Baixa conscientização da vacina pós-transplante de fígado: análise e estratégia educacional / Escaso conocimiento de vacunación tras un trasplante hepático: estrategia educativa y análisis / Low post-liver transplant vaccine awareness: analysis and educational strategy

Resumo Objetivo Avaliar o conhecimento de pacientes e profissionais de saúde sobre os protocolos de vacinação no pós-transplante hepático antes e após a aplicação de uma estratégia educativa de conscientização nessa população. Métodos Os pacientes (n=124) foram submetidos à intervenção educativa através do acesso a uma página web com vídeos educativos e, para os profissionais de saúde (n=111), através de um simpósio e acesso à informação na página virtual do projeto. Para analisar o efeito da intervenção, análises qualitativas de conhecimento foram realizadas por meio de questionários antes e depois das intervenções. Resultados Entre os pacientes, predominou o sexo masculino (66,9%) e a média de idade foi de 55,2 anos (DP + 15,9). 82,2% dos pacientes procuraram uma UBS para serem vacinados e 13,7% deles, os CRIEs (Centro de Referência para Imunobiológicos Especiais). Apenas 46,7% receberam orientações sobre vacinas após o transplante hepático. Dos 111 questionários respondidos pelos profissionais de saúde, 46,5% não consultaram a carteira de vacinas, 61,3% encaminharam os pacientes para UBS e 38,7%, para um CRIE. Na análise pós-intervenção, 66,1% dos pacientes assistiram a vídeos educativos sobre vacinação. Destes, 62,2% disseram ter melhorado seu entendimento sobre as vacinas e 91,4% se sentem mais seguros para vacinar. Após a intervenção educativa, 45 profissionais de saúde responderam ao questionário. 30,4% afirmaram saber quais vacinas prescrever e 67,4% indicaram vacinas para familiares de pacientes. Conclusão A estratégia educacional proposta aplicada neste estudo mostrou aumentar a conscientização sobre os protocolos de imunização pós-transplante hepático. Isso pode contribuir para evitar o risco potencial de falta de informação e não abordagem da vacinação pelos profissionais de saúde.

Resumen Objetivo Evaluar los conocimientos de pacientes y profesionales de la salud sobre protocolos de vacunación tras un trasplante hepático, antes y después de aplicar una estrategia educativa de sensibilización en esta población. Métodos Los pacientes (n=124) fueron sometidos a la intervención educativa mediante el acceso a un sitio web con videos educativos, y los profesionales de la salud (n=11), mediante un simposio y el acceso a información en la página web del proyecto. Para analizar el efecto de la intervención, se realizaron análisis cualitativos de conocimiento con cuestionaros antes y después de la intervención. Resultados Entre los pacientes, el sexo masculino fue predominante (66,9 %) y la edad promedio fue 52,2 años (SD + 15,9). El 82,2 % de los pacientes fue a una Unidad Básica de Salud (UBS) para recibir la vacuna y el 13,7 % de ellos acudió a un Centro de Referencia para Inmunobiológicos Especiales (CRIE). Solo el 46,7 % recibió instrucciones sobre vacunación tras el trasplante hepático. De los 111 cuestionarios respondidos por profesionales de la salud, el 46,5 % no consultó el catálogo de vacunas, el 61,3 % derivó a los pacientes a una UBS y el 38,7 % a un CRIE. En el análisis posintervención, el 66,1 % de los pacientes miró los videos educativos sobre vacunación. De ellos, el 62,2 % mencionó haber mejorado su comprensión sobre vacunas y el 91,4 % se sintió más seguro para vacunarse. Después de la intervención educativa, 45 profesionales de la salud respondieron el cuestionario. El 30,4 % afirmó saber qué vacunas prescribir y el 67,4 % recomendó vacunas a familiares de los pacientes. Conclusión La estrategia educativa propuesta aplicada en este estudio demostró un aumento de conocimiento sobre los protocolos de inmunización tras un trasplante hepático. Esto pude ayudar a evitar el riesgo potencial de la falta de información y el no abordar el tema de la vacunación por parte de los profesionales de la salud.

