88 research outputs found
Representations of violence revealed by children, adolescents and their families at social risk : stories of resilience and paths
No full textOrientador: Orly Zucatto Mantovani de AssisTese (doutorado) - Universidade Estadual de Campinas, Faculdade de EducaçãoResumo: A presente pesquisa investigou as representações de violência reveladas por crianças, adolescentes e suas famílias em situação de risco social. A investigação foi realizada com crianças e adolescentes abrigados na Chácara Meninos de 4 Pinheiros, organização nãogovernamental, localizada em Mandirituba, região metropolitana de Curitiba - Paraná - Brasil, e que abriga oitenta meninos que viveram situações de vulnerabilidade social. O protocolo de pesquisa, elaborado especialmente para esta investigação, é composto por sete histórias sobre violência, com vistas a caracterizar o ciclo de violências sofrido por crianças e adolescentes em situação de risco e de vulnerabilidade social. As histórias apresentam enredos sobre violência na família - violência psicológica, abuso físico e sexual; violência na rua - violência policial, consumo de drogas e violência cometida por turista; violência na escola e ato infracional cometido por adolescente. Para a coleta de dados foi utilizado o referido protocolo, aplicado de acordo com as orientações do método clínico crítico (PIAGET, 1978; 1994; 2002; DELVAL, 2001; 2002; ASSIS, 2002; 2005), as histórias foram apresentadas para crianças, adolescentes e membros de suas famílias, visando compreender "o quê e como" eles pensam sobre as histórias a violência, investigando os porquês de suas respostas. O problema que orientou esta investigação: "a partir do julgamento de histórias de violência, quais são as representações reveladas por crianças e adolescentes em situação de risco social? E quais são as representações reveladas por suas famílias?". Os seguintes objetivos direcionaram a investigação: 1) Identificar e analisar as representações de violência em crianças e adolescentes que sofreram violências, assim como investigar tais representações em suas famílias; 2) Identificar, por meio de entrevistas com coordenador da instituição e com educadores-aprendizes, a história de vida de crianças e adolescentes abrigados, e respectivamente a história de vida de suas famílias, assim como os tipos de violências sofridas por eles; 3) Inferir implicações pedagógico-sociais relacionadas com a prevenção da violência, que envolvam as representações reveladas por crianças, adolescentes e suas famílias. Na análise de dados obtidos nas dezessete entrevistas clínicas, as representações reveladas pelos sujeitos entrevistados foram classificadas em dois grupos, o primeiro grupo composto por representações associadas aos fatores de risco, que interferem e comprometem o desenvolvimento integral da criança e do adolescente; e o segundo grupo, composto por representações associadas aos fatores de proteção que potencializam o desenvolvimento integral de crianças e adolescentes. A análise do conjunto de representações possibilitou a definição de categorias que são explicativas e constitutivas do par dialético: violência/resiliência, que fundamenta a elaboração da tese deste trabalho, pautada na defesa de que ao investigar violência, foi possível identificar também os fatores de proteção e as histórias de resiliência. As histórias de vida de crianças, adolescentes e suas famílias em situação de risco social são caracterizadas e relacionadas às representações reveladas pelos sujeitos. O processo de análise das representações de violência possibilitou inferir nove implicações pedagógico-sociais, que denotam suas perspectivas, educativa e preventiva, relacionadas ao planejamento, desenvolvimento e avaliação de ações, projetos, programas e políticas públicas de prevenção da violência, visando potencializar a resiliência de crianças, adolescentes e suas famílias.Abstract: The present research had investigated the representations of violence revealed by children, adolescents and their families in social risk. The study was conducted with children and adolescents sheltered at Chácara Meninos de 4 Pinheiros, a non-governmental organization, located in Mandirituba, metropolitan region of Curitiba - Paraná - Brasil, which houses shelter eighty children who have experienced situations of social vulnerability. The research protocol, especially designed for this investigation, consists on seven stories about violence, in order to characterize the cycle of violence suffered by children and adolescents in risk and social vulnerability. The stories feature plots about family violence - psychological, physical and sexual abuse, street violence - police violence, drug use and violence committed by tourists, school violence and misdemeanors committed by adolescents. The research methodology is guided by critical clinical method (PIAGET, 1978, 1994, 2002; DELVAL, 2001, 2002; ASSIS, 2002, 2005), in this sense, the stories were presented to children, adolescents and members of their families to understand "what and how" they think about the stories of violence, investigating the whys of their responses. The problem that guided this investigation: "from the judgment of violence history, which are the representations revealed by children and adolescents in social risk? And what are the representations revealed by their families? ". The following objectives guided the research: 1) Identify and analyze the representations of violence in children and adolescents who have suffered violence, as well as investigate any such representations in their families, 2) Identify, through interviews with the coordinator of the institution-learners and educators, the life story of sheltered children and adolescents, respectively, and the life history of their families, as well as the types of violence suffered by them, 3) Infer implications pedagogical and social issues related to violence prevention, involving representations revealed of children, adolescents and their families. In the analysis of data obtained with these seventeen clinical interviews, the representations revealed were classified into two groups, the first group