Submitted by Natalie Mendes (nataliermendes@gmail.com) on 2015-07-24T01:11:42Z No. of bitstreams: 1 marcus_vinicius_pinheiro_mendonca_tese.pdf: 8890182 bytes, checksum: 8c3486b869dff02251529c805a28b23c (MD5) / Made available in DSpace on 2015-07-24T01:11:42Z (GMT). No. of bitstreams: 1 marcus_vinicius_pinheiro_mendonca_tese.pdf: 8890182 bytes, checksum: 8c3486b869dff02251529c805a28b23c (MD5) Previous issue date: 2014-10-10 / Despite the advancement in the care of patients with spinal cord injury, currently there is no specific treatment for neurological lesion. Therapy with mesenchymal stem cells from bone marrow (BMMC) has shown to be a safe and promising technique in various medical fields. The objective of this study is to evaluate the safety of autologous BMMC transplantation for the treatment of chronic spinal cord injury of traumatic origin.Fourteen paraplegic patients (classified as A in ASIA scale) with at least 6-month thoracic or thoracolumbar spinal cord injurywere selected. They underwent aspiration of bone marrow tissue from the iliac crest with further expansion and in vitro characterization; by means of microsurgical procedure, the BMMC suspension was introduced at the level of the spinal cord injury. A 6-month clinical follow-up was performed after surgery, including functional and imaging tests. There was a change in ASIA scale in 7 patients, increased bladder capacity in 5 patients and appearance of the SSEP waveform in one patient. Throughout the observation period, no major complications were observed. The present protocol proved to be safe and, due to significant improvements in neurological symptoms in many patients, also a potentially promising therapeutic method for patients with spinal cord injury. / A despeito do avan?o na assist?ncia do paciente com trauma raquimedular, atualmente n?o h? tratamento espec?fico para a les?o neurol?gica. A terapia com c?lulas-tronco mesenquimais da medula ?ssea (CMMO) tem-se mostrado uma t?cnica segura e promissora em diversas ?reas m?dicas. O objetivo deste estudo ? avaliar a seguran?a do transplante aut?logo de CMMO para o tratamento de les?o medular cr?nica de origem traum?tica. Foram selecionados 14 pacientes parapl?gicos (classificados como A na escala ASIA) com les?o medular tor?cica ou t?raco-lombar h? mais de 6 meses. Eles foram inicialmente submetidos ? aspira??o de tecido da medula ?ssea da crista il?aca, com posterior expans?o e caracteriza??o in vitro de CMMO e, por meio de procedimento microcir?rgico, introduziu-se a suspens?o de CMMO na medula espinhal no n?vel da les?o. Os pacientes foram acompanhados clinicamente, com realiza??o de exames funcionais e de imagem por um per?odo de 6 meses ap?s o procedimento cir?rgico. Houve mudan?a na escala ASIA em 7 pacientes, aumento da capacidade vesical em 5 pacientes e aparecimento de onda ao SSEP em 1 paciente. Durante todo o tempo de observa??o, n?o foram identificadas complica??es potencialmente graves. O presente protocolo se mostrou seguro e, ainda, devido a melhoras significativas no quadro neurol?gico em boa parte dos pacientes, um m?todo terap?utico potencialmente promissor para pacientes com trauma raquimedular.

