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In selected patients, surgical treatments such as cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have enabled curative treatment options for previously incurable diseases, such as peritoneal carcinomatosis (PC). The introduction of resource demanding surgery could affect the work process, efficiency, and productivity within a surgical department and factors influencing patient postoperative recovery processes may have an impact on the efficiency of patient care after major surgery. The aim of this thesis was to investigate operating room efficiency from the perspective of both staff and leaders’ in two different settings (Papers I and II) and the early postoperative recovery of patients with peritoneal carcinomatosis (Papers III and IV). Interviews were held with 21 people in a county hospital and 11 members of the PC team in a university hospital, and a phenomenographic approach was used to analysis the data (Papers I and II). The patients’ postoperative recovery and pulmonary adverse events (AE) were determined from data retrieved from the electronic health records of 76 patients (Papers III and IV). The concept of efficiency was understood in different ways by staff members and their leaders (Paper I). However, when working in a team, the team members had both organisation-oriented and individual-oriented understanding of efficiency at work that focused on the patients and the quality of care (Paper II). The patients with PC regained gastrointestinal functions and could be mobilised during early postoperative recovery phase, although many patients suffered from psychological disturbances, sleep deprivation, and nausea (Paper III). Postoperative clinical and radiological pulmonary AE were common, but did not affect the early recovery process (Paper IV). In conclusion, leaders who are aware of the variation in understanding the concept of efficiency are better able to create the same platform for staff members by defining the concept of efficiency within the organisation. In a team organisation, the team members have a wider understanding of the concept of efficiency with more focus on the patients. The factors affecting postoperative recovery and pulmonary AE should be considered when designing individualised patient care plans in order to attain a more efficient recovery.

The main question that this thesis addresses is what is the optimal way of producing tissue grown in the peritoneal cavity around a foreign body for its use as a vascular graft? It is known that a foreign body implanted into the peritoneal cavity induces an inflammatory response with cells recruited from within the peritoneal cavity to encapsulate the foreign body. Over the course of two to three weeks these cells produce an organised matrix and differentiate to become myofibroblasts. Tubes of these ‗tissue capsules‘ have been transplanted into the arterial vasculature in several animal models where the tissue capsule differentiates into an arterial structure. This structure consists of a layer of smooth muscle-like cells, adventitia of dense connective tissue including vasa-vasorum and an endothelial layer of flattened mesothelial cells. In order to determine whether the tissue would further differentiate ex vivo in response to mechanical stimulus an in-vitro bioreactor system was built to house tissue capsules produced in a variety of animal models. This bioreactor system could house 4 tissue capsules under physiological conditions including standard pulse rates, pressures and temperatures experienced by an artery. Boiled blood clot (BBC) scaffolds were implanted into the peritoneal cavity of rats to produce tissue capsules. After two weeks of development in the peritoneal cavity, tissue capsules were harvested and implanted into the bioreactor. Tissue capsules grafted into the bioreactor were subjected to mechanical force for a range of time-points, pressure, pulse and flow rates. When analysing tissue immunohistochemically, elastin, myosin, αSMA and desmin were detected. This staining was not consistent across all samples and only present in small parts of some tissue tested. Western analysis did not show any expression of αSMA or myosin. Finally the morphology of the tissue also resembled that of tissue previously implanted into the arterial circulation, but development of mechanical properties were not to the extent that would make the tissue useful as a vascular graft. The bioreactor system was thus modified to be able to house tissue for a period of 3 weeks. This system successfully housed tissue capsules under mechanical force in physiological ranges. Next, a range of materials were tested for their ability to be included into the peritoneal implant device used for the large animal model. Elasteon 80A did not produce any cellular growth or peritoneal pathology in all implanted samples (n = 4). Cloisite, a pro-inflammatory material produced large tissue capsule development over a 2 week implant period in 25% of samples however this tissue was heavily adhered to the greater omentum and dependent on its vascular supply. This data suggested that Elasteon could be used to coat the outer surface of a peritoneal implant device to decrease the rate of peritoneal adhesions. Three devices were designed and fabricated for their use in generating tissue for the modified Mitrofanoff procedure which requires a length of tissue to be implanted between the umbilicus and the bladder as a fistula. In all three cases no implantable material was produced that could be used for this procedure. To modify the device that could be used to produce tissue for any surgical application, a range of devices was produced and the animal model was changed to pigs. Materials incorporated into these devices include Dexon mesh and polyethylene. These devices also did not produce any tissue that could possibly be used as a vascular graft. A novel material, polymer BD347 was then produced for use in developing tissue within the interior of the device to provide greater growth and mechanical properties for developing a vascular graft. In toxicological studies, the replacement rate of cells was unaffected after seven days of incubation of fibroblasts at confluence with the polymer. A range of mechanical properties from pig vasculature was gained so that a sheet of polymer with similar properties to that of a vascular graft could be made. This polymer was fabricated as a tube and implanted into the peritoneal cavity of rats. The implanted polymer remained free-floating with a capsule of tissue in 78% of cases. A device was designed that has the ability to impart a physiological pulsation force on the developing tissue capsule in the peritoneal cavity using a sheep model. When two devices were implanted for a period of 10 days in each animal these devices produced no complications for the animal. Upon harvest all devices were free of adhesion and did not cause any peritoneal or dermal infection. In 100% of cases this device produced tissue that was thick and consistent along the length of the implant. The quality of tissue differed greatly macroscopically between tissue produced around pulsing and non-pulsing scaffolds, but microscopically the structure of both tissues was not significantly different. Approximately 90% of cells in this tissue stained positively for CD45. Tissue in pulsing devices produced a higher amount of vimentin expression in CD45 positive staining cells than tissue in non-pulsing devices. Mechanical properties of tissue in pulsed devices were also much greater than tissue in non-pulsed devices. Two of the pulsed tissues were grafted into the carotid artery of sheep as arterial patches. In one animal tissue lasted a period of 1 week before it ruptured. In the second animal tissue lasted a period of 2 weeks at which time the animal was sacrificed. In this sheep a layer of endothelial cells had migrated to populate areas of the tissue patch. Pulsation of the implant device enhanced the development of tissue capsule in the peritoneal cavity towards arterial properties. These studies provide information on the materials and designs required to produce peritoneal-derived tissue capsules that can be used in a range of surgical applications. These studies also provide information on how this tissue responds to mechanical force and provides an in vitro system for testing this tissue. This work in this thesis has produced a device that is in the stage of pre-clinical development to be used as a potential therapy for cardiovascular disease. This device is a novel development from previous devices used for generating tissue capsules for engraftment and is a significant contribution to work in developing a replacement artery.

