Prevalência de ansiedade e depressão e suas comorbidades em pacientes com doença renal crônica em hemodiálise e diálise peritoneal

Introdução: Os pacientes com doença renal crônica (DRC) que realizam terapia renal substitutiva (TRS) estão sujeitos a maior prevalência de distúrbios de humor. Objetivo: O objetivo do presente estudo é comparar a prevalência de ansiedade e depressão nos pacientes que realizam hemodiálise (HD) e diálise peritoneal (DP), levando em conta comorbidades que podem contribuir para isso. Métodos: O estudo foi realizado em Ponta Grossa, PR, com pacientes portadores de DRC, utilizando os inventários de depressão e ansiedade de Beck (BDI e BAI) e a Escala Hospitalar de Ansiedade e Depressão (EHAD). Resultados: Foram estudados 155 pacientes, 128 no grupo em HD e 27 em DP. No primeiro, depressão foi encontrada em 22,6% dos pacientes no BDI e em 9,3% na EHAD, e ansiedade em 25,7% no BAI e em 11,7% na EHAD. No grupo em DP, 29,6% dos pacientes apresentaram depressão no BDI e 14,8% na EHAD, e ansiedade em 11,1% no BAI e em nenhum na EHAD. Conclusão: A realização de hemodiálise ou diálise peritoneal não influenciou na prevalência de ansiedade ou depressão nos pacientes com DRC.

Redução da água corporal de renais crônicos em diálise peritoneal se associa com melhor controle da hipertensão arterial

Introdução: A hipertensão arterial tem alta prevalência em renais crônicos, sendo a hipervolemia um de seus fatores causais. Objetivo: Avaliar a influência da redução da volemia no controle pressórico e em parâmetros ecocardiográficos de pacientes renais crônicos em diálise peritoneal contínua. Métodos: Doze renais crônicos sem sinais clínicos de hipervolemia foram submetidos à intensificação da diálise com o objetivo de reduzir o peso corporal em 5%. A volemia foi avaliada pela bioimpedância elétrica e pela ultrassonografia de veia cava inferior (VCI). Os voluntários foram submetidos à monitorização ambulatorial da pressão arterial e a exame ecocardiográfico no período basal e após 5 semanas de intervenção. Resultados: Após a intensificação da ultrafiltração, houve redução significativa do peso corporal, da água extracelular e do diâmetro inspiratório da VCI, enquanto o índice de colapsamento da VCI não alterou de modo significativo. A despeito da redução do número de anti-hipertensivos, a pressão sistólica do período de sono reduziu de 138,4 ± 18,6 para 126,7 ± 18,0 mmHg, o descenso pressórico do sono aumentou e o diâmetro sistólico final do ventrículo esquerdo reduziu significantemente. Conclusão: A redução da volemia de pacientes em diálise peritoneal, clinicamente euvolêmicos, se associou a melhor controle pressórico e à diminuição do diâmetro sistólico final do ventrículo esquerdo.

Qualidade de vida de pacientes renais crônicos em diálise peritoneal e hemodiálise

ResumoIntrodução:Há controvérsias quanto à qualidade de vida (QV) de pacientes renais crônicos tratados com diferentes métodos dialíticos.Objetivo:Comparar a QV de pacientes renais crônicos em diálise peritoneal (DP) e hemodiálise (HD).Métodos:Estudo transversal nos três centros de diálise de Pelotas/RS. Pacientes em DP foram entrevistados após consulta mensal de rotina e os em HD, entre 1ª-2ª horas da sessão dialítica, com questionário estruturado. QV foi avaliada com Short-Form Health Survey (SF-36). Médias dos oito domínios do SF-36 foram comparadas entre os grupos.Resultados:Dos 345 pacientes elegíveis (63 em DP e 282 em HD), foram entrevistados 317 (8% de perdas/recusas). Cerca da metade nos dois grupos estava em diálise há no máximo 3 anos. Havia maioria de mulheres em DP e de homens em HD. Pacientes em DP relataram menos "dor" do que os em HD (escores médios 76,5 e 64,3, respectivamente; p = 0,0040). Não houve diferença nos demais domínios do SF-36.Discussão:A utilização de HD em Pelotas é um pouco menor que a detectada pelo Censo Brasileiro de Diálise (2011), sendo o uso de DP semelhante ao de alguns países europeus. Melhor escore no domínio "dor" entre pacientes em DP é consistente com o observado em outros estudos, embora haja também relatos de nenhuma diferença entre as modalidades e de vantagens da DP em outros domínios que não foram detectados no atual estudo.Conclusão:É semelhante a QV dos pacientes em DP ou HD, exceto no domínio dor, que foi menos intensa entre os pacientes em DP.

