Introdução: flebite é um dos eventos adversos presente em grande parte das instituições de saúde podendo comprometer a assistência ao paciente. A compreensão do tema faz-se importante para que melhor possam ser trabalhadas estratégias de prevenção e para tanto, é imprescindível conhecer suas características e eventuais associações relacionadas ao seu aparecimento. O estudo teve como objetivo geral avaliar as características dos pacientes com flebites notificadas e características desses eventos adversos em um hospital de médio porte em Ribeirão Preto, São Paulo. Material e Método: trata-se de um estudo quantitativo, descritivo, exploratório, retrospectivo e transversal, aprovado pelo Comitê de Ética em Pesquisa da Escola de Enfermagem de Ribeirão Preto/USP com coleta de dados das notificações realizadas entre 2012 a 2014. Na instituição hospitalar em que o estudo foi desenvolvido, 373 pacientes apresentaram 436 episódios de flebites. Os dados foram coletados por meio de um instrumento tendo como fonte de consulta as fichas de notificação e prontuários eletrônicos dos pacientes. Resultados: a média de flebite em 2012 foi de 2,13%(±0,009), em 2013 de 2,91%(±0,010) e em 2014 de 1,84%(±0,008), inferiores a 5%, que é o aceitável; a idade média dos pacientes foi de 59,3 anos sendo 50,7% do sexo feminino e 82,8% de cor branca. A Pneumonia foi o diagnóstico que mais levou à internação e 49,6% dos pacientes tinham hipertensão. Ocorreram 436 flebites com destaque a um paciente em que ocorreram cinco flebites no período de 30 dias; a classificação da flebite com maior ocorrência foi a de grau 2 (45,4%), o calibre do cateter mais utilizado foi o 22 G (29,7%); o local mais utilizado para punção dos acessos venosos foi o membro superior esquerdo (53,4%); os profissionais que mais realizaram as punções foram auxiliares/técnicos de enfermagem (62,6%). Quanto aos medicamentos utilizados na vigência das flebites, 96,2% eram antibióticos; o tempo de permanência do cateter desde sua inserção até o momento em a flebite apareceu foi de 48 horas (31,1); 20,9% das flebites notificadas eram de punções realizadas em outros serviços, que não a instituição onde o estudo foi realizado. Ocorreu variação nos resultados de exames coletados anterior e posteriormente à ocorrência da flebite como Hemoglobina, Glóbulos Brancos, Proteína C Reativa e Plaquetas; no entanto, apenas os dois últimos apresentaram resultados estatisticamente significantes (p=0,0095 e p=0,0001 respectivamente). Observa-se resultado estatisticamente significante (p=0,0172) na associação da flebite de grau 2 com o cateter de calibre n°22 G. Conclusão: o estudo agrega conhecimentos à área da enfermagem e é o primeiro abordando este tema realizado na instituição hospitalar. Apesar de o numero de flebite ser menor que o aceitável pela literatura, é preciso empenho e dedicação para que esse índice diminua ainda mais, pois isso influencia diretamente na qualidade da assistência e na segurança do paciente / Introduction: phlebitis is one of the adverse events presented in most part of health institutions that can put assistance to patients in danger. The comprehension of this theme made of great importance for a better worked prevention strategy and therefore, it is vital to know its characteristics and casual associations related to its appearance. The study has as general objective evaluate the phlebitis patients´characteristics notified and these adverse events characteristics in a medium-sized hospital in Ribeirão Preto, São Paulo. Material and Method: it is about a quantitative, descriptive, exploratory, retrospective and transversal study, approved by the Ethical Committee in Research from Nursing School in Ribeirão Preto/USP with the notification data collection applied out between 2012 to 2014. At the hospital institution which the study was developed, 373 patients presented 436 phlebitis episodes. The data were collected through an instrument having as source the notification records and patients electronical handbooks. Results: the phlebitis average in 2012 was 2,13%(±0,009), in 2013 2,91%(±0,010) and in 2014 1,84%(±0,008), inferior to 5%, which is acceptable; the mean age patients was 59,3 years old being 50,7 female and 82,8% white skin. Pneumonia was the diagnosis that took patients to hospital admission and 49,6% of the patients had hypertension. 436 phlebitis occurred with emphasis to one patient that had five phlebitis within 30 days; the phlebitis classification with higher occurrence was of degree 2 (45,4%), the most used caliber catheter was 22 G (29,7%); the most used for vein puncture access was the left upper limb (53,4%); the professional who most performed vein puncture were assistants/technical nursing (32,6%). According to the medications used during phlebitis moments, 96,2% were antibiotics; the time spent for the catheter since its insertion until the moment that the phlebitis appeared was 48 hours (31,1); 20,9% of notified phlebitis were from other punctures applied in other services, which were not in the institution that the study was conducted. It occurred variation in the collected exam results before and after the phlebitis occurrence like hemoglobin, white blood cells, Reactive Protein C; therefore, only the two last ones presented significant statistically results (p=0,0095 and p=0,0001 respectively). It is observed significant statistically results (p= 0,0172) in association with phlebitis of degree 2 with the catheter of caliber number 22 G. Conclusion: the study adds knowledge to the area of nursing and it is the first approaching theme that has happened in the hospital institution. Despite the number of phlebitis being smaller than the acceptable by the literature, it is necessary effort and dedication to this index diminish even more, because of that it directly influences in the patient´s assistance quality and the patient´s security

