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Efeitos da inibição do sistema renina-angiotensina-aldosterona e do betabloqueio com Carvedilol na cardiopatia chagásica crônica
Get PDFChagas disease, caused by Trypanosoma cruzi (T. cruzi), was discovered and reported by Carlos Chagas, a Brazilian physician, in 1909. Unfortunately, near to a century since its original description, it continues to represent a terrible impact on humanity. Chagasmyocardiopathy pathogenesis and consequent heart failure do not seem to differ from other forms of idiopathic and ischemic myocardiopathy. Bearing this in mind, we consider that the results of great clinical assays in patients with cardiac insufficiency can be extended tothose carriers of Chagas cardiomyopathy. Even though it is admitted that pathophysiology of Chagas cardiomyopathy is similar to non-chagasic myocardiopathy, there are many peculiarities in Chagas myocardiopathy. For this prospective study, we selected a group of 42 patients with chronic Chagas cardiomyopathy (CCC). The selection was madeconsecutively among patients assisted in the Ambulatório de Referência em Doença de Chagas do HC-UFMG (Reference Ambulatory in Chagas Disease of the Teaching County Hospital of the Federal University of Minas Gerais). The premise used for the selectionwas the presence of the left ventricle diastolic diameter (LVD) larger than 55mm or 2.7 cm/m2 and at least one of the following criteria: left ventricular ejection fraction (LVEF) smaller than 55% (modified Simpson) or evidence of diffuse or segmental systolic dysfunction. Patients with any co-morbidities, which might have caused confusion to the data analysis, were excluded. The primary aim of the study was a change in the LVEF after renin-angiotensin system inhibition (RASi) and after addition of carvedilol. Secondary objectives were changes in clinical, life quality, radiological, neurohormonal (BNP), and inflammatory (RANTES, MCP1, and MIP1) parameters, as well as the behavior of the anti-adrenergic and anti-muscarinic antibodies. The study was divided in two phases:Phase I was named RASi and the second one, carvedilol/placebo. These patients were assessed for clinical, life quality, radiological, ECG, neurohormonal and inflammatory aspects in the beginning and at the end of each phase. The protocol of dosage optimization of enalapril (20 mg BID) and spironolactone (25 mg MID) was applied to the selectedgroup. Subsequently, the group was randomly assigned to a carvedilol group (n=19) and a placebo group (n=20). Both were uptitrated to use carvedilol or placebo 25mg qd. The utilization of other drugs, such as furosemide, hidroclorotiazidics, digoxin and amiodarone were guided in accordance to clinical requirement, respecting their basic indications andrestrictions. In phase I, it was observed that the therapeutic optimization was safe and efficient, being characterized by a meaningful improvement on the clinical examination (Framingham score p = 0.0004), life quality, radiological (reduction in the cardiothoracic index p = 0.002) and echocardiographic parameters (improvement of the index TEI p =0.013). Regarding the analysis of the differences of the LVEF (p = 0.249) and the LVD (p = 0.335) before and after RASi, statistical significance was not observed. However, when patients were rated according to the degree of systolic dysfunction (EF < = 45%), a significant difference was observed (p = 0.017) between the two variables prior and afterthe optimized treatment. BNP and RANTES levels decreased and anti1 receptor antibody levels increased significantly (p = 0.032; p = 0.001; p = 0.020, respectively). After the association of carvedilol, it was observed a trend towards an increase in LVEF (p=0.066) in the carvedilol group, but not in the placebo group (p=0.241). The difference between these groups also showed a trend to significance (p=0.09). After the association of carvedilol, there was no additional improvement on clinical, life quality, and neurohormonal parameters, but there was no criterion of worsening as well. However, it was not observed clinical or hemodynamic worsening. RANTES levels showed significant increase (p=0.013), but there was no difference between groups (p=0.351). The anti1receptor antibodies showed a trend to additional