Troponin I serum levels predict the need of dialysis in incident sepsis patients with acute kidney injury in the intensive care unit

Abstract Introduction: Sepsis, an extremely prevalent condition in the intensive care unit, is usually associated with organ dysfunction, which can affect heart and kidney. Objective: To determine whether the cardiac dysfunction and the Troponin I forecast the occurrence of acute renal failure in sepsis. Methods: Cardiac dysfunction was assessed by echocardiography and by the serum troponin I levels, and renal impairment by AKIN criteria and the need of dialysis. Twenty-nine patients with incident sepsis without previous cardiac or renal dysfunction were enrolled. Results and Discussion: Patients averaged 75.3 ± 17.3 years old and 55% were male. Median APACHE II severity score at ICU admission was 16 (9.7 - 24.2) and mortality rate in 30 days was 45%. On the fifth day, 59% had ventricular dysfunction. Troponin serum levels on day 1 in the affected patients were 1.02 ± 0.6 ng/mL compared with 0.23 ± 0.18 ng/mL in patients without heart dysfunction (p = 0.01). Eighteen out of 29 patients (62%) underwent renal replacement therapy (RRT) and the percent of patients with ventricular dysfunction who required dialysis was higher (94% vs. 16%, p = 0.0001). Values of troponin at day 1 were used to develop a ROC curve to determine their ability to predict the need of dialysis. The area under the curve was 0.89 and the cutoff value was 0.4 ng/mL. Conclusion: We found that an elevation in serum troponin levels, while guarding a relationship with ventricular dysfunction, can be a precious tool to predict the need for dialysis in sepsis patients.

Qualidade de vida de pacientes renais crônicos em hemodiálise ou diálise peritoneal: estudo comparativo em um serviço de referência de Curitiba - PR

Resumo Introdução: A doença renal crônica (DRC) compromete saúde e rotina de seu portador. No estágio V da DRC, o paciente torna-se elegível para iniciar a terapia substitutiva renal por hemodiálise (HD), diálise peritoneal (DP) ou transplante renal. O tipo de tratamento pode ser importante para melhorar a qualidade de vida do paciente. Objetivo: Comparar a qualidade de vida de pacientes renais crônicos em estágio V-D (em diálise) que realizam DP domiciliar ou HD. Métodos: Estudo transversal com coleta prospectiva, por conveniência, por meio da aplicação de questionários socioeconômicos e KDQOL-SF 36 em pacientes do ambulatório de DP e pacientes em HD da Fundação Pró-Renal e clínicas-satélite de Curitiba-PR. Resultados: Amostra de 338 pacientes, sendo 222 em HD, e 116 em DP. Idade média de 54,4 ± 15,28 anos para HD e 58,0 ± 13,99 para DP. Variáveis: situação do trabalho (p < 0,05), estímulo por parte da equipe de diálise (p < 0,01) e satisfação do paciente (p < 0,001) foram favoráveis à DP, enquanto que funcionamento físico (p < 0,05) e função emocional (p < 0,01) foram favoráveis à HD. Conclusão: Objetivamente, a DP mostrou-se melhor em relação à qualidade de vida por apresentar um maior número de itens com resultados significativos quando comparada à HD. Porém, as duas variáveis de maior significância encontradas na HD (funcionamento físico e funcionamento emocional) têm um impacto maior no bem-estar e no cotidiano no ambiente externo à clínica do que aquelas superiores na DP, tornando a HD mais favorável à qualidade de vida do paciente.