of representations was associated with risk factors, which interfere and hamper the development of the child and adolescent, and the second group was composed by representations associated with protective factors that enhance the overall development of children and adolescents. The analysis of all possible representations have turned possible the definition of categories, that are explanatory and constitutive dialectical pair: violence/resilience, that underlies the development of the thesis of this work, based on the defense that when violence were investigated, it was also possible to identify protective factors and stories of resilience. The life stories of children, adolescents and their families in social risk are characterized and related to representations revealed by the subjects. The process of analysis the violence representations infer to nine possible social-teaching implications, which denote their educational and preventive perspectives, related to planning, development and evaluation of actions, projects, programs and policies to prevent violence in order to enhance the resilience of children, adolescents and their families.Résumé: Cette recherche étudie les représentations de la violence révélées par les enfants, lesadolescents et leurs familles en situation de risque social. L'étude a été realisée auprès desenfants et des adolescents qui sont hébergés dans la petite ferme "Meninos de 4 Pinheiros", organisation non-gouvernementale, située à Mandirituba, région métropolitaine de Curitiba- Paraná - Brésil, qui acceuille quatre-vingts enfants qui ont vécu des situations de vulnérabilité sociale. Le protocole de recherche, spécialement développé pour cette enquête, se compose de sept histoires sur la violence, afin de caractériser le cycle de la violence subie par les enfants ET les adolescents à risque et la vulnérabilité sociale. Les histoires portent sur la violence familiale - psychologique, les abus physiques et sexuels; la violence de rue - la violence policière, laconsommation de drogues et la violence commise par les touristes; la violence à l?école ET l'acte infractionnel d?adolescent. Pour le recueil des données nous avons utilisé le protocole, appliqué em conformité avec les directives de la méthode clinique-critique (PIAGET, 1978, 1994, 2002; DELVAL, 2001, 2002; ASSIS, 2002, 2005), en ce sens, les histoires ont été présentées aux participants pour comprendre "ce qui et comment" ils pensent des histoires sur la violence et d'enquêter sur le pourquoi de leurs réponses. Le problème qui a guidé cette recherche: "à partir du jugement des histoires de violence, qui sont les représentations révélées par les enfants et les adolescents dans la situation de risque social? Et quelles sont lês représentations révélées par leurs familles?". Les objectifs de cette recherche: 1) Identifier ET analyser les représentations de la violence chez les enfants et les adolescents qui ont subi dês violences, ainsi que d'enquêter de telles représentations dans leurs familles; 2) Identifier l'histoire de la vie des enfants et des adolescents et l'histoire de vie de leurs familles, ainsi que les types de violence qu'ils subissent; 3) Déduire les implications pédagogiques-sociales liées à la prévention des violences. Dans l'analyse des données obtenues dans les dix-sept entretienscliniques, les représentations révélées par les personnes interrogées ont été classées en deux groupes, le premier groupe de représentations facteurs de risque associés, qui interfèrent ET entravent le développement de l'enfant et de l'adolescent; et le second groupe composé de représentations associées à des facteurs de protection qui favorisent le développement global des enfants et des adolescents. L'analyse de toutes les représentations a permis la définition de catégories qui sont explicatives et constitutives de la paire dialectique: violence/résilience, qui soutient le développement de la thèse de ce travail, basé sur le fait qu'en investigant la violence il est également possible d'identifier les facteurs de protection et les histoires de résilience. Le processus d'analyse des représentations de violence a permis de déduire neuf implications pédagogique-sociales, qui dénotent leurs perspectives éducatives et préventives, relatives àla planification, au développement et à l'évaluation des actions, projets, programmes et politiques publiques pour prévenir la violence, avec l?intention de développer la résilience des enfants, des adolescents et de leurs familles.DoutoradoPsicologia, Desenvolvimento Humano e EducaçãoDoutor em Educaçã
Ações atribuídas à família, à escola e às redes de proteção para garantir o desenvolvimento integral da criança e do adolescente : uma pesquisa bibliográfica
No full textOrientador: Prof.ª. Dr.ª Eliane Cleonice Alves Precoma.Monografia (graduação) - Universidade Federal do Paraná, Setor de Educação, Curso de Graduação em PedagogiaInclui referências : p. 72-77Resumo : A presente pesquisa teve como objetivo investigar, a partir da pesquisa bibliográfica (SALVADOR, 1977) quais as ações atribuídas pelos (as) autores (as) à família, à escola e às redes de proteção para a promoção e garantia do desenvolvimento integral das crianças e dos adolescentes. A metodologia de investigação fundamenta-se nos seguintes procedimentos: 1) busca de artigos no Banco de Dados SCIELO, considerando os critérios de inclusão: artigos que contenham as expressões; família, escola e redes de proteção; artigos publicados em revistas nacionais nas áreas de Ciências Humanas, Ciências Sociais Aplicadas e Ciências da Saúde; artigos publicados em Língua Portuguesa e artigos publicados no período de 2008 a 2014; 2) diante do número considerável de artigos encontrados no banco de dados SCIELO, realizamos uma nova busca, na qual incluímos palavras-chaves relacionadas ao tema, aos critérios de inclusão, tais como; criança, adolescentes, crianças e adolescentes, família, escola, redes de proteção, redes de apoio, fatores de risco, fatores de proteção e vulnerabilidade; 3) busca de teses no Banco de Dados da UFPR, UNICAMP e USP, para a análise dos dados colhidos. 