OS ALUNOS DAS CLASSES ESPECIAIS E O PROCESSO DE INCLUSÃO EDUCACIONAL

Este trabalho surgiu das discussões relacionadas ao processo educativo de alunos frequentadores do ensino comum e classes especiais, proposta na disciplinade Fundamentos da Educação Inclusiva, do primeiro curso de Pedagogia, Modalidade de Educação à Distância, em 2014. A necessidade de compartilhar osdesafios e dificuldades encontrados no processo de inclusão educacional dosalunos com este perfil, nos levou a um aprofundamento teórico que ocorreuatravés de pesquisas bibliográficas, bem como a realização de uma observaçãoparticipativa das autoras nas classes especiais, as quais nos permitiram estabelecer alguns apontamentos e reflexões. Dentre eles, destacamos a escassarelação da estrutura, em contraste com os possíveis resultados esperados pelaspolíticas educacionais. Além disso, relatamos as dificuldades encontradas peloseducadores em efetivar o processo inclusivo e, ao mesmo tempo, organizar oensino de forma a promover o desenvolvimento cognitivo, afetivo e social destascrianças. Nesse sentido, consideramos que o processo inclusivo ainda se mostracomo complexo e desafiador no ambiente escolar

Increased Percentages of T Helper Cells Producing IL-17 and Monocytes Expressing Markers of Alternative Activation in Patients with Sepsis

BACKGROUND: A shift from Th1 to Th2 as well as an increase in Treg CD4+T cell subsets has been reported in septic patients (SP). Furthermore, these patients display modulation of monocyte function, with reduced production of pro-inflammatory cytokines upon LPS stimulus, which resembles the phenotype of alternatively activated macrophages. In this study, we evaluated the percentages of T cells differentiated into Th1, Th17 and Treg subsets, as well as the percentage of monocytes expressing markers of alternatively activated monocytes/macrophages (AAM) in SP. METHODOLOGY/PRINCIPAL FINDINGS: Peripheral blood mononuclear cells (PBMC) were obtained from 32 healthy volunteers (HV) and from SP at admission (D0, n = 67) and after 7 days of therapy (D7, n = 33). Th1 and Th17 (CD3+CD8-) lymphocytes were identified by the intracellular detection of IFN-γ and IL-17, respectively, spontaneously and after PMA/Io stimulation, and Treg cells were identified by Foxp3+CD127- expression. Monocytes were evaluated for CD206 and CD163 expression. Absolute numbers of CD4+T lymphocytes were measured in whole blood samples by flow cytometry. The Mann-Whitney or Wilcoxon test was applied, as appropriate. The percentage of Th1 cells was lower in SP than in HV at admission after PMA/Io stimulation, whereas the percentage of Th17 cells was higher. In patients' follow-up samples, a higher percentage of Th1 cells and a lower percentage of Th17 cells were observed on D7 compared with the D0 samples. Treg cells remained unchanged. Septic patients showed a markedly increased proportion of monocytes expressing CD163 and CD206. CONCLUSIONS/SIGNIFICANCE: Upon in vitro stimulus, the percentage of T helper lymphocytes producing IL-17 was higher in SP than in HV at admission, and the percentage producing IFN-γ was lower, a pattern that was reversed during follow-up. The increased expression of CD163 and CD206 indicates that monocytes may acquire the AAM phenotype during sepsis

Influência do status perfusional nas saturações venosas de oxigênio central e mista em pacientes sépticos

