In this paper I investigate the limitations of memory, physical and psychological effects on individuals’ perception that effect memory, and the impact of those limitations on our ability to recall objective truth. The paper is introduced with an explanation of my interest in the subjective narrative voice in historical accounts and questions the possibility of a completely objective voice. In the first chapter, a fantastical biographical story of the life of Tycho Brahe is used as an example of the difficulty in parsing truth from legend. Descriptions of changes in scientific methods exemplify the uncertainty of scientific fact. I propose that Brahe sought empirical data to replace the unfiltered memory perception an anosmic lacks. Additionally, if Brahe had a sense of smell his murder may have been unsuccessful. In the second chapter I describe anosmia, then explain the dominant theories of how olfaction takes place, and memory storage through smell. Memory recall through associated odors is unfiltered by the intellect, and unalterable, while other forms of memory are subject to change as our psyche continually reforms the experience. An objective account of events is impossible. I search instead for histories where myth, legend, truth, and imagination converge.

La détection du délirium à l’aide d’outils est importante pour pouvoir intervenir le plus rapidement et efficacement possible. Le but de ce projet de recherche est d’évaluer l’efficacité d’une intervention de transfert de connaissances (TC) sur mesure auprès d’infirmières sur le taux d’utilisation conforme d’un outil de détection du délirium (ODD). L’intervention auprès d’infirmières a été basée sur les barrières et facilitateurs à utiliser un tel ODD identifiés par un questionnaire (n=30) et deux groupes de discussion (n=4). Les barrières identifiées par le questionnaire reflétaient un besoin de connaissances et d’amélioration des compétences infirmières. L’une des barrières identifiée à partir des groupes de discussion était le manque de connaissances sur les causes possibles du délirium et les interventions infirmières à privilégier selon ces causes. Les activités de TC retenues étaient une capsule clinique sur les manifestations du délirium évaluées par un ODD et une carte aide-mémoire sur des interventions infirmières possibles. Les taux d’utilisation de l’ODD ont été évalués en pré et post implantation d’une intervention de TC (devis pré-post test) à partir d’une revue de 242 dossiers médicaux de patients (avant n=121 ; après n=121). Aucune différence significative n’a été notée entre les périodes pré et post intervention de TC (p > .99). Une explication réside dans le taux déjà élevé (> 85%) d’utilisation de l’ODD observé avant l’intervention de TC pour deux des trois quarts de travail. L’intervention de TC basée sur les barrières et les facilitateurs a été appréciée par les infirmières et elle pourrait avoir le potentiel de promouvoir une pratique basée sur les résultats probants. / The use of an assessment tool for delirium detection (ATDD) is important to intervene as quickly and as efficiently as possible. The aim of the study was to evaluate the efficacy of a knowledge transfer tailored intervention (KT-TI) to optimize the conform use of an ATDD by nurses. The intervention was based on barriers and facilitators to the use of an ATDD. The barriers identified with the questionnaire (n=30) revealed a need for knowledge and an improvement of nursing skills. One of the barriers identified in focus groups (n=4) was the lack of knowledge on delirium causes and specific nursing interventions to favour accordingly. The chosen KT activities were a clinical capsule on delirium manifestations as evaluated by the ATDD, and a pocket sized information card on possible nursing interventions. The rate of conform use of an ATDD was evaluated in pre and post KT intervention (pre-post design) with a review of 242 patient’s medical charts (pre n=121; post n=121). No significant difference was noted between pre and post KT-TI (p > 0.99). An explanation for this resides in the fact that the observed rate of use of an ATDD by nurses was already high (> 85%) in pre KT-TI on two work shifts. The KT intervention based on barriers and facilitators to change was appreciated by nurses and it may have the potential to promote evidence-based practice.

No description available.

