O adolescente frente ao transplante de células tronco-hematopoiéticas: contribuições para as ações do Enfermeiro na equipe multiprofissional

O câncer constitui um problema de saúde pública para o mundo desenvolvido e também para nações em desenvolvimento. Segundo a estimativa realizada pelo Inca para o ano de 2012, a partir dos dados dos Registros de Câncer de Base Populacional (RCBP), o percentual mediano dos tumores pediátricos encontrava-se próximo de 3%. Para o ano de 2012, com exceção dos tumores da pele não melanoma, estavam previstos 384.340 casos novos de câncer. Destes, ocorrerão cerca de 11.530 casos novos de câncer em crianças e adolescentes até os 19 anos. Este estudo teve por objeto as expectativas de vida do adolescente frente ao transplante de células tronco hematopoiéticas (TCTH) e como objetivos: descrever as expectativas dos adolescentes que se submeteram ao TCTH e analisar compreensivamente as expectativas de vida destes jovens que se submeteram ao TCTH. Trata-se de estudo de natureza qualitativa, pautado no referencial teórico-metodológico da fenomenologia sociológica de Alfred Schutz. O cenário para sua realização foi uma unidade de Transplante de Medula Óssea, localizada em um hospital federal de referência nacional, localizado na cidade do Rio de Janeiro. Os participantes do estudo foram oito adolescentes, na faixa etária entre 12 e 18 anos de idade, que se encontravam em fase pós-TCTH, em acompanhamento no hospital diariamente ou já de alta hospitalar da unidade. Para a realização do trabalho de campo, foi utilizada a entrevista fenomenológica como instrumento de captação das falas, as quais foram guiadas pelas seguintes questões orientadoras: fale para mim como foi esse período de adoecimento para você. Quais as suas expectativas em relação ao transplante de células tronco hematopoiéticas? O que você espera da sua vida diária/cotidiana agora após a realização do transplante de células tronco hematopoiéticas? As falas foram transcritas, analisadas para então serem categorizadas. A partir da análise compreensiva, emergiram quatro categorias: Ser curado; Ter uma vida normal; Ter uma profissão; Constituir família; e Apresentando o motivo porque. O estudo possibilitou através dos relatos dos adolescentes mergulhar e adentrar no seu universo de significados sobre o que eles esperam do TCTH para a apreensão do que pensam sobre a sua inserção no mundo da vida após a sua realização, como também remeteu para a ação profissional que vislumbra a atuação multidisciplinar na perspectiva do nós, na qual o adolescente, sua família e a equipe sejam parte integrantes desse processo.

Controle dos atos societários pelas juntas comerciais: uma visão histórica, estrutural e procedimental

Análise do controle dos atos societários submetidos a registro no âmbito das Juntas Comerciais, que são responsáveis pela execução do Registro Público de Empresas Mercantis (RPEM). Para cumprir este desiderato, inicialmente, foi realizado um estudo sobre a evolução histórica do Registro de Comércio abordando o seu surgimento, principalmente, na França e em Portugal, países que serviram de base para análise comparativa do controle dos atos societários que é desenvolvido nestas nações. Nesta linha, deu-se enfoque à evolução histórica do Registro de Comércio no Brasil, buscando-se fazer um contraponto com o Registro Empresarial experimento hodiernamente. Posteriormente, foram delineados os fundamentos, a função do RPEM e a natureza jurídica da Junta Comercial. Neste diapasão, tentou-se delimitar a incidência da hermenêutica jurídica nas decisões proferidas no RPEM. Demonstrando quais os efeitos fáticos que o RPEM produz e como deve ocorrer o saneamento dos vícios encontrados antes e após o arquivamento do documento. Por derradeiro, analisou-se a natureza jurídica do controle dos atos societários e quais os limites para o exame das formalidades legais dos atos societários, analisando-se, inclusive, decisões judiciais proferidas pelo Poder Judiciário do Estado do Rio de Janeiro que visaram limitar ou não o poder de ingerência dos examinadores da Junta Comercial. Dentro deste mote, o estudo procurou delimitar a responsabilidade civil da Junta Comercial e dos seus agentes que realizam o controle dos atos societários.