4) Leitura dos artigos, identificando as ações preconizadas pelos autores. Os resultados nos artigos revisados sugerem que as relações entre a família, a escola e as redes de proteção podem ser explicitadas pelas seguintes conclusões: a) A família, a escola e as redes de proteção são importantes para o desenvolvimento integral da criança e do adolescente; b) Crianças e adolescentes que não possuem o apoio da família, dos amigos ou de algum adulto com quem possam contar, têm mais chances de sofrer com eventos estressores; c) Necessidade de programas e políticas sociais voltadas para a criança, o adolescente e a família, em especial aquelas em vulnerabilidade social; d) Estimular a formação inicial e continuada que vise a reflexão dos profissionais para o empoderamento e melhoria nas condições de trabalho em redes de proteção; e) Um mesmo contexto pode culminar tanto em um fator de risco como em um fator de proteção; f) Os fatores de proteção individual tais como, espiritualidade, autoestima, autoconfiança, assim como, redes de proteção contribuem para a promoção da resiliência. A partir dos dados levantados foi possível construir uma rede conceitual, visando, a sistematização das ações atribuídas à família, à escola e às redes de proteção na garantia do desenvolvimento integral da criança e do adolescente e inferir implicações pedagógico-sociais, que possam contribuir para a promoção e garantia dos direitos das crianças e adolescentesAbstract : This research and investigation from the bibliographical research (SALVADOR, 1997) which the actions assigned by the authors to the family, to the school and to the protections networks, which promote and ensure the integral development of children and teenagers. The investigation methodology is based on the following procedures: 1) The search for articles was made on SCIELO Data Bank, considering the inclusion criterias: articles containing the expressions: family, school, protection networks, articles published on national human, health and social magazines; articles published in Portuguese language and articles published between 2008 and 2014; 2) With the considerable number of data found on SCIELO Data Bank, we made a new search which includes key-words related to the teme, the inclusion criterias such as ; children, teenagers, family, school, children and teenagers, protection networks, support networks, risk of factors, protection factors,risk factors and vulnerability; 3) Research on UFPR,USP and UNICAMP Data Bank and each theses, for the analyse of the collected datas. 4) Reading of the articles, identifying the actions recommended by the authors. The results on the review edarticles follow the relationship between the family, the school and the protection network. We can conclude that: a) The family, the school and the protection network are very important to the integral children and teens development. b) Children and teens which doesn't have family or even friend support has more chances of suffer in stressors moments; c) The need of programs and politics focus on children, teenagers and family, special those ones in social vulnerability situation; d) Stimulate the initial and continuing formation which aimed the reflection of the professionals to the empowerment in works condition and protection networks; e) The same context may result both in a risk factor and protection factor; f)The individual protection factors, spirituality, self-esteem and self-confidence just like the protections networks contributed to the resilience promotion. From the collected data was possible build a conceptual network aimed the systematization of actions attributed to families, schools and protection networks, ensuring the children and teens integral development and infer social pedagogical implications, which could contributed to the promotion and insurance of children and teenagers rights
A trajetória de vida de dois educadores sociais : caminhos para a (RE) construção da identidade profissional
No full textOrientador: Prof.a. Dr.a Eliane Cleonice Alves Precoma.Monografia (graduação) - Universidade Federal do Paraná, Setor de Educação, Curso de Graduação em PedagogiaInclui referências : p. 112-118Resumo : A presente investigação tem como problemática discutir como o/a educador/a social (re)constrói sua identidade pessoal e profissional ao longo de sua trajetória de vida? Investigar a trajetória de vida e a formação que ocorrem em processos informais e as histórias de vida de educadores/as sociais foram essenciais para ressignificar o trabalho realizado com crianças, adolescentes e famílias em vulnerabilidade social, bem como suscitar a relevância e importância deste trabalho social. Esse foco orienta os objetivos desta investigação: 1) Identificar motivações que levaram o/a educador/a social escolher esta profissão; 2) Identificar os processos de formação/autoformação na prática desses profissionais; 3) Identificar e discutir suas perspectivas em relação a esta profissão. A abordagem metodológica da investigação é qualitativa (LUDKE; ANDRÉ, 1986) tendo como interlocutor a teoria da complexidade (MORIN, 2011). Nesta investigação a ênfase é a metodologia autobiográfica (SOUZA, 2007; JOSSO, 1988, 2007, 2012; DOMINICÉ, 1988; PUYANA; BARRETO, s/d). A metodologia de investigação fundamenta-se nos seguintes procedimentos: 1) revisão de literatura; 2) os sujeitos e seus espaços de atuação, sendo uma educadora social e um educador social que trabalham com crianças, adolescentes e famílias em situação de vulnerabilidade social, com formação de nível médio e/ou ensino superior; 3) os instrumentos da investigação, sendo a entrevista semiestruturada de cunho exploratório (LUDKE; ANDRÉ, 1986; SZYMANSKI, 2008); 4) a apresentação e discussão dos resultados. Neste trabalho desenvolvemos o tratamento dos dados buscando uma aproximação conceitual da análise compreensiva (PRETTO, 2011), que identifica dimensões e mecanismos que tenham influenciado as experiências do sujeito, considerando seu contexto histórico e social. A aproximação da análise compreensiva das entrevistas permitiu encontrar as seguintes dimensões: 1) as motivações que levaram os educadores a escolher e atuar nesta profissão e suas relações com a