Introdução. A progressão da síndrome metabólica (SMet) para a doença cardiovascular é complexa, multifatorial e pode estar associada, em parte, com a hiperativação simpática e com a diminuição da sensibilidade barorreflexa (SBR), mecanismos fortemente associados à hipertensão arterial (HAS). Adicionalmente, na hipertensão a resposta da pressão arterial (PA) durante o teste de esforço cardiopulmonar máximo (TECP) e na pressão arterial de 24h (MAPA) está prejudicada. Não é conhecido se pacientes com SMet mas sem hipertensão, apresentam estes prejuízos. Hipóteses. Pacientes com SMet com nível normal de PA clínica apresentam:(1) Resposta aumentada da PA pico e da PA de recuperação em resposta ao exercício máximo; (2) Prejuízo na PA de 24 horas Além disso, analisamos se estas alterações se correlacionam com a atividade nervosa simpática muscular (ANSM) e com a SBR. Métodos. Foram selecionados 72 pacientes recém-diagnosticados com SMet (ATP III), alocados em 3 grupos conforme a classificação da PA (segundo as Diretrizes 2013 ESH/ESC):, SMet hipertensos (HT, n=16, 51±9 anos, 33±4 kg/m2), SMet pré-hipertensos (PHT, n=29, 47±10 anos, 31±3 kg/m2) e SMet normotensos (NT, n=27, 46±7 anos, 32±4 kg/m2). Um grupo controle (C, n=19, 48±2 anos, 25±2 kg/m2) pareado por gênero e idade foi envolvido no estudo. Foram avaliados: a ANSM (microneurografia); a SBR (análise das flutuações espontâneas da PA sistólica e FC) para aumentos (SBR+) e diminuições da PA (SBR-); medidas auscultatórias da PA no pré-teste, pico, 1°, 2° e 4° min de recuperação (TECP); e PAS e PAD de 24 horas, vigília, sono e despertar (MAPA de 24h). O estudo foi dividido em duas partes: Parte 1 - todos os grupos com SMet (HT, PHT e NT) e C foram estudados; e Parte 2 - somente o grupo SMet NT foi comparado ao C. Resultados - Parte 1. Os grupos SMet (HT, PHT e NT) foram semelhantes entre si e apresentaram prejuízo quando comparado ao grupo C nas características físicas, na capacidade física e nos fatores de risco da SMet. Na PAS pico atingida no TECP, o grupo SMet HT apresentou valores superiores quando comparado com SMet PHT, NT, e C (217±23 vs. 202±22; 195±17; 177±24 mmHg; respectivamente; P=0,03). Apresentaram resposta da PAS exagerada (PAS >190 mmHg para mulheres e > 210 mmHg para homens) 81% no grupo HT, 55% no PHT, 37% no NT e 21% no C. Na MAPA, SMet HT apresentou maior PA de 24h que os outros 3 grupos. (P < 0,001). A ANSM foi maior nos grupos SMet HT, PHT e NT quando comparados ao C (33±7; 30±7; 29±6; vs. 18±1 disparos/min, respectivamente, P < 0,001). Somente o grupo SMet HT apresentou menor SBR+ quando comparado ao grupo C (6±3; 8±3; 9±3; vs. 11±5 mmHg/ms; P=0,002). Os grupos SMet HT e PHT apresentaram menor SBR-, enquanto SMet NT foi semelhante ao C (7±2; 9±4; 10±3; vs. 12±5 mmHg/ms; P < 0,05). Houve correlação entre a SBR- e a PAS pico (r=-0,32, P=0,04) com todos os sujeitos dos grupos da SMet e C. Resultados Parte 2. Exceto na PAS no 4º min de recuperação, o grupo SMet NT apresentou maior PAS e PAD comparado ao C em todos os momentos do TECP. O comportamento da PAS e PAD pela área sob a curva (ASC) total foi maior no SMet NT comparado ao C. Na MAPA de 24h, SMet NT apresentou menor PAD no sono que C. Além disso, SMet NT apresentou menor SBR+ e SBR- e maior ANSM comparado ao C. Interessantemente, no subgrupo de pacientes com SMet NT (n=10, 37%) que apresentou PAS pico exagerada a SBR- se correlacionou fortemente com a PAS pico (r=-0,70, P=0,02) e com a PAS no 1º min de recuperação (r=-0,73, P=0,04). Conclusão: Pacientes com SMet, mesmo normotensos, já apresentam resposta exacerbada da PAS e da PAD durante o TECP, dos quais 40% com PAS pico exagerada. A disfunção autonômica pode explicar, pelo menos em parte, esta reposta exacerbada / Introduction. The progression of the metabolic syndrome (MetS) to cardiovascular disease is complex, multifactorial and may be associated in part with sympathetic hyperactivation and reduced baroreflex sensitivity (BRS), mechanisms strongly associated with arterial hypertension (AH). Additionally, in hypertension, the BP response during the maximal cardiopulmonary exercise test (CPET) and 