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1.
JAMA ; 322(3): 216-228, 2019 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-31310297

RESUMO

Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain. Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation. Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium. Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.


Assuntos
Delírio/prevenção & controle , Família/psicologia , Unidades de Terapia Intensiva/organização & administração , Visitas a Pacientes , Ansiedade , Brasil , Esgotamento Profissional , Cuidados Críticos/psicologia , Estudos Cross-Over , Depressão , Feminino , Educação em Saúde , Hospitalização , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
2.
Rev Soc Bras Med Trop ; 52: e20180514, 2019 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-31141055

RESUMO

INTRODUCTION: Travel medicine is aimed at promoting health risk reduction. However, travelers' perception of risk is subjective and may influence implementation of recommendations. This study reports on travelers' perception of risk, pre-travel characteristics, and recommended interventions. METHODS: This is a descriptive cross-sectional study. RESULTS: This study included 111 individuals. Most travelers (74%) perceived their risk as low. Significant differences in travel-related risk perception between practitioners and travelers were observed (Gwet's agreement coefficient [AC1] 0.23; standard error 0.10; 95% confidence interval 0.02-0.44). CONCLUSIONS: Future studies should investigate the relationship between travelers' perception of risk and implementation of recommendations.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Doença Relacionada a Viagens , Viagem/estatística & dados numéricos , Adulto , Brasil , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores Socioeconômicos , Vacinas/administração & dosagem
3.
BMC Infect Dis ; 19(1): 319, 2019 Apr 11.
Artigo em Inglês | MEDLINE | ID: mdl-30975092

RESUMO

BACKGROUND: The identification and management of cardiovascular risk factors became a major clinical issue among HIV-infected individuals in the post-cART era. As in the past decades the link between acute infections and cardiovascular diseases became clear in the general population, we sorted to investigate the role of severe infections on incident cardiovascular diseases (CVDs) among HIV-infected individuals. METHODS: HIV-infected individuals aged ≥18 years, with no history of CVD were followed from January 2000 to December 2013 until the occurrence of the first CVD event, death or end of study, whichever occurred first. To explore the effect of severe infections on the incidence of CVD we used extended Cox regression models and stratified post-hospitalization follow-up time into three periods: < 3 months, 3-12 months and > 12 months post discharge. RESULTS: One hundred-eighty four persons from 3384 HIV-infected individuals developed incident CVD events during the follow-up (incidence rate = 11.10/1000 PY (95%CI: 9.60-12.82)). Risk of an incident CVD was 4-fold higher at < 3 months post-hospitalization for severe infections (adjusted hazard ratio [aHR], 4.52; 95% confidence interval [CI] 2.46-8.30), after adjusting for sociodemographic and clinical factors as well as comorbidities. This risk remained significant up to one year (3-12 months post hospital discharge aHR 2.39, 95% CI 1.30-4.38). Additionally, non-white race/ethnicity (aHR 1.49, 95% CI 1.10-2.02), age ≥ 60 years (aHR 2.01, 95% CI 1.01-3.97) and hypertension (aHR 1.90, 95% CI 1.38-2.60) were associated with an increased risk of CVD events. High CD4 (≥ 500 cells/mm3: aHR 0.41, 95% CI 0.27-0.62) and cART use (aHR 0.21, 95% CI 0.14-0.31) reduced the risk of CVD events. CONCLUSIONS: We provide evidence for a time-dependent association between severe infection and incident cardiovascular disease in HIV-infected individuals. cART use, and high CD4 count were significantly associated with reduced hazards of CVD.