Introdução: A cirurgia cardíaca resulta em taxa considerável de complicações neurológicas, incluindo delirium, disfunção cognitiva e acidente vascular cerebral isquêmico. Supõe que a fisiopatologia envolva embolia, aterotrombose, hipofluxo, redução do débito cardíaco e alterações da autorregulação cerebral. O balão de contrapulsação intra-aórtico (BIA) é um dispositivo de assistência circulatória comumente utilizado no perioperatório de pacientes de alto risco com o objetivo de otimização do débito cardíaco e da perfusão coronária. Apesar do benefício hemodinâmico do BIA, não é conhecido seu efeito na hemodinâmica encefálica. Objetivo: Avaliar os efeitos do BIA na hemodinâmica encefálica em pacientes de alto risco submetido a cirurgia cardíaca com circulação extracorpórea (CEC). Métodos: Trata-se de um subestudo do estudo clínico prospectivo e randomizado \"Balão de contra-pulsação intra-aórtico eletivo em pacientes de alto risco submetidos a cirurgia cardíaca\", realizado no Instituto do coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre 2014 e 2016. Dos 181 pacientes incluídos no estudo randomizado, 67 pacientes foram incluídos no subestudo. Os pacientes eram adultos, submetidos a cirurgia cardíaca de revascularização miocárdica (RM) com fração de ejeção menor ou igual a 40% e/ou EuroScore maior ou igual a 6. Os mesmos foram randomizados para uso do BIA logo após a indução anestésica ou para grupo controle. A velocidade de fluxo sanguíneo cerebral (VFSC) pelo ultrassom Doppler transcraniano e a pressão arterial (PA) pelo Finometer foram continuamente gravados por 5 minutos antes da cirurgia (T1), 24h após (T2) e 7 dias após (T3). O índice de autorregulação (ARI) foi estimado através da resposta ao degrau da VFSC a mudanças na PA, derivados da análise da função de transferência. As seguintes complicações clínicas neurológicas foram avaliadas: delirium, disfunção cognitiva e acidente vascular cerebral isquêmico. Resultados: Dos pacientes incluídos no estudo, 34 foram alocados para a estratégia de uso profilático do balão intra-aórtico e 33 para a estratégia controle. Não houve diferenças significativas entre os grupos BIA e controle respectivamente, nos três tempos de avaliação, em relação ao ARI (T1 - 5,5 ± 1,9 vs 5,7 ± 1,7; T2 - 4,0 ± 1,9 vs 4,1 ± 1,6; T3 - 5,7 ± 2,0 vs 5,7 ± 1,6, P= 0,978) e em relação à VFSC (T1 - 57,3 ± 19,4 vs 59,3 ± 11,8; T2 - 74,0 ± 21,6 vs 74,7 ± 17,5; T3 - 71,1 ± 21,3 vs 68,1 ± 15,1; P=0,952). O grupo BIA e o grupo controle apresentaram incidência semelhante de complicações neurológicas (delirium na unidade de terapia intensiva - 26,5% vs 24,2%, P=0,834, acidente vascular cerebral isquêmico - 3,0% vs 2,9%, P=1,00, e declínio cognitivo pós-operatório através das escalas Mini Mental State Examination MMSE - 16,7% vs 40,7%; P= 0,073 e Avaliação Cognitiva Montreal MoCA - 79,16% vs 81,5%; P= 1,000). Conclusões: O uso profilático do BIA em pacientes de alto risco submetidos à cirurgia de revascularização do miocárdio não altera a hemodinâmica encefálica e não está associado ao aumento de complicações neurológicas como delirium, declínio cognitivo e acidente vascular cerebral isquêmico / Introduction: Cardiac surgery is associated with a high incidence of neurologic complications, such as delirium, cognitive decline and stroke. The pathophysiology probably involves embolism, thrombosis, decreased cardiac output and abnormalities in cerebral autoregulation. The intraaortic balloon pump (IABP) is an assist device commonly in high-risk patients undergoing cardiac surgery aiming to increase the cardiac output and to improve the coronary perfusion. However, the effect of the IABP on the cerebral hemodynamic is unknown. Objectives: To assess the effect of IABP on cerebral hemodynamics in high-risk patients undergoing cardiac surgery with cardio-pulmonary bypass (CPB). Methods: This is a substudy of the randomized controlled trial \"Intraaortic Balloon Counterpulsation in Patients Undergoing Cardiac Surgery (IABCS trial)\", performed at the Heart Institute/University of Sao Paulo, from 2014 to 2016. Of the 181 patients included in the IABCS, 67 were included if they were submitted to cardiac surgery and if they had one of these two criteria: left ventricular ejection fraction equal or lower than 40% and/or EuroSCORE equal or higher than 6. Patients were allocated to the strategy of prohylatic IABP after anesthesia induction or to control. Cerebral blood flow velocity (CBFV) through transcranial Doppler and blood pressure (BP) through Finometer or intra-arterial line were continuously recorded over 5 minutes preoperatively (T1), after 24h (T2) and 7 days after surgery (T3). Autoregulation index (ARI) was estimated from the CBFV response to a step change in BP derived by transfer function analysis. The following complications neurologic were evaluated: delirium, cognitive decline and stroke. Results: Of the included patients, 34 were allocated to the IABP group and 33 to control group. There were no significant differences between the IABP and the control respectively in the following parameters: ARI (T1 - 5.5 ± 1.9 vs 5.7 ± 1.7; T2 - 4.0 ± 1.9 vs 4.1 ± 1.6; T3 - 5.7 ± 2.0 vs 5.7 ± 1.6, P= 0.978), CBFV (T1 - 57.3 ± 19.4 vs 59.3 ± 11.8; T2 - 74.0 ± 21.6 vs 74.7 ± 17.5; T3 - 71.1 ± 21.3 vs 68.1 ± 15.1; P=0.952). Both groups (IABP and control) had similar incidence of neurological complications (delirium - 26.5% vs 24.2%, P=0.834, stroke - 3.0% vs 2.9%, P=1.00, and cognitive decline through the scales Mini Mental State Examination MMSE - 16,7% vs 40,7%; P= 0.073 and Montreal Cognitive Assessment MoCA - 79.16% vs 81.5%; P= 1.000). Conclusions: The prophylactic use of IABP in high-risk patients undergoing cardiac surgery does not change the cerebral hemodynamic and is not associated with higher incidence of neurologic complications such as delirium, cognitive decline and stroke

Thèse : Lettres : Zurich : 1987-88. / Bibliogr. p. 229-236.

Dans le milieu clinique des soins intensifs, l’induction du coma médicamenteux (i.e. iatrogénique) par les sédatifs et les analgésiques est souvent associée à une augmentation significative du délirium. De plus, l’utilisation de sédatifs et d’analgésiques comme le fentanyl et le midazolam sans interruption et sans ajustement aux besoins du patient augmentent la durée de séjour, les coûts et la mortalité. Le but de cette étude était d’explorer les facteurs de variabilité pouvant influencer la survenue du coma iatrogénique et du délirium tel que : les facteurs génétiques/sociodémographiques et la co-administration de médicaments substrats ou inhibiteurs de CYP3A4/3A5 ou de la glycoproteine P. L’étude prospective à visée observationnelle a été effectuée à l’unité de soins intensifs de l’hôpital Maisonneuve-Rosemont avec 53 patients perfusés avec fentanyl ou midazolam. La faisabilité du modèle pharmacocinétique du fentanyl a été mise en évidence à partir des échantillons sanguins des patients et était compatible avec les données cliniques. Cette étude montre donc que contrairement au profil génomique de CYP3A5 (p value = 0,521) et MDR1 (p value = 0,828), les effets des interactions médicamenteuses entre les inhibiteurs CYP3A4/CYP3A5 et fentanyl/midazolam représentent un facteur de risque pour le coma iatrogénique (p value = 0,014). Ces effets peuvent être facilement identifiés et sont prévisibles; résultats qui seront utiles aux praticiens – intensivistes dans le choix d’une thérapie pharmacologique appropriée pour prévenir les complications morbides comme le coma iatrogénique et le délirium. / When sedatives such as midazolam or opiate analgesics such as fentanyl administered to critically ill patients and medication-induced coma occurs, increased delirium is observed. In addition, there is an increase in the length of stay in ICU, in costs and mortality. The purpose of this study was to explore the factors of variability affecting the incidence of iatrogenic coma and delirium: genetics/socio demographics factors, co-administration of substrates/inhibitors of CYP3A4/3A5 or P-gp. We performed a prospective cohort observational study of 53 hospitalized patients treated with fentanyl or/and midazolam in the intensive care unit of the Maisonneuve-Rosemont hospital The feasibility of pharmacokinetics modeling using blood samples from critically ill patients was demonstrated and was compatible with clinical data. This study suggests that contrary to genomic variants in the CYP3A5 (p value = 0,521) and MDR1 (p value = 0,828) genes, the effect of drugs and drugs interactions between inhibitors of CYP3A4/3A5 and fentanyl/ midazolam constitutes the main risk factor for iatrogenic coma (p value - 0,014). These effects are easily identifiable and predictable, and are very important for intensive care workers to make the appropriate choice of medication in order to prevent morbid complications such as iatrogenic coma and delirium.

