Thesis (M.S.)--University of Michigan, 1979.

Introdução: A polineuromiopatia do doente crítico (PNMDC) é uma freqüente complicação neuromuscular adquirida na Unidade de Terapia Intensiva (UTI). O principal fator de risco está relacionado à sepse e à disfunção de múltiplos órgãos sendo que sua incidência pode variar entre 50 a 100%. A confirmação do diagnóstico é feita pela eletroneuromiografia, porém sugere-se que as características clínicas (fraqueza muscular, alterações sensoriais e de reflexos e dificuldade de desmame da ventilação mecânica) possam ser suficientes para o diagnóstico clínico. Objetivo: Identificar sinais clínicos que possam ser utilizados como marcadores para auxiliar no diagnóstico de PNMDC à beira do leito em pacientes sépticos. Resultados: Cinquenta pacientes foram avaliados e divididos em dois grupos conforme o resultado da eletroneuromiografia (PNMDC e não PNMDC). Os pacientes com PNMDC tinham idade maior e eram mais graves (APACHE IV e SAPS 3), permaneceram maior período hospitalizados e necessitaram de suporte ventilatório por mais tempo. Os pontos de corte: <40 para escore Medical Research Council (MRC); <7 kg para dinamometria em homens e <4 kg em mulheres; <34 cmH2O para pressão expiratória máxima e >-40 cmH2O para pressão inspiratória máxima conseguiram identificar com bons níveis de sensibilidade e de especificidade os pacientes com PNMDC. Conclusões: A força muscular esquelética pelo escore MRC, dinamometria e pressões respiratórias máximas é uma método simples que permite a identificação de PNMDC em uma avaliação clínica à beira do leito. / Introduction: Critical illness polyneuromyopathy (CIPNM) is a frequent acquired neuromuscular complication in the Intensive Care Units (ICU). The main risk factor is related to sepsis and multiple organs dysfunction and the incidence of this disorder can reach 50-100%. The diagnosis is made by electromyography, but it is suggested that the clinical features (muscle weakness, sensory and reflexes changes and difficulty in weaning patients from mechanical ventilation) may be sufficient for clinical diagnosis. Objective: To identify clinical signs that may be used as markers to help in the bedside diagnosis of CIPNM in septic patients. Results: Fifty patients were evaluated and divided into two groups according to the results of electromyography (CIPNM and non-CIPNM). The patients with CIPNM were older, showed more severe illness (Apache IV and Saps 3), remained hospitalized for longer period of time, and required longer period of ventilatory support than non-CIPNM. The cutoffs that could identify the patients with CIPNM with good levels of sensitivity and specificity were: Medical Research Council (MRC) score <40; dynamometry <7 kg for men and <4 kg for women, maximal expiratory pressure (MEP) <34 cmH2O and maximal inspiratory pressure (MIP) > -40 cmH2O . Conclusions: The assessment of skeletal muscle strength by MRC score, dynamometry and maximum respiratory pressure is a simple method that allows the diagnosis of CIPNM through a clinical examination at the bedside.

