone turnover during hibernation. Osteocalcin (OCN) and undercarboxylated OCN increased dramatically in the serum of hibernating bears. These increases were inversely correlated with adiponectin, glucose, and serotonin, suggesting that OCN may have a unique role in energy homeostasis during hibernation. Finally, MC3T3-E1 osteoblasts were cultured in the serum from active and hibernating bears, and seasonal cell responses were quantified. Cells cultured in serum from hibernating bears had a reduced caspase-3/7 response, and more living cells, after apoptotic threat. The caspase-3/7 response was positively correlated to serum adiponectin and to gene expression of OCN and Runx2, suggesting that reduced caspase-3/7 activity may be related to the reduced differentiation potential of osteoblasts in hibernation serum, and that adiponectin is a potential effector hormone. In summary, the activities of osteoblasts and osteoclasts are reduced during hibernation in bears. This reduced turnover is due, in part, to hormonal control. Further study of potential effectors adiponectin and neuropeptide Y may provide insight into the biological mechanism through which bears maintain bone throughout hibernation.

Modifying Post-Operative Medical Care after EBV Implant May Reduce Pneumothorax Incidence.

OBJECTIVE Endoscopic lung volume reduction (ELVR) with valves has been shown to improve COPD patients with severe emphysema. However, a major complication is pneumothoraces, occurring typically soon after valve implantation, with severe consequences if not managed promptly. Based on the knowledge that strain activity is related to a higher risk of pneumothoraces, we asked whether modifying post-operative medical care with the inclusion of strict short-term limitation of strain activity is associated with a lower incidence of pneumothorax. METHODS Seventy-two (72) emphysematous patients without collateral ventilation were treated with bronchial valves and included in the study. Thirty-two (32) patients received standard post-implantation medical management (Standard Medical Care (SMC)), and 40 patients received a modified medical care that included an additional bed rest for 48 hours and cough suppression, as needed (Modified Medical Care (MMC)). RESULTS The baseline characteristics were similar for the two groups, except there were more males in the SMC cohort. Overall, ten pneumothoraces occurred up to four days after ELVR, eight pneumothoraces in the SMC, and only two in the MMC cohorts (p=0.02). Complicated pneumothoraces and pneumothoraces after upper lobe treatment were significantly lower in MMC (p=0.02). Major clinical outcomes showed no significant differences between the two cohorts. CONCLUSIONS In conclusion, modifying post-operative medical care to include bed rest for 48 hours after ELVR and cough suppression, if needed, might reduce the incidence of pneumothoraces. Prospective randomized studies with larger numbers of well-matched patients are needed to confirm the data.

Comparação entre a técnica femoral com dispositivo de hemostasia e a técnica radial em pacientes submetidos à estratégia invasiva precoce