Les personnes âgées occupent une proportion importante des lits dans les centres hospitaliers de soins de courte durée québécois et leur présence est en augmentation. Parmi ces personnes, plusieurs présentent un état confusionnel aigu (ÉCA), voire un délirium, au cours de leur hospitalisation. Les soins infirmiers qu’elles requièrent sont complexes et les études portant sur la formation continue des infirmières tiennent peu compte de cette réalité. Les approches utilisées dans les études sont surtout centrées sur l’acquisition de connaissances et d’habiletés techniques et négligent les aspects créatifs, relationnels, critiques, réflexifs et éthiques essentiels à une prestation de soins infirmiers de qualité. On y retrouve également peu d’informations sur la conception de l’intervention éducative et sur son évaluation. C’est dans cette perspective que le but de l’étude était de mettre à l’essai et d’évaluer qualitativement le processus et les résultats d’une intervention éducative auprès d’infirmières soignant des personnes âgées hospitalisées en ÉCA. Plus particulièrement, ce sont les conditions facilitant et contraignant l’intervention, les aspects les plus utiles pour la pratique, les différents savoirs exprimés et les résultats de soins perçus par les participantes qui étaient recherchés. C’est en s’inspirant de la pédagogie narrative de Diekelmann (2001) et des savoirs infirmiers de Chinn et Kramer (2008) que l’intervention a été conçue et évaluée. La description d’expériences de soins vécues par les infirmières et la création d’un environnement d’apprentissage favorisant l’interprétation, en groupe, de ces expériences à l’aide d’informations théoriques et empiriques caractérisent la pédagogie narrative à la base de cette intervention. Pour atteindre le but, une étude de cas a été retenue. La stratégie d’échantillonnage par choix raisonné a permis de sélectionner des participantes travaillant sur les trois quarts de travail, ayant différents niveaux de formation et une expérience comme infirmière variant de huit mois à 36 ans, dont l’âge variait de 23 à 64 ans. L’échantillon, composé de 15 infirmières soignant fréquemment des personnes en ÉCA et travaillant sur des unités de soins chirurgicaux cardiologiques et orthopédiques, était réparti dans trois groupes égaux de cinq participantes. L’intervention éducative comprenait quatre journées de formation offertes à intervalle de trois semaines pour une durée totale de 12 semaines. Au cours de chacune de ces journées, les participantes devaient effectuer un travail écrit réflexif concernant une situation de soins vécue avec une personne en ÉCA et, par la suite, partager, interpréter et s'interroger sur ces situations en faisant des liens avec des informations théoriques et empiriques sur l’ÉCA dans le cadre d’un atelier de groupe. Une triangulation de méthodes de collecte de données, incluant des notes de terrain de l’investigatrice, les travaux réflexifs des participantes, des questionnaires complétés par les participantes après chaque journée de formation et une entrevue individuelle avec chaque participante réalisée par une intervieweuse externe à la fin de l’intervention, a permis de décrire la mise à l’essai de l’intervention et d’évaluer qualitativement son processus et ses résultats. Une analyse de contenu des données qualitatives intra et inter participante a été effectuée. La mise à l’essai de l’intervention a mis en évidence l’importance de tenir compte des besoins variés des participantes et d’ajuster l’intervention éducative d’un groupe à l’autre, notamment eu égard aux contenus théoriques et empiriques sur l’ECA. L’évaluation du processus souligne que l’intervention a été facilitée par les attitudes et la diversité des expériences des participantes, ainsi que par l’utilisation de situations de soins réelles permettant d’intégrer la théorie dans la pratique. L’accès à de nouveaux outils d’évaluation des personnes en ÉCA a été perçu particulièrement utile par les participantes. Quant à l’évaluation des résultats, elle a permis de rendre visibles de nombreux savoirs empiriques, éthiques et esthétiques et certains savoirs personnels et émancipatoires exprimés par les participantes. Les participantes ont, entre autres, réalisé des évaluations plus approfondies des personnes en ÉCA, ont réduit ou évité les mesures de contrôle physiques des personnes atteintes et ont impliqué davantage les familles dans les soins. L’évaluation a aussi permis de