rise (p=0.050) with significant difference between groups (p=0.029). We concluded that, for patients with CCC, optimization of treatment with enalapril and spironolactone followed by the addition of carvedilol was safe and with benefits for their cardiac function and clinical status. Larger trials are needed to show effects on mortality and hospitalization.A doenca de Chagas, causada pelo protozoario Trypanosoma cruzi (T. cruzi), foi descoberta e descrita pelo medico brasileiro Carlos Chagas em 1909 (CHAGAS, 1909). Infelizmente, proximo de completar um seculo de sua descricao original, continua representando terrivel impacto sobre a humanidade. A fisiopatologia da cardiopatia chagasica e consequente insuficiencia cardiaca nao parecem diferir das formas demiocardiopatia idiopatica ou isquemica. Com base nessas premissas, julga-se que os resultados dos grandes ensaios clinicos em insuficiencia cardiaca podem ser extrapolados aqueles portadores de miocardiopatia chagasicoa. Nao obstante, mesmo que se admitasimilaridade fisiopatologica entre a miocardiopatia chagasica com as outras varias formas de miocardiopatia, sabe-se que a forma cardiaca da doenca de Chagas apresenta varias peculiaridades patogenicas. Este e um estudo prospectivo em que foi selecionado um grupode 42 pacientes com cardiopatia chagasica cronica (CCC). A selecao foi feita de forma consecutiva dentre pacientes atendidos no Ambulatorio de Referencia em Doenca de Chagas do Hospital das Clinicas da UFMG. Utilizou-se como criterio de selecao a presenca de diametro diastolico do ventriculo esquerdo (VED) maior que 55mm ou 2,7cm/m2 e pelo menos um dos seguintes: fracao de ejecao do ventriculo esquerdo (FEVE) menor que 55% (Simpson modificado) ou deficit de funcao do ventriculo esquerdo segmentar ou global. Foram excluidos pacientes com quaisquer co-morbidades que servissem de confusao a analise dos dados. O objetivo primario foi melhora da fracao de ejecao apos inibicao do SRAA e apos adicao do carvedilol. Como objetivos secundarios analisaram-se o comportamento clinico, da qualidade de vida, radiologico, neuro-hormonal (BNP), inflamatorio (RANTES, MCP1, MIP1¿) e o comportamento dos anticorpos antireceptores adrenergico À1 e muscarinico M2. O estudo foi dividido em duas fases. Fase I,denominada inibicao do sistema renina-angiotencina-aldosterona (iSRAA), e fase II, carvedilol/placebo. No inicio e ao termino de cada fase avaliou-se o comportamento desses pacientes sob os aspectos clinicos, da qualidade de vida, radiologicos, ecocardiograficos,neuro-hormonais e inflamatorios. Na fase I aplicou-se protocolo de otimizacao das dosagens de maleato de enalapril ate a dosagem de 20mg BID e espironolactona (25mg MID). Posteriormente, o grupo foi randomicamente dividido em dois subgrupos denominados carvedilol e placebo. Ambos receberam carvedilol ou placebo em doses progressivas ate a dose maxima de 25mg BID. A utilizacao de outros medicamentos, como furosemida, hidroclorotiazida, digoxina e amiodarona, foi guiada conforme a necessidade clinica, respeitando-se suas indicacoes e contra-indicacoes. Observou-se, na fase I, que aotimizacao terapeutica foi segura e eficaz, sendo esta caracterizada por melhora importante no exame clinico (escore de Framingham - p=0,0004), na qualidade de vida, nos parametros radiologicos (reducao no indice cardiotoracico - p = 0,002) e ecocardiograficos (melhora do indice de TEI . p = 0,013). Na analise das diferencas da FEVE (p=0,249) e do VED (p=0,335) pre e pos-iSRAA, nao se observou significancia estatistica. No entanto, quando os pacientes foram estratificados de acordo com o grau de disfuncao sistolica (FE.45%), verificou-se diferenca significativa (p=0,017) entre as duas variaveis antes eapos iSRAA. O BNP e RANTES declinaram-se significativamente e os anticorpos antiÀ1 aumentaram significativamente(p=0,032; p=0,001; p=0,020, respectivamente). Depois da adicao do carvedilol, houve tendencia a melhora na FEVE no grupo carvedilol (p=0,066) enao no placebo (p=0,241). A diferenca entre os grupos tambem demonstrou tendencia significativa (p=0.09). Nao houve melhora adicional nos parametros clinicos, de qualidade de vida, neuro-hormonais e radiologicos apos associacao do carvedilol. Entretanto, nao se registrou piora clinica ou hemodinamica. O RANTES se elevou (p=0,013), mas sem diferencas entre os grupos (p=0,351). Os anticorpos antiÀ1 tenderam a adicional elevacao (p=0,050) no grupo carvediol, com significativa diferenca entre os grupos (p=0.029).Concluiu-se que o esquema terapeutico com doses otimizadas de maleato de enalapril e espironolactona seguidas da adicao do carvedilol foi seguro e eficaz, demonstrando melhora clnica, ecocardiografica, neuro-hormonal e inflamatoria em pacientes com CCC. Mais estudos sao necessarios para demonstrar-se sobre a mortalidade e hospitalizacao