The tropical rainforests of the Peruvian Andes are some of the most biodiverse and most vulnerable to climate warming in the world. The Andes are predicted to experience substantial increases in warming of between +2 °C to +5 °C by the end of the century, in addition to an increases in the frequency of high temperature extremes, drought and flood events. The response of these forests to climate change over the next century has global relevance, due to the high levels of endemic species present and the potential role these areas will play as refugia for lowland species. Despite this, the response of tropical montane forests (TMCFs) to climate change remains under-studied. Our current understanding of how Andean species will respond to climate change is based on studies of past compositional changes. Upslope shifts in plant communities of approximately 1.2 - 2.0 m·y-1 have been observed along elevational gradients within Central and South America over the last decade. Based on these migration rates, it has been estimated that the majority of communities will lag behind increases in temperature by 5.5 °C by the end of the century. The implications of this for populations at the trailing range edge is unclear, due to a lack of mechanistic data concerning the acclimatory limits of rainforest species. When faced with rapid warming plant species will need to rapidly adapt, acclimate or migrate in order to survive. In the case of Andean species, migration rates may not be sufficient for a species to remain within its optimal thermal niche and adaptive responses will likely be too slow to be effective, hence individuals will have to acclimate in situ to prevent a decline in performance. The acclimatory ability of species can be quantified by measuring changes in performance, leaf physiology and anatomy in response to experimental manipulations of climate, however such studies are rare within the tropics. Here we carried out a seedling transplant experiment, utilising an extensive 400-3500 m asl elevational gradient in the Peruvian Andes, to simulate climate warming and upslope migration of tree seedlings under real-world conditions. To provide context for the transplant study, natural variation in leaf anatomical traits and physiological stress were explored for twelve species belonging to lowland (LF), mid-elevation (LMF) and tropical montane cloud forest communities. Adults and seedlings from the centre and furthest-most extent of each species' elevational range were studied and compared. Seedlings of each elevational forest community were transplanted downslope and upslope of their local elevational range by the equivalent of ±2 °C and ±4 °C in mean annual temperature. The experiment followed the transplanted seedlings of eleven species over a one year period, monitoring survival, growth and physiological stress (Fv/Fm) of individuals. The acclimatory ability of a subset of these species was quantified by measuring changes in photosynthetic capacity (Vcmax and Jmax), respiratory capacity (Rd) and anatomical traits (Na, Pa, LMA, LDMC) in response to transplantation. The results showed that within the natural population there was little evidence of leaf trait acclimation to elevational shifts in climate, but also little evidence of physiological stress at the trailing range edge. There were however differences in the leaf trait strategies employed by each elevational community, increasing in abiotic stress-tolerance with elevation. Physiological stress was greatest in the seedling population and, unlike the adult population, increased slightly at the trailing edge. This indicated that seedlings were more vulnerable to warming than their adult counterparts and at mid-elevations TMCF seedlings were more vulnerable than LMF seedlings. Seedling survival and growth declined in response to transplantation away from the home elevation for the majority of species, with upslope declines as a result of abiotic limitations, and downslope declines due to biotic limitations. All seedlings were found to be able to acclimate their respiratory capacity in response to transplantation, however this was not the case for photosynthetic capacity. LMF species performed significantly better than TMCF seedlings with transplantation, demonstrating a greater acclimatory capacity for photosynthesis. LMF species were able to adjust Jmax in order to maintain rates at ambient temperatures, but were not able to upregulate Vcmax upslope, whereas TMCF species were not able to respond in either transplant direction. Overall, these findings suggest that under moderate warming scenarios LMF species will have a competitive advantage over TMCF species at mid-elevations, gradually expanding their range into TMCF species' habitat over the next century. As a result of this and due to the slow pace of upslope migration, we predict that TMCF species will undergo range retractions and possible extinctions. The speed of this response will be determined by the trajectory of future warming and the frequency of extreme climatic events.