décrire certains résultats perçus par les participantes sur le bien-être physique et psychologique des personnes soignées et sur les familles. Les personnes en ECA étaient, entre autres, rassurées, plus calmes et soulagées et les familles moins inquiètes et davantage impliquées dans les soins. Les résultats de l’étude mettent en évidence l’applicabilité d’une intervention éducative narrative basée sur un cadre de référence en sciences infirmières et son utilité pour la formation continue dans les milieux de soins. L’étude ouvre la porte à des possibilités de transfert de l’intervention à d’autres populations d’infirmières soignant des clientèles ayant des besoins complexes, notamment en gériatrie, en oncologie ou en soins palliatifs. Des études visant à évaluer l’intervention auprès d’un échantillon plus important et à explorer ses effets sur les personnes soignées et leurs familles sont proposées. / Older persons occupy a growing proportion of the beds in Quebec short-stay hospitals. Many of these persons present acute confusional state (ACS), or delirium, in the course of their hospitalization. The nursing care that they require is complex but studies show that continuing nursing education takes scant account of this reality. The approaches used in these studies have focused above all on the acquisition of knowledge and technical skills and have neglected the creative, relational, critical, reflexive and ethical aspects essential to delivering quality nursing care. In addition, these studies contain little information relative to the design of pedagogical interventions and their evaluation. Against this background, a study was undertaken aimed at field-testing and qualitatively evaluating the process and results of a pedagogical intervention for nurses who care for hospitalized older persons with ACS. The focus was more specifically on identifying the facilitating and constraining conditions to learning, the aspects most useful to practice, the different types of knowledge expressed, and the care outcomes perceived by participants. Inspiration for the design and evaluation of the intervention was drawn from the narrative pedagogy approach developed by Diekelmann (2001) and the various patterns of knowing knowledge defined by Chinn and Kramer (2008). The narrative pedagogy at the root of this intervention consists essentially of describing the lived care experiences of nurses and creating a learning environment conducive to group interpretation of these experiences based on theoretical and empirical data. To achieve the objectives, a case study design was used. Purposive sampling allowed selecting participants working all three work shifts, possessing different levels of training, boasting nursing experience ranging from eight months to 36 years, varying in age from 23 to 64 years. The sample, composed of 15 nurses who worked on cardiac and orthopedic surgery units and who often cared for persons with ACS, was divided into three equal groups of five. The pedagogical intervention comprised four days of training offered at an interval of three weeks for a total duration of 12 weeks. On each of these days, participants had to complete a written reflexive exercise regarding a lived care situation involving a person with ACS and then, in the context of a group discussion, share, interpret and question these situations by drawing connections with available theoretical and empirical data on ACS. A triangulation of data collection methods, including the investigator’s field notes, the participants’ written reflexive exercises, questionnaires completed by the participants after each day of training, and individual interview with each participant carried out by an outside interviewer at the end of the intervention, allowed describing the field-testing of the intervention and qualitatively evaluating its process and results. The qualitative intra and inter-participant data was then subjected to content analysis. Field-testing of the intervention highlighted the importance of taking account of the varied needs of the participants and to adjust the pedagogical intervention from one group to the next, particularly with respect to the theoretical and empirical content on ACS. Process evaluation underscored that the intervention was facilitated by the attitudes and the diversity of experiences of the participants, as well as by the use of real care situations, which allowed integrating theory in practice. Access