<p>Venösa bensår är ett stort hälsoproblem och medför en stor kostnad för</p><p>samhället. Trots att mycket forskning har gjorts inom området</p><p>behandlingar av venösa bensår, appliceras inte detta tillräckligt i vården.</p><p>Patienter som lever med venösa bensår upplever oftast en försämrad</p><p>livskvalitet. Syftet med litteraturstudien var att ur ett</p><p>omvårdnadsperspektiv belysa effekterna av kompressionsbehandlingar</p><p>och hudtransplantationer vid venösa bensår. Resultatet var en bearbetning</p><p>av 18 vetenskapliga artiklar som sammanställdes utifrån olika</p><p>problemområden. Resultatet visade att patientens följsamhet påverkar</p><p>graden av sårläkning. Vid långvarig sårläkning upplevde patienten en</p><p>försämrad livskvalitet men om behandlingen var bekväm och enkel att</p><p>använda ökade följsamheten och därmed sårläkningen avsevärt. Patienten</p><p>upplevde smärtan som den svåraste faktorn, vid behandling med</p><p>hudtransplantation reducerades smärtan avsevärt och patienten fick en</p><p>större frihet. Majoriteten av kompressionsbehandlingarna visade goda</p><p>resultat vid sårläkning men behandlingarna var långdragna vilket</p><p>minskade följsamheten. Det är viktigt att sjuksköterskan har ett väl</p><p>utvecklat holistiskt synsätt och goda, aktuella kunskaper inom området</p><p>för att kunna ge patienten rätt vård. Många sjuksköterskor kände sig dock</p><p>osäkra och deras kunskaper var inte tillräckligt evidensbaserade. Fortsatt</p><p>forskning rekommenderas över sjuksköterskans kompetens och dess</p><p>inverkan på sårläkning vid venösa bensår samt utveckling av</p><p>sjuksköterskeutbildningen inom ämnet sårvård rekommenderas så de</p><p>nyutexaminerade sjuksköterskorna har en god grund i ämnet</p><p>sårbehandling.</p>

