Estudio descriptivo y comparativo de los cambios clínico-epidemiológicos de las Candidemias Nosocomiales en un hospital universitario, análisis de los factores pronóstico asociados a mayor mortalidad y la influencia del tratamiento precoz y adecuado junto con la retirada precoz del catéter en su evolución.Estudio transversal y observacional de pacientes adultos que desarrollaron CN durante su ingreso en el Hospital (enero-2002 a mayo- 2005). Se revisaron las historias clínicas de pacientes con hemocultivos positivos para Candida sp.El análisis comparativo se realizó con un grupo histórico (1993-8).Los resultados se derivan del estudio estadístico clínico-epidemiológico, patrones de cambio, factores pronóstico asociados a mortalidad y protectores de mortalidad.Conclusiones: La mortalidad (50%) no ha variado en los últimos años. C.no albicans predomina sobre C. albicans.Los principales factores pronóstico asociados a mayor mortalidad son: La situación de gravedad crítica inicial, el tratamiento antifúngico tardío y la no retirada precoz del catéter vascular. / Observational study of a group of adult patients with Nosocomial Candidemia (NC) admitted at a university hospital (january 2002 to may 2005). We analised epidemiological, clinical, microbiological and laboratory data and changes respesct to other historical group (1993-1998).Conclusions: Acute severity od illness at onset is associated to mortality in patients with NC whereas early and adequate treatment and early removing of central venous catheter are asociated to cur

Introducción La Neoplasia Endocrina Múltiple tipo 2 (MEN 2) se define como un conjunto de síndromes de herencia autosómica dominante, con alta penetrancia y expresividad variable, en el que mutaciones en el proto-oncogén RET dan origen a tres fenotipos diferentes: Neoplasia Endocrina Múltiple 2A (MEN2A), 2B (MEN2B) y Cáncer Medular de Tiroides Familiar (CMTF). Los distintos componentes clínicos de cada uno de ellos son: - Para MEN2A: Cáncer Medular de Tiroides (CMT), Feocromocitoma, Hiperparatiroidismo. A veces, liquen cutáneo amiloidótico o Enfermedad de Hirschprung. - Para MEN2B: CMT, Feocromocitoma, hábito marfanoide, ganglioneuromatosis intestinal, neuromas mucosos, escoliosis vertebral. - Para CMTF: CMT con o sin Enfermedad de Hirschprung. La importancia de la detección temprana de alteraciones en el proto-oncogén RET reside en la posibilidad de identificar a individuos portadores antes de la aparición de la enfermedad, previniendo así el desarrollo del cáncer medular de tiroides y controlando de cerca el desarrollo de otro de sus componentes clínicos para el tratamiento precoz. Este estudio se centra en la Región de Murcia donde existe una alta prevalencia de MEN2. Con este trabajo se pretende realizar un estudio descriptivo de los pacientes, comparándolos con los datos encontrados en otras poblaciones. Para ello se van a analizar distintos aspectos que se enuncian en el siguiente apartado. Objetivos 1. Analizar epidemiológicamente la presentación de esta enfermedad en la comunidad autónoma de la Región de Murcia. 2. Valorar la utilidad del diagnóstico precoz de esta enfermedad a través del estudio genético de todos los pacientes, estando éstos agrupados por familias. 3. Establecer si existe correlación genotipo-fenotipo. 4. Establecer los principales marcadores clínicos y bioquímicos de la enfermedad 5. Establecer los principales marcadores pronósticos de la enfermedad. 6. Valorar la utilidad clínica de los cambios realizados evolutivamente en las técnicas quirúrgicas. 7. Valorar la importancia del diagnóstico genético preimplantacional (DGP). Métodos A partir de los datos recogidos en las historia clínicas de la consulta monográfica de MEN del Hospital Universitario Virgen de la Arrixaca, se ha realizado un análisis descriptivo de todas las familias MEN 2 conocidas hasta la fecha del presente estudio. En total son 137 individuos portadores de alguna de las mutaciones del proto-oncogén RET, de ellos, 135 expresan fenotipo MEN2A y pertenecen a 25 familias no relacionadas entre sí, y los otros dos pacientes expresan fenotipo MEN 2B. Conclusiones 1. Existencia de una elevada prevalencia de MEN2 en la Región de Murcia (9 casos por 100.000 habitantes), siendo la zona del Altiplano la de mayor incidencia, en concreto los municipios de Yecla y Jumilla. La mutación genética más prevalente en la Región es la Cys634Tyr (codón 634-exón 11). 