Anemia em pacientes submetidos à diálise peritoneal ambulatorial: prevalência e fatores associados

Resumo Introdução: A anemia é uma complicação frequente em pacientes em diálise e poucos estudos avaliaram sua ocorrência em pacientes submetidos à diálise peritoneal (DP). Objetivo: Este estudo teve como objetivo investigar a prevalência e fatores associados à presença de anemia em pacientes submetidos à DP de um único centro onde havia acesso irrestrito a agentes estimulantes da eritropoiese (AEE) e a suplementação de ferro intravenoso. Métodos: Estudo transversal que analisou variáveis demográficas, clínicas e laboratoriais de 120 pacientes. Anemia foi definida como hemoglobina (Hb) < 11g/dl. Resultados: Os pacientes estavam em DP por 17 meses, sendo 86% automatizada. A idade média foi de 58 ± 16,5 anos, 52% dos pacientes eram do sexo feminino e 29% diabéticos. Anemia esteve presente em 34 pacientes (28%). Quando comparados com pacientes sem anemia, aqueles com anemia recebiam maior dose de ferro (p = 0,02) e apresentavam menores triglicérides (p = 0,01). A Hb se correlacionou negativamente com as doses de ferro (r = -0,20;p = 0,03) e AEE (r = -0,23; p = 0,01), e positivamente com albumina (r = 0,38; p = 0,01), triglicérides (r = 0,24; p = 0,01) e índice de saturação da transferrina (r = 0,20; p = 0,03). Na análise múltipla, a concentração de albumina (coefβ = 0,84; 95% IC = 0,381,31;p < 0,001) e a dose de AEE (coefβ = -0,06; 95% IC = 0,00-0,00; p = 0,02) foram associadas de forma independente com a Hb. Conclusões: No presente estudo, anemia foi observada em aproximadamente 30% dos pacientes em programa de diálise peritoneal, com uso irrestrito de AEE e suplementação intravenosa de ferro. A saturação de transferrina e o estado nutricional, avaliado pela albumina, foram os fatores independentes associados à concentração de hemoglobina nesta população.

Continuous hydride generation in the presence of L- cysteine for the determination of arsenic, bismuth, antimony and tin in steels by inductively coupled plasma atomic emission spectrometry

Arsenic, bismuth, germanium, antimony and tin were simultaneously determined by continuous hydride generation and inductively coupled plasma-atomic emission spectrometry . I Hydrides were introduced into four different types of gas-liquid separators. Two of the gas-liquid separators were available in-house. A third was developed for this project and a fourth was based on a design used by CET AC. The best signal intensity was achieved by the type II frit-based gas-liquid separator, but the modified Cetac design gave promise for the future, due to low relative standard deviation. A method was developed for the determination of arsenic, bismuth, antimony and tin in low-alloy steels. Four standard reference materials from NIST were dissolved in 10 mL aqua regia without heat. Good agreement was obtained between experimental values and certified values for arsenic, bismuth, antimony and tin. The method was developed to provide the analyst with the opportunity to determine the analytes by using simple aqueous standards to prepare calibration lines. Within the limits of the samples analyzed, the method developed is independent of matrix.

Exploring the effects of change on nursing practice in acute ambulatory care settings : a qualitative study