24h BP (ABPM) is impaired. It is not known whether patients with MetS but without hypertension present those damages. Hypotheses. Patients with MetS with normal clinical BP level present: (1) Increased response of peak BP and recovery BP in response to maximal exercise; (2) Impaired 24 hour BP. In addition, we analyzed if those changes are associated with muscle sympathetic nerve activity (MSNA) and BRS. Methods. We selected 72 newly diagnosed patients with MetS (ATP III), subdivided in 3 groups according to the BP classification (according to the ESH/ESC Guidelines): hypertensive MetS (HT, n=16, 51±9 years, 33±4 kg/m2), pre-hypertensive MetS (PHT, n=29, 47± 10 years, 31±3 kg/m2) and normotensive MetS (NT, n= 27, 46±7 years, 32±4 kg/m2). A control group (C, n=19, 48±2 years, 25±2 kg/m2) paired by gender and age was involved in the study. The following were evaluated: the MSNA (microneurography); BRS (analysis of spontaneous fluctuations of systolic BP and HR) for increases to BP (SBR+) and for decreases to BP (SBR-); BP auscultatory measurements in the pre-test, peak, 1st, 2nd and 4th min of recovery (CPET); and SBP and DBP of 24 hours, wakefulness, sleep and awakening (24-hour ABPM). The study was divided into two parts: Part 1. All groups with MetS (HT, PHT and NT) were studied; and C group. Part 2. Only the NT MetS group was compared to the C. Results Part 1. The MetS groups (HT, PHT and NT) were similar and were impaired compared to group C in physical characteristics, physical capacity and risk factors of MetS. In the peak SBP reached at CPET, HT MetS group presented higher values when compared to PHT and NT MetS groups and C (217±23 vs. 202±22, 195±17, 177±-24 mmHg, respectively, P=0.03). There was an exaggerated SBP response (SBP > 190 mmHg for women and > 210 mmHg for men) in 81% of the HT group, 55% of the PHT, 37% of the NT and 21% of the C group. In the ABPM, HT MetS had a higher 24-hour BP than the other 3 groups (P < 0.001). The MSNA was higher in HT, PHT and NT MetS groups when compared to C (33±7, 30±7, 29±6, vs. 18±1 burst/min, respectively, P < 0.001). Only the HT MetS group showed lower SBR+ compared to C (6±3, 8±3, 9±3, vs. 11±5 mmHg/ms, P=0.002). The HT and PHT MetS groups presented lower SBR-, while NT MetS was similar to C (7±2; 9 ±4; 10±3, vs. 12±5 mmHg/ms; P < 0.05). There was a correlation between SBR- and peak SBP (r= -0.32, P=0.04) with all subjects from the MetS and C groups. Results Part 2. Except for SBP in the 4th min of recovery, NT MetS presented higher SBP and DBP compared to C at all moments of the CPET. The SBP and DBP responses by AUC analysis were higher in NT MetS compared to C. In 24h ABPM, NT MetS presented lower DBP in the sleep than in C. In addition, NT MetS presented decreased SBR+ and SBR- and increased MSNA compared with C. Interestingly, in the NT MetS subgroup of patients (n=10, 37%) who showed an exaggerated peak SBP, showed a negative correlation between BRS- and peak SBP (r=-.70; P=0.01) and SBP at 1st minute of recovery (r=.73; P=0.04). Conclusion. Patients with MetS, even normotensive, already present an exacerbated SBP and DBP response during CPET, of which 40% with exaggerated peak SBP. Autonomic dysfunction may explain, at least in part, this exacerbated response

O transplante cardíaco permanece sendo o procedimento de escolha para a insuficiência cardíaca refratária, apresentando resultados favoráveis em termos da sintomatologia, qualidade de vida e sobrevida desses pacientes. A hipertensão arterial sistêmica aparece como a comorbidade de maior incidência neste grupo de pacientes, chegando a 95% após cinco anos. O efeito do exercício físico sobre a dinâmica do comportamento tensional na monitorização da pressão arterial ambulatorial durante 24 horas (MAPA-24h) e da rigidez arterial não tem sido estudado neste grupo de pacientes. Nós avaliamos os efeitos da atividade física aeróbia sobre a dinâmica do comportamento tensional na MAPA-24h, rigidez arterial e as variáveis cardiovasculares em indivíduos após um ano de transplante cardíaco. Trinta e nove pacientes de ambos os sexos, randomizados para grupo treino (GT) (n = 29; 45 ± 13 anos) ou grupo controle (GC) (n = 9; 51 ± 11 anos) realizaram, antes e após o período de 12 semanas de seguimento, exames de MAPA-24h, velocidade de onda de pulso carótido-femoral (VOP) e teste de esforço cardiopulmonar, com coletas de amostras sangüíneas para dosagem de norepinefrina (Nor) (repouso e pico). Treinamento físico aeróbio foi realizado três vezes por semana, sendo duas supervisionadas e uma não supervisionada, durante 40 minutos inicialmente com a frequência cardíaca monitorada em 80% do ponto de compensação respiratória. O GT apresentou redução significativa da pressão arterial sistólica nos períodos da média das 24 horas (de 120 ± 11 para 116 ± 14mmHg, p<0,05) e vigília (de 123 ± 11 para 118 ± 13mmHg, p<0,05). A pressão arterial diastólica apresentou redução significativa para os três períodos sendo na média das 24 horas (de 81 ± 9 para 74 ± 9mmHg, p< 0,001), vigília (de 83 ± 9 para 75 ± 10mmHg, p<0,001) e noturno ( de 77 ± 10 para 71 ± 10mmHg, p<0,001). A VOP não apresentou redução significativa após o período de seguimento para ambos os grupos; GT (de 10,0 ± 1,9 para 9,7 ±1,9m/s, p = ns) e GC (de 10,3 ± 2,2 para 10,4 ± 2,8m/s, p = ns), porém os níveis da Nor tiveram aumento significativo no pico do exercício no grupo GT (de 2386 ± 1274 para 3292 ± 1410 pg/ml p<0,01) e também em relação ao grupo GC pós seguimento (3292 ± 1419 versus 2178 ± 659 pg/ml, p<0,05). O treinamento físico aeróbio reduziu a pressão arterial sistólica/diastólica em 4,7/7,5 mmHg durante a vigília e em 3,5/5,8 mmHg durante o sono após TX, além de melhorar o condicionamento cardiorrespiratório com aumento do VO2pico, FCmáx e do tempo de exercício. / Cardiac transplantation remains the procedure of choice for refractory heart failure, with favorable results in terms of symptoms, quality of life and patient survival. Hypertension appears as a higher incidence of comorbidity in this group of patients, reaching 95% after five years. However, the effect of exercise training in the behavior of 24-hour ambulatory blood pressure monitoring (ABPM) and arterial stiffness has not been studied in this group of patients. We assessment the effects of aerobic physical activity in the behavior of ABPM, arterial stiffness and cardiovascular variables in patients being heart transplanted for a year or more. Thirty-nine patients of both genders were evaluated, then randomized to either training group (TG) (n = 29, 45 ± 13 years) or control group (CG) (n = 9, 51 ± 11 years) and reevaluated after 12 weeks of follow-up. Pre and post evaluations combined examinations of ABPM, carotidfemoral pulse wave velocity (PWV) and graded exercise test, with collections of blood samples for measurement of norepinephrine (Nor) (rest and peak). Aerobic exercise was performed in the TG three times-a-week, two supervised and one unsupervised for 40 minutes initially at an intensity of 80% of heart rate achieved at the respiratory compensation point. The TG showed a significant reduction in systolic blood pressure during average of 24 hours (from 120 ± 11 to 116 ± 14mmHg, p < 0.05) and diurnal cycle (from 123 ± 11 to 118 ± 13mmHg, p<0.05). Diastolic blood pressure decreased significantly for the three periods, the average of 24 hours (from 81 ± 9 to 74 ± 9mmHg, p<0.001), diurnal cycle (from 83 ± 9 to 75 ± 10mmHg, p < 0.001) and nighttime (from 77 ± 10 to 71 ± 10mmHg, p < 0.001). The PWV showed no significant reduction after the followup period for both groups; TG ( from 10.0 ± 1.9 to 9.7 ± 1.9m/s, p = ns) and CG (from10.3 ± 2.2 to 10.4 ± 2.8m/s, p = ns) and the levels of the Nor had a significantly higher peak exercise in TG (from 2386 ± 1274 to 3292 ± 1410 pg/ml p <0.01) and also in relation to the control group after follow-up (3292 ± 1419 versus 2178 ± 659 pg / ml, p <0.05). The exercise training reduced both systolic and diastolic blood pressure in 4.7 and in 7.5 mmHg during daytime, respectively. Reduction also happened during nighttime in 3.5 and in 5.8 mmHg for these variables, respectively. Exercise training improved VO2peak, HRmax and time of exercise (cardiorespiratory fitness) after follow-up, as well.

