Psytrance: o ritornelo da alegria : comunicação, design sonoro, música eletrônica

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Semiótica do discurso trágico em Hilda Hilst

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Ocorrência da agitação no despertar em crianças anestesiadas com isoflurano ou sevoflurano: influência do tratamento com a dexmedetomidina

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Medical adverse events in elderly hospitalized patients: A prospective study

OBJECTIVES: To determine the frequency of medical adverse events in elderly patients admitted to an acute care geriatric unit, the predictive factors of occurrence, and the correlation between adverse events and hospital mortality rates. METHODS: This prospective study included 171 admissions of patients aged 60 years and older in the acute care geriatric unit in a teaching hospital in Brazil between 2007 and 2008. The following variables were assessed at admission: the patient age, gender, number of prescription drugs, geriatric syndromes (e. g., immobility, postural instability, dementia, depression, delirium, and incontinence), comorbidities, functional status (evaluated with the Katz Index of Independence in Activities of Daily Living), and severity of illness (evaluated with the Simplified Acute Physiology Score II). The incidence of delirium, infection, mortality, and the prescription of potentially inappropriate medications (based on the Beers criteria) were assessed during hospitalization. An observer who was uninvolved in patient care reported the adverse events. RESULTS: The mean age of the sample was 78.12 years. A total of 187 medical adverse events occurred in 94 admissions (55%). The predictors of medical adverse events were undetermined. Compared with the patients with no adverse events, the patients with medical adverse events had a significantly longer hospital stay (21.41 +/- 15.08 days versus 10.91 +/- 7.21 days) and a higher mortality rate (39 deaths [41.5%] versus 17 deaths [22.1%]). Mortality was significantly predicted by the Simplified Acute Physiology Score II score (odds ratio [OR] = 1.13, confidence interval [CI] 95%, 1.07 to 1.20), the Katz score (OR = 1.47, CI 95%, 1.18 to 1.83), and medical adverse events (OR = 3.59, CI 95%, 1.55 to 8.30). CONCLUSION: Medical adverse events should be monitored in every elderly hospitalized patient because there is no risk profile for susceptible patients, and the consequences of adverse events are serious, sometimes leading to longer hospital stays or even death.

Valutazione preoperatoria del rischio chirurgico in pazienti onco-geriatrici (studio PREOP)

La maggior parte dei pazienti che vengono sottoposti a interventi chirurgici per tumori solidi hanno un’età superiore a 70 anni1. Circa il 30% di questi pazienti vengono considerati “fragili”. Questi infatti presentano numerose comorbidità ed hanno un più elevato rischio di sviluppare complicanze postoperatorie con perdita della riserva funzionale residua. Per questo non esistono sistemi semplici di screening che permettano ai medici responsabili del trattamento di identificare questi pazienti con aumentato rischio postoperatorio. Identificare i pazienti a rischio è infatti il primo passo nel processo attraverso il quale è possibile prevenire in necessarie complicanze postoperatorie come delirio, eventi cardiovascolari e perdita della funzionalità complessiva con conseguente perdita di autonomia. Scopo di questo studio è quello di confrontare l’accuratezza nella previsione di mortalità e morbidità a 30 giorni dei tre test preditivi “Groningen Frailty Index” (GFI); “Vulnerable Elders Survey” (VES-13); “timed up and go test” con alcune componenti del Preoperative Assessment of Cancer in the Elderly (PACE). Lo studio verrà effettuato sui pazienti con età maggiore di 70 anni che dovranno essere sottoposti a intervento chirurgico in anestesia generale per la presenza di una neoplasia solida.