Abstract Objective To evaluate patients' and healthcare professionals' knowledge about vaccination protocols in post-liver transplantation before and after applying an educational awareness strategy in this population. Methods Patients (n=124) underwent the educational intervention through access to a webpage containing educational videos and, for health professionals (n=111), through a symposium and access to information on the project's virtual page. To analyze the effect of the intervention, qualitative analyses of knowledge were carried out using questionnaires before and after the interventions. Results Among patients, males were predominant (66.9%) and the mean age was 55.2 years old (SD + 15.9). 82.2% of patients visited a UBS to be vaccinated and 13.7% of them the CRIEs (Reference Center for Special Immunobiologicals). Only 46.7% received orientation about vaccines after liver transplantation. From the 111 questionnaires answered by health professionals, 46.5% did not check the vaccine portfolio, 61.3% referred patients to UBS and 38.7% to a CRIE. In the post-intervention analysis, 66.1% of patients watched educational videos about vaccination. Of these, 62.2% said they had improved their understanding about vaccines and 91.4% feel safer to vaccinate. After the educational intervention, 45 health professionals answered the questionnaire. 30.4% said they knew which vaccines to prescribe, and 67.4% recommended vaccines to patients' relatives. Conclusion The proposed educational strategy applied in this study shown to increase awareness regarding the post-liver transplant immunization protocols. This may contribute to avoiding the potential risk of lack of information and failure to address vaccination by healthcare professionals.

Autonomic dysfunction is common in liver cirrhosis and is associated with cardiac dysfunction and mortality: prospective observational study

ABSTRACT BACKGROUND: Although autonomic dysfunction has been shown to be associated with liver cirrhosis, the prevalence and prognostic implications are unclear. Abnormal heart rate variability (HRV), a measure of autonomic function, has not been well investigated in cirrhosis. OBJECTIVE: To evaluate the prevalence of high-risk HRV parameters in a cohort of cirrhotic patients and their association with cardiac dysfunction and mortality. DESIGN AND SETTING: Prospective observational study conducted in the Federal University of São Paulo. METHOD: A cohort of 120 patients, comprising 17 healthy controls and 103 cirrhotic outpatients, was evaluated and followed for 10 months. HRV analysis was based on 24-hour Holter monitoring and defined using time-domain and frequency-domain parameters. RESULTS: The HRV parameters were statistically lower in cirrhotic patients than in healthy subjects. High-risk HRV parameters were prevalent, such that 64% had at least one high-risk parameter. Time-domain parameters correlated with Child scores (P < 0.0001). In regression models, HRV parameters were independent predictors of diastolic dysfunction and mortality. During 10 months of follow-up, there were 11 deaths, all of patients with at least one high-risk HRV parameter. Kaplan-Meier analysis estimated low survival rates among patients with standard deviation of normal-to-normal RR intervals (SDNN) < 100. CONCLUSION: Reduced HRV is prevalent in liver cirrhosis and is related to cardiac dysfunction, severity of liver disease and mortality. Abnormal high-risk HRV parameters are prevalent among cirrhotic patients and are also predictors of mortality. Our findings highlight the need for a more careful cardiac evaluation of cirrhotic patients.

Autonomic dysfunction is common in liver cirrhosis and is associated with cardiac dysfunction and mortality: prospective observational study.