As a result of the current changes taking place in the delivery of acute care services, the emergence of acute ambulatory care (AAC) settings is expanding. According to a literature review, the volume, acuity, and complexity of patient care in these settings is increasing while the time the patients spend under the care of nurses is decreasing. Two forces, hospital downsizing and advancing technology, are identified as the major contributors to the shift in acute care delivery. The effects that these changes are having on the clinical nursing practice of registered nurses working in AAC settings are not known. Given that AAC settings are rapidly expanding, it can be anticipated that the delivery of nursing care will continue to be compressed into a shorter time frame. Therefore, the following qualitative research question was formulated: What are the problems and issues related to clinical nursing practice in acute ambulatory settings? The purpose of this study was to explore the problems and issues associated with change and clinical nursing practice including the educational needs of nurses working in MC settings. Specific objectives of the study included the following: (a) to explore the problems and issues related to nursing practice in select AAC settings; (b) to explore the similarities and differences in perspectives related to role expectation between nurse managers, nurse educators, and staff nurses; and (c) to develop a conceptual framework that will guide the construction of an instrument needed for further research. This study used semistructured individual interviews and focus group sessions to collect data from the three categories of registered nurses. More specifically, data were collected from one nurse manager, two charge nurses, two nurse educators and fifteen staff nurses, working in three different MC settings of a major teaching hospital. Collected data were separately analyzed by the researcher and an external rater following grounded theory methodology. By using open and axial coding, the problems and issues identified by nurses were grouped into several major and minor themes. In final analysis, by using selective coding, the four core themes (intensification, moderation, frustration, and adaptation) were extracted. Each core theme was presented and discussed in relation to hospital downsizing and advancing technology. The relationships among the four core themes were discussed and depicted in a model termed the "Impact and Consequence Model on Nursing Practice in MC Settings." Implications for further research are discussed and research hypotheses, based on the research findings, are presented.

An analysis of the relationship between self-efficacy and performance in a continuous gymnastic routine

Research has shown a consistent correlation between efficacy and sport performance (Moritz, et aI., 2000). This relationship has been shown to be dynamic and reciprocal over seasons (e.g., Myers, Payment, et aI., 2004), within games (e.g., Butt, et aI., 2003), and across trials (e.g., Feltz, 1982). The purpose of the present study was to examine selfefficacy and performance simultaneously within one continuous routine. Forty-seven undergraduate students performed a gymnastic sequence while using an efficacy measure. Results indicated that the efficacy-performance relationship was not reciprocal; previous performance was a significant predictor of subsequent performance (p < .01; f3s ranged from .44 to .67). Results further revealed significant differences in efficacy beliefs between groups with high and low levels of performance [F (1,571) = 7.16,p < .01]. Findings suggest that high levels of performance within a continuous physical activity task result in higher performance scores and higher efficacy beliefs.

The Influence of Attentional Focus on the Self-Efficacy-Performance Relationship in a Continuous Running Task

The self-efficacy-performance relationship in continuous sport tasks has been shown to be significantly reciprocal yet unequal with stronger influences in the performance-to-self-efficacy pathway rather than self-efficacy-to-performance pathway (e.g., LaForge-MacKenzie & Sullivan, 2014b). Bandura (2012) suggested that sociocognitive variables may influence this relationship. Attention as a sociocognitve factor may bias the processing of performance and self-efficacy information (Bandura, 1982, 1997; Bandura & Jourden, 1991). As confidence and attention are important aspects of peak running performance (Brewer, Van Raalte, Linder, & VanRaalte, 1991), the primary purpose of the present study was to examine the self-efficacy-performance relationship under three conditions of attentional focus. The secondary purpose was to examine self-efficacy and performance as separate constructs under the same conditions of attention. Participants ran continuously for one kilometer in one of three randomly assigned attentional focus conditions: internal-focus (n = 51), external-focus (n = 50), and control (n = 49). Self-efficacy was assessed using a one-item measure every 200 meters. Path analyses examining the primary objective revealed significant self-efficacy-to-performance pathways in all conditions: external-focus (p < .05, βs ranging from -.17 to -.32), internal-focus (p < .05, βs ranging from -.26 to -.36), and control (p < .05, βs ranging from -.29 to -.42). Significant reciprocal relationships were absent in all conditions. ANOVAs examining the secondary objectives found significantly faster performance in the control condition at the start (F (2, 147) = 3.86, p < .05) and end of the task (F (2, 147) = 3.56, p < .05). Self-efficacy was significantly higher in the internal-focus condition at the end of the task (Self-Efficacy 4 (F (2, 147) = 3.21, p < .05) and Self-Efficacy 5 (F (2, 147) = 4.74, p < .05). In contrast to previous within-trial research (e.g., LaForge-MacKenzie & Sullivan, 2014b) self-efficacy-to-performance effects were more significant and robust than performance-to-self-efficacy effects. These results provided support for Bandura’s (2012) suggestion that sociocognitive factors may have the ability to alter the causal structure of the self-efficacy-performance relationship, proposing complexities in the self-efficacy-performance relationship (Sitzmann &Yeo, 2013). Results were discussed from both theoretical and applied perspectives.