A demanda por procedimentos médicos gerados pela transformação dos perfis etários e de morbi-mortalidade das populações tem forçado uma escalada contínua dos custos da assistência que atingem limites críticos em relação à disponibilidade de recursos. É neste contexto onde a priorização é a regra e o desperdício inaceitável, que métodos de otimização vem sendo desenvolvidos, dentre eles o “Audit and feedback”. De um total de 176 médicos de uma regional de cooperativa, 130 constituíram a amostra para estudo Quase-experimento com total de dois anos de seguimento (2004- 2005). As informações tratavam do “Índice de Solicitações de Serviços Auxiliares de Diagnose e Terapia” (Is SADT) e eram fornecidas de modo que cada profissional sabia qual era a sua posição dentro do grupo da mesma especialidade, mas não tinha condições de identificar os demais. Apesar do número absoluto de SADT realizados ter sido no mínimo o quádruplo do esperado para a população de beneficiários, o retorno de informações visando à conscientização pelo método “Audit and Feedback” não foi capaz de provocar diferenças significas nas solicitações de procedimentos nos diferentes grupos de médicos, conforme constatado após análise estatística. Não se evidenciou nenhuma relação significativa das variáveis independentes deste estudo (sexo, tempo de formado e tempo de cooperado), com os Índices de Solicitações de SADT dos médicos que estavam acima ou abaixo da mediana nos diferentes estratos. Persiste como desafio, a comprovação do fator ou fatores responsáveis por esta resposta. Propõe-se um conjunto de ações a serem associadas, uma vez que o processo de conscientização isoladamente foi inócuo. / Changing age, morbidity and mortality profiles of populations have caused an increase in the demand for medical procedures and a continuous increase in the cost of health services that is reaching limits in terms of available resources. It is in the context of prioritization as the rule and waste as unacceptable that optimization methods have been developed, among them “audit and feedback”. Of a total of 176 physicians of a regional cooperative, 130 were included in the study sample. The procedure ordering behaviour of each physician in the sample was monitored during all of 2004 and 2005. Audit: each month the an “index of solicitations for auxiliary diagnostic and treatment services”, or SADT, basically the average number of orders per consultation for the month, was calculated for each physician. Feedback: SADT for all participating physicians, organized by speciality and rank, were sent to each participating physician. The results were presented in a way that each physician could locate themselves in the ranking without being able to identify where any other physicians placed in the ranking. Despite absolute number of SADT on average fourfold that expected for the demographic profile of the population being served, statistical analysis of the results showed that the “Audit and Feedback” optimization method did not have a significant effect on the ordering behaviour of physicians or in the sample, un-grouped or grouped by speciality, gender, time in practice or time in the cooperative. Nor did grouping according the whether and individual physician was initially above or below the median SADT reveal any significant effect of the method on ordering behaviour. The results do show that factors other than how a physician's individual SADT compares to that of his or her peers, determines their procedure ordering behaviour. Identifying these factors remains an important challenge in the context of health services optimization.

O sistema de saúde vem se transformando pressionado por mudanças sociodemográficas, políticas e econômicas. Essas modificações impõem aos gestores a necessidade de conhecer de maneira particularizada o perfil de demandas da população usuária. Neste contexto, o presente estudo tem por objetivo identificar o padrão e as características de utilização de um serviço de atenção primária à saúde a nível ambulatorial. Como objetivos específicos buscou-se traçar o perfil sociodemográfico dos usuários de unidades de APS, avaliar os motivos das consultas, identificar o tipo de atendimento utilizado e a categoria profissional responsável pelo atendimento, avaliar a relação das consultas com as ações programáticas desenvolvidas nos serviços de saúde e identificar a associação entre a vulnerabilidade da área de moradia e os motivos de consulta. Foi realizado um estudo transversal com dados retrospectivos do Serviço de Saúde Comunitária do Grupo Hospitalar Conceição (SSC-GHC). A fonte primária foi o Boletim de Atendimento(BA), emitido para cada consulta efetuada no período de 1/01/2011 a 31/12/2011. O total de consultas avaliadas foi de 34.014 realizadas em duas unidades da Zona Norte de Porto Alegre por profissionais de nível superior de diferentes categorias profissionais. . A fonte primária do banco de dados foi o BA, emitido para cada atendimento ambulatorial. A análise dos dados foi feita com o programa estatístico SPSS versão 18.0. A análise descritiva respeitou as características e a distribuição das variáveis. As variáveis contínuas e com distribuição normal foram descritas por meio da média e desvio padrão e as variáveis contínuas e sem distribuição normal foram apresentadas como mediana (intervalo interquartil). As variáveis categóricas foram descritas como números absolutos. O número total de consultas efetivadas foi de 34.014, realizadas por 5.033 pessoas com cadastro nas unidades. A participação de moradores de área de risco foi de 31,3%. O número de pessoas consideradas hiperutilizadores - com mais de 6 consultas/ano - foi de 2.216 (44%). Os hiperutilizadores realizaram 78% das consultas. Estavam presentes hiperutilizadores em 53,7% das famílias. Os hiperutilizadores tinham como característica predominante ser mulher (67,8%), pertencer à faixa etária dos 20 aos 49 anos ou de mais de 60 anos. Os problemas relacionados à saúde mental e comportamental têm um percentual