família, a comunidade, a instituição de trabalho, a cultura e as redes de proteção; 2) os processos de formação e autoformação na prática destes profissionais, marcada pelas dimensões das experiências nos espaços de atuação, pela singularidade e coletividade, pelas condições de trabalho do/da educador/a que interferem na prática formativa, apontando para a dimensão da autorreflexão e autoconsciência como prática e possibilidade formativa; 3) as perspectivas do/da educador/a social em relação a sua profissão revelam, a partir de seus relatos, percepções de insegurança, angústia e medo, e ao mesmo tempo afetividade, volição e amorosidade. A aproximação conceitual da análise compreensiva das duas entrevistas permite inferir que a identidade pessoal e profissional é marcada por um tempo e um espaço, que se modificam a cada geração, e que os/as educadores/as sociais reconstroem as suas identidades à medida que se sentem ou não pertencentes, negando certa identidade e/ou negociando no interior das relações outras identidades. A profissão do educador/a social no Brasil precisa de uma formação básica e continuada adequada às necessidades do trabalho socioeducativo, bem como de condições de trabalho favoráveis à construção de práticas reflexivas em seus ambientes de atuação.Abstract : The present research has as problematic to discuss how the social educator (re) builds his personal and professional identity throughout his life trajectory? Investigating the life trajectory and training that occur in informal processes and the life histories of social educators were essential to re-signify the work done with children, adolescents and families in social vulnerability, as well as to raise the relevance and importance of this social work. This focus guides the objectives of this research: 1) Identify motivations that led the social educator to choose this profession; 2) To identify the processes of formation/self-training in the practice of these professionals; 3) Identify and discuss your perspectives regarding this profession. The methodological approach of the research is qualitative (LUDKE; ANDRÉ, 1986), having as interlocutor the theory of complexity (MORIN, 2011). In this research the emphasis is on the autobiographical methodology (SOUZA, 2007; JOSSO, 1988, 2007, 2012; DOMINICÉ, 1988; PUYANA; BARRETO, s/d). The research methodology is based on the following procedures: 1) literature review; 2) the subjects and their spaces of action, being a social educator and a social educator working with children, adolescents and families in a situation of social vulnerability, with a secondary education and/or higher education; 3) the research tools, the semistructured interview being an exploratory one (LUDKE; ANDRÉ, 1986; SZYMANSKI, 2008); 4) presentation and discussion of results. In this work we develop the data treatment seeking a conceptual approximation of the comprehensive analysis (PRETTO, 2011), which identifies dimensions and mechanisms that have influenced the experiences of the subject, considering their historical and social context. The approximation of the comprehensive analysis of interviews allowed us to find the following dimensions: 1) the motivations that led educators to choose and act in this profession and their relationships with family, community, work institution, culture and protection networks; 2) the processes of formation and self-training in the practice of these professionals, marked by the dimensions of the experiences in the spaces of action, by the singularity and collectivity, by the working conditions of the educator that interfere in the formative practice, pointing to the dimension of self-reflection and self-awareness as practice and formative possibility; 3) the perspectives of the social educator in relation to their profession reveal, from their reports, perceptions of insecurity, anguish and fear, and at the same time affectivity, volition and amorousness. The conceptual approach of the comprehensive analysis of the two interviews allows us to infer that personal and professional identity is marked by a time and a space, which changes with each generation, and that social educator reconstruct their identities as they feel or not, denying a certain identity and/or negotiating within the relationships other identities. The profession of the social educator in Brazil needs a basic and continuous training adequate to the needs of the socio-educational work, as well as working conditions favorable to the construction of reflective practices in its working environments
Estudis sobre la insuficiència renal en la cirrosi hepàtica: Anàlisi del pronòstic i investigació en el tractament farmacològic de la síndrome hepatorenal
No full text[cat]
Des que es va definir la síndrome hepatorenal (SHR), als anys 60 del segle passat, s’han fet grans progressos en el coneixement d’aquesta entitat. La SHR és una insuficiència renal característica dels pacients amb cirrosi hepàtica (CH) amb molt mal pronòstic a curt plaç. El tractament curatiu és el trasplantament hepàtic perquè elimina la CH que és l’origen del problema. Però no sempre està indicat el trasplantament o no s’arriba a temps de realitzar-lo. Els estudis basats en la fisiopatologia de la SHR han estat la base per investigar sobre tractaments que puguin revertir la insuficiència renal i serveixin de pont cap al trasplantament. Fins al moment de la publicació dels treballs que formen part d’aquesta tesi, s’havien fet alguns estudis amb vasoconstrictors esplàcnics que suggerien que aquests fàrmacs eren els més efectius en la reversió de la SHR. Però no s’havien publicat estudis prospectius i aleatoritzats al respecte i aquesta és l’aportació d’un dels estudis: avaluar l’efecte de la terlipressina junt amb l’albúmina sobre la funció renal i la supervivència en pacients amb CH i SHR. Es van aleatoritzar 46 pacients, 23 en el grup de terlipressina i albúmina i 23 en el grup d’albúmina sola. La milloria de la funció renal es va donar en 10 (43,5%) dels pacients tractats amb terlipressina i albúmina i en 3 (8,7%) dels pacients tractats amb albúmina sola (p=0,017). En l’anàlisi multivariat, els factors independents predictius