Introdução: A polineuromiopatia do doente crítico (PNMDC) é uma freqüente complicação neuromuscular adquirida na Unidade de Terapia Intensiva (UTI). O principal fator de risco está relacionado à sepse e à disfunção de múltiplos órgãos sendo que sua incidência pode variar entre 50 a 100%. A confirmação do diagnóstico é feita pela eletroneuromiografia, porém sugere-se que as características clínicas (fraqueza muscular, alterações sensoriais e de reflexos e dificuldade de desmame da ventilação mecânica) possam ser suficientes para o diagnóstico clínico. Objetivo: Identificar sinais clínicos que possam ser utilizados como marcadores para auxiliar no diagnóstico de PNMDC à beira do leito em pacientes sépticos. Resultados: Cinquenta pacientes foram avaliados e divididos em dois grupos conforme o resultado da eletroneuromiografia (PNMDC e não PNMDC). Os pacientes com PNMDC tinham idade maior e eram mais graves (APACHE IV e SAPS 3), permaneceram maior período hospitalizados e necessitaram de suporte ventilatório por mais tempo. Os pontos de corte: <40 para escore Medical Research Council (MRC); <7 kg para dinamometria em homens e <4 kg em mulheres; <34 cmH2O para pressão expiratória máxima e >-40 cmH2O para pressão inspiratória máxima conseguiram identificar com bons níveis de sensibilidade e de especificidade os pacientes com PNMDC. Conclusões: A força muscular esquelética pelo escore MRC, dinamometria e pressões respiratórias máximas é uma método simples que permite a identificação de PNMDC em uma avaliação clínica à beira do leito. / Introduction: Critical illness polyneuromyopathy (CIPNM) is a frequent acquired neuromuscular complication in the Intensive Care Units (ICU). The main risk factor is related to sepsis and multiple organs dysfunction and the incidence of this disorder can reach 50-100%. The diagnosis is made by electromyography, but it is suggested that the clinical features (muscle weakness, sensory and reflexes changes and difficulty in weaning patients from mechanical ventilation) may be sufficient for clinical diagnosis. Objective: To identify clinical signs that may be used as markers to help in the bedside diagnosis of CIPNM in septic patients. Results: Fifty patients were evaluated and divided into two groups according to the results of electromyography (CIPNM and non-CIPNM). The patients with CIPNM were older, showed more severe illness (Apache IV and Saps 3), remained hospitalized for longer period of time, and required longer period of ventilatory support than non-CIPNM. The cutoffs that could identify the patients with CIPNM with good levels of sensitivity and specificity were: Medical Research Council (MRC) score <40; dynamometry <7 kg for men and <4 kg for women, maximal expiratory pressure (MEP) <34 cmH2O and maximal inspiratory pressure (MIP) > -40 cmH2O . Conclusions: The assessment of skeletal muscle strength by MRC score, dynamometry and maximum respiratory pressure is a simple method that allows the diagnosis of CIPNM through a clinical examination at the bedside.

Survivors of critical illness have a high prevalence of long-term cognitive and psychiatric morbidity and poor quality of life years after hospital discharge. Data are lacking regarding whether cognitive screening tests predict which critically ill patients may be at risk to develop long-term cognitive sequelae and whether cognitive sequelae predict the patients everyday functioning. This study sought to determine whether cognitive screening tests, including the Mini-Mental State Examination (MMSE) and Mini-Cog, predict long-term cognitive sequelae and everyday functioning in survivors of critical illness 6-month post-hospital discharge. A second purpose was to investigate whether cognitive sequelae are associated with poor everyday functioning in critically ill survivors. Finally, the relationship between cognitive sequelae and quality of life was assessed. Survivors of critical illness had a high rate of cognitive impairments at hospital discharge, as well as long-term cognitive and psychiatric sequelae, deficits in everyday functioning, and reduced quality of life at 6-month follow-up. The MMSE and Mini- Cog did not predict long-term cognitive sequelae or everyday functioning at 6-months. Cognitive sequelae were not associated with poor everyday functioning; however, impaired attention, memory, and mental processing speed predicted problems with managing home/transportation, and impaired attention predicted problems in health and safety, social adjustment, and memory/orientation. Cognitive sequelae were associated with reduced quality of life in the role physical domain. Altogether, these findings lend additional knowledge to the literature regarding cognitive and psychiatric sequelae, everyday functioning, and reduced quality of life in critically ill patients, and may have clinical implications for the critical care providers, patients, and caregivers. Given the large population of survivors of critical illness each year, strategies aimed at recognizing, preventing and treating these morbidities are important research and public health concerns. Investigations into the clinical and economic burden of these morbidities and methods to mitigate them, including patient screening and referral to appropriate mental health and rehabilitation services, are warranted.

We carried out an observational, retrospective and descriptive study in order to identify the clinical and epidemiological characteristics of children with SARS-CoV-2 infection admitted to a Peruvian national referral hospital. We included patients from one month old to fourteen years old hospitalized between March and August 2020. A total of 125 patients with SARS-CoV-2 infection were admitted, 18.4% (n = 23) had critical illness and 16.8% (n = 21) had multisystem inflammatory syndrome (MIS-C). The absence of comorbidities and previous history of epidemiological contact were more frequent in patients with MIS-C. Patients in critical condition and patients with MIS-C had lower lymphocyte and platelet counts, and higher C-reactive protein, ferritin and D-dimer values than patients who did not have said conditions. Six (4.8%) out of 125 children died, as well as 3 (13%) children from the group of patients in critical condition. None of the children with MIS-C died. / Revisión por pares

No description available.