Credit and Debt in medieval England, c.1180-c.1350

Schofield, Phillipp, and N. J. Mayhew, eds., Credit and Debt in medieval England, c.1180-c.1350 (Oxford: Oxbow Books, 2002), pp.x+164 RAE2008

Síndrome de Kelly

Projeto de Pós-Graduação/Dissertação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Medicina Dentária

On the Size Distribution of Autonomous Systems

This paper explores reasons for the high degree of variability in the sizes of ASes that have recently been observed, and the processes by which this variable distribution develops. AS size distribution is important for a number of reasons. First, when modeling network topologies, an AS size distribution assists in labeling routers with an associated AS. Second, AS size has been found to be positively correlated with the degree of the AS (number of peering links), so understanding the distribution of AS sizes has implications for AS connectivity properties. Our model accounts for AS births, growth, and mergers. We analyze two models: one incorporates only the growth of hosts and ASes, and a second extends that model to include mergers of ASes. We show analytically that, given reasonable assumptions about the nature of mergers, the resulting size distribution exhibits a power law tail with the exponent independent of the details of the merging process. We estimate parameters of the models from measurements obtained from Internet registries and from BGP tables. We then compare the models solutions to empirical AS size distribution taken from Mercator and Skitter datasets, and find that the simple growth-based model yields general agreement with empirical data. Our analysis of the model in which mergers occur in a manner independent of the size of the merging ASes suggests that more detailed analysis of merger processes is needed.

Déficits immunitaires primaires: diagnostic, prise en charge, quelques perspectives.

Severe primary immunodeficiencies (PID) are rare; their global incidence is comparable to that of childhood leukemia; they include more than 100 different entities. Clinical manifestations are: unusually severe or frequent infections or infections that do not respond to adequate treatment; an increased risk of certain malignancies; sometimes auto-immune manifestations. Delayed diagnosis and management of PID can lead to severe and irreversible complications or to death. PID can become manifest only in the adult; in common variable immune deficiency, the median age at diagnosis is between the 2nd and the 3rd decade of life. PID are often transmitted genetically; recent progresses in molecular biology have allowed more precise and earlier, including antenatal, diagnosis. Molecular treatment of 3 infants with a severe immunodeficiency has recently been achieved in April 2000. Those progresses were mostly based on the study of immunodeficiency databases. We present here the work of a Belgian group specialized in PID; meetings have started in June 1997. This group establishes guidelines for the diagnosis and treatment of PID, adapted to the local situation. The elaboration of a national register of PID is also underway; this has to provide all guaranties of anonymity to patients and families. Such a register already exists at the European level; it has provided the basis for new diagnostic and therapeutic possibilities. The inclusion of Belgian data in this register should allow essential progresses essential for our patients.

Comparative effectiveness studies to improve clinical outcomes in end stage renal disease: the DEcIDE patient outcomes in end stage renal disease study.

BACKGROUND: Evidence is lacking to inform providers' and patients' decisions about many common treatment strategies for patients with end stage renal disease (ESRD). METHODS/DESIGN: The DEcIDE Patient Outcomes in ESRD Study is funded by the United States (US) Agency for Health Care Research and Quality to study the comparative effectiveness of: 1) antihypertensive therapies, 2) early versus later initiation of dialysis, and 3) intravenous iron therapies on clinical outcomes in patients with ESRD. Ongoing studies utilize four existing, nationally representative cohorts of patients with ESRD, including (1) the Choices for Healthy Outcomes in Caring for ESRD study (1041 incident dialysis patients recruited from October 1995 to June 1999 with complete outcome ascertainment through 2009), (2) the Dialysis Clinic Inc (45,124 incident dialysis patients initiating and receiving their care from 2003-2010 with complete outcome ascertainment through 2010), (3) the United States Renal Data System (333,308 incident dialysis patients from 2006-2009 with complete outcome ascertainment through 2010), and (4) the Cleveland Clinic Foundation Chronic Kidney Disease Registry (53,399 patients with chronic kidney disease with outcome ascertainment from 2005 through 2009). We ascertain patient reported outcomes (i.e., health-related quality of life), morbidity, and mortality using clinical and administrative data, and data obtained from national death indices. We use advanced statistical methods (e.g., propensity scoring and marginal structural modeling) to account for potential biases of our study designs. All data are de-identified for analyses. The conduct of studies and dissemination of findings are guided by input from Stakeholders in the ESRD community. DISCUSSION: The DEcIDE Patient Outcomes in ESRD Study will provide needed evidence regarding the effectiveness of common treatments employed for dialysis patients. Carefully planned dissemination strategies to the ESRD community will enhance studies' impact on clinical care and patients' outcomes.

