Abstract available through the Journal of the American College of Cardiology.

0BABSTRACT This thesis is focused on enteral nutrition. This issue is an integral part of intensive and resuscitation care, but it is also a part of standard and follow-up care. There are more and more new resources and the products for enteral nutrition are improving. The theoretical part deals with malnutrition, discusses the different components of nutrition. Much of the thesis forms ways of application of nutrition. The issue is a nasogastric tube, a nasojejunal tube, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy, feeding button or sipping. There are further expanded the introductions, nursing care, indications and contraindications of these options. The following chapters analyse the modes of enteral feeding, advantages and disadvantages of enteral nutrition compared to parenteral. The practical part is focused on research using anonymous questionnaires in the area of enteral nutrition. The survey was conducted in four departments of three teaching hospitals in Prague. It was focused on nurses and paramedics in medical intensive metabolic care units. The survey had 73 respondents. The aim was to identify the mode of feeding that nurses prefer and how they apply it, analyze the extent to which the nurses actively involve themselves in this, how they are oriented in...

The presented Master’s Thesis aims at determining stress and strain distribution in proximal femur with applied PCCP and DHS systems. The DHS system has been widely and successfully used for treating intertrochanteric fractures of proximal femur; in some cases, however, complications concerning implant cut-out and excessive fracture collapse occur. To minimize the risk of stabilization failure, the PCCP system was designed. In the Thesis, the process of creating the numerical model is described and the results obtained by employing Finite Element Method are presented. The 3D models of implants’ geometry were created based on the real objects. The model of proximal femur geometry was built by utilizing a series of CT scans and divided into two bodies with respect to the AO classification afterwards. The loading was obtained by solving the static equilibrium equations for the loose lower extremity. The computation was run in Ansys Workbench v13 software. In the hip screws of the PCCP system, lower values of equivalent stress can be found when compared to the DHS system. However, the equivalent strain generated in the proximal fragment is 3-times higher when the PCCP system is employed than in case of DHS system which may be due to the self-cutting design of PCCP screws. By employing PCCP system, the risk of implant failure is decreased. On the other hand, the bone tissue of the proximal fragment in close vicinity of the implant screws seems to be overloaded and prone to collapse.

A population based cross-sectional time series analysis was conducted using three Ontario administrative databases, to assess trends over time in the surgical management of kidney stone disease. All kidney stone treatments performed with extracorporeal shockwave lithotripsy (SWL), ureteroscopy (URS) and percutaneous nephrolithotomy between July 1, 1991 and December 31, 2010, were included. Time series modeling with exponential smoothing and autoregressive integrated moving average models demonstrated a significant increase in the utilization of URS over time (23.69% to 59.98%, p<0.0001), with a reciprocal significant decrease in the utilization of SWL (68.77% to 33.36%, p<0.0001). As a result of this shift in treatment paradigm, time series modeling also demonstrated an associated significant decrease in the need for ancillary treatment over time (22.12% to 16.01%, p<0.0001) and a significant increase in the need for hospital readmission (8.01% to 10.85%, p<0.0001) or emergency room visit (7.58% to 9.95%, p=0.0024) within 7 days following treatment.

A population based cross-sectional time series analysis was conducted using three Ontario administrative databases, to assess trends over time in the surgical management of kidney stone disease. All kidney stone treatments performed with extracorporeal shockwave lithotripsy (SWL), ureteroscopy (URS) and percutaneous nephrolithotomy between July 1, 1991 and December 31, 2010, were included. Time series modeling with exponential smoothing and autoregressive integrated moving average models demonstrated a significant increase in the utilization of URS over time (23.69% to 59.98%, p<0.0001), with a reciprocal significant decrease in the utilization of SWL (68.77% to 33.36%, p<0.0001). As a result of this shift in treatment paradigm, time series modeling also demonstrated an associated significant decrease in the need for ancillary treatment over time (22.12% to 16.01%, p<0.0001) and a significant increase in the need for hospital readmission (8.01% to 10.85%, p<0.0001) or emergency room visit (7.58% to 9.95%, p=0.0024) within 7 days following treatment.