2. El diagnóstico precoz mediante el despistaje genético de los familiares de los casos índice de MEN2 es de vital importancia para evitar la aparición de CMT mediante el abordaje terapéutico en estadios pre-tumorales. 3. Se evidencia la asociación entre el genotipo y fenotipo. 4. La exploración clínica, las técnicas de imagen e histopatológicas son fundamentales para el estadiaje de los tumores del MEN2. 5. Los principales marcadores de evolución y pronóstico del CMT son el estadio tumoral y la edad al diagnóstico. 6. La mejora en las técnicas quirúrgicas y de tratamientos coadyuvantes hace que en las últimas décadas haya un mayor porcentaje de curaciones y/o estabilizaciones del CMT. La cirugía profiláctica se posiciona como el mejor avance quirúrgico en el tratamiento/profilaxis del CMT del MEN2. 7. El diagnostico genético preimplantacional hace posible la selección embrionaria con el fin de poder erradicar la transmisión de esta enfermedad. / Multiple Endocrine Neoplasia type 2A (MEN2A), type 2B (MEN2B) and Familial Medullary Thyroid Cancer (FMTC). The different clinical components of each one are the following: - MEN2A: Medullary Thyroid Carcinoma (MTC), Pheochromocitoma, Primary Parathyroid Hyperplasia. Sometimes, lichen planus amyloidotic or Hirschprung Disease - MEN2B: MTC, Pheochromocitoma, marfanoid habitus, intestinal ganglioneuromas, mucosal disturbances involving lips and tongue, spinal scoliosis - FMTC: MTC with or without Hirschprung Disease An early detection of mutations in the RET proto-oncogene has been shown as the possibility to identify individuals carriers before the onset of illness, preventing the development of medullary thyroid cancer and also controlling the development of another of its clinical components for early treatment. This study is focused in the Region of Murcia, where a high prevalence of MEN type 2 is existed. A descriptive study of the patients is intended in this work, compared with the data found in other populations. Different aspects or objectives are set out in the following paragraph. Objectives 1. Study the epidemiology of this disease in the Region of Murcia. 2. Study the usefulness of early diagnosis of this disease through genetic screening. 3. Establish a possible genotype-phenotype correlation. 4. Establish the main clinical and biochemical markers of this disease. 5. Establish the main prognostic markers of this disease. 6. Evaluate the usefulness of evolutionary changes in surgical techniques. 7. Evaluate the importance of preimplantation genetic diagnosis (PGD). Methods A descriptive analysis of all MEN 2 families known until now has been made from the data collected in the clinical histories at the monographic MEN consultation in the University Hospital Virgen de la Arrixaca (Murcia). In total 137 individuals have been carriers of some of the RET proto-oncogene mutations, which 135 show phenotype MEN 2A belonging to 25 families not related to each other. The other two patients show phenotype MEN 2B. Conclusions 1. A high prevalence of MEN type 2 in Region de Murcia (9 cases per 100000 residents) has been found. The highest incidence is been in the Altiplano area, in particular the population of Yecla and Jumilla. The genetic mutation Cys634Tyr (codon 634 - exon 11) is been the most prevalent in the Region. 2. Early diagnosis with genetic screening is found vital to prevent the MTC through the therapeutic approach in pre-tumoral stages. 3. A genotype-phenotype correlation has been demonstrated. 4. The clinical examination, imaging and histopathologic techniques have been shown as essential to staging MEN type 2 tumours. 5. Tumour stage and age at diagnosis have been identified as the main markers of evolution and prognosis of MTC. 6. The improvement in surgical techniques and others medical treatments have made that in recent decades there is a higher percentage of cures or stabilization of MTC. Prophylactic surgery has been positioned as the best surgical advance in the treatment/prophylaxis of MTC in MEN type 2. 7. The pre-implantation genetic diagnosis has allowed the embryo selection in order to be able to eradicate the transmission of this disease.