to new tools for assessing persons with ACS was perceived to be particularly useful by the participants. As for the results evaluation, it allowed revealing various types of knowledge, including of the empirical, ethical and esthetic sort, but also some personal and emancipatory knowledge expressed by the participants. Moreover, the participants performed more in-depth assessments of persons with ACS, reduced or avoided the use of physical control measures on these persons, and involved families more in care. The evaluation also allowed documenting some of the effects perceived by the participants on the physical and psychological well-being of care recipients and their families. Persons with ACS were reassured, calmer and soothed, among other things, while families were less worried and more involved in care. The study’s results evidence the applicability of a narrative pedagogy intervention based on a nursing frame of reference and its utility in continuing education in the field of care. The study opens up the possibility of transferring the intervention to other populations of nurses who tend to clienteles with complex needs, particularly in geriatric, oncological and palliative care. It is proposed that future studies evaluate the intervention on a larger sample and explore its effects on the persons cared for and their families.

The aim: was to describe and compare a group of experts and critical care nurses' agreement in detecting delirium in intubated, ventilator treated patients with sedation / analgesia, before and after an in house training intervention with the instrument Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Method: A quasi-experimental study, one group pretest - posttest design. A convenience sample of 17 critical care nurses in a general intensive care unit included. To detect delirium the instrument CAM-ICU was used, 21 paired tests before and 22 after an educational intervention. Main Results: The results showed that after an in house training intervention sensitivity and kappa coefficient improved of the characteristic 1 "acute onset and fluctuating course," an improvement that was significant. In other features, and overall values were signs of numerical improvement and deterioration in sensitivity, specificity and kappa coefficient but no significant change. Conclusion: Implementing a new instrument for detecting delirium in clinical practice requires education and follow-up. A small sample of critical care nurses with varying ability to use the new instrument and the fact that patients' status may change rapidly making it difficult to draw any conclusions from this study. It is clear, however, that education and follow-up is needed when new care routines are introduced, and that further studies are needed to clarify whether the CAM-ICU is a valit and reliable instrument to use in clinical practice. / Syftet var att beskriva och jämföra en expertgrupp och intensivvårdssjuksköterskors överensstämmelse i att detektera delirium hos intuberade, respiratorbehandlade patienter med sedering/analgesi, före och efter en utbildningsintervention med instrumentet Confusion assessment method for the intensive care unit (CAM-ICU). Metod: En kvasiexperimentell studie, en grupps pretest – posttest design. Ett bekvämlighetsurval på en allmän intensivvårdsavdelning där inkluderades 17 intensivvårdssjuksköterskor. För att detektera delirium användes instrumentet CAM-ICU, 21 parmätningarna före och 22 efter en utbildningsintervention. Huvudresultat: Resultatet visade att efter utbildningsinterventionen förbättrades sensitiviteten och kappa koefficienten i kännetecken 1 ”akut insättande eller fluktuerande förlopp”, en förbättring som var signifikant. I övriga kännetecken och totalvärden fanns tecken på numerär förbättring och försämring i sensitivitet, specificitet och kappakoefficient men ingen signifikant förändring. Slutsats: Att implementera ett nytt instrument för att detektera delirium i klinisk verksamhet kräver utbildning och uppföljning. Ett litet sample av intensivvårdssjuksköterskor med varierad förmåga att använda det nya instrumentet samt det faktum att patienters status hastigt kan förändras gör det svårt att dra några slutsatser av denna studie. Klart är dock att utbildning och uppföljning behövs när nya vårdrutiner införs, och att ytterligare studier behövs för att klargöra om CAM-ICU är ett valit och reliabelt instrument att använda i klinisk verksamhet.