Barriers to and facilitators of interventions to counter publication bias: thematic analysis of scholarly articles and stakeholder interviews.

BACKGROUND: When the nature and direction of research results affect their chances of publication, a distortion of the evidence base - termed publication bias - results. Despite considerable recent efforts to implement measures to reduce the non-publication of trials, publication bias is still a major problem in medical research. The objective of our study was to identify barriers to and facilitators of interventions to prevent or reduce publication bias. METHODS: We systematically reviewed the scholarly literature and extracted data from articles. Further, we performed semi-structured interviews with stakeholders. We performed an inductive thematic analysis to identify barriers to and facilitators of interventions to counter publication bias. RESULTS: The systematic review identified 39 articles. Thirty-four of 89 invited interview partners agreed to be interviewed. We clustered interventions into four categories: prospective trial registration, incentives for reporting in peer-reviewed journals or research reports, public availability of individual patient-level data, and peer-review/editorial processes. Barriers we identified included economic and personal interests, lack of financial resources for a global comprehensive trial registry, and different legal systems. Facilitators identified included: raising awareness of the effects of publication bias, providing incentives to make data publically available, and implementing laws to enforce prospective registration and reporting of clinical trial results. CONCLUSIONS: Publication bias is a complex problem that reflects the complex system in which it occurs. The cooperation amongst stakeholders to increase public awareness of the problem, better tailoring of incentives to publish, and ultimately legislative regulations have the greatest potential for reducing publication bias.

Validation of ICDPIC software injury severity scores using a large regional trauma registry.

BACKGROUND: Administrative or quality improvement registries may or may not contain the elements needed for investigations by trauma researchers. International Classification of Diseases Program for Injury Categorisation (ICDPIC), a statistical program available through Stata, is a powerful tool that can extract injury severity scores from ICD-9-CM codes. We conducted a validation study for use of the ICDPIC in trauma research. METHODS: We conducted a retrospective cohort validation study of 40,418 patients with injury using a large regional trauma registry. ICDPIC-generated AIS scores for each body region were compared with trauma registry AIS scores (gold standard) in adult and paediatric populations. A separate analysis was conducted among patients with traumatic brain injury (TBI) comparing the ICDPIC tool with ICD-9-CM embedded severity codes. Performance in characterising overall injury severity, by the ISS, was also assessed. RESULTS: The ICDPIC tool generated substantial correlations in thoracic and abdominal trauma (weighted κ 0.87-0.92), and in head and neck trauma (weighted κ 0.76-0.83). The ICDPIC tool captured TBI severity better than ICD-9-CM code embedded severity and offered the advantage of generating a severity value for every patient (rather than having missing data). Its ability to produce an accurate severity score was consistent within each body region as well as overall. CONCLUSIONS: The ICDPIC tool performs well in classifying injury severity and is superior to ICD-9-CM embedded severity for TBI. Use of ICDPIC demonstrates substantial efficiency and may be a preferred tool in determining injury severity for large trauma datasets, provided researchers understand its limitations and take caution when examining smaller trauma datasets.

Early clopidogrel versus prasugrel use among contemporary STEMI and NSTEMI patients in the US: insights from the National Cardiovascular Data Registry.