Background and objectives: Although there is controversy regarding the role of venous oxygen saturation in the initial resuscitation of septic patients with hypoperfusion these markers are still widely used. This study aimed to evaluate the correlation and concordance between central (SvcO(2)) and mixed (SvO(2)) oxygen saturation in septic shock patients with or without hypoperfusion in addition to the impact of these differences in patient conduction. Methods: Patients with septic shock were monitored with pulmonary artery catheter and the following subgroups of hypoperfusion were analyzed: 1) lactate > 28 mg.dL(-1); 2) base excess 6 mmHg; 4) SvO(2) 28 mg.dL(-1) and SvO(2) 28 mg.dL(-1) and SvcO(2) 28 mg.dL-1; 2) Excesso de bases ≤ -5 mmoL.L-1; 3) Gradiente venoarterial de CO2 > 6 mmHg; 4) SvO2 28 mg.dL-1 e SvO2 28 mg.dL-1 e SvcO2 < 75%. Resultados: Foram incluídas 70 amostras de 24 pacientes. Houve apenas correlação moderada entre SvO2 e SvcO2 (r = 0,72; p = 0,0001) e não houve boa concordância entre essas variáveis (viés de 7,35% e limites de concordância de 95% de -3,0%-17,7%). A análise dos subgrupos de acordo com a presença de hipoperfusão não mostrou diferenças na concordância entre as variáveis. Houve discordância na conduta clínica em 13,8% dos casos (n = 9). Conclusões: Existe correlação moderada entre SvO2 e SvcO2, entretanto a concordância entre elas é inadequada. Não foi possível demonstrar que a presença de hipoperfusão altera a concordância entre a entre SvO2 e SvcO2. O uso da SvO2 em vez da SvcO2 pode levar a alterações na conduta clínica numa parcela pequena, porém clinicamente relevante, dos pacientes.Univ Fed Sao Paulo, Escola Paulista Med, Hosp Univ, Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Escola Paulista Med, Hosp Univ, Sao Paulo, SP, BrazilWeb of Scienc

Mortality Predictors in Renal Transplant Recipients with Severe Sepsis and Septic Shock

Introduction: the growing number of renal transplant recipients in a sustained immunosuppressive state is a factor that can contribute to increased incidence of sepsis. However, relatively little is known about sepsis in this population. the aim of this single-center study was to evaluate the factors associated with hospital mortality in renal transplant patients admitted to the intensive care unit (ICU) with severe sepsis and septic shock.Methods: Patient demographics and transplant-related and ICU stay data were retrospectively collected. Multiple logistic regression was conducted to identify the independent risk factors associated with hospital mortality.Results: A total of 190 patients were enrolled, 64.2% of whom received kidneys from deceased donors. the mean patient age was 51 +/- 13 years (males, 115 [60.5%]), and the median APACHE II was 20 (16-23). the majority of patients developed sepsis late after the renal transplantation (2.1 [0.6-2.3] years). the lung was the most common infection site (59.5%). Upon ICU admission, 16.4% of the patients had = 2 organ failures at admission, and 27.9% experienced septic shock within the first 24 hours of ICU admission. the overall hospital mortality rate was 38.4%. in the multivariate analysis, the independent determinants of hospital mortality were male gender (OR = 5.9; 95% CI, 1.7-19.6; p = 0.004), delta SOFA 24 h (OR = 1.7; 95% CI, 1.2-2.3; p = 0.001), mechanical ventilation (OR = 30; 95% CI, 8.8-102.2; p<0.0001), hematologic dysfunction (OR = 6.8; 95% CI, 2.0-22.6; p = 0.002), admission from the ward (OR = 3.4; 95% CI, 1.2-9.7; p = 0.02) and acute kidney injury stage 3 (OR = 5.7; 95% CI, 1.9-16.6; p = 0.002).Conclusions: Hospital mortality in renal transplant patients with severe sepsis and septic shock was associated with male gender, admission from the wards, worse SOFA scores on the first day and the presence of hematologic dysfunction, mechanical ventilation or advanced graft dysfunction.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Hospital do RimUniversidade Federal de São Paulo, Unidade Transplante, Disciplina Nefrol, São Paulo, BrazilUniversidade Federal de São Paulo, Disciplina Anestesiol Dor & Terapia Intens, São Paulo, BrazilUniversidade Federal de São Paulo, Unidade Transplante, Disciplina Nefrol, São Paulo, BrazilUniversidade Federal de São Paulo, Disciplina Anestesiol Dor & Terapia Intens, São Paulo, BrazilWeb of Scienc

Duration of hemodynamic effects of crystalloids in patients with circulatory shock after initial resuscitation