Fatores associados à Lesão Renal Aguda em uma unidade de terapia intensiva de um hospital público em Belo Horizonte, Minas Gerais
No full textAcute kidney injury (AKI) is a well recognized complication in hospitalized and critically ill patients. It is associated with a significant increase in morbidity, mortality and health care costs. In intensive care units (ICU), the cause of AKI is commonly associated with multiple factors, among which the use of potentially nephrotoxic drugs is often neglected as a preventable cause of AKI. This is a prospective cohort study that evaluated the AKI as a primary outcome in ICU patients at a teaching hospital in Belo Horizonte, Brazil. Adult patients with ICU length of stay greater than 24 hours and hospital stay lower or equal to 7 days were evaluated for potential eligibility. Patients should not present any change on kidney function at the time of ICU admission. Data collection was performed from October 2014 to February 2015, including 122 patients, mostly originated from the surgical department (46.7%). An average of 22.0 ± 9.4 drugs was prescribed and from 2 to 24 potentially nephrotoxic drugs were used per patient. Mechanical ventilation was required for 67.2% of patients and at least one vasoactive drug was used in 68.0% of cases. An incidence of AKI was observed in 23.8% of patients, among them 10 required dialysis, seven reached the third stage of AKI and seven were referred to additional treatment after ICU discharge. Eleven (9%) patients died and seven of them developed AKI. The bivariate analysis showed that age (p = 0.006) and APACHE II score (p = 0.001) had higher median among patients who developed AKI compared to those who did not develop AKI. In the logistic regression, the number of medications (OR: 1.15; 95% CI: 1.05 to 1.27) presented a statistically significant correlation with the development of AKI. Understanding the factors associated with the occurrence of AKI in ICU patients is of great importance. Besides, the importance of pharmacists' role in the care of critically ill patients helps early identification of renal dysfunction induced by drugs, providing the prevention and appropriate management of these patients.A lesão renal aguda (LRA) é uma complicação bem reconhecida em pacientes hospitalizados e doentes críticos e está associada a um aumento significativo da morbidade, mortalidade e despesas com cuidados de saúde. No contexto das unidades de terapia intensiva (UTI), a causa da LRA é comumente associada a múltiplos fatores, dentre os quais o uso de medicamentos com potencial nefrotóxico é frequentemente ignorado. Trata-se de um estudo de coorte prospectivo avaliando a ocorrência de LRA, como desfecho primário, em pacientes internados em UTI de um hospital de ensino em Belo Horizonte- MG. Foram avaliados para potencial elegibilidade, pacientes adultos com tempo de permanência na UTI maior que 24 horas e internação hospitalar inferior ou igual a sete dias e que não apresentaram alteração da função renal, no momento da internação na UTI. Realizou-se a coleta de dados no período de outubro de 2014 a fevereiro de 2015. Foram estudados 122 pacientes, sendo a maioria proveniente da clínica cirúrgica (46,7%). Identificou-se média de 22,0±9,4 medicamentos prescritos, variando de 2 a 24 fármacos com potencial nefrotóxico, por paciente. Houve necessidade de ventilação mecânica em 67,2% dos pacientes e de pelo menos um fármaco vasoativo em 68% dos casos. Dos pacientes acompanhados, 29 (23,8%) desenvolveram LRA, dos quais 10 requereram hemodiálise, sete chegaram ao estágio 3 de LRA e sete foram encaminhados para tratamento complementar após alta da UTI. Foram a óbito 11 (9%) pacientes, dos quais sete tinham desenvolvido LRA. A análise bivariada mostrou