Acute Pain Service: A 10-Year Experience.

BACKGROUND: Pain management after surgery is crucial to decrease perioperative morbidity and mortality. Acute pain services (APS) are multidisciplinary teams that represent a modern strategy to address pain inside hospitals. The APS defines and applies pain treatment protocols specific for each surgery. To evaluate the performance of the APS at our institute, we performed a large retrospective cohort study focusing on complications of epidural analgesia and IV opiates. METHODS: Data from the 10 years of activity of the APS were collected. Pain was assessed using the VAS at rest (VASr) and during movement (VASm) at each daily visit; the presence of side effects and complications was also assessed. RESULTS: A total of 17,913 adult patients were followed by APS during the study period. Epidural analgesia was used in 7,776 cases (43%), while 9,239 (52%) patients used IV patient-controlled analgesia (PCA). A combination of the 2 was used in 87 patients (0.5%). A total of 456 perineural catheters (2.6%) were placed, while 442 patients(2.5%) used other analgesic techniques. We recorded 163 dural punctures during catheter placement, with no epidural hematoma, epidural abscess, or meningitis, and no permanent modification in sensitive or motor functions. CONCLUSIONS: In our large case series, APS was confirmed safe and effective in treating postoperative pain, using both epidural analgesia and IV PCA with morphine.

Islet transplantation stabilizes hemostatic abnormalities and cerebral metabolism in individuals with type 1 diabetes.

OBJECTIVE Islets after kidney transplantation have been shown to positively affect the quality of life of individuals with type 1 diabetes (T1D) by reducing the burden of diabetes complications, but fewer data are available for islet transplantation alone (ITA). The aim of this study was to assess whether ITA has a positive impact on hemostatic and cerebral abnormalities in individuals with T1D. RESEARCH DESIGN AND METHODS Prothrombotic factors, platelet function/ultrastructure, and cerebral morphology, metabolism, and function have been investigated over a 15-month follow-up period using ELISA/electron microscopy and magnetic resonance imaging, nuclear magnetic resonance spectroscopy, and neuropsychological evaluation (Profile of Mood States test and paced auditory serial addition test) in 22 individuals with T1D who underwent ITA (n = 12) or remained on the waiting list (n = 10). Patients were homogeneous with regard to metabolic criteria, hemostatic parameters, and cerebral morphology/metabolism/function at the time of enrollment on the waiting list. RESULTS At the 15-month follow-up, the group undergoing ITA, but not individuals with T1D who remained on the waiting list, showed 1) improved glucose metabolism; 2) near-normal platelet activation and prothrombotic factor levels; 3) near-normal cerebral metabolism and function; and 4) a near-normal neuropsychological test. CONCLUSIONS ITA, despite immunosuppressive therapy, is associated with a near-normalization of hemostatic and cerebral abnormalities.

31P-magnetic resonance spectroscopy (31P-MRS) detects early changes in kidney high-energy phosphate metabolism during a 6-month Valsartan treatment in diabetic and non-diabetic kidney-transplanted patients.

(31)P-magnetic resonance spectroscopy ((31)P-MRS) is a non-invasive tool to study high-energy phosphate (HEP) metabolism. We evaluate whether 31P-MRS can detect early changes in kidney HEP metabolism during a 6-month trial with Valsartan. Twenty consecutive stable and normotensive kidney-transplanted patients were enrolled. Nine of them received short-term low-dose Valsartan treatment (80 mg/day) for 6 months, while 11 controls received no medication. Kidney HEP metabolism was evaluated both at baseline and after treatment by (31)P-MRS with a 1.5 T system (Gyroscan Intera Master 1.5 MR System; Philips Medical Systems, Best, The Netherlands). Valsartan-treated patients (n = 9) showed a significant increase in ß-ATP/Pi ratio, a marker of kidney HEP metabolism (baseline = 1.03 ± 0.08 vs. 6 months = 1.26 ± 0.07, p = 0.03). In contrast, the b-ATP/Pi ratio in the control group (n = 11) did not change (baseline = 0.85 ± 0.10 vs. 6 months = 0.89 ± 0.08, ns). The improvement in the ß-ATP/Pi ratio was not associated with a reduction in arterial blood pressure or in urinary albumin excretion. Kidney-localized (31)P-MRS can detect early changes in kidney HEP metabolism during a short-term low-dose Valsartan treatment in stable normotensive kidney-transplanted patients.

Near normalization of metabolic and functional features of the central nervous system in type 1 diabetic patients with end-stage renal disease after kidney-pancreas transplantation.