No período de 1981-2010, foram estudados, retrospectivamente, 54 casos de criptococose em pacientes com transplante de órgão sólido, identificados no Laboratório de Micologia da Santa Casa Complexo Hospitalar, Porto Alegre, RS. A criptococose ocorreu em 31 transplantados de rim, 13 de fígado, 7 de pulmão, 2 de pâncreas e rim, e 1 de coração. A idade média foi de 47,91 ± 13,98 (12-76 anos). Um total de 38 pacientes do sexo masculino (70,4%). As manifestações clínicas mais frequentes (54 pacientes) foram febre, cefaléia, vômito, tosse e estado mental alterado. Os achados radiográficos mais comuns no tórax, em 27 pacientes, foram nódulo, consolidação, cavitação e derrame pleural, sendo 10 com comprometimento pulmonar comprovado. Trinta e quatro apresentavam acometimento do sistema nervoso central, 7 tinham envolvimento cutâneo, e 4 em outros locais. O liquor, sangue e urina, respectivamente, contribuíram para o diagnóstico microbiológico com maior frequência. A maioria das infecções, nesta série de pacientes com criptococose, foi causada por Cryptococcus neoformans (92,7%). Pela primeira vez na literatura, documentamos C. gattii em pacientes com transplante de pulmão. Finalmente, quanto ao regime imunossupressor primário utilizado, houve maior mortalidade entre os pacientes que usaram o regime terapêutico baseado em ciclosporina e menor naqueles que usaram tacrolimus. / In the period of 1981 to 2010, 54 cases of cryptococcosis in patients with solid organ transplantation indetified at Mycology Laboratory in Santa Casa Hospital Complex, Porto Alegre, RS, were retrospectively studied. Cryptococcois occured in 31 kidney, 13 liver, 7 lung, 2 kidney-pancreas, and 1 heart transplant. The mean age was 47.3 years old (range, 12-76; SD 13.98). A total of 38 patients were male (70.4%). The most frequent clinical manifestation (54 patients) was fever, headache, vomiting, cough and altered mental status. The most common chest radiographic fidings, in 27 patients, were nodules, masses, consolidation, cavitation, and pleural effusion, 10 with proved pulmonary involvement. Thirty four patients had central nervous system involvement, 7 with cutaneous involvement, and 4 at other sites. The cerebospinal fluid, blood, and urine had the highest yield for the microbiologic diagnosis, respectivelly. Nearly all infections in this series of patients with cryptococcosis involved Cryptococcus neoformans (92.7%). By the first time in the literature, we documented C. gattii in lung transplant patients. Finally, considering the type of primary immunosupressive agent used, there was a higher mortality rate on patients with cyclosporine based therapy, and lowest in those with tacrolimus.

Submitted by Suzana Dias (suzana.dias@famerp.br) on 2018-11-05T17:05:38Z No. of bitstreams: 1 BethaniaBuzato_dissert.pdf: 632580 bytes, checksum: 7aba72bd2238a18e0fa3cb142f6188a2 (MD5) / Made available in DSpace on 2018-11-05T17:05:38Z (GMT). No. of bitstreams: 1 BethaniaBuzato_dissert.pdf: 632580 bytes, checksum: 7aba72bd2238a18e0fa3cb142f6188a2 (MD5) Previous issue date: 2018-03-27 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Chronic kidney disease (CKD) is highly prevalent and is currently a worldwide public health problem. It entails physical and psychological consequences and requires adaptation and change of lifestyle. Also, alterations in sexual function of men and women affected by such a disease, as well as decrease in libido are found in both sexes. Objective: to evaluate the performance and sexual satisfaction of women with chronic kidney disease and compare levels of performance and sexual satisfaction in the two main modalities of renal replacement therapy – hemodialysis and renal transplantation. Method: a descriptive cross-sectional study with 49 women enrolled in renal replacement therapy modalities (hemodialysis and renal transplantation) at Hospital de Base in the city of São José do Rio Preto - SP. For data collection, it was used data sheet containing socio-demographic information, scale for evaluation of sexual activity in women (SQ-F) and semi-structured interview. Results: 65,3% of collaborators have reported intense changes in body image after CKD, as well as decrease in libido and sexual performance. About 89,8% of collaborators present impairement in the SQ-F question regarding sexual desire. In the comparison between treatments, difference was significant in all SQ-F, except for question related to pain. When the total score of the instrument was evaluated, the group undergoing hemodialysis achieved a mean score of 39,0 (poor to unfavorable), and the kidney transplant group 70,0 (regular to good). Transplant collaborators has nine times greater chance (odds ratio – 9,2) of achieving better score in the instrument. Conclusion: the performance and sexual satisfaction of women with chronic kidney disease are impaired, which may be associated with different factors. In the