No description available.

Liver transplantation is the only definitive treatment for transthyretin amyloidosis, with an excellent 5-year survival in endemic countries where the Met30 mutation is predominant. We report our experience of liver transplantation for transthyretin amyloidosis. We reviewed the clinical records of 17 transplanted patients (11 males, 6 females; age at liver transplant: 45.7±11.7 years). We had a wide spectrum of non-Met30 mutations (52.9%), with a predominance of Gln89 (23.5%). Five-year survival after transplantation was 43.8%; at multivariate analysis, both non-Met30 mutations (HR 17.3, 95% CI 1.03-291.7) and modified BMI (HR 0.50, 95% CI 0.29-0.87) showed significant and independent prognostic roles (P=0.048 and P=0.015, respectively). Five out of the 9 non-Met30 carriers received combined heart transplantation because of severe cardiomyopathy; they showed a trend towards a better prognosis vs. the 4 patients who did not receive combined heart transplantation (although not statistically significant; P=0.095). At follow-up, no significant improvement of transthyretin amyloidosis manifestations was observed. The results of liver transplantation for transthyretin amyloidosis in our population are poorer than those reported in the literature probably because of the high prevalence of non-Met30 mutations.

Aim: To evaluate the early response to treatment to an antiangiogenetic drug (sorafenib) in a heterotopic murine model of hepatocellular carcinoma (HCC) using ultrasonographic molecular imaging. Material and Methods: the xenographt model was established injecting a suspension of HuH7 cells subcutaneously in 19 nude mice. When tumors reached a mean diameter of 5-10 mm, they were divided in two groups (treatment and vehicle). The treatment group received sorafenib (62 mg/kg) by daily oral gavage for 14 days. Molecular imaging was performed using contrast enhanced ultrasound (CEUS), by injecting into the mouse venous circulation a suspension of VEGFR-2 targeted microbubbles (BR55, kind gift of Bracco Swiss, Geneve, Switzerland). Video clips were acquired for 6 minutes, then microbubbles (MBs) were destroyed by a high mechanical index (MI) impulse, and another minute was recorded to evaluate residual circulating MBs. The US protocol was repeated at day 0,+2,+4,+7, and +14 from the beginning of treatment administration. Video clips were analyzed using a dedicated software (Sonotumor, Bracco Swiss) to quantify the signal of the contrast agent. Time/intensity curves were obtained and the difference of the mean MBs signal before and after high MI impulse (Differential Targeted Enhancement-dTE) was calculated. dTE represents a numeric value in arbitrary units proportional to the amount of bound MBs. At day +14 mice were euthanized and the tumors analyzed for VEGFR-2, pERK, and CD31 tissue levels using western blot analysis. Results: dTE values decreased from day 0 to day +14 both in treatment and vehicle groups, and they were statistically higher in vehicle group than in treatment group at day +2, at day +7, and at day +14. With respect to the degree of tumor volume increase, measured as growth percentage delta (GPD), treatment group was divided in two sub-groups, non-responders (GPD>350%), and responders (GPD<200%). In the same way vehicle group was divided in slow growth group (GPD<400%), and fast growth group (GPD>900%). dTE values at day 0 (immediately before treatment start) were higher in non-responders than in responders group, with statistical difference at day 2. While dTE values were higher in the fast growth group than in the slow growth group only at day 0. A significant positive correlation was found between VEGFR-2 tissue levels and dTE values, confirming that level of BR55 tissue enhancement reflects the amount of tissue VEGF receptor. Conclusions: the present findings show that, at least in murine experimental models, CEUS with BR55 is feasable and appears to be a useful tool in the prediction of tumor growth and response to sorafenib treatment in xenograft HCC.