que a idade (p = 0,006) e escore APACHE II (p = 0,001) tiveram medianas mais elevadas entre os pacientes que desenvolveram LRA em comparação com os que não desenvolveram LRA. Na regressão logística, o número de medicamentos (OR: 1,15; IC 95%: 1,05 1,27), independentemente do seu potencial nefrotóxico, demonstrou estar associado ao desenvolvimento de LRA. A compreensão dos fatores associados à ocorrência de LRA em pacientes internados em UTI é de grande relevância e, além de reforçar a importância da atuação do farmacêutico no cuidado de pacientes críticos, serve de subsídio para a identificação precoce da disfunção renal induzida por medicamentos, propiciando a prevenção e o manejo adequado desses pacientes
Fatores associados à Lesão Renal Aguda em uma unidade de terapia intensiva de um hospital público em Belo Horizonte, Minas Gerais
Get PDFAcute kidney injury (AKI) is a well recognized complication in hospitalized and critically ill patients. It is associated with a significant increase in morbidity, mortality and health care costs. In intensive care units (ICU), the cause of AKI is commonly associated with multiple factors, among which the use of potentially nephrotoxic drugs is often neglected as a preventable cause of AKI. This is a prospective cohort study that evaluated the AKI as a primary outcome in ICU patients at a teaching hospital in Belo Horizonte, Brazil. Adult patients with ICU length of stay greater than 24 hours and hospital stay lower or equal to 7 days were evaluated for potential eligibility. Patients should not present any change on kidney function at the time of ICU admission. Data collection was performed from October 2014 to February 2015, including 122 patients, mostly originated from the surgical department (46.7%). An average of 22.0 ± 9.4 drugs was prescribed and from 2 to 24 potentially nephrotoxic drugs were used per patient. Mechanical ventilation was required for 67.2% of patients and at least one vasoactive drug was used in 68.0% of cases. An incidence of AKI was observed in 23.8% of patients, among them 10 required dialysis, seven reached the third stage of AKI and seven were referred to additional treatment after ICU discharge. Eleven (9%) patients died and seven of them developed AKI. The bivariate analysis showed that age (p = 0.006) and APACHE II score (p = 0.001) had higher median among patients who developed AKI compared to those who did not develop AKI. In the logistic regression, the number of medications (OR: 1.15; 95% CI: 1.05 to 1.27) presented a statistically significant correlation with the development of AKI. Understanding the factors associated with the occurrence of AKI in ICU patients is of great importance. Besides, the importance of pharmacists' role in the care of critically ill patients helps early identification of renal dysfunction induced by drugs, providing the prevention and appropriate management of these patients.A lesão renal aguda (LRA) é uma complicação bem reconhecida em pacientes hospitalizados e doentes críticos e está associada a um aumento significativo da morbidade, mortalidade e despesas com cuidados de saúde. No contexto das unidades de terapia intensiva (UTI), a causa da LRA é comumente associada a múltiplos fatores, dentre os quais o uso de medicamentos com potencial nefrotóxico é frequentemente ignorado. Trata-se de um estudo de coorte prospectivo avaliando a ocorrência de LRA, como desfecho primário, em pacientes internados em UTI de um hospital de ensino em Belo Horizonte- MG. Foram avaliados para potencial elegibilidade, pacientes adultos com tempo de permanência na UTI maior que 24 horas e internação hospitalar inferior ou igual a sete dias e que não apresentaram alteração da função renal, no momento da internação na UTI. Realizou-se a coleta de dados no período de outubro de 2014 a fevereiro de 2015. Foram estudados 122 pacientes, sendo a maioria proveniente da clínica cirúrgica (46,7%). Identificou-se média de 22,0±9,4 medicamentos prescritos, variando de 2 a 24 fármacos com potencial nefrotóxico, por paciente. Houve necessidade de ventilação mecânica em 67,2% dos pacientes e de pelo menos um fármaco vasoativo em 68% dos casos. Dos pacientes acompanhados, 29 (23,8%) desenvolveram LRA, dos quais 10 requereram hemodiálise, sete chegaram ao estágio 3 