Thesis advisor: Rosanna F. DeMarco / The purpose of this study was to understand the lived experience and meanings of percutaneous injury (PI) and its aftermath among US registered nurses. An interpretive phenomenological approach was utilized to carry out the study which included nine percutaneous injury experiences. Van Manen's existential framework was used as a reflective guide. Findings from this study emerged as three essential themes which were common to all participants: being shocked: the potential of a serious or life-threatening infection; needing to know it's going to be okay; and sensing vulnerability. The first theme, <italic>being shocked</italic>, was identified as the primary mode of living with the sudden occurrence of PI. In the moment of injury, participants' language reflected shock and an immediate consciousness of the potential threat of a serious or life-threatening infection. Nurses' responses were visceral and emotional. All acted on their need to reduce foreign blood contamination and the urgency they felt for immediate care. <italic>Needing to know it's going to be okay</italic> represented the initial meaning of living in the aftermath of PI as nurses assessed their risk and sought post exposure intervention and caring responses from others. <italic>Sensing vulnerability</italic> was identified as the secondary mode of living in the aftermath of PI as participants reflected on the fragile nature of health into the future, distinguished between supportive vs. non-supportive relationships in their overall PI experience, and identified the need to be vigilant in the future with respect to their health, life and PI prevention. Together, these three essential themes and their dimensions represent the essence and meanings of percutaneous injury and its aftermath for at least one group of US registered nurses. Findings in this study support the conclusion that the lived experience of PIs and its aftermath imposed a significant psychological burden on nurses. These findings offer a better understanding of the essence and meanings of PI and its aftermath and contribute knowledge to inform nursing education, nursing practice, health policy and future research. / Thesis (PhD) — Boston College, 2010. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Thesis advisor: Barabara Hazard / This randomized controlled trial (RCT) examined a discharge nursing intervention (DNI) aimed at promoting self-regulation of care for early discharge interventional cardiology patients. The purpose of this study was to compare medication adherence, patient satisfaction, use of urgent care, and illness perception in patients with cardiovascular disease (CVD) undergoing interventional revascularization procedures who receive usual care and those who receive a DNI. The Common Sense Model (CSM) of illness representation provided the theoretical foundation for this study. The CSM is a cognitive parallel processing model that draws relationships between illness representation, coping methods, and illness outcomes to help explain the process by which people make sense of their illness. Intervention research aimed at life style changes to reduce secondary events after treatment for CVD is needed to guide evidence based care. Treatment for CVD has shifted from surgical repair with prolonged hospitalizations to interventional procedures requiring shorter hospital stays. This trend reduces nursing time to monitor complications and provide education about medication management and lifestyle changes. Patients recover in short stay areas and return home within hours or one to two days of the procedure. Cardiac disease is then managed as a chronic, but often stable condition. With this change in the delivery of care, several trends have emerged that have implications for quality nursing care and patient outcomes: a) the burden of care shifts from the hospital setting to home, b) patients are discharged without extensive education about complications and disease management, c) the occurrence of secondary events and disease progression remain a valid threat, and d) nurses with expert practice are in a unique position to assist patients and families with CVD management. This study addressed the following questions. 1. Do patients receiving the nursing intervention differ significantly from those receiving usual care on medication adherence? 2. Do patients receiving the nursing intervention differ significantly from those receiving usual care on patient satisfaction? 3. Is there a significant difference in the utilization of urgent care between those patients receiving the nursing intervention when compared to those patients receiving usual care? 4. Does a difference exist between the patients receiving the nursing intervention and those patients receiving usual care on illness perception, as measured by seven components of the IPQ-R: time line (acute and chronic), consequence, personal control, treatment (cure) control, illness coherence, timeline (cyclical), and emotional representations? Purposive sampling was used to select a sample of patients admitted for interventional procedures at an academic teaching hospital. One hundred and fifty four patients were and randomized into control and experimental groups. Final analyses included data from 129 patients. Sixty-four participants in the experimental group received the DNI which included: 1) additional written information about