Bakgrund Hopp innebär att vi fortfarande tror på en potentiell framtid. När ett barn drabbas av en allvarlig sjukdom orsakar sjukdomen ofta att känslor pendlar mellan hopp och hopplöshet inför de komplikationer som uppstår under sjukdomens gång. För att sjuksköterskan ska kunna ge god omvårdnad krävs familjefokuserad omvårdnad vid mötet med familjerna. Sjuksköterskan kan använda sig av föräldrarnas kunskap för att få en så bra relation till barnet som möjligt, samtidigt som föräldrarna behöver vägledas av sjuksköterskan. Syfte Syftet var att beskriva hur sjuksköterskan kan inge och bevara hopp hos föräldrar vars barn vårdas på sjukhus på grund av allvarlig sjukdom. Metod Denna litteraturöversikt baserades på 15 vetenskapliga artiklar. Databassökningen genomfördes i databaserna PubMed och CINAHL, där både kvalitativa och kvantitativa studier inkluderades. De inkluderade artiklarna kvalitetsgranskades enligt Sophiahemmets bedömningsmall och analyserades med stöd av Kristenssons (2014) Integrerade analys. Resultat Fyra kategorier skapades; Sjuksköterskans behov av kunskap om hoppets betydelse för föräldrar, Sjuksköterskans samtalande, Stödjande och trygghetsskapande funktion, Anpassad information och utbildning samt Användning av strategier. Resultatet utvisar att hopp alltid finns närvarande hos föräldrarna - även om hoppet ibland upplevdes svårare att hålla fast vid. Föräldrarnas hopp består huvudsakligen av en förlitan om barnets tillfrisknande, och en önskan om att barnet skulle undgå allt för många negativa vårdupplevelser. Resultatet beskriver även att sjuksköterskan, beroende på föräldrarnas behov, kan ge anpassad information genom individualiserad utbildning och stöd. Slutsats Sammanfattningsvis visar resultatet att sjuksköterskan med hjälp av ett helhetsperspektiv och förmedlandet av olika hanteringsstrategier kan förbättra familjens välbefinnande och öka föräldrars känsla av hopp. Sjuksköterskan kan genom samtal, undervisning och anpassad information inge och bevara hopp till föräldrar vars barn vårdas på grund av allvarlig sjukdom utan att för den delen förmedla en felaktig bild av barnets prognos. / Background Hope means that we believe in a potential future. When a child is suffering from a critical illness the illness often triggers fluctuating feelings between hope and hopelessness due to complications during the treatment-process. Nurses ability to provide good nursing in the meeting with families requires family-focused care. The nurse can use parents' knowledge to develop the best possible relationship with the child meanwhile guiding the parents through the treatment process.  Aim The aim was to describe how the nurse can inspire and maintain hope within parents whose child is treated in a hospital due to critical illness. Method This literature review was based on 15 research articles. A database search was conducted through CINAHL and PubMed, from which both qualitative and quantitative studies were included. The articles were later quality-assessed in accordance to Sophiahemmet’s matrix and analyzed through Kristensson’s (2014) Integrated analysis.  Results Four categories were created; The nurse's need of knowledge about the meaning of hope to parents, The nurse´s conversational-, supportive- and comforting function, Adapted information and education and The use of strategies. The result shows that parental hope is constantly present, although it occasionally can be difficult to retain. Parental hope consists of a reliance in the child's recovery while hoping that the child won’t suffer through too many negative experiences. The result also describes how the nurse can provide customized information through individualized education and support.  Conclusions In summary, the result shows that the nurse, through a holistic perspective and the use of different coping strategies, can improve the family's wellbeing and sense of hope. Through conversations, education and adapted information, the nurse can inspire and maintain hope within parents whose children are treated due to critical illness without conveying an unrealistic image of the child's prognosis.

No description available.