de LRA e sete foram encaminhados para tratamento complementar após alta da UTI. Foram a óbito 11 (9%) pacientes, dos quais sete tinham desenvolvido LRA. A análise bivariada mostrou que a idade (p = 0,006) e escore APACHE II (p = 0,001) tiveram medianas mais elevadas entre os pacientes que desenvolveram LRA em comparação com os que não desenvolveram LRA. Na regressão logística, o número de medicamentos (OR: 1,15; IC 95%: 1,05 1,27), independentemente do seu potencial nefrotóxico, demonstrou estar associado ao desenvolvimento de LRA. A compreensão dos fatores associados à ocorrência de LRA em pacientes internados em UTI é de grande relevância e, além de reforçar a importância da atuação do farmacêutico no cuidado de pacientes críticos, serve de subsídio para a identificação precoce da disfunção renal induzida por medicamentos, propiciando a prevenção e o manejo adequado desses pacientes
Efeitos da inibição do sistema renina-angiotensina-aldosterona e do betabloqueio com Carvedilol na cardiopatia chagásica crônica
No full textChagas disease, caused by Trypanosoma cruzi (T. cruzi), was discovered and reported by Carlos Chagas, a Brazilian physician, in 1909. Unfortunately, near to a century since its original description, it continues to represent a terrible impact on humanity. Chagasmyocardiopathy pathogenesis and consequent heart failure do not seem to differ from other forms of idiopathic and ischemic myocardiopathy. Bearing this in mind, we consider that the results of great clinical assays in patients with cardiac insufficiency can be extended tothose carriers of Chagas cardiomyopathy. Even though it is admitted that pathophysiology of Chagas cardiomyopathy is similar to non-chagasic myocardiopathy, there are many peculiarities in Chagas myocardiopathy. For this prospective study, we selected a group of 42 patients with chronic Chagas cardiomyopathy (CCC). The selection was madeconsecutively among patients assisted in the Ambulatório de Referência em Doença de Chagas do HC-UFMG (Reference Ambulatory in Chagas Disease of the Teaching County Hospital of the Federal University of Minas Gerais). The premise used for the selectionwas the presence of the left ventricle diastolic diameter (LVD) larger than 55mm or 2.7 cm/m2 and at least one of the following criteria: left ventricular ejection fraction (LVEF) smaller than 55% (modified Simpson) or evidence of diffuse or segmental systolic dysfunction. Patients with any co-morbidities, which might have caused confusion to the data analysis, were excluded. The primary aim of the study was a change in the LVEF after renin-angiotensin system inhibition (RASi) and after addition of carvedilol. Secondary objectives were changes in clinical, life quality, radiological, neurohormonal (BNP), and inflammatory (RANTES, MCP1, and MIP1) parameters, as well as the behavior of the anti-adrenergic and anti-muscarinic antibodies. The study was divided in two phases:Phase I was named RASi and the second one, carvedilol/placebo. These patients were assessed for clinical, life quality, radiological, ECG, neurohormonal and inflammatory aspects in the beginning and at the end of each phase. The protocol of dosage optimization of enalapril (20 mg BID) and spironolactone (25 mg MID) was applied to the selectedgroup. Subsequently, the group was randomly assigned to a carvedilol group (n=19) and a placebo group (n=20). Both were uptitrated to use carvedilol or placebo 25mg qd. The utilization of other drugs, such as furosemide, hidroclorotiazidics, digoxin and amiodarone were guided in accordance to clinical requirement, respecting their basic indications andrestrictions. In phase I, it was observed that the therapeutic optimization was safe and efficient, being characterized by a meaningful improvement on the clinical examination (Framingham score p = 0.0004), life quality, radiological (reduction in the cardiothoracic index p = 0.002) and echocardiographic parameters (improvement of the index TEI p =0.013). Regarding the analysis of the differences of the LVEF (p = 0.249) and the LVD (p = 0.335) before and after RASi, statistical significance was not observed. However, when patients were rated according to the degree of systolic dysfunction (EF < = 45%), a significant difference was observed (p = 0.017) between the