de milloria de la funció renal van ser el volum urinari basal, la creatinina sèrica, el recompte de leucocits i el tractament amb terlipressina i albúmina. La supervivència a 3 mesos no va ser significativament diferent entre els dos grups de tractament (terlipressina i albúmina 27% vs albúmina sola 19%, p=0,7). En l’anàlisi multivariat, els factors independents predictius de supervivència als 3 mesos van ser el MELD basal i la resposta al tractament. A falta d’altres opcions, la terlipressina junt amb albúmina és l’opció terapèutica més efectiva per revertir la SHR i és el tractament que s’ha d’utilitzar, sobretot en els pacients en lista per a trasplantament hepàtic, com a pont fins a l’arribada de l’organ necessari. D’altra banda, malgrat els progressos realitzats en la SHR, els pacients amb CH poden presentar altres tipus d’insuficiència renal i aquest és un camp poc estudiat. En el segon estudi que forma part d’aquesta tesi, basant-nos en un gran número de pacients hospitalitzats, es van avaluar els diferents tipus d’insuficiència renal que poden presentar els pacients amb CH des del punt de vista de la repercusió en el pronòstic. Es van incloure de forma prospectiva, 562 pacients amb CH i insuficiència renal a l’ingrés o que la van desenvolupar durant el mateix. La causa de la insuficiència renal es va classificar en 4 grups: associada a infeccions, a deplecció de volumen, SHR i nefropatia parenquimatosa. La insuficiència renal associada a infeccions va ser la més freqüent (46%), seguida de l’associada a hipovolèmia (32%), SHR (13%) i nefropatia parenquimatosa (9%). Un 17.6% dels casos presentava combinació de causes. La probabilitat de supervivència als 3 mesos va ser del 73% en la nefropatia parenquimatosa, 46% en la insuficiència renal associada a hipovolèmia, 31% en la insuficiència renal associada a infecciones i 15% en la SHR (p1.5mg/dl) were prospectively included. The cause of RF was classified into 4 groups: RF associated with bacterial infections, RF associated with volume deplection, HRS and parenchymal nephropathy. The primary end point was survival at 3 months. The frequency of RF was: RF associated with infections: 213 cases ( 46%),hypovolemia-associated RF: 149 (32%), HRS: 60 (13%), and parenchymal nephropathy: 41 (9%). Three-month probability of survival was73% for parenchymal nephropathy, 46% for hypovolemia-associated RF, 31% for RF associated with infections, and 15% for HRS (P<.0005). In the multivariate analysis, cause of RF was independently associated with prognosis, together with MELD score, serum sodium and hepatic encephalopathy. This information may help in decision making in liver transplantatio
Protocolo de enfermagem para dor torácica em um serviço de emergência hospitalar: aplicação e avaliação
No full textDissertação (mestrado profissional) - Universidade Federal de Santa Catarina, Centro de Ciências da Saúde, Programa de Pós-Graduação Multidisciplinar em Saúde, Florianópolis, 2014.A avaliação da dor torácica é uma atribuição complexa e frequente dos enfermeiros nos serviços de emergência hospitalar. No Brasil as doenças cardiovasculares a reflexo da incidência mundial constituem a principal causa de morte. A dor torácica é considerada sintoma principal para a Síndrome Coronariana Aguda, portanto uma preocupação dos profissionais de saúde e pacientes. Apesar da dimensão das queixas de dor torácica nos serviços de emergência existe deficiência da padronização das condutas para a Enfermagem e para os estudos para construção de protocolos assistenciais. Portanto, este estudo propôs a aplicação de um protocolo para avaliação da dor torácica no Serviço de Acolhimento com Classificação de Risco (SACR) do Serviço de Emergência de um Hospital Universitário do Sul do país, que não conta com protocolos específicos de Enfermagem. Optou-se por um protocolo desenvolvido e utilizado em um serviço de excelência do país, o Hospital Israelita Albert Einstein de São Paulo/SP. Trata-se de uma pesquisa qualitativa, do tipo transversal, prospectiva e descritiva. O desenvolvimento deste estudo foi norteado por duas vertentes essenciais, o reconhecimento do perfil do paciente com dor torácica atendido no serviço e a identificação da avaliação do protocolo sugerido pelos enfermeiros do SACR. Os dados encontrados demonstraram uma demanda de pacientes com dor torácica expressivamente feminina (65,7%), caracterizando a baixa procura masculina pelos serviços de saúde. A maioria dos casos pouco-urgentes (66%) contra (4,5%) emergentes; Sobressai a classificação dos enfermeiros estipulando emergenteem 50,7% das classificações e pouco-urgente em 22,4% o que reflete uma valorização da dor torácica por parte dos profissionais ao utilizar o protocolo. Verificou-se a expressiva incidência dos fatores de risco para o IAM associados à dor torácica, 47,8% dos pacientes são hipertensos e 26,9% deles possuem história familiar de Doença Arterial Coronariana. Quanto à avaliação do protocolo realizada pelos enfermeiros, os dados obtidos dão conta de que há um consenso entre os enfermeiros de que o protocolo sugerido prioriza o atendimento à Síndrome Coronariana Aguda, identifica melhor o tipo de dor, conferindo respaldo para a sua prática e sendo considerado útil e aplicável ao serviço. O estudo possibilitou reconhecer que o protocolo sugerido está em consonância com a realidade da atuação dos enfermeiros na classificação de risco, que utilizam atualmente um instrumento generalista, não direcionado à Enfermagem. Desse modo, será apresentado à Diretoria de Enfermagem do HU para possível institucionalização.Abstract : The evaluation of chest pain is a complex and frequent assignment of nurses in hospital emergency departments. In Brazil cardiovascular diseases worldwide incidence reflection of the leading causes of death. Chest pain is regarded as a primary symptom for Acute Coronary Syndrome therefore a concern of health professionals and patients. Despite the scale of the complaints of chest pain in emergency departments deficiency of the standardization of approaches for Nursing and studies for construction of care protocols. Therefore, this study proposed the implementation of