Background: in the later stages of circulatory shock, monitoring should help to avoid fluid overload. in this setting, volume expansion is ideally indicated only for patients in whom the cardiac index (CI) is expected to increase. Crystalloids are usually the choice for fluid replacement. As previous studies evaluating the hemodynamic effect of crystalloids have not distinguished responders from non-responders, the present study was designed to evaluate the duration of the hemodynamic effects of crystalloids according to the fluid responsiveness status.Methods: This is a prospective observational study conducted after the initial resuscitation phase of circulatory shock (>6 h vasopressor use). Critically ill, sedated adult patients monitored with a pulmonary artery catheter who received a fluid challenge with crystalloids (500 mL infused over 30 min) were included. Hemodynamic variables were measured at baseline (T0) and at 30 min (T1), 60 min (T2), and 90 min (T3) after a fluid bolus, totaling 90 min of observation. the patients were analyzed according to their fluid responsiveness status (responders with CI increase >15% and non-responders <= 15% at T1). the data were analyzed by repeated measures of analysis of variance.Results: Twenty patients were included, 14 of whom had septic shock. Overall, volume expansion significantly increased the CI: 3.03 +/- 0.64 L/min/m(2) to 3.58 +/- 0.66 L/min/m(2) (p < 0.05). From this period, there was a progressive decrease: 3.23 +/- 0.65 L/min/m(2) (p < 0.05, T2 versus T1) and 3.12 +/- 0.64 L/min/m(2) (p < 0.05, period T3 versus T1). Similar behavior was observed in responders (13 patients), 2.84 +/- 0.61 L/min/m(2) to 3.57 +/- 0.65 L/min/m(2) (p < 0.05) with volume expansion, followed by a decrease, 3.19 +/- 0.69 L/min/m(2) (p < 0.05, T2 versus T1) and 3.06 +/- 0.70 L/min/m(2) (p < 0.05, T3 versus T1). Blood pressure and cardiac filling pressures also decreased significantly after T1 with similar findings in both responders and non-responders.Conclusions: the results suggest that volume expansion with crystalloids in patients with circulatory shock after the initial resuscitation has limited success, even in responders.Universidade Federal de São Paulo, Disciplina Anestesiol Dor & Terapia Intens, BR-04024900 São Paulo, BrazilUniversidade Federal de São Paulo, Disciplina Anestesiol Dor & Terapia Intens, BR-04024900 São Paulo, BrazilWeb of Scienc

Guidelines for the treatment of severe sepsis and septic shock: management of the infectious agent, source control and antimicrobial treatment

Sepsis is a common and lethal condition that carries a substantial financial burden. In addition, it is the main cause of death in intensive care units. Early diagnosis and treatment of patients has been clearly shown to improve prognosis. Therefore, early diagnosis of the infecting agent, control of the primary infection site and the use of appropriate antibiotic therapy are fundamental to improving outcomes. This guideline reviews the available evidence in the literature concerning infection control and therapy strategies.A sepse tem alta incidência, alta letalidade e custos elevados, sendo a principal causa de mortalidade em unidades de terapia intensiva. Está claramente demonstrado que pacientes reconhecidos e tratados precocemente tem melhor prognóstico. Nesse sentido, a abordagem precoce do agente infeccioso, tanto no sentido do controle do foco infeccioso como da antibioticoterapia adequada são fundamentais para a boa evolução do paciente. A presente diretriz aborda as evidências disponíveis na literatura em relação às principais estratégias para controle e tratamento.Sociedade Brasileira de Infectologia – SBIAssociação de Medicina Intensiva Brasileira – AMIBAssociação Médica Brasileira – AMBInstituto Latino Americano de Sepse – ILASUNIFESP, EPMSciEL

Microcirculation improvement after short-term infusion of vasopressin in septic shock is dependent on noradrenaline

OBJECTIVES: To assess the impact of vasopressin on the microcirculation and to develop a predictive model to estimate the probability of microcirculatory recruitment in patients with septic shock. METHODS: This prospective interventional study included patients with septic shock receiving noradrenaline for less than 48 hours. We infused vasopressin at 0.04 U/min for one hour. Hemodynamic measurements, including sidestream dark-field imaging, were obtained immediately before vasopressin infusion, 1 hour after vasopressin infusion and 1 hour after vasopressin withdrawal. We defined patients with more than a 10% increase in total vascular density and perfused vascular density as responders. ClinicalTrials.gov: NCT02053675. RESULTS: Eighteen patients were included, and nine (50%) showed improved microcirculation after infusion of vasopressin. The noradrenaline dose was significantly reduced after vasopressin (p=0.001) and was higher both at baseline and during vasopressin infusion in the responders than in the non-responders. The strongest predictor for a favorable microcirculatory response was the dose of noradrenaline at baseline (OR=4.5; 95% CI: 1.2-17.0; p=0.027). For patients using a noradrenaline dose higher than 0.38 mcg/kg/min, the probability that microcirculatory perfusion would be improved with vasopressin was 53% (sensitivity 78%, specificity 77%). CONCLUSIONS: In patients with septic shock for no longer than 48 h, administration of vasopressin is likely to result in an improvement in microcirculation when the baseline noradrenaline dose is higher than 0.38 mcg/kg/min