Effects of rivastigmine on actigraphically monitored motor activity in severe agitation related to Alzheimer's disease: a placebo-controlled pilot study

Acetylcholinesterase inhibitors (AChEIs) are effective in the treatment of cognitive symptoms in Alzheimer's disease (AD). Because the behavioral and psychological symptoms of dementia (BPSD) have also been attributed to central cholinergic deficits, we examined whether the AChEI rivastigmine can reduce motor activity as measured in a rater-independent manner by wrist actigraphy in agitated AD patients. A total of 20 consecutive AD inpatients (13 females, 7 males, 80.4+/-9.1 years, S.D.) were included from our geriatric psychiatry unit, all of whom were exhibiting agitated behavior not attributable to delirium. Patients were assigned randomly and in a single-blinded fashion to rivastigmine 3mg or placebo for 14 days. Motor activity levels were monitored using an actigraph worn continuously on the wrist of the non-dominant hand. At the beginning and end of the study, patients were assessed using the Neuropsychiatric Inventory (NPI) and Nurses' Observation Scale for Geriatric Patients (NOSGER). Patients in the rivastigmine group exhibited less agitation than placebo recipients on the NPI-agitation subscale, but not on NOSGER. Actigraphic measurements showed a tendency towards reduced motor activity in the rivastigmine group. Because rivastigmine usually exerts its main effects after a longer period of time, the short-term effects seen in our study justify further controlled clinical trials examining the use of rivastigmine in BPSD by means of actigraphy.

Temporary neurological dysfunction after surgery of the thoracic aorta: a predictor of poor outcome and impaired quality of life

BACKGROUND: Transient neurological dysfunction (TND) consists of postoperative confusion, delirium and agitation. It is underestimated after surgery on the thoracic aorta and its influence on long-term quality of life (QoL) has not yet been studied. This study aimed to assess the influence of TND on short- and long-term outcome following surgery of the ascending aorta and proximal arch. METHODS: Nine hundred and seven patients undergoing surgery of the ascending aorta and the proximal aortic arch at our institution were included. Two hundred and ninety patients (31.9%) underwent surgery because of acute aortic dissection type A (AADA) and 617 patients because of aortic aneurysm. In 547 patients (60.3%) the distal anastomosis was performed using deep hypothermic circulatory arrest (DHCA). TND was defined as a Glasgow coma scale (GCS) value <13. All surviving patients had a clinical follow up and QoL was assessed with an SF-36 questionnaire. RESULTS: Overall in-hospital mortality was 8.3%. TND occurred in 89 patients (9.8%). As compared to patients without TND, those who suffered from TND were older (66.4 vs 59.9 years, p<0.01) underwent more frequently emergent procedures (53% vs 32%, p<0.05) and surgery under DHCA (84.3% vs 57.7%, p<0.05). However, duration of DHCA and extent of surgery did not influence the incidence of TND. In-hospital mortality in the group of patients with TND compared to the group without TND was similar (12.0% vs 11.4%; p=ns). Patients with TND suffered more frequently from coronary artery disease (28% vs 20.8%, p=ns) and were more frequently admitted in a compromised haemodynamic condition (23.6% vs 9.9%, p<0.05). Postoperative course revealed more pulmonary complications such as prolonged mechanical ventilation. Additional to their transient neurological dysfunction, significantly more patients had strokes with permanent neurological loss of function (14.6% vs 4.8%, p<0.05) compared to the patients without TND. ICU and hospital stay were significantly prolonged in TND patients (18+/-13 days vs 12+/-7 days, p<0.05). Over a mean follow-up interval of 27+/-14 months, patients with TND showed a significantly impaired QoL. CONCLUSION: The neurological outcome following surgery of the ascending aorta and proximal aortic arch is of paramount importance. The impact of TND on short- and long-term outcome is underestimated and negatively affects the short- and long-term outcome.