mais elevado entre os usuários hiperutilizadores, (6,9% vs 3,5%). O profissional mais procurado foi o médico (59,3%) seguido pelo odontólogo (27,5%). Os motivos de consulta encontrados são semelhantes no grupo de hiperutilizadores e não hiperutilizadores e distribuídos dentro do esperado para as faixas etárias. / The health system has been undergoing transformation due to sociodemographic, political and economic changes. These alterations impose to managers the need to individually know the demand profile of the user population. In this context, the present study aims to identify the use pattern and characteristics in primary health care service at ambulatorial level. As for specific objectives, this research intended to develop the sociodemographic profile of Primary Health Care (PHC) units users, evaluate the reasons for consultations, identify the type of service utilized and the professional category responsible for providing the service, assess the relationship between consultations and the programmatic actions performed by health services as well as to identify the association between the vulnerability of the housing area and the reasons for consultation. A cross-sectional study was conducted with retrospective data from the Community Health Service of the Conceição Hospital Group (SSC-GHC). The primary source was the outpatients' charts issued for each consultation in the period between 1/1/2011 and 12/31/2011. The study comprised a total of 34,014 consultations performed in two units of the North Region of Porto Alegre by professionals with tertiary education from different occupational categories. The main objective of this study was to identify use pattern and characteristics of primary health care services at ambulatorial level. The specific objectives were to develop the sociodemographic profile of PHC units users, evaluate the reasons for consultations, identify the type of service utilized and the professional category responsible for providing the service, assess the relationship between consultations and the programmatic actions performed by health care services as well as to identify the association between the vulnerability of the housing area and the reasons for consultation. The primary source of the database was the chart issued for each outpatient’s ambulatory care. The data analysis was realized with the SPSS statistics software version 18.0. The descriptive analysis considered the characteristics and distribution of variables. The continuous variables with normal distribution were described through averages and standard deviation whilst the continuous variables without normal distribution were presented as median (interquartile range). Categorical variables were described as absolute numbers. The total number of consultations was 34,014 referring to 5,033 people registered in the units. The participation of risk area residents was 31.3%. The number of people considered frequent users - with more than 6 consultations per year - amounted to 2,216 (44%). The frequent users accounted for 78% of the consultations. They were present in 53.7% of households. Frequent users were predominantly women (67.8%), belonging to the age group ranging from 20 to 49 years old or over 60. Mental and behavioral health related issues have a higher percentage among frequent users (6.9% vs. 3.5%). The most requested professional was the physician (59.3%) followed by the odontologist (27.5%). The reasons for consultation found are similar in both frequent and non-frequent users and distributed within the expected for the age groups.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Introduction.The study of quality of health services constitutes a major change tool and incentive for health care services, such as pharmaceutical services, meet minimum quality standards and promote a renewal of its work culture. In Brazil, however the development and evaluation of the quality of services such as Medication Review is still in its infancy and needs to be implemented aiming to improve the practices of patient care. Aim. Evaluate structure and process indicators in the implementation of Medication Review services of the ambulatory of a university hospital. Methods. The study was structured in three stages from February 2012 to March 2015. The first stage corresponded to a methodological development research, in which structure and process indicators were collected from national and international literature for use in evaluating the Medication Review services.The second stage corresponded to translation to Portuguese and the transcultural adaptation to Brazil of Scale of Attitudes Toward Physician-Pharmacist Collaboration . The third stage corresponded to a longitudinal study evaluating the process of a collaborative practice model of Medication Review service in the ambulatory of a University Hospital of Sergipe. Results. From the literature (stage 1) were surveyed in the study, 28 indicators divided into structure criteria: physical installations, human resources, material resources, documentation and financing. The evaluation of the structural indicators of Medication Review service showed that the ambulatory has met most of the criteria submitted. About the process was able to gather 54 indicators divided into two categories: 21 technical-managerial indicators and 33 technicalassistance indicators. The second stage resulted in a translated and adapted scale for the Portuguese of Brazil used to evaluate the collaborative attitudes of pharmacists and physicians. In the third stage, the analysis of Medication Review service found that 146 patients were treated on average 2.1 ± 1.1 times during the study.The prescriptions of these patients contained3,3±1,9 drugs and24,5% of them had five or more drugs. The study identified 366 drug therapy problems (DTPs) and most frequent was a indication category (67,5%) and it was observed that patients who have had four to five pharmaceutical consultations has 1.14 times more likely to have identified their DTPs (χ2= 33,83; p<0,0001). Moreover, the analysis showed that patients who had between 1-2 pharmaceutical consultations had 1.22 times more likely to have not resolved their DTPs when compared to the group with more than 3 pharmaceutical consultations (χ2= 3,44; p<0,05). This study also reported 173 pharmaceutical interventions, of which 52,6% were intended for physicians, 46,2% for students of medicine and the most of them were accepted (98,7%). Conclusion. The structure and process indicators may be used to evaluate the implementation of Medication Review service. The pharmacist can collaborate with physicians identifying and solving DTPs, as well as assisting in the monitoring and decision making on pharmacotherapy, benefiting the patient. / Introdução. O estudo da qualidade e da implementação de serviços de saúde configura um importante instrumento de mudança e incentivo para que os serviços de atenção à saúde, como os serviços farmacêuticos, cumpram padrões mínimos e promovam uma renovação da sua cultura de trabalho. No Brasil, entretanto o desenvolvimento e a avaliação da qualidade de serviços como a Revisão da Farmacoterapia ainda é incipiente e precisa ser implementada visando aprimorar as práticas de cuidado ao paciente. Objetivo. Avaliar indicadores de estrutura e processo na implementação de um serviço de Revisão da Farmacoterapia no ambulatório de um Hospital Universitário. Metodologia. O estudo foi estruturado em três etapas, de fevereiro de 2012 a março de 2015. A primeira correspondeu a uma pesquisa de desenvolvimento metodológico, na qual indicadores de estrutura e processo foram reunidos da literatura nacional e internacional para serem utilizados na avaliação do Serviço de Revisão da Farmacoterapia. A segunda etapa correspondeu tradução para o português e adaptação transcultural para o Brasil da Scale of Attitudes Toward Physician-Pharmacist Collaboration . A terceira etapa correspondeu a um estudo longitudinal que avaliou o processo de um modelo colaborativo de serviço de Revisão da Farmacoterapia no ambulatório de um Hospital Universitário de Sergipe. Resultados. A partir da literatura (etapa 1) foram levantados, no estudo, 28 indicadores de estrutura divididos nos critérios: instalações físicas, recursos humanos, recursos materiais, documentação e financiamento. A avaliação dos indicadores de estrutura do serviço de Revisão da Farmacoterapia do ambulatório estudado revelou que o mesmo atendeu a maioria dos critérios apresentados. Quanto ao processo foi possível reunir 54 indicadores divididos em duas categorias: 21 indicadores técnico-gerencias e 33 técnico-assistenciais. Da segunda etapa resultou uma escala traduzida e adaptada para o português do Brasil usada para avaliar as atitudes colaborativas de farmacêuticos e médicos. Na terceira etapa, a análise do serviço de Revisão da Farmacoterapia verificou que 146 pacientes foram atendidos em média 2,1±1,1 vezes durante o estudo. As prescrições médicas desses pacientes continham 3,3±1,9 medicamentos e 24,5% das mesmas tinham cinco ou mais medicamentos. No estudo foram identificados 366 problemas relacionados ao uso de medicamentos (PRMs) sendo a maioria de necessidade (67,5%) e foi observado que os pacientes que tiveram 4 a 5 atendimentos farmacêuticos tem 1,14 vezes mais probabilidade de terem seus PRMs identificados (χ2= 33,83; p<0,0001). Ademais, a análise demonstrou que os pacientes que tiveram entre 1 a 2 atendimentos farmacêuticos apresentaram 1,22 vezes mais probabilidade de não terem seus PRMs resolvidos quando comparado ao grupo com mais de 3 atendimentos farmacêuticos (χ2= 3,44; p<0,05). Neste estudo ainda foram notificadas 173 intervenções farmacêuticas, das quais 52,6% foram destinadas aos médicos, 46,2% aos estudantes de Medicina e a maioria delas (98,7%) foi aceita. Conclusão. Os indicadores de estrutura e processo reunidos podem ser utilizados para avaliar a implementação do Serviço de Revisão da Farmacoterapia. O farmacêutico pode colaborar com os médicos identificando e resolvendo PRMs, bem como auxiliando no monitoramento e na tomada de decisão sobre a farmacoterapia, beneficiando o paciente.

Foram analisados os resultados retrospectivos do transplante de medula óssea alogênico em 100 pacientes portadores de leucemia mielóide crônica, divididos em dois grupos: Grupo I, de 49 pacientes que recebeu alta hospitalar após a pega medular, e grupo II, de 51 pacientes, que recebeu alta precocemente, antes da pega medular, para acompanhamento ambulatorial. Foram comparados os dias de ocupação de leitos hospitalares, a morbidade e a mortalidade entre os grupos de alta até o dia 100 pós transplante. Verificou-se que, no grupo de alta precoce, houve, significativamente, menos dias de ocupação de leitos hospitalares, sem aumento da morbidade e da mortalidade / We analyzed the results of a retrospective study of 100 patients with chronic myelogenous leukemia submitted to allogeneic stem cell transplantation in one of two settings: Group I, with 49 patients, transplanted in the traditional inpatient and group II, with 51 patients, in partial outpatient. We compared the median number of days spent in hospital, morbidity and mortality within 100 after bone marrow transplantation. We concluded that there was a significant reduction in the median of hospital length of stay in the partial outpatient group, without increasing morbidity and mortality

