Background: Malignancy is a significant risk factor for venous thromboembolism (VTE), conferring a 4- to 7-fold increased risk in patients with cancer. Because of its effect on certain tumors, low-molecular-weight heparin (LMWH) has been evaluated as a treatment option for cancer and as an alternative to traditional warfarin therapy in patients with active cancer. LMWH is associated with a reduced recurrence of VTE, fewer adverse bleeding events, and, in some instances, decreased mortality. The American College of Chest Physicians/American Society of Clinical Oncology has recommended LMWH for at least the initial 3 to 6 months when treating VTE in patients with cancer, based on the positive outcomes associated with LMWH. Objective: The purpose of this study was to evaluate physician prescribing patterns for LMWH or warfarin in patients with acute VTE and active cancer. Methods: We conducted a retrospective chart review of hospitalized patients at a community teaching hospital with an affiliated regional cancer center located in a rural area of the United States. Patients included in the analysis had an International Classification of Diseases, Ninth Revision code indicative of any cancer type and a concomitant code for any VTE. The primary outcome was the drug prescribed at discharge for the treatment of VTE. Secondary outcomes included specialty of the prescribing physician, adverse bleeding events, and the need for transfusion. VTE treatment regimen was evaluated using the binomial test, and logistic regression analysis was used to determine correlation of the prescriber’s specialty with the patient’s prescribed regimen. Results: Of 129 patients included in the analysis, 107 (82.9%) were prescribed warfarin compared with 9 (7%) who were prescribed LMWH. Hematologists and oncologists were more likely to prescribe LMWH than general practitioners (odds ratio, 7.8; 95% hazard ratio, 1.5-42). Seven patients had a documented adverse bleeding event and 2 patients required a transfusion. Four of the 7 adverse bleeding events and 1 of the 2 transfusions occurred in the group receiving vitamin K antagonist therapy. Conclusion: Physicians in our system were significantly more likely to prescribe warfarin for acute treatment of VTE in patients with active cancer—despite consistent evidence and multiple evidence­-based guidelines recommending treatment with LMWH in this patient population. This was lower than other observations in Canadian populations but may more accurately represent nonteaching centers in the United States, particularly those in rural areas. Specialists in oncology were significantly more likely to prescribe LMWH than generalists.

In recent years, several new oral anticancer drugs have been approved, many via an accelerated approval process. These new agents have the potential for drug interactions, but lack of familiarity with these drugs by clinicians may increase the risk for drug interactions. We describe an interaction between the new anticancer agent idelalisib (CYP 3A4 inhibitor) and diazepam (CYP 3A4 substrate) that resulted in altered mental status and type II respiratory failure resulting in hospitalization. After discontinuation of both agents, the patient recovered quickly. Idelalisib was reinitiated after discharge. Lorazepam was substituted for diazepam since it is not metabolized via CYP 3A4. Both agents were tolerated well thereafter. This interaction was only flagged by two of four commonly used drug interaction databases. Clinicians should exercise caution with initiating new oral anticancer agents and consider the potential for drug interactions without solely relying on drug interaction databases.

Background: The aim of this study was to design and evaluate a laboratory activity based on scientific inquiry to educate first-year pharmacy students in the U.S. about vaccination theory and the attributes of common pathogens. Methods: The laboratory activity had two principal sections. The first consisted of an interactive game during which students rolled a die to determine outcomes based on a set of pre-determined criteria. In the second section, students generated and tested hypotheses about vaccine theory using a computer simulation that modeled disease transmission within a large population. In each section students were asked to evaluate epidemiological data and make inferences pertinent to vaccination effectiveness. Results: Mean scores on a knowledge-based assessment given immediately before and immediately after the activity increased from 46% to 71%. Discussion: A laboratory activity designed to stimulate scientific inquiry within pharmacy students enabled them to increase their knowledge of common vaccines and infectious diseases.