Dementia with lewy bodies--diagnosis and treatment

Dementia with Lewy bodies (DLB) accounts for 15-20% of all autopsy confirmed dementias in old age. Characteristic histopathological changes are intracellular Lewy bodies and Lewy neurites, with abundant senile plaques but sparse neurofibrillary tangles. Core clinical features are fluctuating cognitive impairment, persistent visual hallucinations and extrapyramidal motor symptoms (parkinsonism). One of these core features has to be present for a diagnosis of possible DLB, and two for probable DLB. Supportive features are repeated falls, syncope, transient loss of consciousness, neuroleptic sensitivity, delusions and hallucinations in other modalities. DLB is clinically under-diagnosed and frequently misclassified as systemic delirium or dementia due to Alzheimer's disease or cerebrovascular disease. Therapeutic approaches to DLB can pose difficult dilemmas in pharmacological management. Neuroleptic medication is relatively contraindicated because some patients show severe neuroleptic sensitivity, which is associated with increased morbidity and mortality. Antiparkinsonian medication has the potential to exacerbate psychotic symptoms and may be relatively ineffective at relieving extrapyramidal motor symptoms. Recently there is converging evidence that treatment with cholinesterase inhibitors can offer a safe alternative for the symptomatic treatment of cognitive and neuropsychiatric features in DLB. This review will focus on the clinical characteristics of DLB, its differential diagnosis and on possible management strategies.

Can geriatric approaches support the care of old patients in emergency departments? A review from a Swiss ED

In the coming decades, old patients will account for an increasing proportion of emergency department (ED) visits. During or after their stay in the ED, they more frequently suffer adverse outcomes than younger patients. There is evidence that specific age-centred approaches improve the outcomes. We therefore reviewed specific conditions needing particular attention in older ED patients, such as cognitive disorders and delirium, impaired mobility and falls, as well as problems related to the activities of daily living, disability, poly-pharmacy, adverse drug effects, co-morbidity and atypical presentation. We also propose steps to further improve the quality of care in older ED patients by using appropriate age-centred management.

The Neuroscience of Visual Hallucinations

Each year, some two million people in the United Kingdom experience visual hallucinations. Infrequent, fleeting visual hallucinations, often around sleep, are a usual feature of life. In contrast, consistent, frequent, persistent hallucinations during waking are strongly associated with clinical disorders; in particular delirium, eye disease, psychosis, and dementia. Research interest in these disorders has driven a rapid expansion in investigatory techniques, new evidence, and explanatory models. In parallel, a move to generative models of normal visual function has resolved the theoretical tension between veridical and hallucinatory perceptions. From initial fragmented areas of investigation, the field has become increasingly coherent over the last decade. Controversies and gaps remain, but for the first time the shapes of possible unifying models are becoming clear, along with the techniques for testing these. This book provides a comprehensive survey of the neuroscience of visual hallucinations and the clinical techniques for testing these. It brings together the very latest evidence from cognitive neuropsychology, neuroimaging, neuropathology, and neuropharmacology, placing this within current models of visual perception. Leading researchers from a range of clinical and basic science areas describe visual hallucinations in their historical and scientific context, combining introductory information with up-to-date discoveries. They discuss results from the main investigatory techniques applied in a range of clinical disorders. The final section outlines future research directions investigating the potential for new understandings of veridical and hallucinatory perceptions, and for treatments of problematic hallucinations. Fully comprehensive, this is an essential reference for clinicians in the fields of the psychology and psychiatry of hallucinations, as well as for researchers in departments, research institutes and libraries. It has strong foundations in neuroscience, cognitive science, optometry, psychiatry, psychology, clinical medicine, and philosophy. With its lucid explanation and many illustrations, it is a clear resource for educators and advanced undergraduate and graduate students.

[An Uncommon Diagnosis].

We report on a 61-year-old patient who suffered from severe protein-energy malnutrition due to an inadequately treated exocrine pancreatic insufficiency. In this context, a thiamine deficiency was not recognized and there were clinical manifestations of beriberi disease with decompensated biventricular heart failure. In the course of time, a manifest niacin deficiency (pellagra) with dermatitis, diarrhea and persistent delirium occurred, which was recognized and could be treated. We highlight differential diagnostic considerations about the consequences and the treatment of malnutrition, with special focus on the classical deficiency diseases beriberi and pellagra.