Assuntos
Doenças Cardiovasculares/etiologia , Infecções por HIV/complicações , Infecção/complicações , Adulto , Contagem de Linfócito CD4 , Doenças Cardiovasculares/epidemiologia , Comorbidade , Grupos Étnicos , Feminino , Infecções por HIV/epidemiologia , Hospitalização , Humanos , Hipertensão/epidemiologia , Incidência , Infecção/microbiologia , Infecção/virologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores de Risco
7.
Rio de Janeiro; s.n; 2013. xx,77 p. graf, ilus, tab.
Tese em Português | LILACS | ID: lil-762496

RESUMO

A terapia antirretroviral de alta potência (TARV) aumentou significativamente a sobrevida e a qualidade de vida dos pacientes portadores de HIV/AIDS, levando, por conseguinte, à cronificação da doença. Neste novo cenário epidemiológico, cresce a importância de complicações cardiovasculares como o infarto agudo do miocárdio e a trombose venosa profunda. A plaqueta tem papel central na gênese destas complicações e seu papel na infecção pelo HIV-1 começa a ser explorado na literatura. No presente trabalho objetivamos avaliar a função plaquetária durante a infecção pelo HIV-1, especificamente o grau de ativação, disfunção mitocondrial, morte celular, produção de óxido nítrico e resposta a estímulos agonistas. Para tal, avaliamos 30 voluntários saudáveis e 26 pacientes infectados pelo HIV- 1 em acompanhamento no Instituto de Pesquisa Clínica Evandro Chagas (IPEC) da Fundação Oswaldo Cruz (FIOCRUZ) de Janeiro de 2012 a Janeiro de 2013. Dentre os pacientes infectados avaliados, 17 apresentavam uso regular de TARV e tinham a carga viral para HIV-1 no sangue periférico indetectável (< 50 cópias/mm3 ) e 9 apresentavam carga viral para HIV-1 no sangue periférico detectável (> 50 cópias/mm3 ). Observamos que a plaqueta dos dois grupos de pacientes portadores de HIV/AIDS analisados exibe um aumento no perfil de ativação (expressão de P-selectina e exposição de fosfatidilserina), aumento na produção de óxido nítrico e menor indução da expressão de P-selectina após estímulo com trombina, quando comparada à resposta da plaqueta de indivíduos controles. Além disso, observamos sinais claros de ativação da via intrínseca de apoptose (diminuição do potencial de membrana mitocondrial, aumento na produção de superóxido mitocondrial, exposição de fosfatidilserina e ativação de caspase 9) mesmo com o controle da replicação viral, atingido com o uso regular de TARV...


The advent of highly active antiretroviral therapy (HAART) has increased life expectancy and the quality of life of patients living with HIV/AIDS. Now, new clinical data emphasizes long term complications of HIV-1 infection, such as cardiovascular diseases. Blood human platelets have a pivotal role in thrombus formation and their physiology during the course of HIV-1 infection has recently begun to be explored. The aim of the present study is to build up this literature by characterizing platelet activation, mitochondrial dysfunction, apoptosis and response to agonist stimulus in HIV/AIDS patients and control subjects. From January of 2012 to January of 2013 we included 30 healthy volunteers and 33 HIV-1 infected subjects from the outpatient clinic of Evandro Chagas Clinical Research Institute (IPEC), Oswaldo Cruz Foundation (FIOCRUZ). Among the HIV-1 population, 18 patients were under HAART therapy and had achieved virological suppression (viral load in peripheral blood < 50 copies/mm3 ) and 9 patients had uncontrolled viral replication (viral load in peripheral blood > 50 copies /mm3 ). We noted that HIV-1 infected individuals exhibit increased platelet activation (P-selectin expression and fosfatidilserine exposition), enhanced nitric oxide (NO) production and abnormal response to agonistic stimulus (thrombin). Moreover, we noted marked sigs of intrinsic apoptotic pathway activation (decreased transmembrane mitochondrial potential, increased superoxide production, fosfatidilserine exposure and caspase 9 activation) in patients under virological suppression achieved through HAART...


Assuntos
Humanos , Síndrome de Imunodeficiência Adquirida , Terapia Antirretroviral de Alta Atividade , HIV-1 , Ativação Plaquetária , Infarto do Miocárdio , Reação em Cadeia da Polimerase
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