Patterns of Gene Expression in Peripheral Blood Mononuclear Cells and Outcomes from Patients with Sepsis Secondary to Community Acquired Pneumonia

Mechanisms governing the inflammatory response during sepsis have been shown to be complex, involving cross-talk between diverse signaling pathways. Current knowledge regarding the mechanisms underlying sepsis provides an incomplete picture of the syndrome, justifying additional efforts to understand this condition. Microarray-based expression profiling is a powerful approach for the investigation of complex clinical conditions such as sepsis. in this study, we investigate whole-genome expression profiles in mononuclear cells from survivors (n = 5) and non-survivors (n = 5) of sepsis. To circumvent the heterogeneity of septic patients, only patients admitted with sepsis caused by community-acquired pneumonia were included. Blood samples were collected at the time of sepsis diagnosis and seven days later to evaluate the role of biological processes or genes possibly involved in patient recovery. Principal Components Analysis (PCA) profiling discriminated between patients with early sepsis and healthy individuals. Genes with differential expression were grouped according to Gene Ontology, and most genes related to immune defense were up-regulated in septic patients. Additionally, PCA in the early stage was able to distinguish survivors from non-survivors. Differences in oxidative phosphorylation seem to be associated with clinical outcome because significant differences in the expression profile of genes related to mitochondrial electron transport chain (ETC) I-V were observed between survivors and non-survivors at the time of patient enrollment. Global gene expression profiles after seven days of sepsis progression seem to reproduce, to a certain extent, patterns collected at the time of diagnosis. Gene expression profiles comparing admission and follow-up samples differed between survivors and non-survivors, with decreased expression of genes related to immune functions in non-survivors. in conclusion, genes related to host defense and inflammatory response ontology were up-regulated during sepsis, consistent with the need for a host response to infection, and the sustainability of their expression in follow-up samples was associated with outcomes.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Albert Einstein Research and Education Institute - Hospital Israelita Albert EinsteinHosp Israelita Albert Einstein, Inst Israelita Ensino & Pesquisa, Ctr Expt Res, São Paulo, BrazilHosp Israelita Albert Einstein, Intens Care Unit, São Paulo, BrazilUniversidade Federal de São Paulo Unifesp, EPM, Hosp São Paulo, Div Infect Dis, São Paulo, BrazilHosp Sirio Libanes, Intens Care Unit, São Paulo, BrazilUniversidade Federal de São Paulo Unifesp, EPM, Dept Gynecol, São Paulo, BrazilUniversidade Federal de São Paulo Unifesp, Intens Care Unit, Hosp São Paulo, São Paulo, BrazilUniversidade Federal de São Paulo Unifesp, EPM, Hosp São Paulo, Div Infect Dis, São Paulo, BrazilUniversidade Federal de São Paulo Unifesp, EPM, Dept Gynecol, São Paulo, BrazilUniversidade Federal de São Paulo Unifesp, Intens Care Unit, Hosp São Paulo, São Paulo, BrazilFAPESP: FAPESP 2006/58744-1Web of Scienc

Short-term effects of passive mobilization on the sublingual microcirculation and on the systemic circulation in patients with septic shock