Culminating experience: Initiation of cholinesterase inhibitors in an inpatient setting

We examined the practice of initiating Cholinesterase Inhibitors (ChEI) in a Veterans Affairs Medical Center. Patients hospitalized in FY 2008 and prescribed ChEI were identified. We reviewed electronic medical records, comparing those started on ChEI during hospitalization with those continuing ChEI from outpatient status. Of 282 patients receiving ChEI during hospitalization, 15.6% (44) were new-starts and 84.3% (238) were continuing medication. Median length of stay was 16 days in new-starts vs. 6 days in continuation patients (P<0.05). 38.6% new-starts were also treated for infection, which is a delirium risk factor. Chart review also suggested possible treatment for delirium by initiation of benzodiazepines and antipsychotics in 11.4% and 22.7% new-starts respectively. We observed a substantive practice of initiating ChEIs in hospitalized elderly who were at risk of delirium. Though there was no difference in 30-day mortality and readmission rates, new-starts were more likely to have a prolonged hospital stay than continuation patients.^

Perfil clínico y social del paciente adicto hospitalizado

Objetivos: Determinar las características clínicas y morbilidad de los pacientes (pac.) adictos ingresados a un Servicio de Clínica Médica. Material y métodos: Estudio protocolizado, observacional, descriptivo y transversal. Criterio de inclusión: pac. adicto con consumo de sustancias ilícitas. Informe preliminar: Periodo: 24 meses. Datos analizados en Epi info 6.4 Resultados: Se incluyeron 40 pac. Prevalencia: 0.2/1000 egresos. El 82.5% eran hombres. Edad media: 31.5 años (DS±9.65). Permanencia media: 11 días (DS±13.98) vs 7.12 (DS±10.1) del Servicio (p=0.016). Consumían cocaína el 82.5% (IC95%67.22-92.66) marihuana el 77.5% (IC95% 61.65- 89.16), tolueno el 10% (IC95%2.79-23.66), floripondio y hachis el 2.5% (IC95% 0.06-13.16) cada uno. En el 2.5% la vía de administración era endovenosa y el 60% eran poliadictos. Solo el 10% recibió tratamiento para abandonar la adicción (100% tratamiento psicológico y 5.13% farmacológico). De clase social pobre el 75%. El 62.5% de los pac. estaban desocupados, tenían antecedentes judiciales el 10% y el 7.5% había estado en prisión. El 92.5% (IC95% 76.34-97.21) era heterosexual, 2.5% hombres que tenían sexo con hombres y bisexuales 5% (IC95% 0.61-16.92). Solo el 10% tenían secundaria completa. El 80% ingreso por Emergencias y por causa infecciosa el 45%. El 12.5% ingreso por complicaciones de la adicción. Las manifestaciones relacionadas con la adicción fueron: manifestaciones del sistema nervioso central: 12.5% (IC95%4.19-26.80); síndrome de abstinencia y temblor 7.5% cada uno y excitación psicomotriz, delirium, signo de foco neurológico y rigidez 5% cada uno. El 100% presentaba alguna comórbida; tabaquismo 80%, depresión 12.8% Y alcoholismo 57.5%, entre otras. Presentaban enfermedades de transmisión sexual 5 pac. (4 HIV, 2 VHC y 1 pediculus pubis). No hubo mortalidad hospitalaria. Conclusión: El paciente adicto internado se caracteriza por ser joven, pertenecer a un grupo social desprotegido, sin trabajo y sin educación, tener poliadicción, con alta carga de comórbidas y de internación, principalmente por complicaciones infecciosas.