OBJECTIVE: The pathogenesis of brain disorders in type 1 diabetes (T1D) is multifactorial and involves the adverse effects of chronic hyperglycemia and of recurrent hypoglycemia. Kidney-pancreas (KP), but not kidney alone (KD), transplantation is associated with sustained normoglycemia, improvement in quality of life, and reduction of morbidity/mortality in diabetic patients with end-stage renal disease (ESRD). RESEARCH DESIGN AND METHODS: The aim of our study was to evaluate with magnetic resonance imaging and nuclear magnetic resonance spectroscopy ((1)H MRS) the cerebral morphology and metabolism of 15 ESRD plus T1D patients, 23 patients with ESRD plus T1D after KD (n = 9) and KP (n = 14) transplantation, and 8 age-matched control subjects. RESULTS: Magnetic resonance imaging showed a higher prevalence of cerebrovascular disease in ESRD plus T1D patients (53% [95% CI 36-69]) compared with healthy subjects (25% [3-6], P = 0.04). Brain (1)H MRS showed lower levels of N-acetyl aspartate (NAA)-to-choline ratio in ESRD plus T1D, KD, and KP patients compared with control subjects (control subjects vs. all, P < 0.05) and of NAA-to-creatine ratio in ESRD plus T1D compared with KP and control subjects (ESRD plus T1D vs. control and KP subjects, P ≤ 0.01). The evaluation of the most common scores of psychological and neuropsychological function showed a generally better intellectual profile in control and KP subjects compared with ESRD plus T1D and KD patients. CONCLUSIONS: Diabetes and ESRD are associated with a precocious form of brain impairment, chronic cerebrovascular disease, and cognitive decline. In KP-transplanted patients, most of these features appeared to be near normalized after a 5-year follow-up period of sustained normoglycemia.

A competência da enfermeira para o cuidado ginecológico à mulher na Atenção Primária à Saúde / The nurse's competence for the gynecological care of women in Primary Health Care

Resumo: As enfermeiras atuantes na Atenção Primária à Saúde (APS) são habilitadas, capacitadas perante a lei e têm atribuições respaldadas na atenção à saúde das mulheres para promoverem o cuidado ginecológico. Faz-se necessário serem competentes para prover cuidado integral às mulheres, tornando-as protagonistas no cuidado recebido, as emponderando mediante conhecimentos, habilidades e atitudes para cuidar com qualidade e segurança, para acolher as necessidades da usuária em sua integralidade e promover cuidados baseados em evidências científicas. Assim, surgiu a inquietação no que tange à competência da enfermeira para realizar o cuidado ginecológico de enfermagem na APS com competência. Nesse sentido, elaborou-se a questão norteadora: Como desenvolver competência nas enfermeiras para atender as necessidades da mulher em sua integralidade durante o cuidado ginecológico na APS por meio da sistematização da assistência de enfermagem com base nas recomendações e diretrizes governamentais? Objetivo: Construir ações para promover o desenvolvimento de competência de enfermeiras no cuidado ginecológico à mulher na APS. Metodologia: Para delineamento metodológico deste estudo, utilizou-se a Pesquisa Convergente Assistencial, realizada na APS de um município da região metropolitana de Curitiba entre agosto e setembro de 2020. Contou com a participação de 31 enfermeiras que prestavam cuidado ginecológico direto e indireto. A coleta de dados se deu por meio de oficinas temáticas com apoio de um roteiro norteador e se utilizou, nesta etapa, o processo denominado Quatro Erres (Rs) proposto por Trentini e Paim. Para análise dos dados, foram seguidos os passos de John W. Creswell,apoiado com uso do software IRAMUTEQ®, pelo método da classificação hierárquica descendente. Resultados: Foram identificadas quatro classes distintas e para cada classe foi atribuída uma nomenclatura derivada da análise aprofundada, sendo denominadas: Classe 1 - "Conhecimento das competências para realização do cuidado ginecológico: facilidades e dificuldades"; Classe 2 - "Ambivalência para desenvolver as competências relacionadas ao cuidado ginecológico no processo de trabalho na saúde da mulher na APS: fatores satisfatórios e insatisfatórios"; Classe 3 - "O protagonismo e a autonomia da enfermeira para realizar o cuidado ginecológico com competência na consulta de enfermagem na APS"; e Classe 4 - "A percepção das enfermeiras sobre a importância da busca pelo conhecimento para cuidar com competência". Considerações finais: As enfermeiras compreendem a necessidade de integrar de forma convergente o saber-fazer-ser, para assim, atuar de forma autônoma e competentemente ao prestar o cuidado ginecológico com base em evidências científicas, garantindo qualidade no cuidado oferecido e visibilidade à profissão. O presente estudo alcançou o objetivo com a construção de Instruções Normativas para a consulta de enfermagem ginecológica na APS com competência, constituindo produto desta dissertação, indo ao encontro dos pressupostos do Programa de Mestrado e da Pesquisa Convergente Assistencial para fomentar melhorias no modo de cuidar, articulando pesquisa e prática profissional, de modo a ter enfermeiras competentes que agreguem valor à sociedade.