Thesis (Ph. D.)--University of Hong Kong, 2007. / Also available in print.

Thesis (Ph. D.)--University of Hong Kong, 2009. / Includes bibliographical references. Also available in print.

Thesis (M.Sc.) -- Memorial University of Newfoundland. / Typescript. Bibliography: leaves 80-86. Also available online.

Thesis (M.N) --Memorial University of Newfoundland, 1997. / Bibliography: leaves 105-112.

Made available in DSpace on 2014-08-13T14:50:43Z (GMT). No. of bitstreams: 0 Previous issue date: 2013-07-19Bitstream added on 2014-08-13T18:00:53Z : No. of bitstreams: 1 000750764.pdf: 553502 bytes, checksum: d8b9b96b06bbcfe3fb747913ca8ae054 (MD5) / As peritonites são sérias e frequentes complicações em pacientes submetidos à terapia de reposição renal, principalmente na diálise peritoneal ambulatorial contínua (CAPD, “continuous ambulatory peritoneal dialysis”). As infecções fúngicas, embora menos frequentes que as bacterianas, estão associadas a uma maior taxa de morbidade e mortalidade, e normalmente tornam impossíveis a CAPD, devido à necessidade de remoção do cateter. Este trabalho visou caracterizar e identificar as peritonites fúngicas com o uso de métodos morfofisiológicos e moleculares, além de avaliar seus perfis de sensibilidade e produção de biofilme in vitro em pacientes submetidos à CAPD do Hospital das Clínicas da Faculdade de Medicina de Botucatu. Foram avaliados trinta isolados de leveduras obtidos de episódios distintos de peritonites, que foram identificados por métodos morfofisiológicos (CHROMagar e auxanograma) e moleculares, tais como o sequenciamento de rDNA, perfil de restrição do gene SADH e padrão do intron do grupo I. Foram também realizados o perfil de sensibilidade antifúngica para as drogas anfotericina B, fluconazol, voriconazol e caspofungina pela técnica de microdiluição em caldo, seguindo o protocolo do CLSI M27-A3 e a produção de biofilme utilizando-se discos de silicone em reação com XTT (sal de tetrazol). Dos 30 isolados de leveduras, observou-se que as espécies de Candida parapsilosis foram as predominantes (n=10), seguida de Candida albicans (n=7), Candida tropicalis (n=6), Candida orthopsilosis (n=5), Candida guilliermondii (n=1) e Kodamaea ohmeri (n=1). Dentre os isolados de C. albicans, caracterizados pelo perfil de intron do grupo I, observou-se predomínio de genótipos do grupo A (n=5) e também a ocorrência de genótipos do grupo B (n=2). Todos os isolados foram sensíveis ao voriconazol e caspofungina, amostras de C.orthopsilosis (n=5), K.ohmeri (n=1), C.guilliermondii (n=1) e C. albicans (n=1) ...