two variables prior and afterthe optimized treatment. BNP and RANTES levels decreased and anti1 receptor antibody levels increased significantly (p = 0.032; p = 0.001; p = 0.020, respectively). After the association of carvedilol, it was observed a trend towards an increase in LVEF (p=0.066) in the carvedilol group, but not in the placebo group (p=0.241). The difference between these groups also showed a trend to significance (p=0.09). After the association of carvedilol, there was no additional improvement on clinical, life quality, and neurohormonal parameters, but there was no criterion of worsening as well. However, it was not observed clinical or hemodynamic worsening. RANTES levels showed significant increase (p=0.013), but there was no difference between groups (p=0.351). The anti1receptor antibodies showed a trend to additional rise (p=0.050) with significant difference between groups (p=0.029). We concluded that, for patients with CCC, optimization of treatment with enalapril and spironolactone followed by the addition of carvedilol was safe and with benefits for their cardiac function and clinical status. Larger trials are needed to show effects on mortality and hospitalization.A doenca de Chagas, causada pelo protozoario Trypanosoma cruzi (T. cruzi), foi descoberta e descrita pelo medico brasileiro Carlos Chagas em 1909 (CHAGAS, 1909). Infelizmente, proximo de completar um seculo de sua descricao original, continua representando terrivel impacto sobre a humanidade. A fisiopatologia da cardiopatia chagasica e consequente insuficiencia cardiaca nao parecem diferir das formas demiocardiopatia idiopatica ou isquemica. Com base nessas premissas, julga-se que os resultados dos grandes ensaios clinicos em insuficiencia cardiaca podem ser extrapolados aqueles portadores de miocardiopatia chagasicoa. Nao obstante, mesmo que se admitasimilaridade fisiopatologica entre a miocardiopatia chagasica com as outras varias formas de miocardiopatia, sabe-se que a forma cardiaca da doenca de Chagas apresenta varias peculiaridades patogenicas. Este e um estudo prospectivo em que foi selecionado um grupode 42 pacientes com cardiopatia chagasica cronica (CCC). A selecao foi feita de forma consecutiva dentre pacientes atendidos no Ambulatorio de Referencia em Doenca de Chagas do Hospital das Clinicas da UFMG. Utilizou-se como criterio de selecao a presenca de diametro diastolico do ventriculo esquerdo (VED) maior que 55mm ou 2,7cm/m2 e pelo menos um dos seguintes: fracao de ejecao do ventriculo esquerdo (FEVE) menor que 55% (Simpson modificado) ou deficit de funcao do ventriculo esquerdo segmentar ou global. Foram excluidos pacientes com quaisquer co-morbidades que servissem de confusao a analise dos dados. O objetivo primario foi melhora da fracao de ejecao apos inibicao do SRAA e apos adicao do carvedilol. Como objetivos secundarios analisaram-se o comportamento clinico, da qualidade de vida, radiologico, neuro-hormonal (BNP), inflamatorio (RANTES, MCP1, MIP1¿) e o comportamento dos anticorpos antireceptores adrenergico À1 e muscarinico M2. O estudo foi dividido em duas fases. Fase I,denominada inibicao do sistema renina-angiotencina-aldosterona (iSRAA), e fase II, carvedilol/placebo. No inicio e ao termino de cada fase avaliou-se o comportamento desses pacientes sob os aspectos clinicos, da qualidade de vida, radiologicos, ecocardiograficos,neuro-hormonais e inflamatorios. Na fase I aplicou-se protocolo de otimizacao das dosagens de maleato de enalapril ate a dosagem de 20mg BID e espironolactona (25mg MID). Posteriormente, o grupo foi randomicamente dividido em dois subgrupos denominados carvedilol e placebo. Ambos receberam carvedilol ou placebo em doses progressivas ate a dose maxima de 25mg BID. A utilizacao de outros medicamentos, como furosemida, hidroclorotiazida, digoxina e amiodarona, foi guiada conforme a necessidade clinica, respeitando-se suas indicacoes e contra-indicacoes. Observou-se, na fase I, que aotimizacao terapeutica foi segura e eficaz, sendo esta caracterizada por melhora importante no exame clinico (escore de Framingham - p=0,0004), na qualidade de vida, nos parametros radiologicos (reducao no indice cardiotoracico - p = 0,002) e ecocardiograficos (melhora do indice de TEI . p = 0,013). Na analise das diferencas da