In the present studies we have explored the link between food hypersensitivity and IgA nephropathy (IgAN) and evaluated treatment options in primary and recurrent disease. Approximately one third of our IgAN patients had a rectal mucosal sensitivity to gluten, as demonstrated by increased local mucosal nitric oxide production and/or myeloperoxidase release after gluten challenge. The gluten sensitivity seemed to be an innate immune reaction unrelated to the pathogenesis of celiac disease. Approximately half of the patients had a rectal mucosal sensitivity to soy or cow’s milk (CM). The levels of IgG antibodies to alfa-lactalbumin, beta-lactoglobulin and casein were significantly higher in CM sensitive as compared with non-sensitive IgAN patients, indicating that an adaptive immune response might be involved in addition to the innate immune reaction observed. With the knowledge of gastrointestinal reactivity enteric treatment was considered as a potential new treatment approach of IgAN. A 6-month prospective trial demonstrated proof-of-concept for the use of enteric budesonide targeted to the ileocaecal region of IgAN patients. We observed a modest, but significant reduction in urine albumin, a minor reduction of serum creatinine and a modest increase of eGFR calculated by the MDRD equation. eGFR calculated from the Cockcroft-Gault formula and cystatin C was not changed. In a retrospective study recurrence of IgAN and graft loss was evaluated in Norwegian and Swedish patients having received a primary renal transplant due to IgAN. Adjusting for relevant covariates, a multiple Cox-regression analysis on time to IgAN recurrence showed that use of statins was associated with reduced risk of recurrence and reduced risk of graft loss. The time lag from diagnosis to first transplantation and female gender were also associated with lower risk of recurrence. Improved graft survival was associated with related donor, low donor age and no or low number of acute rejection episodes.

Made available in DSpace on 2015-05-14T12:59:41Z (GMT). No. of bitstreams: 1 arquivototal.pdf: 679492 bytes, checksum: 3252c196788de3bae30bf110b0d94cce (MD5) Previous issue date: 2009-10-09 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Fibromyalgia is a chronic painful syndrome that affects up to 5% of the population worldwide. It may be associated with sleep or mood disorders and fatigue, and progresses with functional disability. Its pathogenesis consists of disorders of central pain modulation, involvement of the descending inhibitory system and substance P hyperactivity. The drug most commonly used for treatment of this syndrome is amitriptyline, which leads to an improvement in up to 50% of cases. Patients are interested in trying alternative or complementary medicine for the treatment of fibromyalgia. Panax ginseng C.A. Meyer is an herb that has been used for hundreds of years in oriental medicine. Preclinical studies have confirmed the antinociceptive effect of its active metabolites (ginsenosides) on substance P-induced pain, demonstrating an ability to inhibit calcium channels in dorsal medullary neurons. Clinical trials have shown an improvement in quality of life and fatigue with the use of ginseng. The study had as objective to evaluate the therapeutic efficacy of the extract of P. ginseng roots in controlling pain, fatigue, sleep quality, anxiety and quality of life in fibromyalgia. Fifty-two women of 21-60 years of age, who fulfilled the inclusion criteria of the study, were selected. A randomized, double-blind, controlled clinical trial was carried out over 12 weeks to compare the effect of P. ginseng (100 mg/day) with amitriptyline (25 mg/day) and placebo. Variables evaluated were pain, fatigue, sleep quality and anxiety using a visual analogue scale (VAS); pain was evaluated using a tender points count and quality of life using the Fibromyalgia Impact Questionnaire (FIQ). The patients were evaluated at six follow-up visits and results were expressed as means ± standard error (SE) of the mean using analysis of variation (ANOVA) and Tukey s post-hoc test. Thirty-eight women with a mean age of 43 years concluded the study. There were no statistically significant differences between the three groups with respect to baseline characteristics. VAS revealed a reduction in pain in the ginseng group (p<0.0001) with an improvement ≥ 30% from the sixth week of treatment onwards, an improvement in fatigue (p<0.0001) with a reduction ≥ 25% on the sixth week and ≥ 40% on the ninth week; and an improvement in sleep (p=0.0003) with a reduction ≥ 40% in the frequency of this complaint by the 6th week of treatment. The VAS evaluation of pain, fatigue and sleep detected an improvement compared to baseline values; however, there was no statistically significant difference between the three groups. With respect to anxiety, an improvement occurred in the ginseng group compared to baseline (p<0.0001); however, amitriptyline treatment resulted in a significantly greater improvement (p<0.05). Ginseng reduced the number of tender points and improved patients quality of life, as evaluated by the FIQ, compared to baseline in both cases (p<0.0001); however, no difference was found between the groups. Treatment with ginseng resulted in an improvement in all the parameters evaluated compared to baseline; however, there was no difference between this group of patients and those using placebo and amitriptyline, and this one was more effective than placebo or ginseng in improving anxiety. The beneficial effect on all parameters evaluated suggests that further studies should be performed with larger sample sizes and/or higher doses of ginseng to evaluate this herb for future use as a complementary therapy for fibromyalgia. / A fibromialgia é uma síndrome dolorosa crônica que afeta até 5% da população mundial. Pode associar-se com distúrbios do sono, do humor e fadiga, e cursar com incapacidade funcional. Sua patogênese envolve distúrbio de modulação central da dor, comprometimento do sistema inibitório descendente e hiperatividade da substância P. O fármaco mais utilizado na sua terapia farmacológica é a amitriptilina, com melhora em até 50% dos casos. Há muito interesse dos pacientes sobre a medicina alternativa e complementar na terapia da fibromialgia. O Panax ginseng C.A. Meyer é uma erva utilizada pela medicina oriental há centenas de anos. Estudos pré-clínicos comprovaram a ação antinociceptiva dos seus metabólitos ativos (ginsenosídeos) sobre a dor induzida pela substância P, e demonstraram sua capacidade de inibir canais de cálcio nos neurônios da região dorsal medular. Ensaios clínicos sugeriram melhora da qualidade de vida e da fadiga com uso do ginseng. O estudo teve como objetivos: avaliar a eficácia terapêutica do extrato das raízes do P. ginseng no controle da dor, fadiga, qualidade do sono e ansiedade, e qualidade de vida na fibromialgia. Foram selecionadas 52 mulheres, com idades entre 21 e 60 anos, após preencherem os critérios de inclusão para o estudo. Foi desenvolvido um ensaio clínico, randômico, duplo-cego, controlado, por 12 semanas, comparando a ação do P. ginseng (100 mg/dia) com amitriptilina (25 mg/dia) e placebo. Variáveis avaliadas: dor, fadiga, qualidade do sono e ansiedade, por escala visual analógica (EVA); dor, por contagem dos pontos dolorosos; e melhora da qualidade de vida, por meio do Fibromyalgia impact questionnaire (FIQ). As pacientes foram avaliadas em 6 visitas, e os resultados foram dados em média ± EPM, utilizando ANOVA e pós-teste de Tukey. Trinta e oito mulheres concluíram o estudo, com média de idade de 43 anos. Não houve diferença significante nas características basais médias nos três grupos. Na EVA, observou-se: redução da dor no grupo do ginseng (p<0,0001), com melhora ≥ 30% a partir da 6ª semana de terapia; melhora da fadiga (p<0,0001), com redução ≥ 25% a partir da 6ª semana, e ≥ 40% na 9ª semana; e melhora do sono (p= 0,0003), reduzindo ≥ 40% a partir da 6ª semana de terapia. Nas três variáveis avaliadas na EVA, houve melhora em relação ao período basal, mas não houve diferença entre os três grupos. Com relação à ansiedade, o ginseng mostrou-se melhor em relação ao período basal (p<0,0001), mas foi inferior à amitriptilina (p<0,05), na comparação entre os grupos. O ginseng reduziu o número de pontos dolorosos e melhorou a qualidade de vida das pacientes (FIQ), ambos em relação ao período basal (p<0,0001), mas não houve diferença entre os grupos. O ginseng foi capaz de melhorar todos os parâmetros avaliados em relação ao período basal, mas não foi diferente do placebo ou da amitriptilina, e esta foi superior ao placebo e ao ginseng na melhora da ansiedade. Sua atuação benéfica nos parâmetros avaliados sugere a realização de novos ensaios clínicos, com amostras maiores, e/ou com dose maior do ginseng, para uma futura indicação como terapia complementar na fibromialgia.