Introdução: A cirurgia cardíaca resulta em taxa considerável de complicações neurológicas, incluindo delirium, disfunção cognitiva e acidente vascular cerebral isquêmico. Supõe que a fisiopatologia envolva embolia, aterotrombose, hipofluxo, redução do débito cardíaco e alterações da autorregulação cerebral. O balão de contrapulsação intra-aórtico (BIA) é um dispositivo de assistência circulatória comumente utilizado no perioperatório de pacientes de alto risco com o objetivo de otimização do débito cardíaco e da perfusão coronária. Apesar do benefício hemodinâmico do BIA, não é conhecido seu efeito na hemodinâmica encefálica. Objetivo: Avaliar os efeitos do BIA na hemodinâmica encefálica em pacientes de alto risco submetido a cirurgia cardíaca com circulação extracorpórea (CEC). Métodos: Trata-se de um subestudo do estudo clínico prospectivo e randomizado \"Balão de contra-pulsação intra-aórtico eletivo em pacientes de alto risco submetidos a cirurgia cardíaca\", realizado no Instituto do coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre 2014 e 2016. Dos 181 pacientes incluídos no estudo randomizado, 67 pacientes foram incluídos no subestudo. Os pacientes eram adultos, submetidos a cirurgia cardíaca de revascularização miocárdica (RM) com fração de ejeção menor ou igual a 40% e/ou EuroScore maior ou igual a 6. Os mesmos foram randomizados para uso do BIA logo após a indução anestésica ou para grupo controle. A velocidade de fluxo sanguíneo cerebral (VFSC) pelo ultrassom Doppler transcraniano e a pressão arterial (PA) pelo Finometer foram continuamente gravados por 5 minutos antes da cirurgia (T1), 24h após (T2) e 7 dias após (T3). O índice de autorregulação (ARI) foi estimado através da resposta ao degrau da VFSC a mudanças na PA, derivados da análise da função de transferência. As seguintes complicações clínicas neurológicas foram avaliadas: delirium, disfunção cognitiva e acidente vascular cerebral isquêmico. Resultados: Dos pacientes incluídos no estudo, 34 foram alocados para a estratégia de uso profilático do balão intra-aórtico e 33 para a estratégia controle. Não houve diferenças significativas entre os grupos BIA e controle respectivamente, nos três tempos de avaliação, em relação ao ARI (T1 - 5,5 ± 1,9 vs 5,7 ± 1,7; T2 - 4,0 ± 1,9 vs 4,1 ± 1,6; T3 - 5,7 ± 2,0 vs 5,7 ± 1,6, P= 0,978) e em relação à VFSC (T1 - 57,3 ± 19,4 vs 59,3 ± 11,8; T2 - 74,0 ± 21,6 vs 74,7 ± 17,5; T3 - 71,1 ± 21,3 vs 68,1 ± 15,1; P=0,952). O grupo BIA e o grupo controle apresentaram incidência semelhante de complicações neurológicas (delirium na unidade de terapia intensiva - 26,5% vs 24,2%, P=0,834, acidente vascular cerebral isquêmico - 3,0% vs 2,9%, P=1,00, e declínio cognitivo pós-operatório através das escalas Mini Mental State Examination MMSE - 16,7% vs 40,7%; P= 0,073 e Avaliação Cognitiva Montreal MoCA - 79,16% vs 81,5%; P= 1,000). Conclusões: O uso profilático do BIA em pacientes de alto risco submetidos à cirurgia de revascularização do miocárdio não altera a hemodinâmica encefálica e não está associado ao aumento de complicações neurológicas como delirium, declínio cognitivo e acidente vascular cerebral isquêmico / Introduction: Cardiac surgery is associated with a high incidence of neurologic complications, such as delirium, cognitive decline and stroke. The pathophysiology probably involves embolism, thrombosis, decreased cardiac output and