Abstract: Nurses working in Primary Health Care (PHC) are qualified, trained under the law and have attributions supported in women's health care to promote gynecological care. We understand that it is necessary to be competent to provide comprehensive care to women, making them protagonists in the care received, and empowering them. However, we understand that these professionals must have knowledge, skills and attitudes to care with quality and safety, as it welcomes the user's needs and promotes care based on scientific evidence. Thus, concern about the competence of the nurse to perform gynecological nursing care in PHC competently arose. In this sense, the guiding question was elaborated: How to develop competence in nurses to meet the needs of women in their entirety during gynecological care in PHC through the systematization of nursing care based on government recommendations and guidelines? Objective: Build actions to promote the development of nurses' competence in gynecological care for women in PHC. Methodology: For the methodological design of this study, we used the Convergent Care Research, carried out in the PHC of a municipality in the metropolitan region of Curitiba, between August and September 2020. It counted with the participation of 31 nurses, who provided direct and indirect gynecological care. Data collection took place through thematic workshops, with the support of a guiding script, and in this step the process called Quatro Erres (Rs) proposed by Trentini and Paim was used. For data analysis, the steps of John W. Creswell were followed, and it was supported with the use of the IRAMUTEQ® software, using the method of descending hierarchical classification. Results: Four distinct classes were identified; for each class, a nomenclature derived from the in-depth analysis was assigned, and they were called: Class 1 - "Knowledge of the skills to perform gynecological care: facilities and difficulties"; Class 2 - "Ambivalence to develop competencies related to gynecological care in the work process in women's health in PHC: satisfactory and unsatisfactory factors"; Class 3 - "The role and autonomy of the nurse to perform gynecological care with competence in the nursing consultation in PHC"; and Class 4 - "Nurses' perception of the importance of the search for knowledge to care competently". Final considerations: It was possible to show in this study that nurses understand the need to integrate know-how-to in a convergent way, in order to act autonomously and competently when providing gynecological care, based on scientific evidence, ensuring quality in the care offered and visibility to the profession. The present study achieved the objective with the construction of normative instructions for the consultation of gynecological nursing in PHC with competence, constituting the product of this dissertation, meeting the assumptions of the Master's Program and Convergent Care Research, to provoke improvements in the way of caring, articulating research and professional practice, in order to have competent nurses who add value to society.

Mistura de farinhas à base de cereais, para alimentação infantil: multifarinha / Flour mixing of the cereals, for infant food: multiflour

O trabalho teve como objetivo elaborar uma mistura de farinhas (multifarinha), com elevado valor energético-protéico, a ser usada como suplementação de crianças entre 02 a 05 anos atendidas pelo Programa do Leite. Foram desenvolvidas duas formulações de mistura de farinhas, uma a base de farinha de rosca (F1) e outra com farinha de trigo (F2). As amostras cruas foram avaliadas pela análise físico-química. Para as cozidas, foram preparados mamadeiras na concentração de 3 por cento m/V e creme na de 7 por cento m/V e submetidos à análise física e sensorial. Na análise físico-química das amostras cruas foram observados que ambas se encontram dentro dos limites da legislação em vigor. Na análise física as formulações tiveram resultados similares. Na análise sensorial pela ADQ na amostra F1 foi identificada como de melhor aparência, textura, sabor e aroma e no teste de ordenação apresentou diferença significativa ao nível de 5 por cento quanto ao sabor e textura em relação à F2, porém não diferiu do controle. Com base nos dados sugeriu-se a formulação F1 para ser utilizada na produção da multifarinha.

Apresentação da tuberculose pulmonar na criança: o diagnóstico em três casos

Objetivo: relatar a dificuldade no diagnóstico de tuberculose na criança, através da descrição de três casos de tuberculose pulmonar com apresentação radiológica e laboral pouco usual. Descrição: três crianças, inclusive um lactente de 4 meses, apresentaram um quadro respiratório de má resposta ao tratamento antibiótico convencional. Uma das crianças apresentava enfartamento ganglionar cervical. Os exames radiográficos de tórax foram sugestivos da doença, comprovada por avaliação de escarro (1 criança) e lavado brônquico (2 crianças). Sob tratamento evoluíram bem. Conclusões: o quadro de apresentação de tuberculose é variado, e exige suspeição contínua para o diagnóstico, que deve ter confirmação microbiológica