A via de acesso arterial é um importante sítio de complicações após a realização de procedimentos coronários invasivos. Dentre as estratégias para a redução de complicações vasculares, encontra-se estabelecida a eficácia da técnica radial. Os dispositivos de oclusão vascular propiciam maior conforto ao paciente, reduzindo o tempo de hemostasia e repouso no leito. Entretanto, a inconsistência de dados comprovando sua segurança limita sua adoção rotineira como estratégia para redução de complicações vasculares, requerendo evidências de estudos randomizados com metodologia adequada. O objetivo deste estudo foi comparar a incidência de complicações no sítio de punção arterial entre a técnica radial e a técnica femoral com utilização de Angio-Seal em pacientes com síndrome coronariana aguda sem supradesnível do segmento ST submetidos à estratégia invasiva precoce. Trata-se de um ensaio clínico unicêntrico, de não inferioridade, no qual duzentos e quarenta pacientes foram randomizados para a técnica radial ou técnica femoral com utilização de Angio-Seal. O objetivo primário foi a ocorrência de complicações no sítio de punção arterial até 30 dias após o procedimento, incluindo sangramento grave, hematoma >= 5 cm, hematoma retroperitoneal, síndrome compartimental, pseudoaneurisma, fístula arteriovenosa, infecção, isquemia de membro, oclusão arterial, lesão de nervo adjacente ou necessidade de reparo vascular cirúrgico. Em relação às características demográficas e clínicas, houve diferença apenas quanto ao gênero, com presença maior de pacientes do sexo feminino no grupo radial (33,3% versus 20,0%, p=0,020). Não se observaram diferenças entre os grupos quanto ao diagnóstico de admissão, alterações isquêmicas presentes no eletrocardiograma, elevação de marcadores de necrose miocárdica ou escores de risco, bem como quanto à farmacoterapia antitrombótica adjunta e características da intervenção coronária percutânea. A hemostasia foi obtida na totalidade dos procedimentos do grupo radial com a utilização da pulseira compressora seletiva TR Band e em 95% dos procedimentos realizados pela técnica femoral com o Angio-Seal (p=0,029). Exceto pela maior incidência de oclusão arterial no grupo radial comparado ao femoral, não houve diferenças entre os demais desfechos analisados. Segundo o teste de não inferioridade para complicações na via de acesso arterial aos 30 dias, verificou-se que a utilização do Angio-Seal não produziu resultados inferiores ao acesso radial, considerando-se a margem de 15% (12,5% versus 13,3%, diferença -0,83%, IC 95% -9,31 - 7,65, p para não inferioridade <0,001). Os resultados principais deste estudo demonstram que, em uma população de pacientes com diagnóstico de síndrome coronariana aguda sem supradesnível do segmento ST, submetida à estratificação de risco invasiva, a utilização do dispositivo de oclusão vascular Angio-Seal confere ao procedimento efetivado pelo acesso femoral inferioridade na incidência de complicações no sítio de punção arterial aos 30 dias quando comparado ao acesso radial.

A sulphonate based hydrogel for nucleus pulposus repair

Introduction: Lower back pain treatment and compensation costs >$80 billion overall in the US. 75% of back pain is due to disc degeneration in the lumbar region of the spine. Current treatment comprises of painkillers and bed rest or as a more radical solution – interbody cage fusion. In the early stages of disc degeneration the patient would benefit from addition of an injectable gel which polymerises in situ to support the degenerated nucleus pulposus. This involves a material which is an analogue of the natural tissue capable of restoring the biomechanical properties of the natural disc. The nucleus pulposus of the intervertebral disc is an example of a natural proteoglycan consisting of a protein core with negatively charged keratin and chondroitin sulphate attached. As a result of the high fixed charge density of the proteoglycan, the matrix exerts an osmotic swelling pressure drawing sufficient water into support the spinal system. Materials and Methods: NaAMPs (sodium 2- acrylamido 2-methyl propane sulphonic acid) and KSPA (potassium 3- sulphopropyl acrylate) were selected as monomers, the sulphonate group being used to mimic the natural sulphate group. These are used in dermal applications involving chronic wounds and have acceptably low cytotoxicity. Other hydrophilic carboxyl, amide and hydroxyl monomers such as 2-hydroxyethyl acrylamide, ß-carboxyethyl acrylate, acryloyl morpholine, and polyethylene glycol (meth)acrylate were used as diluents together with polyethyleneglycol di(meth)acrylate and hydrophilic multifunctional macromers as cross-linker. Redox was the chosen method of polymerisation and a range of initiators were investigated. Components were packaged in two solutions each containing a redox pair. A dual syringe method of injection into the cavity was used, the required time for polymerisation is circa 3-7 minutes. The final materials were tested using a Bohlin CVO Rheometer cycling from 0.5-25Hz at 37oC to measure the modulus. An in-house compression testing method was developed, using dialysis tubing to mimic the cavity, the gels were swelled in solutions of various osmolarity and compressed to ~ 20%. The pre-gel has also been injected into sheep spinal segments for mechanical compression testing to demonstrate the restoration of properties upon use of the gel. Results and Discussion: Two systems resulted using similar monomer compositions but different initiation and crosslinking agents. NaAMPs and KSPA were used together at a ratio of ~1:1 in both systems with 0.25-2% crosslinking agent, diacrylate or methacrylate. The two initiation systems were ascorbic acid/oxone, and N,N,N,N - tetramethylethylenediamine (TEMED)/ potassium persulphate. These systems produced gelation within 3-7 and 3-5 minutes respectively. Storage of the two component systems was shown to be stable for approximately one month after mixing, in the dark, refrigerated at 1-4oC. The gelation was carried out at 37oC. Literature values for the natural disc give elastic constants ranging from 3-8kPa. The properties of the polymer can be tailored by altering crosslink density and monomer composition and are able to match those of the natural disc. It is possible to incorporate a radio-opaque (histodenz) to enable x-ray luminescence during and after injection. At an inclusion level of 5% the gel is clearly visible and polymerisation and mechanical properties are not altered. Conclusion: A two-pac injection system which will polymerise in situ, that can incorporate a radio-opaque, has been developed. This will reinforce the damaged nucleus pulposus in degenerative disc disease restoring adequate hydration and thus biomechanical properties. Tests on sheep spine segments are currently being carried out to demonstrate that a disc containing the gel has similar properties to an intact disc in comparison to one with a damaged nucleus.