BACKGROUND: Although autonomic dysfunction has been shown to be associated with liver cirrhosis, the prevalence and prognostic implications are unclear. Abnormal heart rate variability (HRV), a measure of autonomic function, has not been well investigated in cirrhosis. OBJECTIVE: To evaluate the prevalence of high-risk HRV parameters in a cohort of cirrhotic patients and their association with cardiac dysfunction and mortality. DESIGN AND SETTING: Prospective observational study conducted in the Federal University of São Paulo. METHOD: A cohort of 120 patients, comprising 17 healthy controls and 103 cirrhotic outpatients, was evaluated and followed for 10 months. HRV analysis was based on 24-hour Holter monitoring and defined using time-domain and frequency-domain parameters. RESULTS: The HRV parameters were statistically lower in cirrhotic patients than in healthy subjects. High-risk HRV parameters were prevalent, such that 64% had at least one high-risk parameter. Time-domain parameters correlated with Child scores (P < 0.0001). In regression models, HRV parameters were independent predictors of diastolic dysfunction and mortality. During 10 months of follow-up, there were 11 deaths, all of patients with at least one high-risk HRV parameter. Kaplan-Meier analysis estimated low survival rates among patients with standard deviation of normal-to-normal RR intervals (SDNN) < 100. CONCLUSION: Reduced HRV is prevalent in liver cirrhosis and is related to cardiac dysfunction, severity of liver disease and mortality. Abnormal high-risk HRV parameters are prevalent among cirrhotic patients and are also predictors of mortality. Our findings highlight the need for a more careful cardiac evaluation of cirrhotic patients.

Nutrition Interventions for Chronic Liver Diseases and Nonalcoholic Fatty Liver Disease.

The progressively increasing rates of obesity have led to a worldwide epidemic of nonalcoholic fatty liver disease (NAFLD), the hepatic manifestation of the metabolic syndrome. It is currently the most common cause of liver disease worldwide and projected to be the leading indication for liver transplantation in the United States by 2020. NAFLD is associated with both liver-related and overall mortality. Undoubtedly, nutrition interventions are key in the treatment of NAFLD, to reverse the disease, and prevent disease progression, complications, and associated comorbidities, including cardiovascular disease and diabetes.

Avaliação da qualidade de vida de pacientes com dispepsia não investigada com base no questionário SF-36: um estudo controlado / Quality of life investigation in patients with non-investigated dyspepsia based on the SF-36 questionnaire: a controlled study

Introdução: O termo "dispepsia não investigada" (DNI) diz respeito a um conjunto de sintomas frequentemente atribuídos a desordens do transito digestivo alto, mas que não foram explorados por métodos diagnósticos específicos. Independente de sua natureza funcional ou orgânica, a DNI tem alta prevalência, inclusive no Brasil, constituindo relevante problema de saúde pública. Estima-se que essa condição possa interferir significativamente na qualidade de vida dos indivíduos, a exemplo do que já foi previamente constatado para outras enfermidades. No entanto, esse fato é ainda pouco conhecido, sobretudo em nosso meio. Objetivo: Avaliar a qualidade de vida de adultos com DNI através dos questionário de qualidade de vida Medical Outcome Study Short Form-36 Health Survey (SF-36) comparando-os com controles saudáveis. Métodos: No ano de 2007, foram estudados consecutivamente, pacientes com DNI atendidos em ambulatório de atenção primária à saúde (G1). Para análise comparativa, foram avaliados controles saudáveis pareados por idade e sexo (G2). Empregou-se o questionário de qualidade de vida SF-36 em todos os indivíduos do G1 e G2, com cálculo dos escores médios obtidos nos oito domínios contemplados por essa ferramenta. Na análise estatística adotou-se nível de significância estatística...

Colite pseudomembranosa simulando abdome agudo cirúrgico: relato de caso / Pseudo-membranosis Colitis simulating acute surgical abdomen: case report

A colite pseudomembranosa é causa de diarréia associada ao uso de antibióticos, sendo provocada por reação inflamatória intestinal às toxinas do Clostridium difficile. Apresenta-se neste relato o caso de um paciente masculino de 76 anos que, após internações recorrentes devido a causas respiratórias, evoluiu com diarréia, febre e dor abdominal, com sinais de irritação peritoneal, simulando de abdômen agudo cirúrgico. A retossigmoidoscopia associada à biópsia foi o método que estabeleceu o diagnóstico de colite pseudomembranosa, possibilitando tratamento clínico bem-sucedido, evitando-se a intervenção cirúrgica.