Background: Persons with dementia diseases are today a large group that will increase significantly over the next few years. Behavioral and Psychological Symptoms of Dementia (BPSD) are very common and can cause major suffering. For dementia care professionals, persons with dementia suffering from BPSD may induce stress in the caregiving situation. With proper training and support, this stress may be reduced. In the BPSD register, the dementia care professionals may get information, advice and help suggesting non-pharmacological interventions that can help the person with dementia. Aim: The aim of the study was to investigate caregivers opportunities and experiences in implementing BPSD registration and follow up of non-pharmacological interventions in the caregiving situation within residential care for dementia. Furthermore, the aim was to compare if the dementia caregivers experience had significance for the experienced value of BPSD registration in Behavioral and Psychological Symptoms of Dementia. Method: A quantitative survey was conducted on residential care for dementia, N=5. The study- specific questionnaire covered possibility for BPSD- registration and interventions, considered value of BPSD estimation, and if non-pharmacological interventions are performed followed up, and considered to reduce BPSD. The results are presented using tables and diagrams. Kruskal Wallis test was used to compare variables between subgroups with varying working experience. Result: Most dementia caregivers considered that they had possibility to conduct BPSD registration 50% (n=28). They expressed 88% (n=49) that the non-pharmacological interventions that were initiated and performed decreased BPSD. Further they experienced BPSD follows up being important, 100% (n=56). There were no statistically significant differences between number of professional years and the compared variables (p-values ranged 0,266-0,981). Conclusion:The study found that dementia care professionals considered having possibilities to perform BPSD estimation, non-pharmacological interventions and follow- up. BPSD registration was experienced to be a helping tool for the dementia providers; and the length of the working experience had no significant relation to how they graded the value of the BPSD estimation.

Alla kirurgiska ingrepp, oavsett omfattning, orsakar vävnadsskada med efterföljande smärta. Obehandlad eller otillräckligt behandlad smärta kan leda till postoperativa komplikationer såväl fysiologiska som psykologiska. Farmakologisk behandling och framförallt behandling med opioider är ofta förknippat med biverkningar. Ett komplement till farmakologisk smärtbehandling kan vara icke-farmakologisk behandling såsom exempelvis musik. Musik är en gammal social företeelse som har visat sig ha positiv effekt på oro, stress och smärta. Studiens syfte var att undersöka musikens effekter på postoperativ smärta. Studien genomfördes som en litteraturstudie och resultatet baseras på femton vetenskapliga och peer-reviewed artiklar. Resultatet visade på att majoriteten av de patienter som genomgick ett kirurgiskt ingrepp och fick musikintervention skattade sin smärta lägre än de patienter som inte fick det. Musikintervention är en enkel, riskfri och kostnadseffektiv metod som kan ses som ett komplement till farmakologisk behandling av postoperativ smärta. / All surgical procedures, whatever the extent, cause tissue damage with subsequent pain. Untreated or inadequately treated pain can lead to both physiological and psychological postoperative complications. Pharmacological treatment and especially opioid treatment is often associated with side effects. A complement to pharmacological may be non-pharmacological pain management such as music. Music is an old social phenomenon which has shown to have a positive effect on anxiety, stress and pain. The purpose of the study was to investigate the effects of music on postoperative pain. The study was conducted as a literature study and the result is based on fifteen scientific peer-reviewed articles. The result showed that the majority of patients undergoing surgery and who received music interventions assessed their pain lower than those who did not. Music intervention is a simple, riskfree and cost-effective method which may be a complement to pharmacological treatment of post-operative pain.