BACKGROUND: P2Y12 antagonist therapy improves outcomes in acute myocardial infarction (MI) patients. Novel agents in this class are now available in the US. We studied the introduction of prasugrel into contemporary MI practice to understand the appropriateness of its use and assess for changes in antiplatelet management practices. METHODS AND RESULTS: Using ACTION Registry-GWTG (Get-with-the-Guidelines), we evaluated patterns of P2Y12 antagonist use within 24 hours of admission in 100 228 ST elevation myocardial infarction (STEMI) and 158 492 Non-ST elevation myocardial infarction (NSTEMI) patients at 548 hospitals between October 2009 and September 2012. Rates of early P2Y12 antagonist use were approximately 90% among STEMI and 57% among NSTEMI patients. From 2009 to 2012, prasugrel use increased significantly from 3% to 18% (5% to 30% in STEMI; 2% to 10% in NSTEMI; P for trend <0.001 for all). During the same period, we observed a decrease in use of early but not discharge P2Y12 antagonist among NSTEMI patients. Although contraindicated, 3.0% of patients with prior stroke received prasugrel. Prasugrel was used in 1.9% of patients ≥75 years and 4.5% of patients with weight <60 kg. In both STEMI and NSTEMI, prasugrel was most frequently used in patients at the lowest predicted risk for bleeding and mortality. Despite lack of supporting evidence, prasugrel was initiated before cardiac catheterization in 18% of NSTEMI patients. CONCLUSIONS: With prasugrel as an antiplatelet treatment option, contemporary practice shows low uptake of prasugrel and delays in P2Y12 antagonist initiation among NSTEMI patients. We also note concerning evidence of inappropriate use of prasugrel, and inadequate targeting of this more potent therapy to maximize the benefit/risk ratio.

The Impact of Worsening Heart Failure in the United States.

In-hospital worsening heart failure represents a clinical scenario wherein a patient hospitalized for acute heart failure experiences a worsening of their condition, requiring escalation of therapy. Worsening heart failure is associated with worse in-hospital and postdischarge outcomes. Worsening heart failure is increasingly being used as an endpoint or combined endpoint in clinical trials, as it is unique to episodes of acute heart failure and captures an important event during the inpatient course. While prediction models have been developed to identify worsening heart failure, there are no known FDA-approved medications associated with decreased worsening heart failure. Continued study is warranted.

Survival patterns among lymphoma patients with a family history of lymphoma

Purpose: Genetic factors are important in the etiology and pathogenesis of chronic lymphocytic leukemia (CLL), Hodgkin's lymphoma (HL), and non-Hodgkin's lymphoma (NHL). Only a few small studies have assessed clinical characteristics and prognosis for familial patients, with inconsistent findings. Methods: Using population-based registries from Sweden and Denmark, 7,749 patients with CLL, 7,476 patients with HL, and 25,801 patients with NHL with linkable first-degree relatives were identified. Kaplan-Meier curves were constructed to compare survival in patients with lymphoma with and without a family history of lymphoma. The risk of dying was assessed using adjusted Cox proportional hazard models. Results: We found 85 patients with CLL (1.10%), 95 patients with HL (1.28%), and 206 patients with NHL (0.80%) with a family history of any lymphoma. Five-year mortality was similar for patients with CLL (hazard ratio [HR], 1.28; 95% CI, 0.95 to 1.72), HL (HR, 0.78; 95% CI, 0.49 to 1.25), and NHL (HR, 0.91; 95% CI, 0.74 to 1.12) versus without a family history of any lymphoma. Mortality was also similar for patients with versus without a family history of the same lymphoma. T-cell/anaplastic lymphoma patients with a family history of NHL had poorer outcome 5-years after diagnosis (HR, 5.38; 95% CI, 1.65 to 17.52). Results were similar for 10 years of follow-up. Conclusion: With the exception of T-cell/anaplastic lymphoma, survival patterns for patients with CLL, HL, and NHL with a family history of lymphoma were similar to those for sporadic patients, suggesting that most familial lymphomas do not have an altered clinical course. Our findings provide no evidence to modify therapeutic strategies for patients with CLL, HL, or NHL based solely on family history. © 2008 by American Society of Clinical Oncology.


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Restorative Justice as a Response to Sexual Offending – Addressing the Failings of Current Punitive Approaches

This article explores the use of restorative justice as a response to sexual crime. The management of high risk sex offenders, particularly in the community post-release, has been a key focus of contemporary popular and political debates on sexual offending. Many offenders fail to come to the attention of the criminal justice system. For those that do, there is the almost blanket application of recent control in the community measures such as sex offender registries and community notification which have failed to prevent reoffending. The response by the media and the public to the presence of sex offenders in the community may also impede offender rehabilitation. The use of punishment alone via formal criminal justice is, therefore, an inadequate deterrent for sexual crimes. Although controversial, this article advocates the use of restorative practices with sexual crime as a proactive, holistic response to the problem and ultimately as a more effective means of reducing the incidence of sexual offences and sex offender recidivism.