comparison between groups, this study demonstrated significantly better sexual functioning in the transplant group. / A doença renal crônica apresenta elevada prevalência e constitui atualmente, um problema de saúde pública mundial. Acarreta consequências físicas, psicológicas e exige adaptação e mudança de estilo de vida. São também encontradas alterações na função sexual de homens e mulheres acometidos pela Doença Renal Crônica, assim como a diminuição da libido em ambos os sexos. Objetivo: avaliar o desempenho e a satisfação sexual de mulheres portadoras de Doença Renal Crônica e comparar os níveis desempenho e satisfação sexual nas duas principais modalidades de terapia renal substitutiva – hemodiálise e transplante renal. Método: estudo descritivo transversal, tendo como participantes 49 mulheres inseridas em modalidades de terapia renal substitutiva: Hemodiálise e Transplante Renal no Hospital de Base na cidade de São José do Rio Preto - SP. Foi utilizada para coleta de dados, ficha contendo informações sócio demográficas, escala para avaliação da atividade sexual na mulher (QS-F) e entrevista semiestruturada. Resultados: 65,3% das colaboradoras identificaram mudanças intensas na imagem corporal após a DRC. Assim como, diminuição na libido e no desempenho sexual. Cerca de 89,8% das colaboradoras apresentam prejuízo na questão do QS-F referente ao desejo sexual. Na comparação entre os tratamentos, a diferença foi significativa em todas as questões do QS-F, exceto na questão relacionada à dor. Quando avaliado pelo escore total do instrumento o grupo em tratamento hemodialítico alcançou a pontuação média de 39,0 (ruim a desfavorável), já o grupo de transplante renal 70,0 (de regular a bom). As colaboradoras em transplante apresentam probabilidade nove vezes maior (odds ratio – 9,2) de alcançarem melhor escore no instrumento. Conclusão: houve prejuízo clinicamente significativo no desempenho e satisfação sexual das mulheres portadoras de doença renal crônica, alterações que podem estar associadas a diferentes fatores. Na comparação de grupos, este estudo demonstrou um funcionamento sexual significativamente melhor no grupo transplante.

The purpose of the research investigation is to consider the potential opportunities through which corporate governance may be developed to better suit the developing commercial culture within Poland. In order to do this, I formulate the following research questions: ‘What are the weaknesses of the Polish corporate governance system?’, ‘What changes should be made to corporate governance in Poland?’, and ‘Is a hybrid corporate governance model a choice for Poland?’ The concept of hybridisation is fairly new, and involves combining different approaches to corporate governance, eg it embraces combining elements of the board management and monitoring models. I examine several changes to corporate governance that can be called hybrid. They were implemented in South Africa, Japan, Malaysia, the UK and the US. The main focus, however, is put on Polish corporate governance, which I investigate from the angle of those changes. Doctrinal research is combined with a set of interviews conducted with business practitioners in Poland. Interviewees are asked to express their opinion about corporate governance in Poland. Questions are asked in the context of changes that were made to corporate governance in countries mentioned above. The interviews produce results that overlap with the doctrinal research. Polish companies have a highly consolidated share ownership structure, which has a negative influence on the allocation of power between corporate organs. The supervisory board is an organ through which the controlling shareholders extend their power. Under the Company Code 2000, the supervisory board usually appoints and removes members of the management board, and instructs them in the decision making process. The statutes might give a broader scope of powers to the supervisory board. All this results in various forms of expropriation in companies, such as, for example, stealing of profits by governing bodies, overpaying executives, or installing unqualified family members in managerial positions. In general, interviewees are pleased with the currently binding corporate governance in Poland. The majority of them are pessimistic about implementing such large changes in Poland as, for example, a one-tier board system. A significant number of interviewees propose minor changes to the Polish system of corporate governance. It should be highlighted that several non-managerial interviewees turn out to have more liberal approaches to potential changes to corporate governance in Poland. The research fills a gap in knowledge on hybrid corporate governance, as this issue has hardly been touched by the Polish legal doctrine. It also systematises and develops knowledge on hybrid corporate governance worldwide, and develops knowledge on legal transplant.

