Thesis (M.P.H.M. (Primary Health Care Management))--Mahidol University, 2008. / LICL has E-Thesis 0038 ; please contact computer services.

Thesis (M.H.A.)--University of Michigan, 1958.

Thesis (M.S.)--University of Michigan, 1980.

Thesis (M.S.)--University of Michigan, 1980.

Thesis (M.H.A.)--University of Michigan, 1958.

O estudo é qualitativo e foi desenvolvido a partir da observação e interação direta com pacientes internados na Unidade de Queimados - Emergência do Hospital das Clínicas - Faculdade de Medicina de Ribeirão Preto (USP). Teve como objetivos conhecer os significados que os pacientes atribuíam à vivência da queimadura e detectar o processo de ajuda que o enfermeiro de saúde mental pode estabelecer. As bases teóricas que nortearam o estudo, centraram-se nos fundamentos de ROGERS(1966), de VINOGRADOV & YALOM(1992) e na teoria de CAPLAN(1950). A amostra foi constituída por 13 adultos de ambos os sexos, diferentes idades, ocupações e procedências. Os dados foram obtidos mediante a entrevista individual não diretiva e reuniões em grupo, que serviram, também, como veículo da assistência de enfermagem de saúde mental. O material foi submetido à análise temática conforme preconizado por BARDIN(1977). Daí emergiram temas comuns no discurso dos pacientes propiciando o conhecimento sobre a experiência vivida. Foram comuns as alusões referentes ao banho, curativo e a cirurgia, cujas percepções e significados compuseram o que se denominou de ciclo da dor. Esteve presente ainda, o tema solidão relacionado a vínculos familiares e pessoas significativas e por fim, as percepções dos pacientes a respeito da assistência recebida pela equipe de saúde. A partir da vivência da pesquisadora, enquanto profissional que estabeleceu um processo interativo durante 3 meses, foi possível relatar a experiência de ser uma enfermeira de saúde mental junto a essa população e ampliar o auto-conhecimento através da avaliação crítica de suas intervenções terapêuticas. Recomenda-se que o enfermeiro esteja igualmente atento a manifestações de dor externa (física) e interna (emocional) dos pacientes. / This is a qualitative study and was developed from the observation and direct interaction with inpatients at the Unidade de Queimados - Emergência do Hospital das Clínicas - Faculdade de Medicina de Ribeirão Preto (USP). Had as objectives to know the meaning that the patients ascribed to the burning experience and to detect the aid process that the mental health nursing can establish. The theoretical foundations that guided the study were centered on ROGERS(1966), VINOGRADOV & YALOM(1992) and CAPLAN\'s(1950) theories. The sample was constituted by 13 adults of both sexes, different ages, occupations and origins. The data were obtained from individual non directive interview and group meetings, which also served as a vehicle for mental health nursing assistance. The material was submitted to a theme analysis as indicated by BARDIN(1977). From that, common topics arised from the patients speeches, giving us a knowledge of the living experience. References to the baths, dressings and surgery were common, and the perceptions and significances formed what we call pain cicle. The theme loneliness was also present related to family ties and significant people and, at last, the patients perceptions about the assistance received from the health staff. From the researcher\'s experience as a professional who established an interactive process during 3 months, it was possible to report the experience of being a mental health nurse with this population, and to enlarge self knowledge by a critical evaluation of one\'s therapeutic interventions. It is recommend that the nurse has to be alert to manifestations of the patient\'s external (physical) and internal (emotional) pain.