Venösa bensår är ett stort hälsoproblem och medför en stor kostnad för samhället. Trots att mycket forskning har gjorts inom området behandlingar av venösa bensår, appliceras inte detta tillräckligt i vården. Patienter som lever med venösa bensår upplever oftast en försämrad livskvalitet. Syftet med litteraturstudien var att ur ett omvårdnadsperspektiv belysa effekterna av kompressionsbehandlingar och hudtransplantationer vid venösa bensår. Resultatet var en bearbetning av 18 vetenskapliga artiklar som sammanställdes utifrån olika problemområden. Resultatet visade att patientens följsamhet påverkar graden av sårläkning. Vid långvarig sårläkning upplevde patienten en försämrad livskvalitet men om behandlingen var bekväm och enkel att använda ökade följsamheten och därmed sårläkningen avsevärt. Patienten upplevde smärtan som den svåraste faktorn, vid behandling med hudtransplantation reducerades smärtan avsevärt och patienten fick en större frihet. Majoriteten av kompressionsbehandlingarna visade goda resultat vid sårläkning men behandlingarna var långdragna vilket minskade följsamheten. Det är viktigt att sjuksköterskan har ett väl utvecklat holistiskt synsätt och goda, aktuella kunskaper inom området för att kunna ge patienten rätt vård. Många sjuksköterskor kände sig dock osäkra och deras kunskaper var inte tillräckligt evidensbaserade. Fortsatt forskning rekommenderas över sjuksköterskans kompetens och dess inverkan på sårläkning vid venösa bensår samt utveckling av sjuksköterskeutbildningen inom ämnet sårvård rekommenderas så de nyutexaminerade sjuksköterskorna har en god grund i ämnet sårbehandling.

Background - Current guidelines suggest that all cancer patients with venous thrombosis be treated with long-term low molecular weight heparin. Whether treatment strategies should vary according to clinical characteristics remains unknown. // Systematic review - A systematic review was performed to determine current understanding of the association between malignancy characteristics in patients with cancer-associated VTE and the risk of VTE recurrence. Four retrospective and 6 prospective studies were included. They suggest that lung cancer, metastases, and adenocarcinomas confer an increased the risk of recurrence and breast cancer a low risk. // Survey - I performed survey to evaluate thrombosis experts’ opinion about the low risk of VTE recurrence they would consider acceptable for patients with cancer- associated thrombosis 103 specialists participated. 80% of respondents agreed that a risk of recurrent VTE during anticoagulation below 7% is low enough. 92% agreed that a CPR that categorizes risk of recurrence is relevant. // Retrospective Study - I performed a single retrospective cohort study to assess the feasibility of derivation of a CPR that stratifies VTE recurrence risk in patients with cancer–associated thrombosis. The study included 543 patients. A multivariate analysis selected female, lung cancer and prior history of VTE as high risk predictors and breast cancer and stage I disease as low risk. // Conclusion - Patients with cancer-associated thrombosis do have varying risks of recurrent VTE depending on clinical characteristics.

Statement of the problem The primary objective of this thesis was to determine the best study design to evaluate the safety and effectiveness of an intermediate dose of low molecular weight heparin for secondary prevention of pregnancy associated VTE (PAVTE). An RCT was deemed unfeasible,so the use of a single arm study with prior evaluation of feasibility with a pilot study is proposed. // Methods - A systematic review was conducted to evaluate the efficacy of current strategies used for secondary prevention of PAVTE.A survey was used to elicit the non-inferiority margin. // Results - The pooled proportion of recurrent VTE in patients treated with full dose LMWH was 0.012(95% CI 0.006 to 0.02) and the rate of major bleeding was 0.025(95% CI=0.01 to 0.041). The non-inferiority margin was elicited at 2.5%. // Conclusions - Although a randomized controlled trial should be conducted whenever possible, in certain scenarios they are unfeasible. Therefore, an alternative study design should perhaps be used to evaluate the safety and efficacy of therapeutic strategies.