a protocol for evaluation of chest pain in Home Service with Risk Rating ( SACR ) of the Emergency Department of a University Hospital in the South , which has no specific protocols of Nursing . We opted for a protocol developed and used in service excellence in the country, the Albert Einstein Jewish Hospital in São Paulo / SP. This is a qualitative research, cross-sectional, prospective and descriptive. The development of this study was guided by two main components, the recognition profile of the patient with chest pain attended the service and the identification of the evaluation of the protocol suggested by the nurses SACR. The data obtained showed a demand for female patients with chest pain significantly (65.7 %), featuring low male demand for health services. Most bit - urgent cases (66 %) versus (4.5 %) emerging; stands out the classification of nurses stating emerging in 50.7 % of ratings and little - urgent in 22.4 % which reflects an appreciation of pain chest by professionals when using the protocol. There was a significant incidence of risk factors for AMI associated with chest pain, 47.8 % of patients were hypertensive and 26.9 % of them have a family history of coronary artery disease. Regarding the evaluation of the protocolperformed by nurses, data obtained realize that there is a consensus among nurses suggested that the protocol prioritizes compliance with Acute Coronary Syndrome, identifies the best kind of pain, giving support to your practice and being considered useful and applicable to the service. This study enabled us to recognize that the suggested protocol is in line with the reality of action by nurses in risk rating, which currently use a general tool, not directed to Nursing. Thus, it will be presented to the Board of Nursing HU for possible institutionalization
Ferric carboxymaltose for iron deficiency at discharge after acute heart failure: a multicentre, double-blind, randomised, controlled trial
No full textBackground: Intravenous ferric carboxymaltose has been shown to improve symptoms and quality of life in patients with chronic heart failure and iron deficiency. We aimed to evaluate the effect of ferric carboxymaltose, compared with placebo, on outcomes in patients who were stabilised after an episode of acute heart failure. Methods: AFFIRM-AHF was a multicentre, double-blind, randomised trial done at 121 sites in Europe, South America, and Singapore. Eligible patients were aged 18 years or older, were hospitalised for acute heart failure with concomitant iron deficiency (defined as ferritin <100 μg/L, or 100–299 μg/L with transferrin saturation <20%), and had a left ventricular ejection fraction of less than 50%. Before hospital discharge, participants were randomly assigned (1:1) to receive intravenous ferric carboxymaltose or placebo for up to 24 weeks, dosed according to the extent of iron deficiency. To maintain masking of patients and study personnel, treatments were administered in black syringes by personnel not involved in any study assessments. The primary outcome was a composite of total hospitalisations for heart failure and cardiovascular death up to 52 weeks after randomisation, analysed in all patients who received at least one dose of study treatment and had at least one post-randomisation data point. Secondary outcomes were the composite of total cardiovascular hospitalisations and cardiovascular death; cardiovascular death; total heart failure hospitalisations; time to first heart failure hospitalisation or cardiovascular death; and days lost due to heart failure hospitalisations or cardiovascular death, all evaluated up to 52 weeks after randomisation. Safety was assessed in all patients for whom study treatment was started. A pre-COVID-19 sensitivity analysis on the primary and secondary outcomes was prespecified. This study is registered with ClinicalTrials.gov, NCT02937454, and has now been completed. Findings: Between March 21, 2017, and July 30, 2019, 1525 patients were screened, of whom 1132 patients were randomly assigned to study groups. Study treatment was started in 1110 patients, and 1108 (558 in the carboxymaltose group and 550 in the placebo group) had at least one post-randomisation value. 293 primary events (57·2 per 100 patient-years) occurred in the ferric carboxymaltose group and 372 (72·5 per 100 patient-years) occurred in the placebo group (rate ratio [RR] 0·79, 95% CI 0·62–1·01, p=0·059). 370 total cardiovascular hospitalisations and cardiovascular deaths occurred in the ferric carboxymaltose group and 451 occurred in the placebo group (RR 0·80, 95% CI 0·64–1·00, p=0·050). There was no difference in cardiovascular death between the two groups (77 [14%] of 558 in the ferric carboxymaltose group vs 78 [14%] in the placebo group; hazard ratio [HR] 0·96, 95% CI 0·70–1·32, p=0·81). 217 total heart failure hospitalisations occurred in the ferric carboxymaltose group and 294 occurred in the placebo group (RR 0·74; 95% CI 0·58–0·94, p=0·013). The composite of first heart failure hospitalisation or cardiovascular death occurred in 181 (32%) patients in the ferric carboxymaltose group and 209 (38%) in the placebo group (HR 0·80, 95% CI 0·66–0·98, p=0·030). Fewer days were lost due to heart failure hospitalisations and cardiovascular death for patients assigned to ferric carboxymaltose compared with placebo (369 days per 100 patient-years vs 548 days per 100 patient-years; RR 0·67, 95% CI 0·47–0·97, p=0·035). Serious adverse events occurred in 250 (45%) of 559 patients in the ferric carboxymaltose group and 282 (51%) of 551 patients in the placebo group. Interpretation: In patients with iron deficiency, a left ventricular ejection fraction of less than 50%, and who were stabilised after an episode of acute heart failure, treatment with ferric carboxymaltose was safe and reduced the risk of heart failure hospitalisations, with no apparent effect on the risk of cardiovascular death. Funding: Vifor Pharma
Distal renal tubular acidosis developments in its diagnosis and pathophysiology
No full textThis thesis describes two groups of experiments, both relating to the
condition of distal renal tubular acidosis (dRTA).