DE LA TESIS:Al margen de las patologías social, infecciosa, carencial, etc., por las que a menudo es atendido en los Centros Hospitalarios el sujeto alcohólico, el alcohol en sí mismo le origina una patología clínica diversa que afecta a casi todos los sistemas del organismo. Entre ellos, uno de los menos estudiados es el sistema muscular esquelético, bien porque en pocas ocasiones crea riesgo vital al enfermo alcohólico, bien por lo difícil de su estudio sistematizado, en el sentido de ofrecer sólo hallazgos poco específicos. El hecho de que en nuestro quehacer diario en un Servicio de Medicina Interna de un Hospital General, un porcentaje alto de enfermos reuniera los criterios aceptados por el "National Council on Alcoholism", para ser calificados como alcohólicos, nos motivó al estudio de la patología que podía presentar su sistema muscular esquelético. Por otra parte queríamos familiarizamos con una patología sin duda alguna íntimamente relacionada con la Medicina Interna General. Cuántas, sino, son las enfermedades que propiamente corresponden al médico internista general en las que el sistema muscular ad quiere la personalidad suficiente para dar protagonismo a la entidad clínica en cuestión. El sometemos a una disciplina y sistemática de estudio de la miopatía que pudieran presentar un determinado grupo de alcohólicos, grupo de pacientes por otra parte fácilmente asequibles en nuestro medio, ofrecería sin duda nuevas perspectivas de trabajo en el campo de la Medicina Interna General a la hora de estudiar el grupo de enfermedades (conectivopatías, vasculitis, endocrinopatías, etc.) a las que antes hacíamos alusión. Visto lo anterior, presentamos los objetivos de nuestra tesis doctoral, que serían los siguientes:1. Determinar la frecuencia con que los pacientes alcohólicos sufren miopatía, en una serie de enfermos alcohólicos consecutivos que ingresaron en un Servicio de Medicina Interna General. 2. Profundizar en los criterios anatomo-patológicos tanto a nivel histológico como histoquímico, de la miopatía que presentan los pacientes alcohólicos. 3. Analizar las correlaciones existentes entre la miopatía alcohólica y las lesiones hepáticas y hematológicas inducidas por este tóxico.

Made available in DSpace on 2015-12-06T23:47:04Z (GMT). No. of bitstreams: 0 Previous issue date: 2006 / Esta pesquisa teve como objetivo geral caracterizar e discutir, nas vinte e duas edicoes da obra Cecil Textbook of Medicine, a relacao medico-paciente, no que se refere a abordagem conceitual, as suas finalidades e a perspectiva do desenvolvimento profissional, pelo estudante de medicina, da competencia relacional com seus pacientes. 0 referencial teorico adotado enfocou a producao de varios autores e pesquisadores que configuram as aproximacoes teorico-¬conceituais sobre a relacao medico-paciente, no periodo de 6000 anos passados ate os momentos atuais. Foi tambem revista a obra Cecil Textbook of Medicine, em uma visao historica. 0 estudo consistiu de uma pesquisa documental com enfoque qualitativo, analisando ao longo das edicoes do livro, suas caracteristicas gerais e as reformulacoes apresentadas, conforme o grupo de editores responsaveis. No periodo em que Cecil foi o responsavel pela edicao nao foram observadas mencoes a relacao medico-paciente, consistindo o livro do estudo de uma serie de doencas, sequencialmente apresentadas. Apos a morte de Cecil, os editores foram, em geral, autores de textos introdutorios que apresentavam, em diversas edicoes, a tematica da relacao medico-paciente. Alguns capitulos, ao longo dos anos, estudaram o tema com profundidade, enfatizando seus aspectos humanisticos. Contudo, a visao funcional da interacao, com vistas a obtencao de dados confiaveis a respeito da doenca e da comunicacao de possiveis estrategias de diagnostico e tratamento foi ganhando forca a partir da 15a. edicao, ate que na versao atual a medicina baseada em evidencias desconsidera os aspectos humanos da relacao e foca