A realização de transplante de fígado é a única opção, na ausência de alternativas clínicas e cirúrgicas, quando o paciente é acometido por hepatopatia aguda ou crônica. A assistência de enfermagem ao receptor de transplante de fígado é complexa e relevante, em todas as fases do processo. Assim, o objetivo do estudo foi analisar as evidências disponíveis na literatura sobre o cuidado de enfermagem ao receptor de transplante de fígado no período pós-operatório. A revisão integrativa foi o método de revisão selecionado para a condução do estudo. A busca dos estudos primários foi realizada nas bases de dados PubMed, CINAHL e LILACS, sendo a amostra composta de 12 estudos primários. Os estudos primários foram agrupados em duas categorias: A) alterações fisiológicas de receptores de transplante de fígado no período pós-operatório (n=7) e B) experiências relatadas e alterações emocionais de receptores de transplante de fígado no período pós- operatório (n=5). O conhecimento aprofundado e pautado em evidências recentes das alterações fisiológicas nos diferentes sistemas do organismo humano e das experiências relatadas e alterações emocionais de receptores de transplante de fígado possibilitam ao enfermeiro a elaboração do planejamento da assistência de enfermagem fundamentado nas reais necessidades do paciente e da família. Além desses aspectos, o conhecimento proporciona a implementação de intervenções direcionadas para a prevenção, redução ou controle das complicações que podem acometer o paciente, no período pós-operatório. Na análise do conjunto dos resultados evidenciados dos estudos primários incluídos na revisão integrativa, infere-se a necessidade de investimentos na condução de pesquisas direcionadas para o cuidado de enfermagem ao receptor de transplante de fígado devido à escassez de estudos na literatura (internacional e nacional), principalmente aquelas que poderão investigar intervenções que possam ser implementadas na prática clínica para prevenir, minimizar e/ou controlar as alterações fisiológicas e emocionais do paciente, contribuindo para a melhoria da assistência de enfermagem e, consequentemente, para o sucesso do tratamento / Performing liver transplantation is the only option, in the absence of clinical and surgical alternatives, when the patient is suffering from acute or chronic liver disease. Nursing care for the liver transplant recipient is complex and relevant at all stages of the process. Thus, this study aimed to analyze the evidence available in the literature on nursing care for the liver transplant recipient in the postoperative period. The integrative review method was selected to conduct the study. The primary studies were searched in PubMed, CINAHL and LILACS, and the sample consisted of 12 primary studies. The primary studies were grouped into two categories: A) physiological changes of liver transplant recipients in the postoperative period (n=7) and B) reported experiences and emotional changes of liver transplant recipients in the postoperative period (n=5). The deepen knowledge and guided by recent evidence of physiological changes in the different systems of the human organism and of the reported experiences and emotional changes of liver transplant recipients allow nurses preparing the planning of nursing care based on the real needs of the patient and of the family. Besides these aspects, the knowledge provides the implementation of targeted interventions for the prevention, reduction or control of the complications that can affect the patient in the postoperative period. In the analysis of all evidenced results of the primary studies included in the integrative review, it is inferred the need for investments in conducting research directed to the nursing care of the liver transplant recipient due to a lack of studies in (international and national) literature, especially those that may investigate interventions that can be implemented in clinical practice to prevent, minimize and/or control the physiological and emotional changes of the patient, contributing to the improvement of nursing care and thus for a successful treatment