taking medications, 2) a medication pocket card, 3) a list of 3 cardiac internet sites,and 4) a phone call, 24 hours post procedure, from an expert cardiac nurse to review discharge instructions. Sixty-five participants in the control group received usual care. Analyses on four outcome measures, medication adherence, use of urgent care, patient satisfaction, and illness perception, revealed one statistically significant result. Participants in the experimental group, receiving the DNI, scored significantly higher than the control group on one measure, the timeline (acute/chronic) component of illness perception (p = .006) indicating a greater appreciation of the chronicity of their disease. Otherwise, there were no significant group differences found. This study provides support for nursing intervention research guided by self-regulation theory that examines the patient's perception of illness. Patients with cardiac disease who received the DNI were statistically more likely to acknowledge that their illness would last a long time. This awareness, may improve adherence to a prescribed regimen of medication and lifestyle modification. Nursing interventions guided by an understanding of patients' belief that their cardiovascular disease is chronic will add to the body of knowledge that informs providers about decisions patients make concerning medication adherence and lifestyle modifications. However, the results underscore the limitations of adding additional discharge care to this population of patients to improve medication adherence, use of urgent care, and patient satisfaction. Future research should include a longitudinal study to examine how patients who perceive their disease to be chronic in nature managed their medications and care decisions at home. / Thesis (PhD) — Boston College, 2009. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

No intuito de simplificar a gastrostomia endoscópica percutânea (GEP) suprimindo- se a utilização de um endoscópio ou métodos de imagem, a gastrostomia magnética percutânea (GMP) foi concebida como nova opção técnica. Objetivo: investigar factibilidade de nova técnica para GMP por estudo experimental controlado, comparada à técnica GEP. Método: quatorze porcos foram submetidos a GEP (grupo ENDO, 7 animais) ou a GMP (grupo MAG), e submetidos a eutanásia 7 dias após o procedimento. Foram avaliados sucesso técnico, peso, tempo de procedimento e número de ocorrências/complicações (complicação menor – sem necessidade de nova intervenção). Para análise estatística foram aplicados o teste não paramétrico de Mann-Whitney e o teste exato de Fisher. Valores de p<0.05 indicaram significância estatística. Resultados: Todos os procedimentos realizados foram tecnicamente bem-sucedidos. Doze animais apresentaram evolução pós-operatória favorável. Dois animais (um de cada grupo) foram a óbito precocemente, não atribuível ao acesso gástrico. Houve no total 5 ocorrências/ complicações menores (4 no grupo MAG), sendo 3 dessas relacionadas ao tubo de gastrostomia. Houve maior perda de peso no grupo MAG comparado ao grupo ENDO, com significância estatística (peso médio em gramas 115±131(desvio-padrão) e -83±128, respectivamente, p=0,04). O tempo de procedimento foi maior para o grupo MAG comparado ao grupo ENDO, com significância estatística (tempo médio em segundos 471±140 e 882±239, respectivamente, p=0,001). Conclusão: a gastrostomia percutânea magnética é tecnicamente factível, porém necessita de melhorias no dispositivo devido a complicações relacionadas ao tubo de gastrostomia. Comparado ao método tradicional endoscópico, a gastrostomia magnética apresentou maior tempo de procedimento e maior perda de peso. / In order to simplify a Percutaneus Endoscopic Gastrostomy (PEG) procedure and obviate the need of imaging methods, a Percutaneous Magneticallyguided Gastrostomy (PMG) has been conceived. OBJECTIVE to investigate preclinical application of a novel magnetic device for PMG through an experimental controlled trial compared to PEG. METHODS fourteen domestic pigs were assigned for ENDO group (undergoing PEG, 7 animals), and MAG group (undergoing PMG). All animals were euthanized 7 days after procedure. Aspects related to technical success, procedure duration and clinical outcome (weight changes, event/complication rate) were evaluated. These were statisctically evaluated using Mann-Whitney (non-parametric) and Fisher’s exact test. Values of p<0.05 were considered statistically significant. RESULTS technical success was achieved for all animals undergoing the procedures. Of these, 12 had a favorable clinical outcome. Two animals died in less than 24 hours (one from each group), not directly related to gastric access. There were 4 minor complications (4 of them for group MAG), and 3 of these were tube-related. Weight loss was statistically significantly higher for group MAG (mean weight in grams 115±131(standard-deviation) e - 83±128, respectively, p=0.04). The procedural time was statistically significant higher for group MAG compared to ENDO (mean time in seconds 471±140 e 882±239, respectively, p=0.001). CONCLUSION a magnetically-guided percutaneous gastrostomy without imaging is technically feasible, however a device improvement is needed because of tube-related complications. Compared to percutaneous endoscopic gastrostomy, the magnetically-guided percutaneous gastrostomy technique is more time-consuming and had more weight loss.