There were three objectives of this study. The first was to determine if commercially available fluorochromes could be used to determine the glucocorticoid receptor (GR) density and binding affinity (BA) in equine peripheral blood mononuclear cells. The second was to determine if there was a correlation between elevated plasma cortisol and GR density or binding affinity in healthy adult horses. The third objective was to evaluate the HPA axis in adult horses presenting with systemic inflammatory response syndrome (SIRS), and to determine where any alterations in HPA axis function occur in these patients compared to healthy adults. For the first part of the study, peripheral venous blood was collected from 3 healthy research horses on 3 days. Peripheral blood mononuclear cells were isolated using Ficoll gradient centrifugation. Phycoerythrin (PE)-CD44 was then used to extracellularly label leukocytes, and then an intracellular GR antibody was used to determine a baseline measurement of GR density and fluorescein isothiocyanate (FITC)-dexamethasone was used to determine binding affinity via flow cytometric analysis. Comparison of control samples to those for CD44, GR density, and GR binding affinity showed a statistically significant difference for all samples (P<0.0001, P<0.0001, and P<0.0001 respectively). This showed that the CD44, GR antibody, and FITC-dexamethasone could successfully be used to analyze equine peripheral blood mononuclear cells for GR activity. For the second part of the study, an ACTH stimulation test was performed on 8 healthy horses in order to induce an increase in endogenous cortisol production. Plasma cortisol levels, GR density, and GR binding affinity were measured at baseline, 4, 8, and 24 hours after treatment. Median basal cortisol concentration was 4.9, range 3.2-6.1 μg/dl. This initially increased following ACTH stimulation to 5.6, range 4.8-7.4 μg/dl, then showed a significant decrease by 8 hours post ACTH administration to 1.4, range 1.1-2.7 μg/dl (P=0.0221). No correlation was observed between plasma cortisol concentration in healthy horses and GR density or binding affinity (r=-0.145, P=0.428 and r=0.046, P=0.802, respectively). For the third phase of the study, horses (N=10) with systemic inflammatory response syndrome (SIRS) were compared to healthy, age and sex matched controls (N=10) presenting for lameness evaluation or ophthalmologic examination. Blood was collected from SIRS cases and controls on presentation to the Equine Medical Center. A CBC, serum biochemistry, and serum ACTH and cortisol measurements were performed. GR density and binding affinity were also determined. Nonsurvivors had a significantly decreased GR binding affinity (P=0.008) and demonstrated a trend towards an increase in the ACTH:cortisol ratio. ROC analysis was performed for serum ACTH and cortisol concentrations, the ACTH:cortisol ratio, GR density and GR binding affinity, and triglycerides to determine cut-off values associated with nonsurvival. These were then used to analyze this population using Fischer's exact test to determine the odds ratio (OR) associated with nonsurvival for each variable. This revealed that a serum triglyceride concentration greater than 28.5 mg/dl was associated with nonsurvival (OR=117, 95% CI, 1.94-7060). The other variables were not found to be significantly associated with nonsurvival, although a Delta BA% of less than 35.79% was found to be closely associated with nonsurvival (OR=30.33, 95% CI, 0.96-960.5). Additionally, a significant negative correlation was detected between the plasma ACTH concentration and Delta BA% (r=-0.685, P=0.029) and the ACTH:cortisol ratio and the Delta BA% (r=-0.697, P=0.025). This study showed that nonsurviving horses with SIRS had a significantly decreased GR binding affinity compared to survivors, and a tendency toward an increase in their ACTH:cortisol ratios. This confirms that HPA axis dysfunction occurs in adult horses with SIRS as tissue resistance to glucocorticoids, and potentially relative adrenal insufficiency as well. These results suggest that there are horses with SIRS that might benefit from "physiologic" doses of synthetic glucocorticoids to complement their relative adrenal insufficiency in addition to their poor tissue sensitivity. Further research should focus on methods to more rapidly determine which horses might benefit from treatment with glucocorticoids on presentation, as well as to more accurately determine prognosis for survival. / Master of Science