Background - Current guidelines suggest that all cancer patients with venous thrombosis be treated with long-term low molecular weight heparin. Whether treatment strategies should vary according to clinical characteristics remains unknown. // Systematic review - A systematic review was performed to determine current understanding of the association between malignancy characteristics in patients with cancer-associated VTE and the risk of VTE recurrence. Four retrospective and 6 prospective studies were included. They suggest that lung cancer, metastases, and adenocarcinomas confer an increased the risk of recurrence and breast cancer a low risk. // Survey - I performed survey to evaluate thrombosis experts’ opinion about the low risk of VTE recurrence they would consider acceptable for patients with cancer- associated thrombosis 103 specialists participated. 80% of respondents agreed that a risk of recurrent VTE during anticoagulation below 7% is low enough. 92% agreed that a CPR that categorizes risk of recurrence is relevant. // Retrospective Study - I performed a single retrospective cohort study to assess the feasibility of derivation of a CPR that stratifies VTE recurrence risk in patients with cancer–associated thrombosis. The study included 543 patients. A multivariate analysis selected female, lung cancer and prior history of VTE as high risk predictors and breast cancer and stage I disease as low risk. // Conclusion - Patients with cancer-associated thrombosis do have varying risks of recurrent VTE depending on clinical characteristics.

Despite chronic dialysis treatment, patients with end stage renal disease undergoing maintenance haemodialysis (HD) remain at a substantially increased risk of morbidity. Previous reports using Doppler ultrasound (DU) during HD have revealed microembolic signals (ME) in the venous circulation. In vitro studies confirm the emergence of microbubbles of air that may pass the security system of the HD circuit without triggering the alarm. The aim of this thesis was to elucidate the presence of ME during HD and examine methods that might reduce exposure to ME in vivo. The first study utilized DU to verify the presence of ME in 40 patients during standard HD. Investigation within 30 minutes after the start of HD and just before the end of session revealed the presence of ME in the venous blood line during both phases. The air trap did not alert for the presence of ME. This indicated that ME may pass into the patient during the entire HD run. Study 2 analyzed the presence of ME prior to start and during HD when measured at the AV-access and also carotid artery. A total of 54 patients were examined using DU as the investigative technique. ME increased significantly after start of HD in the AV-access, but also at the carotid artery site. These data indicated that ME can enter the body and even pass the lung barrier. The question arose if microbubbles of air are resorbed or may cause ischemic lesions in organs such as the brain. Study 3 examined whether the amount of ME detected in the AV-access would change by using either a high or a low blood level in the venous air trap/chamber. This was a prospective, randomized and double-blind study of 20 HD patients who were their own controls. After 30 min of standard HD, measurement of ME with DU was performed for two minutes. The chamber setting was changed and after another 30 minutes a new recording was carried out for two minutes. Data showed that setting a high blood level significantly reduced the extent of ME that entered the patient. The results also indicated that ME consisted mainly of microbubbles. In study 4, twenty patients were randomized in a cross-over setting of HD. Three options were used: a wet-stored dialyzer with high blood level (WH) and a dry-stored dialyzer using either a high (DH) or a low (DL) blood level in the venous chamber. The exposure of ME, detected by DU, was least when using mode WF, more with mode DH, and most with mode DL. There was a correlation between higher blood flow and more extensive exposure to ME. Study 5 was an autopsy study of a chronic HD patient with the aim of searching for microbubbles deposited in organs. Microbubbles of gas were verified in the vessels of the lungs, brain and heart. By using a fluorescent stain of anti-fibrinogen it was verified that the microbubbles were covered by clots that had to be preformed before death occurred. This indicated that air microbubbles are not completely absorbed and could result in embolic deposition in the organs of HD patients. In conclusion, these in vivo studies showed that ME pass the air trap without inducing an alarm and enter the venous blood line of the patient. The data confirmed the presence of ME in the AV-access and also in the carotid artery. Autopsy data of a deceased HD patient demonstrated the presence of microbubbles in the capillaries of the lungs, but also in the systemic circulation such as in the brain and the heart. A high blood level in the venous chamber and wet-stored dialyzer can reduce, but not eliminate the exposure to microbubbles for patients undergoing HD.