A exposição à radiação ultravioleta (RUV) pode levar a um desequilíbrio no balanço oxidante/antioxidante da pele causando prejuízos à sua integridade e levando a diversas alterações, entre as quais o envelhecimento precoce e o câncer de pele. Na tentativa de diminuir os efeitos biológicos mediados pelos radicais livres gerados pela RUV na pele, tem sido proposto a fotoquimioproteção com a utilização de antioxidantes tópicos. Dentre a gama de compostos disponíveis para serem empregados na fotoquimioproteção, a própolis, por sua pronunciada atividade antioxidante, entre suas inúmeras atividades biológicas, é uma matéria-prima com promissora ação tópica. Desta forma, extratos de própolis alcoólico e glicólico (EPA e EPG) foram caracterizados quanto à sua composição polifenólica e quanto à sua capacidade antioxidante frente a diversos radicais livres. Formulações adicionadas destes extratos foram desenvolvidas e submetidas a estudos de estabilidade física e funcional, estudos de liberação, permeação e retenção cutânea in vitro, bem como estudos preliminares de eficácia in vivo. Os resultados demonstraram que os extratos de própolis são capazes de seqüestrar eficientemente diversos radicais livres, principalmente radicais superóxido. Quando estes extratos foram adicionados em formulações de produtos para uso tópico, a atividade antioxidante foi mantida. Nos estudos prévios de estabilidade física foi observado que as formulações mais estáveis foram desenvolvidas com Hostacerin® SAF (menor conteúdo graxo) e Polawax® (maior conteúdo graxo). No entanto, somente a formulação desenvolvida com Polawax® apresentou estabilidade satisfatória por 1 ano quando armazenada à temperatura ambiente e a 40º.C 2º.C/70%UR 5%. Nos estudos de liberação, permeação e retenção cutânea foi observado a influência do conteúdo graxo na performance das formulações. A cinética de liberação das formulações tanto do ácido p-cumárico (utilizado como marcador), como dos compostos equivalentes ao extrato de própolis (EEP) demonstraram seguir o modelo de Higuchi. A formulação desenvolvida com Polawax® apresentou a melhor retenção cutânea, com retenção de 0,013 e 0,030 µL de EEP.cm-2 para as peles de camundongo e de porco, respectivamente. Em adição, esta formulação apresentou baixos níveis de permeação cutânea, sendo adequada para aplicação tópica fotoquimioprotetora. Nos estudos in vivo, esta formulação adicionada de EPA, foi capaz de diminuir o eritema, inibir o edema e aumentar a cicatrização de camundongos sem pêlo expostos à radiação UVB. Além disso, também foi observado a proteção da depleção da glutationa endógena (GSH). Os resultados preliminares de eficácia in vivo sugerem que formulações contendo o extrato de própolis apresentam boas perspectivas para serem utilizadas para prevenir e tratar os danos causados na pele pela radiação UV. / The ultraviolet radiation (UVR) exposition may lead to the skin oxidant/antioxidant imbalance injuring its integrity and leading to several disorders, such as ageing and skin cancer. In order to improve the biological effects caused by free radicals generated by UVR in skin, it has been suggested the photochemoprotection by using topical antioxidants. Among the available compounds to be employed in hotochemoprotection, propolis, due to its important antioxidant activity, among its innumerous biological activities, is a promising topical raw-material. Next, ethanolic and glycolic propolis extracts (EPE, GPE) were characterized in relation to their polyphenolic composition, and in relation to their antioxidant activity against several free-radicals. Formulations added with these extracts were developed and undergone to physical and functional stability studies, in vitro release and skin permeation and retention studies, as well as in vivo preliminary efficacy studies. The results showed that the propolis extracts are able to scavenge several free radicals efficiently, mainly superoxide radicals. When these extracts were added to formulations of topical products, their antioxidant activity were maintained. In the physical stability studies, it was observed that the most stable formulations were developed with Hostacerin® SAF (lower fat content) and Polawax® (higher fat content). However, only the formulation developed with Polawax® showed satisfactory stability for 1 year stored at room temperature and at 40º.C 2º.C/70%UR 5%UR. In the release, permeation and retention studies, it was observed the fat content influence in the formulation performance. The release profile of p-coumaric acid (used as marker compound) and the compounds equivalent to propolis extract (EPE) followed the Higuchi model. The formulation developed with Polawax® showed the best skin retention, retaining 0,013 and 0,030 L EPE.cm-2 in hairless mouse skin and in pig skin, respectively. In addition, this formulation presented low permeation, which is desired for photochemoprotective topical employment. In the in vivo studies, this formulation added with EPE was able to diminish erithema, inhibit oedema and increase cicatrisation in hairless mice exposed to UVB radiation. In addition, it was also observed the protection of the endogenous glutathione (GSH) depletion. The in vivo preliminary efficacy results suggest that formulations added with propolis extract present good perspectives to be employed to prevent and treat the injuries caused in skin by UV radiation.