FEVE (p=0,249) e do VED (p=0,335) pre e pos-iSRAA, nao se observou significancia estatistica. No entanto, quando os pacientes foram estratificados de acordo com o grau de disfuncao sistolica (FE.45%), verificou-se diferenca significativa (p=0,017) entre as duas variaveis antes eapos iSRAA. O BNP e RANTES declinaram-se significativamente e os anticorpos antiÀ1 aumentaram significativamente(p=0,032; p=0,001; p=0,020, respectivamente). Depois da adicao do carvedilol, houve tendencia a melhora na FEVE no grupo carvedilol (p=0,066) enao no placebo (p=0,241). A diferenca entre os grupos tambem demonstrou tendencia significativa (p=0.09). Nao houve melhora adicional nos parametros clinicos, de qualidade de vida, neuro-hormonais e radiologicos apos associacao do carvedilol. Entretanto, nao se registrou piora clinica ou hemodinamica. O RANTES se elevou (p=0,013), mas sem diferencas entre os grupos (p=0,351). Os anticorpos antiÀ1 tenderam a adicional elevacao (p=0,050) no grupo carvediol, com significativa diferenca entre os grupos (p=0.029).Concluiu-se que o esquema terapeutico com doses otimizadas de maleato de enalapril e espironolactona seguidas da adicao do carvedilol foi seguro e eficaz, demonstrando melhora clnica, ecocardiografica, neuro-hormonal e inflamatoria em pacientes com CCC. Mais estudos sao necessarios para demonstrar-se sobre a mortalidade e hospitalizacao
Going Beyond Counting First Authors in Author Co-citation Analysis
Get PDFThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Mobilização precoce de pacientes criticamente doentes: ensaio clínico aleatorizado
No full textContext. Investigations of physiotherapy applied to intensive care have focused attention on the early management of critically ill patients, aimed at decisionmaking to minimize the complications inherent in the admission and treatment of primary disorders related to long periods of bed rest. Purpose. To evaluate the applicability of a protocol the early mobilization to facilitate the exit of bed for patients in intensive care unit. Method. Randomized clinical trial carried out in hospital Risoleta Tolentino Neves / MG. Patients were randomized into two groups(treatment - control and n = 67 - n = 67). The groups were compared based on age, gender, lactate, Acute Physiology and Chronic Health Evaluation II, C-reactive protein, duration of mechanical ventilation and diagnosis. The control group was accompanied throughout the length of stay by the physiotherapy team from the usual care and the treatment group, beyong that follow was submitted to the proposed protocol. The protocol was initiated from 24 hours after admission and consisted of four stages of activities in accordance with the level of awareness andstrength in upper and lower limbs which was also used as parameter ofprogression. All variables were submitted to Kolmogorov Smirnov test for normality and subjected to Mann Whitney U and chi-square test. Results. The characteristics of the groups were similar at baseline. Of the total 134 patients, there were 14 exclusions (7 in the treatment group and 7 in control) due to complications during hospitalization. There were two adverse events attributed to the protocol, and a loss of peripheral venous access and a loss of nasoentérica probe. The proportion of patients who left the bed was different between groups, 61 patients in the treatment group and only two in the control (p = 0.001). The length of stay in ICU was 264.76 hours vs. 379.71 hours (p = 0.122) in the treatment and control groups, respectively. There was no statistically significant difference between groups in length of hospital stay, the treatment group had an average of 28.6 days of hospitalization (95% CI - 21.37 to 35.83) days, while the control had an average of 36, 1 (95% CI - 28.04 to 44.13) (p = 0.159). The treatment group had a mean duration of mechanical ventilation was 5.36 (95% CI - 3.32 to 7.40) days while the control group had an average of 7.66 (95% CI - 5.09 to 10, 22) days (p = 0.094). In this study, the ICU mortality reached 18.7% (25 patients) was not statistically different between groups (p = 0.506), maintaining the same standard, the mortality rate was 26.1% (35 patients) (p = 0.844). The average cost for each hour of admission recorded by HRTN abril-setembro/11 the period was R 14,746 , 28 average / patient while the control group was responsible for R 55,70/paciente, levando em consideração o tempo de internação (horas) na UTI o grupo tratamento foi responsável pelo montante de R21.148,62 média/paciente (p=0,122). Conclusão.Os achados dessa pesquisa foram similares a estudos prévios e é possível afirmar que a mobilização precoce é segura, eficaz e favorece a saída precoce do leito, principalmente quando iniciadas após as 24h de admissão na UTI. Mobilização precoce foi clinicamente relevante em todos os contextos, reduzindo o tempo de internação na UTI, bem como seus custos totais