Background: Active mobilization is not possible in patients under deep sedation and unable to follow commands. In this scenario, passive therapy is an interesting alternative. However, in patients with septic shock, passive mobilization may have risks related to increased oxygen consumption. Our objective was to evaluate the impact of passive mobilization on sublingual microcirculation and systemic hemodynamics in patients with septic shock. Methods: We included patients who were older than 18 years, who presented with septic shock, and who were under sedation and mechanical ventilation. Passive exercise was applied for 20 min with 30 repetitions per minute. Systemic hemodynamic and microcirculatory variables were compared before (T0) and up to 10 min after (T1) passive exercise. p values <0.05 were considered significant. Results: We included 35 patients (median age [IQR 25-75%]: 68 [49.0-78.0] years mean (+/- SD) Simplified Acute Physiologic Score (SAPS) 3 score: 66.7 +/- 12.1 median [IQR 25-75%] Sequential Organ Failure Assessment (SOFA) score: 9 [7.0-12.0]). After passive mobilization, there was a slight but significant increase in proportion of perfused vessels (PPV) (T0 [IQR 25-75%]: 78.2 [70.9-81.9%] T1 [IQR 25-75%]: 80.0 [75.2-85.1] % p = 0.029), without any change in other microcirculatory variables. There was a reduction in heart rate (HR) (T0 (mean +/- SD): 95.6 +/- 22.0 bpm T1 (mean +/- SD): 93.8 +/- 22.0 bpm p < 0.040) and body temperature (T0 (mean +/- SD): 36.9 +/- 1.1 degrees C T1 (mean +/- SD): 36.7 +/- 1.2 degrees C p < 0.002) with no change in other systemic hemodynamic variables. There was no significant correlation between PPV variation and HR (r = -0.010, p = 0.955), cardiac index (r = 0.218, p = 0.215) or mean arterial pressure (r = 0.276, p = 0.109) variation. Conclusions: In patients with septic shock after the initial phase of hemodynamic resuscitation, passive exercise is not associated with relevant changes in sublingual microcirculation or systemic hemodynamics.Fundacao de Apoio a Pesquisa do Estado de Sao Paulo FAPESPUniv Fed Sao Paulo, Anesthesiol Pain & Intens Care Dept, Napoleao Barros 737, BR-04024002 Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Anesthesiol Pain & Intens Care Dept, Napoleao Barros 737, BR-04024002 Sao Paulo, SP, BrazilFAPESP: 2012 19 051-1Web of Scienc

Proteomic study revealed cellular assembly and lipid metabolism dysregulation in sepsis secondary to community-acquired pneumonia

Sepsis is a life-threatening disorder characterized by organ dysfunction and a major cause of mortality worldwide. The major challenge in studying sepsis is its diversity in such factors as age, source of infection and etiology. Recently, genomic and proteomic approaches have improved our understanding of its complex pathogenesis. In the present study, we use quantitative proteomics to evaluate the host proteome response in septic patients secondary to community-acquired pneumonia (CAP). Samples obtained at admission and after 7 days of follow-up were analyzed according to the outcomes of septic patients. The patients' proteome profiles were compared with age-and gender-matched healthy volunteers. Bioinformatic analyses of differentially expressed proteins showed alteration in the cytoskeleton, cellular assembly, movement, lipid metabolism and immune responses in septic patients. Actin and gelsolin changes were assessed in mononuclear cells using immunofluorescence, and a higher expression of gelsolin and depletion of actin were observed in survivor patients. Regarding lipid metabolism, changes in cholesterol, HDL and apolipoproteins were confirmed using enzymatic colorimetric methods in plasma. Transcriptomic studies revealed a massive change in gene expression in sepsis. Our proteomic results stressed important changes in cellular structure and metabolism, which are possible targets for future interventions of sepsis.Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP)Conselho Nacional de Desenvolvimento Cientifico e Tecnologico, CNPqFAPESPUniv Fed Sao Paulo, Hosp Sao Paulo, Div Infect Dis, Escola Paulista Med, BR-04039032 Sao Paulo, BrazilUniv Fed Sao Paulo, Dept Biochem, Escola Paulista Med, BR-04023900 Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Dept Microbiol Immunol & Parasitol, Escola Paulista Med, BR-04023062 Sao Paulo, BrazilUniv Fed Sao Paulo, Intens Care Unit, Hosp Sao Paulo, Escola Paulista Med, BR-04024002 Sao Paulo, BrazilHosp Israelita Albert Einstein, Intens Care Unit, BR-05652900 Sao Paulo, BrazilHosp Sirio Libanes, Intens Care Unit, BR-01409001 Sao Paulo, BrazilUniv Fed Sao Paulo, Hosp Sao Paulo, Div Infect Dis, Escola Paulista Med, BR-04039032 Sao Paulo, BrazilUniv Fed Sao Paulo, Dept Biochem, Escola Paulista Med, BR-04023900 Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Dept Microbiol Immunol & Parasitol, Escola Paulista Med, BR-04023062 Sao Paulo, BrazilUniv Fed Sao Paulo, Intens Care Unit, Hosp Sao Paulo, Escola Paulista Med, BR-04024002 Sao Paulo, BrazilFAPESP: 2011/20401-4FAPESP: 2013/15636-8CNPq: 305685/2011-2Web of Scienc