Estado funcional y mortalidad en pacientes neoplásicos hospitalizados

Objetivos: Analizar el estado funcional y su relación con morbimortalidad en pacientes con neoplasias internados en Cínica Médica. Material y métodos: Estudio descriptivo, protocolizado y observacional. Se analizaron variables clínicas, estado funcional, situación anímica y morbimortalidad en pacientes oncológicos hospitalizados y se compararon pacientes con Índice de Karnofsky <40 puntos (grupo A) y >40 puntos (grupo B). Los datos fueron analizados en EPI Info 6.04. Informe de los primeros 3 meses. Resultados: En el período de estudio, ingresaron 66 pacientes con neoplasias, 21 (31.8%) en A, con Karnofsky promedio de 25 puntos (DS±12.09) y 45 (68.2%) en B, con Karnofsky promedio de 77 puntos (DS±16.65). El 77.3% presentó tumores sólidos y el 22.7% hematológicos y las neoplasias más frecuentes fueron del tracto gastrointestinal (19.6%), mama (12.1%), pulmón (9.1%) y primario oculto (7.6%). El estadio tumoral IV fue el más frecuente en ambos grupos (89.5% de A y 88.9% de B)(pNS). La edad media en A fue de 59.57 (DS±13.71) y 52.48 años (DS±15.65) en B (pNS) y el género masculino fue más frecuente en A (66.7 y 44.4% respectivamente) (p<0.05). La permanencia media fue de 17.57 en A (DS±20.84) y de 13.53 días (DS±16.29) en B (pNS). La evaluación de Actividades Básicas de la Vida Diaria [0.81 (DS±1.25) vs 4.57 puntos (DS±1.15)] y Actividades Instrumentales [0.57 (DS±0.74) vs 4 puntos (DS±1.37)] fue superior en B (p<0.05) y no hubo diferencias en la comorbilidad (85.7 vs 82.2%)(pNS). Las infecciones (52.4 vs 26.7%), causa social (38.1 vs 4.4%), complicaciones neoplásicas (81 vs 51.1%) y dolor (81 vs 51.1%) fueron los motivos de internación más frecuentes en A (p<0.05). Los pacientes de A recibieron con mayor frecuencia cuidados paliativos (90.5 vs46.7%) y quimioterapia (90.5 vs 46.7%)(p<0.05), sin diferencias en radioterapia (23.8 vs 13.3%) y cirugía (33.3 vs 33.3%)(pNS). No hubo diferencias entre ambos grupos en la presencia de depresión clínica (69.9 vs 53.3%) y pérdida de peso (86.4 vs 84.2%)(pNS). El síndrome confusional (85.7 vs 11.1%), postración (61.9 vs 6.7%) y escaras (23.8 vs 4.4%) fueron más frecuentes en A (p<0.05). La mortalidad hospitalaria fue 52.4% en A y 8.9% en B (p<0.05). Conclusiones: El grado de estado funcional evaluado por Karnofsky menor de 40 puntos se asoció significativamente a: mayor mortalidad, uso de quimioterapia, cuidados paliativos, internación por infecciones, dolor y complicaciones neoplásicas y presencia de síndrome confusional, postración y escaras de decúbito (p<0.05).

Proyectar con el delirio. Del Método Crítico Paranoico al gueto de Varsovia a través de Coney Island

RESUMEN. A partir de las diferentes definiciones entre “caer” o “estar” en la paranoia y los conceptos que se le relacionan, esta investigación descubre las diferentes herramientas proyectuales que permiten utilizar la arquitectura como medio para conducir a la sociedad al error, al delirio. Asumiendo que hoy en día el modo en el que se percibe la realidad es consecuencia de un proceso de moldeamiento psíquico, se realiza un proceso retroactivo en Coney Island (1900) y el Gueto de Varsovia (1940) para estudiar, confrontar y poner en duda los distintos formas de aprendizaje con los que actualmente se proyecta. Se pretende, tomando conciencia de lo anterior, plantear las bases de un nuevo método proyectual que sabiendo que es delirante juega con su funcionamiento paranoico. ABSTRACT. From the different definitions between "fall" or "to be" in the paranoia and its related concepts, this research finds out different tools which uses Architecture as a means to lead society to failure, delirium. Assuming that today the way reality is perceived is the result of a mental shaping process,a retrospective process in Coney Island (1900) and the Warsaw Ghetto (1940) is done in order to explore, confront and question various forms of learning with are currently used to design in architecture. It is intended, becoming aware of the above, to lay the groundwork for a new methodological approach in conception that knowing it is delirious, plays with its paranoid functioning.