Introdução: Controle glicêmico estrito tem sido recomendado para pacientes gravemente enfermos. Entretanto, sua implementação pode ser difícil devido à sobrecarga da equipe de enfermagem, controle inadequado da glicemia e aumento do risco de hipoglicemia. Objetivos: Avaliar a eficácia e segurança de três protocolos de administração de insulina para controle glicêmico em pacientes clínicos admitidos em unidades de terapia intensiva (UTI). Métodos: Foram incluídos pacientes clínicos admitidos em UTI com ao menos uma glicemia maior ou igual a 150mg/dl e pelo menos uma das seguintes características: estar sob ventilação mecânica; politraumatismo; grande queimadura; apresentar ao menos 3 critérios de síndrome da resposta inflamatória sistêmica. Esses indivíduos foram alocados aleatoriamente para um dos seguintes tratamentos: protocolo A insulina regular endovenosa contínua (IREVC) visando manter glicemias entre 100mg/dL e 130mg/dL, com ajustes guiados por software para microcomputador ou handheld device; protocolo B - IREVC visando manter glicemias entre 80mg/dl e 110mg/dl; protocolo C insulina intermitente subcutânea, a partir de glicemias maiores do que 150mg/dl. Para cada paciente as medidas repetidas de glicemia foram sumarizadas como mediana. A avaliação de eficácia foi realizada comparando-se as médias de medianas de glicemia entre os grupos. A segurança foi avaliada comparando-se a incidência de hipoglicemia (40 mg/dl) entre os grupos. Resultados: Foram incluídos 167 pacientes. As médias e desvios-padrão calculados a partir das medianas de glicose foram de 125,0±17,7 mg/dl, 127,1±32,2mg/dl e 158,5±49,6 mg/dl para os pacientes alocados para os protocolos A, B e C, respectivamente (P<0,001 para comparação entre grupos A, B e C; P=0,34 para comparação entre grupo A e B). A incidência de hipoglicemia foi de 12 casos (21,4%) no protocolo A, 24 casos (41,4%) no protocolo B e 2 casos (3,8%) no grupo C (P<0,001 para comparação entre protocolos A, B e C; P=0,02 para comparação A versus B). Não houve diferenças de mortalidade ou quanto a outros desfechos clínicos entre os protocolos; exceto diferenças marginais na quantidade de dias sob noradrenalina (protocolo C<A<B). Conclusões: O protocolo de infusão de insulina com ajustes guiados por software para computador (protocolo A) permite controle tão eficaz da glicemia quanto o protocolo padrão de controle glicêmico estrito (protocolo B), mantendo a glicemia em níveis pós-prandiais normais (80-140 mg/dl), com menor risco de episódios de hipoglicemia. Hipoglicemia foi rara entre os pacientes do protocolo C, porém os níveis de glicemia foram maiores do que entre os pacientes tratados com o protocolo A ou B / Introduction: Strict glycemic control has been recommended for critically ill patients. However, its implementation may face difficulties with increased nursing workload, inadequate blood glucose control and higher risk of hypoglycemia. Objectives: To evaluate the efficacy and safety of three insulin protocols in medical ICU patients (MICU). Methods: MICU patients with at least one blood glucose of at least 150 mg/dL and one or more of the following characteristics were included: mechanical ventilation; at least three criteria for systemic inflammatory response syndrome; admitted because of trauma or burn. Patients were randomized to one of the following treatments: protocol A - continuous insulin infusion with adjustments guided by handheld device or desktop software targeting blood glucose levels between 100mg/dL-130mg/dL; protocol B continuous insulin aiming blood glucose levels between 80mg/dl-110mg/dl; protocol C conventional treatment intermittent subcutaneous administration of insulin if blood glucose levels exceeded 150mg/dL. Efficacy was measured by the mean of patients median blood glucose and safety was measured by the incidence of hypoglycemia (40 mg/dL). Results: 167 patients were included. Mean and standard deviation of patients median blood glucose was 125.0±17.7 mg/dl, 127.1±32.2mg/dl and 158.5±49.6 mg/dl for protocols A, B and C, respectively (P<0.001 for all protocol comparison; P=0.34 for protocol A versus B). 12 patients (21,4%) evolved with at least one episode of hypoglycemia in protocol A, 24 (41.4%) in protocol B, and 2(3.8%) in protocol C (P<0.001 for all protocol comparison; P=0.02 for protocol A versus B). There were no differences regarding mortality or other clinical outcome, except for a marginal difference on the number of days on norepinephrine (C < A < B). Conclusions: A computer guided insulin infusion protocol protocol A causes less episodes of hypoglycemia than and is as efficacious as the standard strict glycemic control protocol protocol B for controlling glucose at normal non-fasting levels (80 mg/dL 140mg/dL) in MICU patients. Hypoglycemia was rare under protocol C, however blood glucose levels were higher than protocol A or B