In the first, an alternative diagnostic test of dRTA to the ‘gold standard’
short ammonium chloride (NH4Cl) test was assessed. This was achieved
by the simultaneous oral administration of the diuretic furosemide and
the mineralocorticoid fludrocortisone to increase distal sodium delivery
and a-intercalated cell proton secretion. I evaluated 11 control subjects
and 10 patients with known dRTA by giving oral NH4Cl or
furosemide/fludrocortisone in random order on separate days. 3
subjects were unable to complete the study due to vomiting after the
NH4Cl, however there were no adverse effects with
furosemide/fludrocortisone administration. The urine pH decreased to
less than 5.3 in the controls with both tests, whereas no patients were
able to lower their urine pH below 5.3 with either test. The simultaneous
administration of furosemide/fludrocortisone proved to be an easy,
effective and well-tolerated alternative to the standard NH4Cl test for the
diagnosis of dRTA.
The second group were laboratory-based molecular physiology
experiments. Anion exchanger 1 (AE1) mediates electroneutral anion
exchange across cell membranes. It is the most abundant protein in the
red cell membrane, but is also found in the basolateral membrane of
renal a-intercalated cells, where it is required for urinary acidification.
Point mutations have been described that convert the red cell AE1 into a
cation conductance. AE1 mutations can also cause hereditary dRTA. I
investigated the properties of four dRTA associated AE1 mutations
(R586H, G609R, S613F and G701D) by heterologous expression in
Xenopus Laevis oocytes. These mutants proved to be functional anion
exchangers, unlike the red cell mutants, but also demonstrated a cation
‘leak’. I found a very large leak property in the G701D mutant, which is
prevalent in SE Asia. I hypothesised that this property might confer a survival advantage. I characterised three other AR dRTA-associated AE1
mutants found in SE Asia, S773P, \Delta850 and A858D via similar transport
experiments in AE1-expressing Xenopus oocytes. These three SE Asian
mutants also had cation leaks of similar magnitude to that seen in
G701D, a property that distinguishes them as a discrete group. The
clustering of these cation-leaky AE1 mutations to malarious areas of SE
Asia suggests that they may confer malaria resistance
Alirocumab and cardiovascular outcomes after acute coronary syndrome
No full textBACKGROUND Patients who have had an acute coronary syndrome are at high risk for recurrent ischemic cardiovascular events. We sought to determine whether alirocumab, a human monoclonal antibody to proprotein convertase subtilisin-kexin type 9 (PCSK9), would improve cardiovascular outcomes after an acute coronary syndrome in patients receiving high-intensity statin therapy. METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled trial involving 18,924 patients who had an acute coronary syndrome 1 to 12 months earlier, had a low-density lipoprotein (LDL) cholesterol level of at least 70 mg per deciliter (1.8 mmol per liter), a non-highdensity lipoprotein cholesterol level of at least 100 mg per deciliter (2.6 mmol per liter), or an apolipoprotein B level of at least 80 mg per deciliter, and were receiving statin therapy at a high-intensity dose or at the maximum tolerated dose. Patients were randomly assigned to receive alirocumab subcutaneously at a dose of 75 mg (9462 patients) or matching placebo (9462 patients) every 2 weeks. The dose of alirocumab was adjusted under blinded conditions to target an LDL cholesterol level of 25 to 50 mg per deciliter (0.6 to 1.3 mmol per liter). The primary end point was a composite of death from coronary heart disease, nonfatal myocardial infarction, fatal or nonfatal ischemic stroke, or unstable angina requiring hospitalization. RESULTS The median duration of follow-up was 2.8 years. A composite primary end-point event occurred in 903 patients (9.5%) in the alirocumab group and in 1052 patients (11.1%) in the placebo group (hazard ratio, 0.85; 95% confidence interval [CI], 0.78 to 0.93; P<0.001). A total of 334 patients (3.5%) in the alirocumab group and 392 patients (4.1%) in the placebo group died (hazard ratio, 0.85; 95% CI, 0.73 to 0.98). The absolute benefit of alirocumab with respect to the composite primary end point was greater among patients who had a baseline LDL cholesterol level of 100 mg or more per deciliter than among patients who had a lower baseline level. The incidence of adverse events was similar in the two groups, with the exception of local injection-site reactions (3.8% in the alirocumab group vs. 2.1% in the placebo group). CONCLUSIONS Among patients who had a previous acute coronary syndrome and who were receiving highintensity statin therapy, the risk of recurrent ischemic cardiovascular events was lower among those who received alirocumab than among those who received placebo
Effects of alirocumab on cardiovascular and metabolic outcomes after acute coronary syndrome in patients with or without diabetes: a prespecified analysis of the ODYSSEY OUTCOMES randomised controlled trial