a utilidade do processo na tomada de decisoes. Futuras edicoes do Cecil terao como desafio conciliar a visao humanistica anteriormente apresentada com o referencial cientifico das evidencias, na relacao medico-paciente / The present research aimet to study and discuss the doctor-patient relationship in the twenty-two editions of “Cecil Textbook of Medicine”, considering concepts, objectives and the possibilities of development, by medical students, of professional competency concerning interaction with patients. The theorical referencial focused the production of several authors and researchers about the subject, from 6000 years ago to present. The “Cecil Textbook of Medicine” was also reviewed, in a hystorical perspective. The study consisted of a documental qualitative research, analysing in all the editions of the book it’s general characteristics and changes introduced by editors. When Cecil was responsible for edition, the doctor-patient was not mentioned and the book studied human diseases, sequentially presented. After Cecil’s death the editors presented, themselves, introductory chapters were doctor-patient relationship was studied, focusing humanistic aspects. However, a functional view of the interaction, aiming at obtaining truthful information about diseases and at the communication of possible strategies of diagnostic and therapy emerged since 15th. edition. The last edition, supported by evidence-based medicine, disconsiders human aspects of the relation and stresses its utility in desicion making processes. Future editions of Cecil will have to reconcile the humanistic view previously presented with the search for cientific evidences in doctor-patient relationship. / BV UNIFESP: Teses e dissertações

Orientador : Prof. Dr. José Zanis Neto / Coorientador : Profª. Drª. Maribel Pelaez Dóro, Profa. Dra. Cláudia Lúcia Menegatti / Dissertação (mestrado) - Universidade Federal do Paraná, Setor de Ciências da Saúde, Programa de Pós-Graduação em Medicina Interna. Defesa : Curitiba, 21/03/2017 / Inclui referências : f. 92-110 / Resumo: Introdução: A presente dissertação teve por objetivo revisar sistematicamente as publicações sobre a utilização de instrumentos para avaliação de ansiedade, depressão e qualidade de vida em pacientes pré e pós transplante de células-tronco hematopoiéticas. O transplante de células-tronco hematopoiéticas é uma intervenção clínica utilizada para tratar pacientes com doenças hematológicas, oncológicas, em que o tratamento convencional não foi efetivo, ou para os quais outras alternativas terapêuticas foram consideradas e excluídas. O TCTH pode afetar negativamente a vida dos pacientes, por exemplo, com o desenvolvimento de ansiedade, depressão e déficits na qualidade de vida. Método: Os estudos publicados tiveram como critérios de seleção: somente pesquisas de campo publicadas nas bases de dados Scielo, Portal BVS, Pubmed, Web of Science e Scopus; o público alvo de pacientes em período pré e pós transplante de células-tronco hematopoiéticas de qualquer sexo e faixa etária; estudos que utilizaram de pelo menos um instrumento de aferição de ansiedade, depressão e qualidade de vida; desfechos da aplicação destes instrumentos; idiomas português, inglês e espanhol; publicadas de Janeiro de 1960 a Dezembro de 2016. A partir disso houve a avaliação das evidências científicas pelos testes de relevância I e II propostos por Pereira e Bachion (2006). Em seguida, houve a aplicação de um protocolo de pesquisa criado pelos pesquisadores. Os dados foram analisados descritivamente e comparados com o coeficiente de correlação de Pearson. Resultados: Foram localizados 39 artigos para análise. Os instrumentos localizados para aferir ansiedade na população pré e pós TCTH foram o HADS em 10 (26%) das publicações. O STAI apareceu em segundo lugar, em 4 (10%) das publicações. Os instrumentos para aferir depressão na população indicada neste estudo foram o HADS em 7 (18%) das publicações. Em