Traumatic brain injury is a substantial cause of disability worldwide; recovery is a long-term, intensive process. Patients with traumatic brain injury are admitted to inpatient rehabilitation with the goal of preventing disability and the need for long-term care as well as promoting patient independence. Acknowledging that traumatic brain injury also affects the family, much of the literature focuses on the well-being of families and their needs, bringing attention to family functioning, resilience, and psychosocial well-being. Recognizing the important role of families in health care, Canadian healthcare institutions espouse family-centred philosophy. Not to mention, the resulting impairments from traumatic brain injury and the complex nature of inpatient rehabilitation can also lead to the involvement of families in this process. However, we do not yet fully understand how families are involved in adult inpatient traumatic brain injury rehabilitation. Given the adoption of a family-centred philosophy as well as the potential benefits of family-centred care for patient and family outcomes, it is important to understand this involvement to guide the provision of family-centred health and rehabilitation services. This study is the first step in a program of research that is devoted to understanding family involvement in adult inpatient traumatic brain injury rehabilitation. I used an interpretive qualitative approach with a two-phased sequential design to elucidate how families were involved in the inpatient rehabilitation process. I conducted one-on-one semi-structured interviews with six patients with TBI, four family members, and 10 healthcare professionals followed by observations on the inpatient Acquired Brain Injury ward at a Canadian adult rehabilitation centre. In Phase 1 interviews, both the patients and family members described family involvement as family members being with and supporting the patients, informing other family members as well as the healthcare professionals and keeping themselves informed, helping the patients to make decisions, and participating in care and therapy. The healthcare professionals similarly described family members being with and supporting the patients; however, they conversely illustrated family members’ involvement as providing information to and receiving information from the healthcare professionals as well as making decisions when required or deemed necessary by them, and learning care and therapy. While the observation findings supported the patients’, family members’, and healthcare professionals’ perceptions that family members support the patients by being present and spending time with them, they highlighted the healthcare professional-led nature of the rehabilitation process in the inpatient setting in relation to information sharing, decision making, and care and therapy. They also illuminated the potential impact of the ward environment on family involvement. This study was the first to explore family involvement with this adult patient population in the inpatient rehabilitation setting from the perspectives of patients, family members, and healthcare professionals as well as through direct observation. It revealed that patients and family members had different understandings than healthcare professionals of the ways in which families were involved. Given the adoption of a family-centred philosophy, we need to understand how to operationalize it in this type of adult setting and close the gap between theory and practice.

Colon cancer is a significant risk factor for development of venous thromboembolism (VTE). We assessed trend and outcomes of VTE among hospitalized patients with colon cancer from a Nationwide Inpatient Sample. VTE is associated with higher inpatient mortality and disability but not with length of stay. Hospitalization related to VTE in colon cancer is increasing but mortality continues to decline. Introduction Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalized patients with colon cancer. We assessed nationwide population-based trends in rates of hospitalization and mortality from VTE among patients with colon cancer to determine its impact. Methods We queried the Nationwide Inpatient Sample (NIS) database entries from 2003 to 2011 to identify patients with colon cancer. Bivariate group comparisons between hospitalized patients with colon cancer with VTE to those without VTE were made. Multivariate logistic regression analysis was used to obtain adjusted odds ratios. The Cochrane-Armitage test for linear trend was used to assess occurrences of VTE and mortality rates among patients with colon cancer. Results The total number patients with colon cancer was 1,502,743, of which 41,394 (2.75%) had VTE. The median age of the study population was 69 years; 51.5% were women. After adjusting for potential confounders, compared with those without VTE, patients with colon cancer with VTE had significantly higher inpatient mortality (6.26% vs. 5.52%, OR 1.15, P < .001) and greater disability at discharge (OR 1.38, P < .001), but were not associated with longer length of stay (LOS) or cost of hospitalization. From 2003 to 2011, despite an increase in hospitalization rate with VTE in patients with colon cancer, their mortality steadily declined. Conclusion VTE in hospitalized patients with colon cancer is associated with a significantly higher inpatient mortality and greater disability, but not with longer LOS or cost of hospitalization. Furthermore, even though there has been a trend toward more frequent hospitalizations in this patient population, their mortality continues to decline.

Background: Groote Schuur Hospital (GSH) Division of Dermatology receives many referrals from local clinics and hospitals. Some of these patients are admitted to the dermatology wards for diagnosis and/or management. It is important to look at the spectrum and outcome of these patients who are admitted to dermatology wards at the hospital, to inform policy. Objectives: To characterise the spectrum of dermatological conditions requiring admission, to determine the outcome and to describe the factors that may influence the outcome of dermatological conditions in patients admitted to the dermatology wards at Groote Schuur Hospital in South Africa. Methods: This research employed descriptive retrospective analysis to describe the dermatology inpatients who were admitted to dermatology wards at Groote Schuur Hospital over the period January 2017 to December 2017. Results: There were a total of 120 admissions to Groote Schuur Hospital Dermatology wards in 2017. Of these, 89 (74.1%) were new admissions and 31 (25.8%) re-admissions. The most frequent diagnosis was drug reaction (27.5%), followed by psoriasis (23.3%), eczema (17.5%), and bullous disease (10%). Less common indications for admission were infections, lupus erythematosus, scabies, ulcers, pyoderma gangrenosum and cutaneous small-vessel vasculitis. The outcome of the admission was usually favorable. Conclusions: The most common diagnoses on admission were drug reactions, psoriasis, eczema, and bullous diseases. The generally favorable outcomes would support the future use of inpatient care for people with severe skin disorders.