Utilização de endopróteses auto-expansíveis em tumores concomitantes de esôfago e região pré-pilórica: relato de caso / Self-expanding endoprostheses in concomitant esophageal and pre-pyloric malignancies: case report

Endopróteses auto-expansíveis são dispositivos utilizados com objetivo de restituir a patência da luz do Trato Gastrointestinal, sendo consideradas ferramentas bem estabelecidas e minimamente invasivas. Antes de seu desenvolvimento, o único meio para a restituição da continuidade do trânsito era através de cirurgia paliativa, que, embora ainda considerada padrão-ouro, não é isenta de riscos, podendo acarretar aumento nas taxas de morbidade e mortalidade. A utilização de múltiplas próteses na abordagem de tumores localizados em pontos distintos é rara, sendo poucos os casos relatados na literatura. Relatamos o caso de uma paciente de 92 anos com quadro de anemia de etiologia desconhecida e disfagia progressiva. Ao exame endoscópico, observou-se lesão infiltrante de esôfago e lesões vegetantes ulceradas em corpo e antro. Procedeu-se ao controle endoscópico da hemorragia gástrica. A família autorizou a introdução de endoprótese auto-expansível somente no esôfago inicialmente. Contudo, após nova reavaliação e explicação da possibilidade de obstrução gástrica, procedeu-se, um mês após, à colocação de endoprótese também na região pré-pilórica. Durante os últimos nove meses de sobrevida depois da introdução da segunda prótese, observou-se melhora importante da qualidade de vida da paciente.

Self-expanding endoprostheses are well established and minimally invasive devices used to re-establish patency of the gastrointestinal tract. Before their development, patency could only be re-established through palliative surgery, a procedure that though still the gold standard, carries a significant risk and increases morbidity and mortality rates. Management of localized tumors with multiple prostheses is still rarely reported in the literature. We report a 92-year-old women with anemia of unknown origin and progressive dysphagia. Endoscopy revealed an infiltrative lesion of the esophagus along with ulcerated vegetative lesions of gastric body and antrum. Gastric hemorrhage was endoscopically controlled. The family initially agreed with the introduction of a self-expanding prosthesis in the esophagus alone. On re-evaluation one month later the possibility of gastric obstruction was discussed and the introduction of a prepyloric endoprosthesis was agreed upon. Significant improvement in life quality was observed in the last nine months of survival following introduction of the second prosthesis.

Long-term results with azathioprine therapy in patients with corticosteroid-dependent Crohn's disease: open-label prospective study.

BACKGROUND: A substantial number of patients with Crohn's disease (CD) become dependent on steroids after induction therapy. Treatment with azathioprine (AZA) may be beneficial in such patients. The present open-label study evaluated the long-term safety and efficacy of AZA in steroid-dependent CD patients. METHODS: Adult patients with steroid-dependent CD were enrolled for AZA therapy over a 7-year period. The average dose of AZA was 2.0-3.0 mg/kg per day, adjusted according to clinical response and occurrence of adverse effects. Steroid therapy was tapered off according to a predefined schedule. Long-term outcome and adverse reactions were evaluated. RESULTS: Sixty-nine patients were prospectively included. Steroid-free remission was achieved in 68-81% of patients, partial response in 14.5-27.3% and failure to respond to AZA in 4-15.9% over the initial 48 months. However, the rate of wean from steroid therapy decreased to 53-60% while the rate of failure increased from 6.7% to 17.6% after this period. A breakthrough of symptoms during continuous AZA therapy was common, particularly after 48 months on AZA. The mean leukocyte count at the end of 12 months of therapy was significantly lower in patients who achieved complete response on AZA than in the non-responders (5197 +/- 1250 cells/mm(3) vs 8340 +/- 1310 cells/mm(3), respectively; P < 0.01). Azathioprine was relatively well-tolerated and the incidence of serious adverse effects was small. CONCLUSIONS: Azathioprine was relatively safe and moderately effective for long-term maintenance of steroid-free clinical remission in corticosteroid-dependent CD patients. Patients were more successfully weaned from prednisone treatment, and clinical remission was more often maintained during the first 48 months of AZA therapy. A significant decrease in the white blood cell count at the end of 12 months on AZA was the single factor associated with weaning from steroid dependence.