Venous disease will affect 1-3% of the western world at some point in their lives, yet there are few effective treatments for the venous system [1]. One such disease is chronic venous insufficiency (CVI), a painful and debilitating illness that affects the superficial and deep vein valves of the legs. When the valves become incompetent they allow reflux and subsequent pooling of blood. Current clinical therapies are only moderately; and therefore, the need for a better solution remains. Prosthetic venous valves were constructed from a novel hydrogel biomaterial patented by Georgia Tech. The valves had flexible cusps similar to normal, anatomic venous valves. The purpose of this work was to evaluate the thrombotic potential of the GT venous valve in an in vitro study and to design a percutaneous delivery system. In vitro thrombosis model provides an appropriate intermediate step between valve development and in vivo analysis, which is necessary to determine the biocompatibility of the prosthetic device. The flow system was modified from a one-pass, flow-through thrombosis assay using whole blood [2] to mimic pulsatile physiologic conditions. Cessation of flow indicated thrombotic obstruction. Histological analysis was performed using H and E staining and Carstairs stain (specific for platelets). A group of valves were lined with Dacron to confirm the thrombotic potential of the system. All Dacron valves were occluded by thrombus connecting the polymer fibers with adherent platelets. Whole blood perfused through the GT prosthetic valves exhibited no thrombosis or platelet adherence. All GT valves were patent and competent after blood perfusion. H and E staining revealed no thrombus deposition on the GT vein valves. A percutaneous delivery system was designed after evaluating the GT valves for their compressibility and plastic deformation over time. Appropriate stents, catheters and sheaths were selected. As designed, this system will be utilized in an ovine trial of the valve. Due to the low in vitro thrombotic potential and strong history of PVA as a medical implant material, positive trial results are expected. With successful animal and human trials this valve can provide a potential intervention for the 7 million people suffering from CVI.

Thesis (Ph.D.)--Flinders University, Faculty of Medicine, Dept. of Human Physiology. / Typescript bound. Includes bibliographical references: (leaves 332-374) Also available online via the Web.

Intro/Aims: Venous thromboembolism (VTE) is a common complication in cancer patients. The role of thrombophilic polymorphisms in cancer related VTE remains poorly explored. Aim 1 of this study was to determine if Factor V Leiden (G1691A), Prothrombin (PT) G20210A or methylenetetrahydrofolate reductase (MTHFR) C677T are associated with the increased occurrence of VTE in adult oncology subjects compared to nononcology subjects. Aim 2 of this study was to determine if cancer patients with the MTHFR C677T polymorphism who are treated with antimetabolite therapy have an increased incidence of VTE compared to cancer patients who are treated with other chemotherapy.Setting/Methods: A descriptive, comparative, retrospective chart analysis was utilized for this study in an outpatient hematology, oncology clinic in Southern Arizona. Enrolled were 100 adult subjects (age 18 - 85) with documented history of VTE (27 subjects with cancer and 73 noncancer). Subjects were evaluated for Factor V Leiden, PT G20210A, and MTHFR C677T prior to the study. Eleven subjects were treated with antimetabolite chemotherapy and 8 subjects were treated with other chemotherapy.Results: The overall polymorphism frequency for Factor V Leiden was 21%, PT G20210A 4%, and MTHFR C677T 50%. Factor V Leiden was found in 11.1% of cancer subjects and 24.7% of noncancer subjects. Prothrombin G20210A was found in 3.7% of cancer subjects and 4.1% of noncancer subjects. MTHFR C677T was present in 25.9% of cancer subjects and 58.9% of noncancer subjects. No statistical significance was observed between subjects treated with an antimetabolite and positive for MTHFR C677T compared with those treated with other types of chemotherapy.Conclusion: Analysis of the data collected in this study demonstrated overall higher rates than the expected frequencies of all polymorphism for both the cancer and noncancer patients with documented VTE. In this small retrospective study, the only significant finding was that the MTHFR C677T polymorphism was more prevalent in the noncancer group.Currently, there are no specific guidelines for VTE prevention in the outpatient oncology setting. Identification of risk factors, including prothrombotic mutations may reduce risk of VTE and provide guidance for prophylactic treatment recommendations in the outpatient setting.