Efecto antibacteriano de algunas tetraciclinas sobre bacterias fagocitadas por leucocitos polimorfonucleares obtenidos de exudado peritoneal de conejo

Tesis (Maestría en Ciencias con Especialidad en Microbiología Médica) UANL

A Representation Theorem for Domains with Discrete and Continuous Variables.

This paper proves a new representation theorem for domains with both discrete and continuous variables. The result generalizes Debreu's well-known representation theorem on connected domains. A strengthening of the standard continuity axiom is used in order to guarantee the existence of a representation. A generalization of the main theorem and an application of the more general result are also presented.

La programmation régionale des services ambulatoires de Laval : une avenue dans la responsabilisation populationnelle des soins de santé

Face aux pressions continues que subissent les systèmes de santé, de nombreuses réformes sont perpétuellement en cours pour améliorer le processus de soins et par conséquent, offrir des soins de qualité et accroître le niveau de santé des populations. Les réformes que connaissent actuellement les systèmes de santé visent à optimiser l’impact des services sur la santé de la population en introduisant le concept de la responsabilité populationnelle. Par ailleurs, il existe de plus en plus un consensus sur la nécessité d’établir une relation directe et durable entre les prestataires et la population des territoires desservies pour être en mesure de tenir compte des contextes personnels et sociaux des patients et de leurs familles et pour assurer la continuité des soins dans le temps et d’un service à l’autre. Cette thèse porte sur la Programmation régionale de services ambulatoires (PRSA) de Laval. Elle analyse cette programmation comme une solution innovatrice dans la mise en œuvre de la responsabilisation populationnelle des soins. La stratégie de recherche combine à la fois une revue intégrative de la littérature qui vise à analyser le bien-fondé de la PRSA; une étude quasi-expérimentale pour examiner ses effets; et enfin, une recherche synthétique de cas pour comprendre l’évolution de la PRSA et analyser l’institutionnalisation du changement dans les organisations de la santé. Dans le premier article, nous nous sommes employés à analyser le bien fondé c’est-à-dire la plausibilité des mécanismes causaux présumés. La PRSA est un modèle d’intégration régionale basée sur une approche populationnelle. La stratégie de réseaux intégrés de soins et de case management combinée avec une approche populationnelle telle que mise de l’avant par le PRSA sont trois éléments essentiels en faveur d’une responsabilité populationnelle des soins. À l’aide d’une revue intégrative de la littérature, nous avons démontré qu’il s’agit d’une programmation capable de consolider une intégration régionale en mettant de l’avant une approche populationnelle permettant de bien cibler les besoins des populations du territoire à desservir. Le deuxième article examine les effets populationnels de la PRSA en termes de réduction de la durée moyenne de séjour et de l’augmentation de la rétention régionale. Une approche quasi expérimentale a été utilisée. En ce qui concerne la durée moyenne de séjour, on n’observe aucune diminution pour l’asthme ni pour la démence. Par contre, il est plausible que l’implantation de la PRSA ait permis une diminution de la durée moyenne de séjour pour les maladies coronariennes, les MPOC, l’embolie pulmonaire et le cancer du sein. Pour la rétention régionale, aucun effet n’a été observé pour les MPOC, l’embolie pulmonaire et la démence. Une augmentation de la rétention régionale a été observée pour les maladies coronariennes, l’asthme et le cancer du sein. Cette augmentation pourrait être attribuée à la PRSA. Dans le troisième article, nous avons examiné les facteurs susceptibles d’expliquer l’évolution de la PRSA. En partant du point de vue des responsables de la programmation de la PRSA et les gestionnaires actuels de la programmation de services de la région de Laval, nous avons tenté de mieux cerner les facteurs qui ont provoqué la suspension du déploiement de la PRSA. Les résultats indiquent que les changements fréquents dans les structures dirigeantes du réseau de la santé ainsi que l’interférence de plusieurs autres réformes ont été un obstacle dans le maintien de la PRSA. Dans le contexte actuel des réformes en santé où l’approche de réseaux intégrés de soins et de responsabilité populationnelle sont mises de l’avant, les résultats de cette thèse apportent un éclairage certain sur l’opérationnalisation de ces orientations.