La physiopathologie de l’anévrysme de l’aorte abdominale (AAA) est multifactorielle. De la plaque athéro-thrombotique jusqu’à l’anévrisme menaçant, les phénomènes hémodynamiques, protéolytiques, oxydatifs et inflammatoires jouent un rôle aussi complexe qu’interdépendant. Aucun traitement pharmacologique n’a fait la preuve de son efficacité. Dans ce travail, nous étudions 2 voies pharmacologiques potentielles, et développons un modèle murin d’exclusion endovasculaire. La rapamycine est utilisée en oncologie. Ses propriétés anti-inflammatoires, antiprolifératives et anti-angiogéniques stabilisaient la progression anévrismale dans un modèle établi d’AAA. L’AZD9668 est un inhibiteur sélectif de l’élastase. Sécrétée par les neutrophiles, cette protéase joue un rôle clé dans la physiopathologie anévrismale. Les propriétés thérapeutiques ont été étudiées sur un modèle murin potentialisé par l’injection systémique de Porphyromonas Gingivalis, entretenant la réaction inflammatoire et protéolytique pariétale. Dans un second temps, nous avons développé un modèle murin d’exclusion endovasculaire. La spécificité de ce traitement a soulevé de nouvelles problématiques, soulignant le rôle crucial de l’activité biologique du thrombus. L’exclusion endovasculaire d’un AAA sur les modèles de grands animaux est complexe et coûteuse. Nous avons ainsi décrit la technique sur un modèle reconnu d’AAA chez le rat. Le traitement pharmacologique des AAAs a démontré son efficacité sur modèles murins, mais est difficilement transposable à l’homme en raison des effets secondaires. Un traitement endoluminal véhiculant un principe actif délivré in-situ permettrait de stabiliser durablement les AAA. / Abdominal aortic aneurysm (AAA) pathophysiology is multifactorial. From the athero-thrombotic plaque to a threatening aneurysm, hemodynamic, proteolysis, oxidation and inflammation play a complex but interdependent role. No pharmacological treatment has yet proved to be efficient. In this work, we study 2 potential pharmacological targets, and develop a murine model of endovascular abdominal aneurysm repair (EVAR). Rapamycine is used in oncology. Its anti-inflammatory, anti-proliferative and antiangiogenic properties stabilized aneurysm progression on an established AAA. AZD9668 is an elastase selective inhibitor. Secreted by neutrophils, this protease plays a key role in aneurysmal pathophysiology. Its therapeutic benefits have been study on a murine AAA model potentiated by Porphyromonas Gingivalis systemic injection, maintaining inflammatory reaction and wall proteolysis. Then, we developed a murine endovascular aneurysm exclusion model. EVAR raised new concern, underlining the crucial role of the thrombus biological activity. Endovascular AAA exclusion on big animals is complex and expensive. We hence described the technic on a rat AAA well known model. Pharmacological AAAs treatment has proved to be efficient on murine models, but is hard to transpose to humans because of systemic side effects. An endoluminal treatment carrying active drugs, and delivered in-situ, could durably stabilize AAAs.

SAMMANFATTNING Introduktion: Depression är en av de vanligaste sjukdomarna världen över och utgör en stor börda för de drabbade och även en stor kostnad för samhället. Fysisk aktivitet används som en del av behandlingen för personer med depression och har visat sig minska depressionssymtom och öka livskvalitén. Det saknas dock en fördjupad kunskap om patienters upplevelser kring fysisk aktivitet vid depression. En ökad kunskap kan ge sjuksköterskan verktyg för individanpassad stöttning och motivation till patienter med depression.   Syfte: Syftet var att beskriva patienters upplevelser av fysisk aktivitet som behandlingsform vid depression och depressionssymtom. Metod: Designen för examensarbetet var en allmän litteraturstudie där tio kvalitativa artiklar inom området systematiskt kvalitetsgranskats och sammanställts genom en resultatanalys. Resultat: Deltagarna i studierna upplevde att de genom att utföra fysisk aktivitet blev mer kapabla att klara av saker i vardagen, fick ett ökat självförtroende och hittade ett sätt att hantera depressiva symtom. Dessutom beskrevs en hälsosammare livsstil såsom förbättrad sömn och fler sociala kontakter, den fysiska aktiviteten bidrog även till en ökad kroppsmedvetenhet. Viktiga aspekter för den fysiska aktiviteten var att deltagarna upplevde ett sammanhang och fick möjlighet att dela sina upplevelser med andra i samma situation. Deltagarna upplevde både fysiska och psykiska hinder för att kunna genomföra fysisk aktivitet.  Slutsats: Genom fysisk aktivitet som behandlingsform upplevde deltagarna att de blev både psykiskt och fysiskt starkare. Sjuksköterskan har ett viktigt ansvarsområde i att agera omvårdnadsstöd till personer med depression, att initiera åtgärder för att upprätthålla individanpassad träning och att samverka med andra professioner.  