Introdução: A gestação após transplante de órgãos tem se tornado cada vez mais comum, especialmente após avanços das técnicas em relação ao transplante e novos imunossupressores adotados na terapêutica. Objetivo: Avaliar os resultados maternos e perinatais das pacientes gestantes submetidas a transplante renal prévio. Método: No período de 1995 a 2007, foram avaliados restrospectivamente todos os casos de pacientes submetidas a transplante renal, que tiveram parto na Clínica Obstétrica do HCFMUSP. Resultados: Foram selecionadas 31 gestações em 22 pacientes. A idade média foi de 29 anos (18-39). Em 52% dos casos (16 casos) a gestação ocorreu 5 anos após o transplante. Em 21 pacientes (68%) o esquema imunossupressor utilizado foi composto por ciclosporina, azatioprina e prednisona. A incidência de abortamentos foi de 22% (7 casos). A hipertensão esteve presente em 21 casos (87,5%), seguida de anemia 17 (70,83%) e prematuridade 15 (71%). A função renal no início do pré-natal teve o seguinte comportamento: uréia no início 45±7,1 mg/dl (28-105) e no parto 68±27,6 (35-128); creatinina no início do pré-natal 1,28±0,55 mg/dl (0,9-3,6) e no parto 2,06±1,16 mg/dl (1,12-6,4); ácido úrico no início 6,1±1,5 mg/dl (3,5-9,2) e no parto 8,54±2,79 mg/dl (2-14) e a proteinúria de 24 horas no início 0,19±0,09 g/vol.24h (0,03-0,31) e no parto 1,34±0,96 g/vol.24h (0,11-3,65). A via de parto: oito (33%) partos por via vaginal e 16 (66%) foram cesarianas. A idade gestacional média ao nascimento foi de 34,8±2,29 semanas (28-38) e o peso ao nascimento foi 2366,5±261,6g (1100-4650). As complicações neonatais foram: icterícia 15 (71,5%); desconforto respiratório 10 (47,6%); hipoglicemia 5 (23,8%); anemia 4 (19%), intubação orotraqueal 3 (14,3%), utilização NPP 3 (14,3%), hipocalcemia 3 (14,3); pneumonia 2 (9,5%); hemorragia intracraniana 1 (4,8%) e sepse 1 (4,8). Ocorreram 3 óbitos fetais. Conclusão: a taxa de sobrevida neonatal no estudo de foi de 88%, a hipertensão foi a intercorrência materna mais freqüente, a utilização da terapêutica imunossupressora utilizada não levou a malformação fetal e a morbidade neonatal esteve associada a complicações inerentes da prematuridade 15 casos (71%). / Introduction: The pregnancy after organ transplant has become very common, especially after the technical advance related to new immunosuppressive therapy on the transplant. Objective: Analysis of the maternal and pregnancy outcomes of the patients that has renal transplant. Method: During the period between 1995 and 2007, it was analyzed retrospectively all the patient submitted on renal transplant, and also has had delivery in the Hospital das Clínicas of the University of São Paulo Medical School. Results: We have obtained a total of 31 pregnancies in 22 patients. The average age was 29 years of age (18- 39). In 52 % of the cases (16 cases) the pregnancy occurred 5 years after the transplant. In 21 patients (68%) the immunosuppressive treatment used was based on ciclosporine, azatioprine and prednisone. The incidence of abortion was 22% (7 cases), that was excluded. The hypertension was present in 21 cases (87,5%), followed by anemia 17 (70,83%) and prematurity 15 (71%). In the beginning of the pre-natal the renal function presented the following: serum urea in the beginning of prenatal care was 45±7,1 mg/dl (28-105)and the time of delivery was 68±27,6 (35-128); serum creatinine in the beginning was 1,28±0,55 mg/dl (0,9-3,6) and the time of delivery was 2,06±1,16 mg/dl (1,12- 6,4);serum uric acid in the beginning of prenatal care was 6,1±1,5 mg/dl (3,5-9,2) and the time of delivery was 8,54±2,79 mg/dl (2-14). The proteinuria 24 hours at the beginning of prenatal care was 0,19±0,09 g/vol.24h (0,03-0,31) and the time of delivery was 1,34±0,96 g/vol.24h (0,11-3,65). Cesarean section was performed in 16 (66%) cases, vaginal delivery in 8 (33%). The mean gestational age at delivery was 34,8±2,29 weeks (range: 28-38) and the mean birthweight at delivery was 2366,5±261,6g (range 1100-4650). The neonatal complications were observed during the study: ictericia 15 (71,5%); respiratory distress 10 (47,6%); hipoglicemia 5 (23,8%); anemia 4 (19%), orotracheal intubation 3 (14,3%), use of NPP 3 (14,3%), hipocalcemie 3 (14,3); pneumonie 2 (9,5%); intracranial hemorrhage 1 (4,8%) e sepses 1 (4,8). Occurred 3 fetal deaths. Conclusion: in the study the statistics of neonatal success was 88%, the most frequent maternal complication was the hypertension. The immunosuppressive therapy utilized didn\'t cause fetal malformation and the neonatal morbid was associated with prematurity complications itself in 15 cases (71%).