Made available in DSpace on 2013-08-07T19:03:52Z (GMT). No. of bitstreams: 1 000431165-Texto+Completo-0.pdf: 850340 bytes, checksum: a2e688c3555bab8a8fa5c9cdf12fa3d4 (MD5) Previous issue date: 2011 / Introduction: Chronic kidney disease is a severe public health ailment in the country. Cognitive deficit is frequent in end-stage kidney disease patients and depression is common is such patients.Objective: evaluate cognitive function in patients with chronic renal failure treated with peritoneal dialysis at Hospital São Lucas da PUC and Hospital Beneficência Portuguesa de Pelotas.Methods: Transversal controlled study. Patients with end-stage kidney disease treated with peritoneal dialysis for at least 3 months, aging at least 18 years-old, and with scores above 18 in the Mini Mental State Examination were included. Patients were excluded if there was previous dementia, known history of stroke, acute disease and in-patients with known learning difficulties. The control group consisted of dialysis patients relatives with similar age and social educational background. Participants were subjected to a single psychometric tests battery at their outpatient clinical appointment, if on peritoneal dialysis. The following tests were employed: Wechsler Adult Intelligence Scale (WAIS-III), Beck Depression Inventory (BDI) and the Mini Mental State Examination (MEEM). Sixty individual were included, 30 peritoneal dialysis patients and 30 controls.Results: The MEEM scores were not different between groups (DP 25. 9+5. 4, Control 26. 8+3. 3, p=0. 462). Only processing speed index of the WAIS-III was altered in peritoneal dialysis patients (DP 90+19. 6, Control 99+14. 3, p=0. 039). Peritoneal dialysis patients had significantly higher BDI score (DP=14, IIQ=6-23; Control=9, IIQ=4-13; p=0. 010). Processing speed index in patients was 12. 7 score points lower in the controls after adjusting for depression and labor activity.Conclusion: Processing speed index of the WAIS-III scale was lower in peritoneal dialysis patients than in controls. Otherwise cognitive function index were not different in peritoneal dialysis when compared to controls of similar age and social-educacional-economical background. / Introdução: A doença renal crônica é um grave problema de saúde pública no país. Déficit cognitivo é comum em pacientes com insuficiência renal crônica terminal e depressão é uma condição prevalente na doença renal crônica terminal.Objetivo: avaliar a função cognitiva de pacientes com insuficiência renal crônica submetidos à diálise peritoneal no Hospital São Lucas da PUC e Hospital Beneficência Portuguesa de Pelotas.Materiais e Métodos: Estudo transversal controlado. Foram incluídos pacientes em tratamento para doença renal crônica terminal, em diálise peritoneal há pelo menos três meses, com idade acima de 18 anos, e pontuação no Mini Exame do Estado Mental acima de 18. Foram excluídos pacientes com demência prévia conhecida, história de acidente vascular cerebral, doença aguda, e hospitalizado com dificuldades de aprendizagem conhecidas. O grupo controle incluiu parentes saudáveis de pacientes em Diálise Peritoneal (DP) e Hemodiálise (HD), mesma idade e nível sócio-educativo. Todos os participantes foram submetidos a uma única aplicação de testes psicométricos no momento da consulta clínica ou agendados. Os testes utilizados foram a Escala de Inteligência Wechsler para Adultos (WAIS-III), o Inventário de Depressão Beck (BDI) e o Mini-Exame do Estado Mental (MEEM). Participaram 60 indivíduos, 30 pacientes em DP e 30 indivíduos saudáveis.Resultados: Os grupos não foram diferentes quanto a escores do MEEM (DP 25,9+5,4, Controle 26,8+3,3, p=0,462) e do WAIS-III, com exceção do índice da velocidade de processamento (DP 90 +19,6, controle 99 + 14,3, p=0,039). Os pacientes em DP apresentaram o escore BDI significativamente maior que os controles (DP=14, IIQ=6-23; Controle=9, IIQ=4-13; p=0,010). Ajustando os dados para presença de depressão e atividade laboral, verificou-se que o índice de velocidade de processamento dos pacientes foi 12,7 pontos menor que nos controles.Conclusão: O índice de velocidade de processamento da escala WAIS-III foi menor nos pacientes em DP do que nos controles. Os demais aspectos da função cognitiva de pacientes em DP não foram diferentes de controles com mesma idade e nível sócio-econômico-educacional.