seguida, aparece o PHQ-9 em 5 (13%) das publicações. Para qualidade de vida, os artigos analisados mostraram que o instrumento SF-36 ocupou 8 (20%) dos dados. Em seguida, o EORTC QLQ - C30, esteve em 7 (18%) das publicações. Em relação aos desfechos, a maior parte dos artigos evidenciaram que na fase pré TCTH o índice de ansiedade e depressão moderados e severos são maiores, enquanto que na fase pós TCTH a ansiedade e depressão mínima/leve tiveram mais publicações. A qualidade de vida na fase pré TCTH indicou piora no estado de saúde, ao passo que na fase pós TCTH verificou-se melhores condições de saúde. Considerações finais: Considerou-se que é de suma importância que a equipe de saúde trabalhe na prevenção, diagnóstico e tratamento dos aspectos emocionais em pacientes TCTH para que o quadro de saúde global dos mesmos corrobore para um prognóstico favorável. Este estudo contribuiu para refletir sobre esta demanda, mas acima de tudo para que os profissionais possam trabalhar com critérios científicos. Palavras-chave: transplante de células-tronco hematopoiéticas; ansiedade; depressão; qualidade de vida; avaliação psicológica. / Abstract: Introduction: The study aimed to systematically review the literature on the use of instruments for the evaluation of anxiety, depression and quality of life in patients in pre and post hematopoietic stem cell transplantation. Hematopoietic stem cell transplantation (HSCT) is a clinical intervention used to treat patients with hematological and oncological diseases whose conventional treatment has not been effective or for which other therapeutic alternatives have been considered and excluded. HSCT may negatively affect patients' lives, for example, through the development of anxiety, depression and deficits in quality of life. Method: We selected scientific publications using as selection criteria: surveys published in Scielo, Portal BVS, Pubmed, Web of Science and Scopus databases; target population of patients pre and post hematopoietic stem cell transplantation of any gender and age; studies comprising at least one instrument for measuring anxiety, depression and quality of life; implementation of such instruments; studies published in Portuguese, English and Spanish; studies published from January, 1960 to December, 2016. Then, the evaluation of the scientific evidences by the tests of relevance I and II proposed by Pereira and Bachion (2006) was performed, followed by the application of a research protocol elaborated by the researchers. Data were analyzed descriptively and compared through the Pearson correlation coefficient. Results: A total of 39 papers were selected for the systematic review and analyzed. The instruments to evaluate anxiety in both pre- and post-HSCT population were HADS in 10 (26%) publications. STAI was the second most cited instrument, in 4 (10%) publications. The instruments for measuring depression in the population were HADS in 7 (18%) publications; PHQ-9 was acknowledged in 5 (13%) publications. For quality of life, SF-36 comprised 8 (20%) studies, followed by EORTC QLQ - C30, in 7 (18%). Regarding the implementation of instruments, most of the papers showed that in pre HSCT phase the moderate and severe indexes of anxiety and depression were higher, whereas in post HSCT phase the minimal/mild indexes of anxiety and depression were shown in more publications. Quality of life in pre HSCT indicated worsening of health status, whereas in post HSCT, better health conditions were observed. Final considerations: It is of paramount importance that the health team work in the prevention, diagnosis and treatment of emotional aspects in HSCT patients so that their overall health might corroborate a favorable prognosis. This study contributed to the reflection on such demand, but above all that professionals might work with scientific criteria. Keywords: hematopoietic stem cell transplantation; anxiety; depression; quality of life; psychological evaluation.