Submitted by Geyciane Santos (geyciane_thamires@hotmail.com) on 2015-06-24T14:51:29Z No. of bitstreams: 1 Dissertação- Antonia Cosmo de Oliveira.pdf: 1586387 bytes, checksum: 0d27e62352ec6a914bc9448c3fddf7da (MD5) / Approved for entry into archive by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2015-06-25T15:21:32Z (GMT) No. of bitstreams: 1 Dissertação- Antonia Cosmo de Oliveira.pdf: 1586387 bytes, checksum: 0d27e62352ec6a914bc9448c3fddf7da (MD5) / Approved for entry into archive by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2015-06-25T15:21:30Z (GMT) No. of bitstreams: 1 Dissertação- Antonia Cosmo de Oliveira.pdf: 1586387 bytes, checksum: 0d27e62352ec6a914bc9448c3fddf7da (MD5) / Approved for entry into archive by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2015-06-25T15:24:31Z (GMT) No. of bitstreams: 1 Dissertação- Antonia Cosmo de Oliveira.pdf: 1586387 bytes, checksum: 0d27e62352ec6a914bc9448c3fddf7da (MD5) / Made available in DSpace on 2015-06-25T15:24:32Z (GMT). No. of bitstreams: 1 Dissertação- Antonia Cosmo de Oliveira.pdf: 1586387 bytes, checksum: 0d27e62352ec6a914bc9448c3fddf7da (MD5) Previous issue date: 2014-08-25 / FAPEAM - Fundação de Amparo à Pesquisa do Estado do Amazonas / The study presented here aimed to analyze the implementation of Transplant Policy in the State of Amazonas, their strengths, challenges and contradictions, as well as its effects on the living conditions of people transplanted, considering this process, the reality of the state of Amazonas in their singularities compared to other regions of the country. The changes in the pattern of disease in Brazilian population, perceived by the growing trend of chronic diseases in recent decades, involve different aspects of living conditions of social groups, demanding in turn, health services at all levels of complexity. As for the state of Amazonas, chronic renal failure is among the leading causes of morbidity, whose treatment involves highly complex procedures, namely kidney replacement therapy through dialysis (hemodialysis or peritoneal dialysis) and transplantation. Such research was conducted in a critical approach through an exploratory research, a qualitative and quantitative data reading, trying to understand the effectiveness of state policy of transplants in the reality of people transplanted kidney, from the perspective of a public policy health in high complexity. The results showed that although the state is still far from the estimate needed to meet the population's demand for a kidney transplant, for those who were able to perform the transplant, life has a new meaning. The fact that they do not need to leave their homes and their families to perform the treatment, represented a considerable social and economic gain. The main challenge for policy transplants in the state of Amazonas is to overcome the dependency relationship maintained with private institutions in the realization of transplants, making it necessary to expand and publicness of the policy to be realized, the social rights won by society and established the principles of the Unified Health System - SUS. / O estudo ora apresentado objetivou a análise da implementação da Política de Transplantes no Estado do Amazonas, suas potencialidades, desafios e contradições, bem como seus efeitos nas condições de vida das pessoas transplantadas, considerando nesse processo, a realidade do Estado do Amazonas em suas singularidades frente às demais regiões do país. As mudanças ocorridas no padrão de adoecimento da população brasileira, percebidas por meio da crescente evolução das doenças crônicas nas últimas décadas, envolvem diferentes aspectos das condições de vida dos grupos sociais, demandando por sua vez, serviços de saúde em todos os níveis de complexidade. Quanto ao Estado do Amazonas, a Insuficiência Renal Crônica encontra-se entre as principais causas de morbidade, cujo tratamento envolve procedimentos de alta complexidade, a saber: terapia de substituição do rim, por meio da diálise (hemodiálise ou diálise peritoneal) ou do transplante. A referida pesquisa foi realizada numa abordagem crítica, através de uma investigação de caráter exploratório, numa leitura