A reposição estrogênica na pós-menopausa revela-se através de benefícios na melhora da qualidade de vida, prevenção e cura da osteoporose, bem como na diminuição da incidência de doenças cardiovasculares. A via percutânea apresenta grande interesse devido a fatores como, manutenção de níveis plasmáticos e eliminação da primeira passagem hepática, responsável pelo surgimento de efeitos colaterais adversos, aliados a relativa simplicidade de desenvolvimento e produção, facilidade na aplicação e versatilidade. Neste trabalho foram viabilizadas formulações de géis hidroalcoólicos contendo estradiol com diferentes bases, adaptando e desenvolvendo metodologias para determinação de características físicas, químicas e tecnológicas, como espalhabilidade, consistência, liodisponibilidade, teor da substância ativa e conservantes, bem como ensaios preliminares de penetração na pele, e em membranas artificiais e de estabilidade física e química de estradiol e dos conservantes. Verificou-se que dois dos gíss desenvolvidos, com bases de carbômero (Carbopol 940®) e hidroxietilcelulose (Cellosize QP 100®), apresentaram características apropriadas no que diz respeito a consistência, espalhabilidade e promoção da penetração de estradiol através da pele. Esta foi avaliada através do desenvolvimento ponderal uterino de ratas castradas e determinação dos níveis séricos de estradiol por fluorimunoensaio, não havendo diferença significativa entre os produtos neste ensaio. Ambas as formulações mostraram-se estáveis fisicamente, porém, o produto desenvolvido com base de hidroxietilcelulose apresentou degradação significativa de estradiol. Os ensaios de absorção de estradiol em membranas artificiais não diferenciou significativamente as formulações quanto ao tipo de base e tempo de exposição, observou-se entretanto, que existe uma relação entre a quantidade aplicada de gel e de estradiol absorvido. / The hormonal replacement therapy for menopausal symptoms intents the healing and prevention of osteoporosis, the decrease of the incidence of cardiovascular diseases as well the improvement of life quality, affording relief from any of a long list of subjective complaints. The election of a transdermal estradiol formulation is due to its abilities to bypass the liver resulting adequate hormonal plasmatic levels. In addition, it is considerably simple to manufacture and to adapt to individual dosages. This research aims the formulation of estradiol as an hydroalcoholic gel using different gelformers. The development and adaptation of methodologies to perform the physical, chemical and biological characterization of the formulated products were also realized. Two of the formulated gels showed appropriate characteristics of consistence, spreading and skin permeation. They were prepared with carbomer (Carbopol 940) and hydroxiethylcellulose (Cellosize QP 100). Biological evaluation was performed by the essay of the uterusweight of castrated rats and by immunofluorescence assay. The statistical analysis showed no differences between the methods and gels. The stability test for the two formulations yielded good physical stability results but the hydroxyethylcellulose gel showed significant estradiol degradation. Although the gels artificial membrane absorptions didn't differ when submeted to difference contact times, it was detected a kind of relationship between the applied gel amount and the absorbed estradiol.