INTRODUÇÃO: O número de sobreviventes após um evento grave tem aumentado consideravelmente, e muitas vezes acarretando um maior tempo de internação na unidade de terapia intensiva (UTI) e hospitalar. Frequentemente esses pacientes evoluem com decréscimo da qualidade de vida e comprometimento das habilidades funcionais para realização de suas atividades de vida diária. Este estudo teve como objetivo avaliar a qualidade de vida relacionada à saúde (QVRS), as atividades básicas de vida diária (ABVD) e as atividades instrumentais de vida diária (AIVD) de pacientes críticos após a alta hospitalar. MÉTODO: Foi realizado um estudo observacional longitudinal, onde foram selecionados pacientes clínicos e/ou cirúrgicos, idade igual ou superior a 18 anos, submetidos a pelo menos 24 horas de ventilação mecânica. As avaliações foram feitas através de questionários direcionados para avaliar a QVRS (SF-36), as ABVD (Índice de Barthel e Índice de Katz) e AIVD (Health Assessement Questionaire Disability índex [HAQ-DI]). Os instrumentos foram aplicados através de entrevista telefônica nos primeiros 30 dias após a alta hospitalar e no terceiro e sexto meses subsequentes. RESULTADOS: Pelos critérios de inclusão foram selecionados 431 pacientes após a alta da UTI, destes 128 preencheram os critérios de exclusão e 142 perdidos antes da alta hospitalar. Dos 161 pacientes que receberam alta hospitalar e, portanto elegíveis para o estudo, foi possível realizar contato com 75, sendo esta a amostra inicial do estudo. Entre os 86 pacientes perdidos, a maioria (61) foi por impossibilidade de contato telefônico (número errado ou inexistente, mudança de cidade e/ou estado), os demais, por recusa, óbito e reinternação. Foram considerados idosos 29 pacientes (38,6 %). Houve melhora progressiva de todos os domínios do SF-36 ao longo do tempo de avaliação, sendo que os domínios mais comprometidos foram: aspecto físico, aspecto emocional e capacidade funcional. O componente físico do SF-36 e o índice de Katz mostraram-se influenciados pela idade (p=0,03) e (p=0,01) respectivamente. O Índice de Katz apresentou influência do Acute Physiology and Chronic Health Evaluation II (p=0,02). As ABVD e AIVD avaliadas pelos questionários Katz, Barthel e HAQ-DI ao longo do tempo, mostraram melhora progressiva nas atividades funcionais de acordo com a pontuação de cada instrumento e com diferenças significativas entre os períodos de avaliação (p<0,05). O HAQ-DI apresentou as atividades usuais como sendo as mais comprometidas. CONCLUSÕES: A QVRS e as ABVD e AIVD dos pacientes avaliados neste estudo apresentaram uma melhora progressiva no decorrer de seis meses após a alta hospitalar, mas ainda apresentando comprometimento até a última avaliação. Os idosos e os mais graves apresentaram maior comprometimento / INTRODUCTION: The number of surviving patients following a severe event has increased considerably, often leading to a longer intensive care unit (ICU) and hospital stay. Frequently, these patients evolve with decreased quality of life and impaired functional abilities to perform their activities of daily living. This study was aimed at evaluating the Health-Related Quality of Life (HRQoL), Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) for critical ill patients after hospital discharge. METHOD: A longitudinal observational study was conducted, and clinical and/or surgical patients aged 18 years-old who had been submitted to at least 24 hours of mechanical ventilation were screened. Assessments were conducted using targeted questionnaires to evaluate HRQoL (SF-36), BADL (Barthel Index and Katz Index), and IADL (Health Assessment Questionnaire Disability Index [HAQ-DI]). These instruments were applied via telephone interviews within the first 30 days following hospital discharge, and three and six months later. RESULTS: According to inclusion criteria, 431 patients were included following hospital discharge; of these, 128 met exclusion criteria, and 142 were lost to follow-up before hospital discharge. Of the 161 patients who had been discharged from hospital and therefore were considered eligible for the study, 75 patients could be contacted; this was the initial sample of the study. For the 86 lost to follow-up patients, most of them (61) could not be contacted by telephone (incorrect or nonexistent number, moved to other city and/or state) and the remaining due to refusal, death, and readmission. 29 patients were considered elderly (38.6%). All SF-36 domains progressively improved in the course of evaluation, and Role-Physical, Role-Emotional and Physical Functioning were the most impaired domains. The physical component of SF-36 and the Katz Index have been shown to be influenced by age (p=0.03 and p=0.01, respectively). Katz Index was also influenced by Acute Physiology and Chronic Health Evaluation II (p=0.02). It was shown that BADL and IADL assessed by Katz, Barthel and HAQ-DI questionnaires over time have progressively improved in terms of functional activities, according to each instrument scoring and significant differences between evaluation periods (p<0.05). HAQ-DI has shown that usual activities were the most impaired. CONCLUSIONS: HRQoL, BADL and IADL for patients evaluated in this study were progressively improved within 6 months after hospital discharge, but these patients were still impaired up to the last evaluation. Elderly and more severe patients demonstrated greater impairment