No full textBackground: After acute coronary syndrome, diabetes conveys an excess risk of ischaemic cardiovascular events. A reduction in mean LDL cholesterol to 1·4–1·8 mmol/L with ezetimibe or statins reduces cardiovascular events in patients with an acute coronary syndrome and diabetes. However, the efficacy and safety of further reduction in LDL cholesterol with an inhibitor of proprotein convertase subtilisin/kexin type 9 (PCSK9) after acute coronary syndrome is unknown. We aimed to explore this issue in a prespecified analysis of the ODYSSEY OUTCOMES trial of the PCSK9 inhibitor alirocumab, assessing its effects on cardiovascular outcomes by baseline glycaemic status, while also assessing its effects on glycaemic measures including risk of new-onset diabetes. Methods: ODYSSEY OUTCOMES was a randomised, double-blind, placebo-controlled trial, done at 1315 sites in 57 countries, that compared alirocumab with placebo in patients who had been admitted to hospital with an acute coronary syndrome (myocardial infarction or unstable angina) 1–12 months before randomisation and who had raised concentrations of atherogenic lipoproteins despite use of high-intensity statins. Patients were randomly assigned (1:1) to receive alirocumab or placebo every 2 weeks; randomisation was stratified by country and was done centrally with an interactive voice-response or web-response system. Alirocumab was titrated to target LDL cholesterol concentrations of 0·65–1·30 mmol/L. In this prespecified analysis, we investigated the effect of alirocumab on cardiovascular events by glycaemic status at baseline (diabetes, prediabetes, or normoglycaemia)—defined on the basis of patient history, review of medical records, or baseline HbA1c or fasting serum glucose—and risk of new-onset diabetes among those without diabetes at baseline. The primary endpoint was a composite of death from coronary heart disease, non-fatal myocardial infarction, fatal or non-fatal ischaemic stroke, or unstable angina requiring hospital admission. ODYSSEY OUTCOMES is registered with ClinicalTrials.gov, number NCT01663402. Findings: At study baseline, 5444 patients (28·8%) had diabetes, 8246 (43·6%) had prediabetes, and 5234 (27·7%) had normoglycaemia. There were no significant differences across glycaemic categories in median LDL cholesterol at baseline (2·20–2·28 mmol/L), after 4 months' treatment with alirocumab (0·80 mmol/L), or after 4 months' treatment with placebo (2·25–2·28 mmol/L). In the placebo group, the incidence of the primary endpoint over a median of 2·8 years was greater in patients with diabetes (16·4%) than in those with prediabetes (9·2%) or normoglycaemia (8·5%); hazard ratio (HR) for diabetes versus normoglycaemia 2·09 (95% CI 1·78–2·46, p<0·0001) and for diabetes versus prediabetes 1·90 (1·65–2·17, p<0·0001). Alirocumab resulted in similar relative reductions in the incidence of the primary endpoint in each glycaemic category, but a greater absolute reduction in the incidence of the primary endpoint in patients with diabetes (2·3%, 95% CI 0·4 to 4·2) than in those with prediabetes (1·2%, 0·0 to 2·4) or normoglycaemia (1·2%, −0·3 to 2·7; absolute risk reduction pinteraction=0·0019). Among patients without diabetes at baseline, 676 (10·1%) developed diabetes in the placebo group, compared with 648 (9·6%) in the alirocumab group; alirocumab did not increase the risk of new-onset diabetes (HR 1·00, 95% CI 0·89–1·11). HRs were 0·97 (95% CI 0·87–1·09) for patients with prediabetes and 1·30 (95% CI 0·93–1·81) for those with normoglycaemia (pinteraction=0·11). Interpretation: After a recent acute coronary syndrome, alirocumab treatment targeting an LDL cholesterol concentration of 0·65–1·30 mmol/L produced about twice the absolute reduction in cardiovascular events among patients with diabetes as in those without diabetes. Alirocumab treatment did not increase the risk of new-onset diabetes. Funding: Sanofi and Regeneron Pharmaceuticals
Lipoprotein(a) and Benefit of PCSK9 Inhibition in Patients With Nominally Controlled LDL Cholesterol
No full textBackground: Guidelines recommend nonstatin lipid-lowering agents in patients at very high risk for major adverse cardiovascular events (MACE) if low-density lipoprotein cholesterol (LDL-C) remains ≥70 mg/dL on maximum tolerated statin treatment. It is uncertain if this approach benefits patients with LDL-C near 70 mg/dL. Lipoprotein(a) levels may influence residual risk. Objectives: In a post hoc analysis of the ODYSSEY Outcomes (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) trial, the authors evaluated the benefit of adding the proprotein subtilisin/kexin type 9 inhibitor alirocumab to optimized statin treatment in patients with LDL-C levels near 70 mg/dL. Effects were evaluated according to concurrent lipoprotein(a) levels. Methods: ODYSSEY Outcomes compared alirocumab with placebo in 18,924 patients with recent acute coronary syndromes receiving optimized statin treatment. In 4,351 patients (23.0%), screening or randomization LDL-C was 13.7 mg/dL or ≤13.7 mg/dL; corresponding adjusted treatment hazard ratios were 0.82 (95% CI: 0.72-0.92) and 0.89 (95% CI: 0.75-1.06), with Pinteraction = 0.43. Conclusions: In patients with recent acute coronary syndromes and LDL-C near 70 mg/dL on optimized statin therapy, proprotein subtilisin/kexin type 9 inhibition provides incremental clinical benefit only when lipoprotein(a) concentration is at least mildly elevated. (ODYSSEY Outcomes: Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab; NCT01663402
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