Systemic and regional hemodynamics in pigs with acute liver failure and the effect of albumin dialysis.

OBJECTIVE: Acute liver failure (ALF) is haemodynamically characterized by a hyperdynamic circulation. The aims of this study were to investigate the systemic and regional haemodynamics in ALF, to measure changes in nitric oxide metabolites (NOx) and to evaluate whether these haemodynamic disturbances could be attenuated with albumin dialysis. MATERIAL AND METHODS: Norwegian Landrace pigs (23-30 kg) were randomly allocated to groups as controls (sham-operation, n = 8), ALF (hepatic devascularization, n = 8) and ALF + albumin dialysis (n = 8). Albumin dialysis was started 2 h after ALF induction and continued for 4 h. Systemic and regional haemodynamics were monitored. Creatinine clearance, nitrite/nitrate and catecholamines were measured. A repeated measures ANOVA was used to analyse the data. RESULTS: In the ALF group, the cardiac index increased (PGT < 0.0001), while mean arterial pressure (PG = 0.02) and systemic vascular resistance decreased (PGT < 0.0001). Renal resistance (PG = 0.04) and hind-leg resistance (PGT = 0.003) decreased in ALF. There was no difference in jejunal blood flow between the groups. ALF pigs developed renal dysfunction with increased serum creatinine (PGT = 0.002) and decreased creatinine clearance (P = 0.02). Catecholamines were significantly higher in ALF, but NOx levels were not different. Albumin dialysis did not attenuate these haemodynamic or renal disturbances. CONCLUSIONS: The haemodynamic disturbances during the early phase of ALF are characterized by progressive systemic vasodilatation with no associated changes in metabolites of NO. Renal vascular resistance decreased and renal dysfunction developed independently of changes in renal blood flow. After 4 h of albumin dialysis there was no attenuation of the haemodynamic or renal disturbances.

Effect of albumin dialysis on intracranial pressure increase in pigs with acute liver failure: a randomized study.

BACKGROUND: Increased intracranial pressure (ICP) worsens the outcome of acute liver failure (ALF). This study investigates the underlying pathophysiological mechanisms and evaluates the therapeutic effect of albumin dialysis in ALF with use of the Molecular Adsorbents Recirculating System without hemofiltration/dialysis (modified, M-MARS). METHODS: Pigs were randomized into three groups: sham, ALF, and ALF + M-MARS. ALF was induced by hepatic devascularization (time = 0). M-MARS began at time = 2 and ended with the experiment at time = 6. ICP, arterial ammonia, brain water, cerebral blood flow (CBF), and plasma inflammatory markers were measured. RESULTS: ICP and arterial ammonia increased significantly over 6 hrs in the ALF group, in comparison with the sham group. M-MARS attenuated (did not normalize) the increased ICP in the ALF group, whereas arterial ammonia was unaltered by M-MARS. Brain water in the frontal cortex (grey matter) and in the subcortical white matter at 6 hrs was significantly higher in the ALF group than in the sham group. M-MARS prevented a rise in water content, but only in white matter. CBF and inflammatory mediators remained unchanged in all groups. CONCLUSION: The initial development of cerebral edema and increased ICP occurs independently of CBF changes in this noninflammatory model of ALF. Factor(s) other than or in addition to hyperammonemia are important, however, and may be more amenable to alteration by albumin dialysis.