Magíster en educación en ciencias de la salud / La Medicina Interna es una especialidad médica dedicada a la atención integral del adulto y es gravitante en la formación de los médicos. Por ello su aprendizaje requiere la adquisición de gran cantidad de conocimientos y en especial de un amplio entrenamiento de habilidades y formación de actitudes. Esto, sumado a la instauración en nuestra Escuela de Medicina de un currículum por competencias, hace necesario implementar instrumentos de enseñanza y evaluación más completos, acorde con los aprendizajes que se desean lograr y medir. Por esta razón se realizó una investigación cualitativa con el objetivo de caracterizar las percepciones que tienen los académicos de la sección de Medicina Interna del Hospital Clínico de la Universidad de Chile y estudiantes de tercer año de Medicina de dicha sede del año 2012, acerca del uso del portafolio como método de enseñanzaaprendizaje y evaluación. Para esto se realizaron entrevistas semiestructuradas a los académicos que desarrollaron docencia de pregrado mediante portafolio en el curso de Medicina I el 2012 y un cuestionario autoaplicado a los alumnos de dicha asignatura al finalizar el año. Así, desde un paradigma interpretativo, se indagó en las percepciones que tienen del uso del portafolio docentes y estudiantes, su utilidad en el proceso de aprendizaje y evaluación, sus fortalezas y debilidades y la influencia de su implementación en el desarrollo del curso. Tras el análisis pudo deducirse que tanto los docentes como los estudiantes consideran que el desarrollo del portafolio fue positivo durante el desarrollo de la asignatura, sin embargo su confección y corrección demanda mucho tiempo, creándose tensión entre la docencia y el rol asistencial que deben cumplir los tutores y estudiantes. / Internal Medicine is a medical specialty dedicated to comprehensive care of adults and is gravitating to the training of doctors. Therefore learning requires the acquisition of wealth of knowledge and extensive training special skills and shaping attitudes. This, coupled with the establishment in our Medical School of a curriculum by competency, necessary implies to implement more complete teaching tools, acoording to the lessons that are to be achieved and measured. For this reason a qualitative research was conducted with the objective of characterizing the perceptions of academics of the Section of Internal Medicine of the Clinical Hospital of the University of Chile and third year students of Medicine that seat in 2012, about the use of the portfolio as a method of teaching-learning and evaluation. For this semistructured interviews were conducted to the academics that developed undergraduate teaching with portfolio during 2012 and a questionnaire to the students of Medicine I at the end of the year. Thus, from an interpretive paradigm, we investigated in the perceptions of the use of portfolio in teachers and students, its usefulness in the learning process and evaluation, strengths and weaknesses and the influence of its implementation in the development of the course. After analysis it could be inferred that both teachers and students consider the development portfolio was positive for the development of the subject, but its preparation and correction time consuming, creating tension between teaching and caring role to be met tutors and students.

O objetivo deste estudo foi analisar os perfis de diagnósticos de enfermagem e dos domínios da classificação antes e após a implementação da classificação da North American Nursing Diagnosis Association – International (NANDA-I) na Clínica Médica do Hospital Universitário da Universidade de São Paulo (HU-USP), realizada entre os anos de 2001 e 2004. A amostra foi composta pelos registros de enfermagem de 31 pacientes admitidos em agosto de 2001 (fase pré, sexo masculino=61,3%, idade média=53,6±20,9 anos, internação por doenças do aparelho circulatório=30%) e de 30 admitidos em agosto de 2004 (fase pós, sexo feminino=60,0%, idade média=60,9±23,1 anos, doenças do aparelho respiratório=30%). Todos os registros de enfermagem das primeiras 24 horas de internação foram manualmente transcritos. Na fase pré foi utilizada a técnica de mapeamento cruzado para inferir os diagnósticos segundo a taxonomia da NANDA-I. Os diagnósticos da fase pós foram transcritos dos registros. Os critérios para incluir os diagnósticos das duas fases para as análises finais foram: consenso de painel de três juízes e a existência de pelo menos um item de prescrição de enfermagem pertinente. As associações entre as freqüências de diagnósticos, domínios e as fases do estudo foram testadas, com nível de significância ?0,10. Os perfis de diagnósticos e domínios foram descritos pela Análise Fatorial Múltipla (AFM). Na fase pré, os diagnósticos mais freqüentes foram: integridade da pele prejudicada (54,8%), dor aguda (48,4%) e risco para integridade da pele prejudicada (45,2%), e na fase pós: dor aguda (66,7%), integridade