Nyckelord: icke farmakologisk behandling, psykisk ohälsa, egenvård, omvårdnad, litteraturöversikt / ABSTRACT Introduction: Depression is one of the most common diseases worldwide and is a great burden for those affected and also a great cost to society. Physical activity is used as part of treatment for people with depression and has been shown to reduce depressive symptoms and increase quality of life. However, there is a lack of in-depth knowledge of patients' experiences of physical activity in depression. Increased knowledge can give the nurse tools for individualized support and motivation for patients with depression. Aim: The purpose was to describe patients' experiences of physical activity as a form of treatment for depression and depressive symptoms. Method: The study design in this thesis was a general literature review where ten qualitative articles were systematically quality reviewed and compiled through a results analysis. Results: The participants in the studies experienced that by performing physical activity they became more capable of coping with things in everyday life, gained increased self-confidence and found a way to deal with depressive symptoms. In addition, a healthier lifestyle such as improved sleep and more social contacts were described, the physical activity also contributed to an increased body awareness. Important aspects of the physical activity were that the participants experienced a context and had the opportunity to share their experiences with others in the same situation. The participants experienced both physical and mental barriers to being able to carry out physical activity.  Conclusion: Through physical activity as part of the treatment, the participants experienced that they became both mentally and physically stronger. Nurses are responsible for acting supportive for people with depression, initiating measures to maintain individualized training and collaboration with other professions. Keywords: non-pharmacological treatment, mental illness, self-care, nursing, literature review

Bakgrund: Smärta är det vanligaste symtomet för vilket personer söker vård. Långvarig smärta behandlas ofta farmakologiskt och i Europa använder hälften av alla med långvarig smärta farmakologisk behandling. Sjuksköterskan kommer oavsett arbetsområde att möta personer med långvarig smärta. Då den farmakologiska behandling som erbjuds ofta upplevs som bristande är det viktigt att sjuksköterskan är insatt i icke farmakologiska behandlingsalternativ och hur patienter upplever dessa. Syfte: Syftet var att undersöka personer med långvarig smärtas upplevelser av icke farmakologisk behandling. Metod: En allmän litteraturstudie där 12 artiklar granskades och analyserades med en tematisk analys. Resultat: Upplevelsen var att icke farmakologisk behandling gav smärtlindring. Behandlingarna som utfördes i grupp medförde en stark känsla av gemenskap och tillhörighet där stödet från gruppen hjälpte personerna att hantera sin smärta på ett konstruktivt sätt. Behandlingarna hade även en positiv inverkan på upplevd kontroll över hälsan, detta genom att motivera till förändrade attityder och eller livsstilsförändringar. Det förekom en rad hinder vid användandet, däribland bristande kunskaper om behandlingarnas metod och syfte samt låg tillgänglighet. Konklusion: Många upplever en god smärtlindring av icke farmakologiska metoder och därmed bör dessa användas mer av sjuksköterskor i dagens hälso- och sjukvård. / Background: Pain is the most common symptom for which people seek healthcare.Long-term pain is often treated pharmacologically and in Europe, half of allindividuals with long-term pain use pharmacological treatment. Regardless of workarea, nurses will encounter people with long-term pain. Since pharmacologicaltreatment often is perceived as deficient, it is important that nurses are familiar withnon-pharmacological alternatives and how patients experience these. Aim: The aimwas to investigate the experience of non-pharmacological treatment from personswith long term pain. Method: A general literature study in which 12 articles wereexamined and analyzed with a thematic analysis. Results: The experience was thatnon-pharmacological treatment provided pain relief. The treatments performed ingroups brought a strong sense of community and belonging where the support fromthe group helped the people to manage their pain in a constructive way. Thetreatments also had a positive effect on perceived control over health, this bymotivating to change attitudes and or lifestyle changes. There were a number ofbarriers including a lack of knowledge about the method and purpose of thetreatments and low availability. Conclusion: Many people experience good pain relieffrom non-pharmacological methods and therefore should be used more by nurses intoday's health care.