Made available in DSpace on 2013-08-07T19:04:23Z (GMT). No. of bitstreams: 1 000439669-Texto+Completo-0.pdf: 2432426 bytes, checksum: 926062560772ee0fef9ad537b63bff41 (MD5) Previous issue date: 2012 / Introduction: Peritoneal dialysis ultrafiltration failure is a functional abnormality associated with increased risk of death and technique failure. Daily ultrafiltration volume early on therapy may predict patient and technique survival. Objective: to determine the relationship between to presence of risk factors, daily ultrafiltration volume, patient and technique survival. Patients and Method: Data were extracted from the observational, multicenter, BRAZPD cohort study. From a population of 2419 suitable patients, 977 incident patients were selected. At the three-month therapy interval, demographic, clinical and technical variables were appraised and daily ultrafiltration volume was analyzed by quartiles (1st: ≤ 700 ml; 2nd: > 700 ml up to ≤ 1100 ml; 3rd: > 1100 ml up to < 1600 ml; 4th: ≥ 1600 ml), as were its changes at the sixth and twelfth follow-up months. Two outcomes were considered : death and technique failure, which were analyzed till the 30th therapy month. Comparison between groups, correlations, patient and technique uni and multivariate survival analyses, using Kaplan-Meier technique and Cox regression analysis, were performed. Results: Age (HR=1. 038; 95% CI: 1. 027-1. 049; P<0. 01), diabetes (HR=1. 416; 95% CI: 1. 043-1. 922; P=0. 03) and number of co-morbidities (HR=2. 687; 95% CI: 1. 336-5. 407; P<0,01) were directly associated with increased patient mortality. The 4th ultrafiltration quartile related with higher patient and technique survival (P=0. 02 and P=0. 10, respectively); peritonitis had a strong negative effect upon therapy maintenance (HR=3. 459; 95% CI: 2. 218-5. 394; P<0. 01). Conclusion: young, non-diabetic patients had increased chance for survival. High ultrafiltration volumes promoted patient and technique survival. Peritonitis significantly reduced the likelihood of technical success. / Introdução: A falha de ultrafiltração na diálise peritoneal é uma anormalidade funcional associada a risco aumentado para morte e para falha técnica. O volume diário de ultrafiltração, aos três meses de terapia, pode ser fator de risco e preditor precoce para sobrevida de paciente e técnica. Objetivo: determinar a relação entre a presença de fatores de risco, volume diário ultrafiltrado e sobrevida de paciente e terapia. Pacientes e Método: estudo de coorte baseado em dados do estudo BRAZPD, multicêntrico, observacional. Foram incluídos 977 pacientes incidentes, dentre 2419 elegíveis. Aos três meses de terapia analisaram-se variáveis demográficas, clínicas e técnicas. O volume diário de ultrafiltração foi analisado por quartis, (1º quartil: ≤ 700 ml; 2º quartil: > 700 ml e ≤ 1100 ml; 3º quartil: > 1100 ml e < 1600 ml; 4º quartil: ≥ 1600 ml, assim como sua variação aos seis e doze meses de seguimento. Dois desfechos foram contemplados: morte e falha técnica, analisados até 30 meses de terapia. Comparações entre grupos, correlações bem como análise univariada de sobrevida - de paciente e técnica - foi feita pela técnica de Kaplan-Meier e multivariada por regressão de Cox. Resultados: idade (HR=1,038; IC 95%: 1,027-1,049; P<0,001), Diabetes Mellitus (HR=1,416; IC 95%: 1,043-1,922; P<0,026) e número de comorbidades (HR=2,687; IC 95% -1,336-5,407; P<0,01) foram diretamente associados com mortalidade aumentada do paciente. O quarto quartil de ultrafiltração associou-se a maior sobrevida do paciente e da técnica (P=0,02 e P=0,10, respectivamente); a ocorrência de peritonite teve impacto negativo para manutenção da terapia (HR=3,459; IC 95%: 2,218-5,394; P<0,01). Conclusão: pacientes jovens, sem diabetes tiveram maior chance de sobrevida. Ter alto volume de ultrafiltração foi favorável à sobrevida de pacientes e da técnica. A ocorrência de peritonite reduziu significativamente a chance de sucesso da técnica.