tissular prejudicada (32,3%) e desobstrução ineficaz de vias aéreas para (43,3%). Seis diagnósticos apresentaram diferença estatística entre as duas fases: integridade da pele prejudicada (de 54,8% para 33,3%, p=0,092); nutrição desequilibrada: menos que as necessidades corporais (de 25,8% para ausência de ocorrência, p=0,005); deambulação prejudicada (de 19,4% para nenhuma ocorrência, p=0,024); proteção ineficaz (de nenhuma ocorrência para 23,3%, p=0,005); perfusão tissular renal (de nenhuma ocorrência para 16,7%, p=0,024); ansiedade (de nenhuma ocorrência para 13,3%, p=0,053). Foram identificados seis domínios na fase pré e sete na pós. Houve diferenças significativas nos domínios: conforto (de 48,3% para 73,3%, p=0,046); nutrição (de 25,8% para 6,6%, p=0,023) e enfrentamento/tolerância ao estresse (de nenhuma ocorrência para 13,3%, p=0,053). Essas diferenças indicam que, após a implementação da classificação, houve maior focalização de respostas de conforto e de enfrentamento e tolerância ao estresse. A AFM indicou diferentes perfis de diagnósticos e de domínios entre as fases, mostrando que na fase pós houve maior amplitude dos fenômenos focalizados pelas enfermeiras. A implementação da classificação da NANDA-I contribuiu para ampliar o foco do cuidado, aumentando a ênfase em fenômenos pouco documentados, como os do domínio de enfrentamento e tolerância ao estresse. O fato de as enfermeiras documentarem esses fenômenos como diagnósticos aumenta a responsabilidade na seleção de intervenções adequadas e na avaliação dos resultados obtidos. Os resultados deste estudo são contribuições importantes para aprimorar os processos de implementação das classificações e para monitorar os seus efeitos na prática clínica de enfermagem. / The aim of this study was to analyze the profiles of nursing diagnoses and domains of the classification before and after the implementation of NANDA-I (North American Nursing Diagnosis Association – International) in the Medical Clinic of the Hospital Universitário da Universidade de São Paulo (HU-USP), carried out from 2001 to 2004. The sample was composed by the nursing records from 31 patients admitted in August 2001 (pre-implementation phase, male=61.3%, mean age=53.6±20.9 years old, admittance due to circulatory system diseases=30%) and from 30 patients admitted in August 2004 (phase post, female=60.0%, mean age=60.9±23.1 years old, respiratory system diseases=30%). All nursing records from the first 24 hours of admittance were manually transcribed. In the phase pre the cross-mapping technique was applied in order to infer the diagnoses according to the NANDA-I taxonomy. The phase post diagnoses were transcribed from the records. The analysis criteria to include the diagnoses from both stages were: a three-referee panel consensus and the existence of at least one pertinent nursing order item. The associations among the diagnose frequencies, domains and study phases were tested, with a significance level of ?0.10. The profiles of diagnoses and domains were described by the Multiple Factorial Analysis (MFA). In the phase pre, the most frequent diagnoses were: skin integrity impaired (54.8%), acute pain (48.4%) and skin integrity impaired risk (45.2%), and in the phase post: acute pain (66.7%), tissue integrity impaired (32.3%) and airway clearence innefective (43.3%). Six diagnoses had statistic difference between the two phases: skin integrity impaired (from 54.8% to 33.3%, p = 0.092); unbalanced nutrition: less than the body requirement (from 25.8% to non-occurrence, p = 0.005); impaired walking (from 19.4% to non-occurrence, p = 0.024); ineffective protection (from non-occurrence to 23.3%, p = 0.005); tissue perfusion ineffective renal (from non-occurrence to 16.7%, p = 0.024); anxiety (from non-occurrence to 13.3%, p = 0.053). Six domains in the phase pre, and seven in the phase post were identified. There were significant differences in the following domains: comfort (from 48.3% to 73.3%, p = 0.046); nutrition (from 25.8% to 6.6%, p = 0.023) and coping/stress tolerance (from non-occurrence to 13.3%, p = 0.053). These differences indicate that, after the implementation classification, there were greater focus on comfort responses and coping/stress tolerance. The MFA presented different profiles of diagnoses and domains between the phases, indicating that on the phase post there was greater amplitude of the phenomena focused by the nurses. The NANDA-I classification implementation contributes to widen the care focus, increasing the emphasis on less-documented phenomena, as the ones of the coping/stress tolerance domain. The fact that the nurses documented such phenomena as diagnoses increases the responsibility in the selection of proper interventions and in the evaluation of the outcomes. The results to this study are important contributions, which aim at improving the processes of the classification implementation, and at monitoring their effects on the nursing clinical practice.