quantitativa e qualitativa dos dados, buscando compreender a efetividade da política estadual de transplantes na realidade das pessoas transplantadas de rim, sob a perspectiva de uma política pública de saúde na alta complexidade. Os resultados evidenciaram que embora o estado ainda esteja longe da estimativa necessária para suprir a demanda da população por transplante de rim, para aqueles que conseguiram realizar o transplante, a vida ganhou um novo significado. O fato de não precisarem se ausentar de seus domicílios, bem como de seus familiares para realizar o tratamento, representou um considerável ganho social e econômico. O principal desafio para a política de transplantes no Estado do Amazonas é superar a relação de dependência mantida junto às instituições privadas na efetivação dos transplantes, fazendo-se necessário a ampliação e publicização da referida política para que se concretizem os direitos sociais conquistados pela sociedade e estabelecidos nos princípios do Sistema Único de Saúde – SUS.

Patients with liver disease have an increased risk for malnutrition because of side effects of the disease. The Nutrition Focused Physical Exam (NFPE) was developed for nutrition professionals to aid physicians in a nutrition-based diagnosis of malnutrition. The purpose of this study was to examine the NFPE for its validity in liver disease patients being evaluated for transplant. In addition, the NFPE was used to assess incidence and severity of malnutrition in end stage liver disease patients and compare these results to already developed malnutrition tools such as the Patient Generated-Subjective Global Assessment (PG-SGA), Triceps Skinfolds (TSF), Mid-Arm Circumference (MAC), Lumbar Index, and Total Psoas Muscle Area (TPA). The NFPE was found to be highly correlated with PG-SGA results. There was a weak correlation between the NFPE and the TSF, MAC, and Lumbar Index/TPA, except when comparing the bottom 25% quartile of the Lumbar Index to severe malnutrition using the NFPE. This resulted in a moderate correlation. The odds-ratio for hospital admission based on malnutrition and severe malnutrition were both extremely high (14.571, 18.857 respectively). These preliminary results reinforce the significance of the NFPE and the need for additional studies using this tool.

The purpose of this experimental research was to determine whether using delta-MELD as a criterion for the liver transplant patient selection process could improve the U.S. liver allocation system. This research closed a gap in current literature on the utility of delta-MELD for liver transplant patient selection. The frameworks of systems theory, the analytic hierarchy process, and the Kalman filter contributed to the development of 2 simulation models of the liver allocation system: one that used delta-MELD and one that did not use delta-MELD. The research question examined whether using delta-MELD could improve the liver allocation system by reducing the number of patients dropping off the wait list and lowering the average MELD score. Statistical t tests of 2 independent scenarios (allocation with and without delta-MELD), each with 70 runs of 180 simulated days on the liver allocation wait list, did not indicate a significant improvement to the liver allocation system by using delta-MELD for liver allocation. However, observations made from the simulation experiment, such as the median patient wait time being 11 months and delta-MELD being more variable at the end-stage of liver diseases, provided insights into how to improve the model of the liver allocation process. In addition, observations made from the status 1 patient subgroup (patients in ICU with about 7 days to live), which were excluded from this research, suggested including status 1 patients and expanding the simulation timespan from 180 to 360 days to better capture the delta-MELD variability from patients at the end-stage of liver disease. This research provides empirical evidence on the applicability of the delta-MELD criterion for non-status 1 patients, and yields recommendations to include status 1 patients in an improved simulation of the donor liver system while using delta-MELD as criterion.