abnormalities in cerebral autoregulation. The intraaortic balloon pump (IABP) is an assist device commonly in high-risk patients undergoing cardiac surgery aiming to increase the cardiac output and to improve the coronary perfusion. However, the effect of the IABP on the cerebral hemodynamic is unknown. Objectives: To assess the effect of IABP on cerebral hemodynamics in high-risk patients undergoing cardiac surgery with cardio-pulmonary bypass (CPB). Methods: This is a substudy of the randomized controlled trial \"Intraaortic Balloon Counterpulsation in Patients Undergoing Cardiac Surgery (IABCS trial)\", performed at the Heart Institute/University of Sao Paulo, from 2014 to 2016. Of the 181 patients included in the IABCS, 67 were included if they were submitted to cardiac surgery and if they had one of these two criteria: left ventricular ejection fraction equal or lower than 40% and/or EuroSCORE equal or higher than 6. Patients were allocated to the strategy of prohylatic IABP after anesthesia induction or to control. Cerebral blood flow velocity (CBFV) through transcranial Doppler and blood pressure (BP) through Finometer or intra-arterial line were continuously recorded over 5 minutes preoperatively (T1), after 24h (T2) and 7 days after surgery (T3). Autoregulation index (ARI) was estimated from the CBFV response to a step change in BP derived by transfer function analysis. The following complications neurologic were evaluated: delirium, cognitive decline and stroke. Results: Of the included patients, 34 were allocated to the IABP group and 33 to control group. There were no significant differences between the IABP and the control respectively in the following parameters: ARI (T1 - 5.5 ± 1.9 vs 5.7 ± 1.7; T2 - 4.0 ± 1.9 vs 4.1 ± 1.6; T3 - 5.7 ± 2.0 vs 5.7 ± 1.6, P= 0.978), CBFV (T1 - 57.3 ± 19.4 vs 59.3 ± 11.8; T2 - 74.0 ± 21.6 vs 74.7 ± 17.5; T3 - 71.1 ± 21.3 vs 68.1 ± 15.1; P=0.952). Both groups (IABP and control) had similar incidence of neurological complications (delirium - 26.5% vs 24.2%, P=0.834, stroke - 3.0% vs 2.9%, P=1.00, and cognitive decline through the scales Mini Mental State Examination MMSE - 16,7% vs 40,7%; P= 0.073 and Montreal Cognitive Assessment MoCA - 79.16% vs 81.5%; P= 1.000). Conclusions: The prophylactic use of IABP in high-risk patients undergoing cardiac surgery does not change the cerebral hemodynamic and is not associated with higher incidence of neurologic complications such as delirium, cognitive decline and stroke

The diploma thesis deals with psychosis. Portraits of people who suffered from some type of psychosis, and which in most cases is caused by long-term drug abuse or drinking of alcohol. This is depicted with figurative painting in such a way that the painting that its style and the color spectrum corrensponds to the profile of a person with this form of mental illness and mental changes in the brain at different stages of of the disease. The output will be a series of paintings of a united size of formats that will be based , thematically a basis of dialogues with people who currently suffer or have suffered from some psychosis. The authenticity of the experiences of these people with toxic psychosis is very sensitive material, therefor it is proccessed, in this series, in such a way that can it bring closer to the viewers to posibally unimaginable situations and ways of perception of reality.