Protecting skeletal muscle with protein and amino acid during periods of disuse

Habitual sedentary behavior increases risk of chronic disease, hospitalization and poor quality of life. Short-term bed rest or disuse accelerates the loss of muscle mass, function, and glucose tolerance. Optimizing nutritional practices and protein intake may reduce the consequences of disuse by preserving metabolic homeostasis and muscle mass and function. Most modes of physical inactivity have the potential to negatively impact the health of older adults more than their younger counterparts. Mechanistically, mammalian target of rapamycin complex 1 (mTORC1) signaling and muscle protein synthesis are negatively affected by disuse. This contributes to reduced muscle quality and is accompanied by impaired glucose regulation. Simply encouraging increased protein and/or energy consumption is a well-intentioned, but often impractical strategy to protect muscle health. Emerging evidence suggests that leucine supplemented meals may partially and temporarily protect skeletal muscle during disuse by preserving anabolism and mitigating reductions in mass, function and metabolic homeostasis.

The rest flies down the wind : complexities of late style in the work of Christina Stead

Examining the late style of a writer is like skirting around quicksand. End-of-career reflection can subvert long standing critical accounts; revisionist publishing histories or newly minted archival work can do likewise. And, as Nancy J. Troy suggests, an artist’s last thoughts are rarely planned as such (15). In the case of Christina Stead any consideration of late style is made more difficult because, chronologically speaking, her ‘late’ works were written some 20 years before her death in 1983. Thus chronology can be deceptive, as Nicholas Delbanco points out in Lastingness: The Art of Old Age. Stead’s last novel, I’m Dying Laughing The Humourist, was completed, at least in rough draft form in 1966, when Stead was 64, but friends and readers suggested many changes. The book was published posthumously in 1986. Stead’s work is receiving increasing critical attention so a discussion of her ‘late style’ is important, particularly given that her fiction seems to refuse so many attempts at category-making. This perspective reveals two interesting aspects of her late work: first her consistent engagement with the problems of age for women, and in particular women writers, and second, the consequence of a life-long attention to the representation of dialogic sound in her novels, a preoccupation that results in what can be termed an aural signature. My discussion refers to Edward Said’s and Nicholas Delbanco’s ideas about late style by way of a focus on selective biographical issues and Stead’s engagement with radical politics before moving to an examination of what can be called an aural signature in several novels. Her fiction demonstrates one of the agreed markers of late style: she was constantly looking forward and looking back through innovation in form and content.