INTRODUÇÃO: O treinamento físico é uma intervenção eficaz para reduzir a pressão arterial (PA) na hipertensão, mas ainda há pouca evidência na literatura sobre os efeitos do treinamento físico em piscina aquecida. Este estudo examina os efeitos do treinamento em piscina aquecida sobre a PA, bem como sobre as respostas neuro-humorais e endoteliais em pacientes hipertensos resistentes. MÉTODOS: Trata-se de um estudo paralelo, randomizado e controlado. Foram investigados 44 pacientes sedentários com hipertensão resistente, randomizados e alocados em dois grupos; 28 pacientes foram submetidos à um protocolo de treinamento, que consistiu de exercícios calistênicos e caminhada dentro de uma piscina aquecida (32°C), realizados por uma hora, três vezes por semana durante doze semanas; e 16 pacientes foram alocados no grupo controle, esses foram orientados a manter suas atividades habituais. As medições feitas antes e após doze semanas do protocolo incluíram: PA de consultório, monitorização ambulatorial da pressão arterial (MAPA), níveis plasmáticos de óxido nítrico, endotelina-1, aldosterona, renina, noradrenalina, adrenalina e dopamina, assim como VO2 pico e função endotelial (hiperemia reativa). RESULTADOS: Após doze semanas, os pacientes do grupo treinamento apresentaram diminuição significativa na PA de consultório (Sistólica de 164,2 ± 3,3 para 128,9 ± 1,9 mmHg e Diastólica de 89,3 ± 1,7 para 78,0 ± 1,6 mmHg (P < 0,01) e na MAPA de 24 horas (Sistólica de 144,8 ± 3,8 para 126,4 ± 2,3 mmHg, Diastólica de 83,8 ± 2,1 para 74,8 ± 1,6 mmHg (P < 0,01), Vigília (Sistólica de 149,0 ± 4,0 para 129,0 ± 2,4 mmHg, Diastólica de 86,9 ± 2,2 para 75,6 ± 1,7 mmHg (P < 0,01); Sono (Sistólica de 136,1 ± 3,6 mmHg para 115,9 ± 1,8 mmHg, Diastólica de 75,9 ± 2,0 para 70,1 ± 1,6 mmHg (P < 0,01). Concomitantemente, o óxido nítrico aumentou significativamente (de 25±2,8 para 75±2,4 ?mol/L (P < 0,01), enquanto a endotelina-1 (de 41 ± 5 para 26 ± 3 pg / mL), a renina (de 35 ± 4 para 3,4 ± 1 ng / mL / h) , a noradrenalina (de 720 ± 54 para 306 ± 35pg / mL), a adrenalina (353,1 ± 4,1 para 169± 2,2 ng/mL) e dopamina ( de 145,1 ± 2,2 para 36,3 ± 3,1 ng/mL) diminuíram significativamente (P < 0,01). A aldosterona plasmática também tendeu a diminuir, embora não significativamente (de 101 ± 9 para 76 ± 4 pg / mL, P = NS). O VO2 pico aumentou, significativamente, após o treinamento (P < 0,01), enquanto a função endotelial permaneceu inalterada, e não foram encontradas alterações significativas no grupo controle. CONCLUSÕES: O treinamento em piscina aquecida reduziu os níveis de PA tanto ambulatorial quanto durante a MAPA de 24 horas em pacientes hipertensos resistentes e esta resposta da PA foi acompanhada por uma redução significativa da acentuada ativação neurohumoral, que caracteriza essa condição clínica. Estes efeitos sugerem que o treinamento em piscina aquecida pode ser uma potencial nova abordagem terapêutica para estes pacientes / BACKGROUND: Regular exercise is an effective intervention to decrease blood pressure (BP) in hypertension, but no data is available concerning the effects of Heated water-based Exercise (HEx). This study examines the effects of HEx on BP as well as on the neurohumoral and endothelial responses in resistant hypertensive patients. METHODS: This is a parallel, randomized controlled trial. We investigated 44 sedentary patients with resistant hypertension, they were randomized and allocated into 2 groups; 28 patients to a HEx training protocol, which was consisted of callisthenic exercises and walking inside a heated pool (32°C), performed for 1 hour, three times a week for 12 weeks; and 16 patients who were allocated on the control group were asked to maintain their habitual activities. The measurements made before and after 12 weeks of the protocol included clinic BP, ambulatory blood pressure monitoring (ABPM), plasma levels of nitric oxide, endothelin-1, aldosterone, renin, norepinephrine, epinephrine and dopamine, as well as peak VO2, and endothelial function (reactive hyperemia). RESULTS: After 12 weeks of HEx, patients showed a significant decrease in clinic BP (SBP from 164.2 ± 3.3 to 128.9 ± 1.9 mmHg; and DBP from 89.3 ± 1.7 to 78.0 ± 1.6 mmHg (P < 0.01); and on 24-h ABPM (24-h (SBP from 144.8 ± 3.8 to 126.4 ± 2.3 mmHg, DBP from 83.8 ± 2.1 to 74.8± 1.6 mmHg (P < 0.01); Daytime (SBP from 149.0 ± 4.0 to 129.0± 2.4 mmHg, DBP from 86.9 ± 2.2 to 75.6 ± 1.7 mmHg (P < 0.01); Nightime (SBP from 136.1± 3.6 mmHg to 115.9 ± 1.8 mmHg, DBP from 75.9 ± 2.0 to 70.1 ± 1.6 mmHg (P < 0.01). Concomitantly, nitric oxide increased significantly (from 25±2,8 to 75±2,4 ?mol/L, P < 0.01), while endothelin-1 (from 41±5 to 26±3 pg/mL), renin (from 35±4 to 3.4±1 ng/mL/h), norepinephrine (from 720±54 to 306±35pg/mL), epinephrine ( from 353,1 ± 4,1 to 169 ± 2,2 ng/mL) and dopamine (from 145,1 ± 2,2 to 36,3 ± 3.1 ng/mL decreased significantly (P < 0.01). Plasma aldosterone also tended to decrease, although not significantly (from 101±9 to 76±4 pg/mL, P=NS). Peak VO2 increased significantly after HEx (P < 0.01), while endothelial function was unchanged. No significant change was detected in the control group. CONCLUSIONS: HEx reduced office BPs and 24-hour ABPM levels in resistant hypertensive patients and this BP response was accompanied by a significant reduction in the marked neurohumoral activation characterized in this clinical condition. These effects suggest that HEx may be a potential new therapeutic approach in these patients

Background The detection of early warning signs is essential in the long-term treatment of bipolar disorders. However, in bipolar patients’ daily life and outpatient treatment the assessment of upcoming state changes faces several difficulties. In this trial, we examine the effectiveness of a smartphone based automated feedback about ambulatory assessed early warning signs in prolonging states of euthymia and therefore preventing hospitalization. This study aims to assess, whether patients experience longer episodes of euthymia, when their treating psychiatrists receive automated feedback about changes in communication and activity. With this additional information an intervention at an earlier stage in the development of mania or depression could be facilitated. We expect that the amount of time will be longer between affective episodes in the intervention group. Methods/design The current study is designed as a randomized, multi-center, observer-blind, active-control, parallel group trial within a nationwide research project on the topic of innovative methods for diagnostics, prevention and interventions of bipolar disorders. One hundred and twenty patients