Variations on the Author
Get PDF“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Appropriate Similarity Measures for Author Cocitation Analysis
Get PDFWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
Mobilização precoce de pacientes criticamente doentes: ensaio clínico aleatorizado
Get PDFContext. Investigations of physiotherapy applied to intensive care have focused attention on the early management of critically ill patients, aimed at decisionmaking to minimize the complications inherent in the admission and treatment of primary disorders related to long periods of bed rest. Purpose. To evaluate the applicability of a protocol the early mobilization to facilitate the exit of bed for patients in intensive care unit. Method. Randomized clinical trial carried out in hospital Risoleta Tolentino Neves / MG. Patients were randomized into two groups(treatment - control and n = 67 - n = 67). The groups were compared based on age, gender, lactate, Acute Physiology and Chronic Health Evaluation II, C-reactive protein, duration of mechanical ventilation and diagnosis. The control group was accompanied throughout the length of stay by the physiotherapy team from the usual care and the treatment group, beyong that follow was submitted to the proposed protocol. The protocol was initiated from 24 hours after admission and consisted of four stages of activities in accordance with the level of awareness andstrength in upper and lower limbs which was also used as parameter ofprogression. All variables were submitted to Kolmogorov Smirnov test for normality and subjected to Mann Whitney U and chi-square test. Results. The characteristics of the groups were similar at baseline. Of the total 134 patients, there were 14 exclusions (7 in the treatment group and 7 in control) due to complications during hospitalization. There were two adverse events attributed to the protocol, and a loss of peripheral venous access and a loss of nasoentérica probe. The proportion of patients who left the bed was different between groups, 61 patients in the treatment group and only two in the control (p = 0.001). The length of stay in ICU was 264.76 hours vs. 379.71 hours (p = 0.122) in the treatment and control groups, respectively. There was no statistically significant difference between groups in length of hospital stay, the treatment group had an average of 28.6 days of hospitalization (95% CI - 21.37 to 35.83) days, while the control had an average of 36, 1 (95% CI - 28.04 to 44.13) (p = 0.159). The treatment group had a mean duration of mechanical ventilation was 5.36 (95% CI - 3.32 to 7.40) days while the control group had an average of 7.66 (95% CI - 5.09 to 10, 22) days (p = 0.094). In this study, the ICU mortality reached 18.7% (25 patients) was not statistically different between groups (p = 0.506), maintaining the same standard, the mortality rate was 26.1% (35 patients) (p = 0.844). The average cost for each hour of admission recorded by HRTN abril-setembro/11 the period was R 14,746 , 28 average / patient while the control group was responsible for R 55,70/paciente, levando em consideração o tempo de internação (horas) na UTI o grupo tratamento foi responsável pelo montante de R21.148,62 média/paciente (p=0,122). Conclusão.Os achados dessa pesquisa foram similares a estudos prévios e é possível afirmar que a mobilização precoce é segura, eficaz e favorece a saída precoce do leito, principalmente quando iniciadas após as 24h de admissão na UTI. Mobilização precoce foi clinicamente relevante em todos os contextos, reduzindo o tempo de internação na UTI, bem como seus custos totais
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