with bipolar disorder will be randomly assigned to (1) the experimental group with included automated feedback or (2) the control group without feedback. During the intervention phase, the psychopathologic state of all participants is assessed every four weeks over 18 months. Kaplan-Meier estimators will be used for estimating the survival functions, a Log-Rank test will be used to formally compare time to a new episode across treatment groups. An intention-to-treat analysis will include data from all randomized patients. Discussion This article describes the design of a clinical trial investigating the effectiveness of a smartphone-based feedback loop. This feedback loop is meant to elicit early interventions at the detection of warning signs for the prevention of affective episodes in bipolar patients. This approach will hopefully improve the chances of a timely intervention helping patients to keep a balanced mood for longer periods of time. In detail, if our hypothesis can be confirmed, clinical practice treating psychiatrists will be enabled to react quickly when changes are automatically detected. Therefore, outpatients would receive an even more individually tailored treatment concerning time and frequency of doctor’s appointments. Trial registration: ClinicalTrials.gov: NCT02782910: Title: “Smartphone-based Ambulatory Assessment of Early Warning Signs (BipoLife_A3)”. Registered May 25 2016. Protocol Amendment Number: 03. Issue Date: 26 March 2018. Author(s): ES.

The impact of acculturation and poor social support as potential risk factors for cardiovascular and metabolic disease amongst Mexican immigrants to the United States (U.S.) is a developing area of research. One theory is that acculturation to U.S. society is negatively associated with health due to the stress of immigration as well as the less healthy diet and lifestyle in the U.S. It is also theorized that positive social support is associated with better health during immigration due to the buffering effect relationships have on stress. Despite these theories, mixed findings have been found regarding the associations between acculturation and social support to health outcomes in this population. Some research has also noted that significant differences exist between the manner in which men and women experience social support and their acculturation patterns. Consequently, the primary purpose of this study was to test the associations between acculturation and health as well as assess gender, social support, and acculturation for potential moderator effects in a sample of Mexican immigrants in Provo, Utah. Acculturation was measured using the Acculturation Rating Scale for Mexican Americans-II (ARMSA-II) which consists of the Anglo Orientation Scale (AOS) and Mexican Orientation Scale (MOS). Social support was determined using both the Interpersonal Support Evaluation List (ISEL) and Sarason Social Support Questionnaire (SSSQ) which has two dimensions: satisfaction with support network and size of support network. Hierarchical multiple regression did not find significant associations between acculturation or social support and health outcomes as measured by ambulatory blood pressure or blood draw values including triglycerides, Hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), and high-density lipoprotein (HDL). A significant association was observed between Anglo Orientation and social support as measured by the ISEL-II. A moderation effect was observed between gender and Anglo orientation with satisfaction in one's support network. No other moderation effects were observed in this study. Implications of the findings, limitations, and directions for future research are discussed.

BACKGROUND: Despite large investments in maternity care services, perinatal health outcomes in the U.S. are among the worst compared to other industrialized countries, with documented perinatal health disparities disproportionately impacting racial and ethnic minorities. Midwifery-led freestanding birth centers (FSBC) have emerged as an underutilized model for the safe and cost-effective care of women with low-risk pregnancies. Despite approximately 85% of all US pregnancies being considered low-risk, only 0.5% of all US births occurred in a FSBC in 2016. The goal of the study is to elucidate strategies used to develop and sustain freestanding birth centers (FSBCs) that are seeking to serve high proportions of publicly-insured women and women of color. METHODS: I conducted an embedded unit case study, including semi-structured in-depth interviews and focus groups with 49 stakeholders from three exemplary FSBCs. Supplemental interviews were led with five key informants from three additional FSBCs and a relevant national membership organization. Additional data sources used to complete this case study include, where relevant and permitted, observations of maternity care settings, patient-provider encounters, management meetings, community events, and review of pertinent documents. Qualitative analysis methods were used to identify common themes and variations. FINDINGS: Midwifery-led birth center care can improve the experience and outcomes of maternity care among publicly insured women of color. The study revealed persistent multi-level challenges, as well as the use of common approaches to overcome these organizational, financial, and cultural barriers, resulting in greater, yet still fragile, access to family-centered intrapartum care within the communities in which these FSBCs operate. CONCLUSIONS: The careful integration of FSBCs into health systems such as a Federally Qualified Health Center (FQHC) may contribute to the broad scale-up of this underutilized model of care. While integrating FSBCs into FQHCs may be helpful in expanding equitable access to birth center care, it is not necessary, and also not sufficient. Expansion efforts should include additional deliberate processes and strategies to ensure equitable uptake and sustainability of birth center care. / 2020-10-23T00:00:00Z