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Women at Gateway Church

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Egor Fedoseev
Egor Fedoseev

Download PORTABLE EMC 2019 Psychiatrie III Pdf


Important for the recognition of withdrawal problems is the fact that among those who experienced withdrawal were also medical professionals. In 2019, two of them, Mark Horowitz and David Taylor published perhaps the most insightful scientific article about how to taper antidepressants thus far (21).




Download EMC 2019 Psychiatrie III pdf


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Many urological diseases affect men, which may be congenital or acquired, malignant or benign, requiring clinical or surgical treatment. They occur at any time in life, presenting acute and self-limited or chronic and debilitating symptoms, which can make the diagnosis complex(11 Shore N, Tutrone R, Roehrborn CG. Efficacy and safety of fexapotide triflutate in outpatient medical treatment of male lower urinary tract symptoms associated with benign prostatic hyperplasia. Ther Adv Urol. 2019;11(14):1-16. doi: 10.1177/1756287218820807 ).


Studies show that with advancing age, LUTS are common in men and increase over the years, both in frequency and severity(33 Nnabugwu II, Ugwumba FO, Udeh EI, Anyimba SK, Okolie LT. The relationship between prevalence and severity of lower urinary tract symptoms (LUTS), and body mass index and mid-abdominal circumference in men in a resource-poor community in Southeast Nigeria: a cross-sectional survey. BMC Urol [Internet]. 2019 [cited 2019 Dec 6];19(1):15. Available from: -019-0444-x -44 Bajunirwe F, Stothers L, Berkowitz J, Macnab AJ. Prevalence estimates for lower urinary tract symptom severity among men in Uganda and sub-Saharan Africa based on regional prevalence data. Can Urol Assoc J. 2018; 12(11):E447-52. doi: 10.5489/cuaj.5105 ). In the United States, approximately 46% of adult men, aged 65 and over have some LUTS ranging from moderate to severe(55 Hoy NY, Dean NS, Wu J, Wollin TA, De SK. The impact of lower urinary tract symptomatology on urine volumes in stone formers. Can Urol Assoc J. 2019;13(8):256-9. doi: 10.5489/cuaj.5530 ). In South Korea, the prevalence was 70.6%(66 Yoo TK, Lee K-S, Sumarsono B, Kim S-T, Kim H-J, Lee H-C, et al. The prevalence of lower urinary tract symptoms in population aged 40 years or over, in South Korea. Investig Clin Urol [Internet]. 2018 [cited 2019 Dec 10];59(3):166. Available from: =10.4111/icu.2018.59.3.166 ), and in Brazil was 69%(77 Soler R, Gomes CM, Averbeck MA, Koyama M. The prevalence of lower urinary tract symptoms (LUTS) in Brazil: Results from the epidemiology of LUTS (Brazil LUTS) study. Neurourol Urodyn. 2017;37(4):1356-64. doi: 10.1002/nau.23446 ).


Sterile materials and the use of aseptic technique are necessary for the insertion of the urinary catheter to avoid urinary tract contamination. National and international protocols for urinary infection prevention recommend closed and sterile system use for urinary drainage, use of an appropriate urethral catheter, collection tube and collection bag followed by an anti-reflux valve, drip chamber and urine collection channel for collecting urine, examinations and adequate and frequent intimate hygiene(1111 Kim B, Pai H, Choi WS, Kim Y, Kweon KT, Kim HA, et al. Current status of indwelling urinary catheter utilization and catheter-associated urinary tract infection throughout hospital wards in Korea: A multicenter prospective observational study. PLoS One. 2017;12(10):1-11. doi: 10.1371/journal.pone.0185369 -1212 Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. [Internet]. 2009 [cited 2019 Oct 8]; Available from: ).


The study showed that the prevalence of urinary problems was higher in men aged between 60 and 79 years, data similar to those found in other studies that indicate that the symptoms increase progressively with aging(1818 Lee SWH, Chan EMC, Lai YK. The global burden of lower urinary tract symptoms suggestive of benign prostatic hyperplasia: a systematic review and meta-analysis. Sci Rep [Internet]. 2017 [cited 2019 Oct 8];7(1):1-10. Available from: -017-06628-8 -017-066... -1919 Kim TH, Han DH, Ryu DS, Lee KS. The impact of lower urinary tract symptoms on quality of life, work productivity, depressive symptoms, and sexuality in Korean men aged 40 years and older: a population-based survey. Int Neurourol J. 2015;19(2):120-9. doi: 10.5213/inj.2015.19.2.120 ).


The level of education was different, especially in the group of patients who used an indwelling urinary catheter, as more than 60% were illiterate. Also, in both groups, the monthly income of about 40% of men did not exceed 1 minimum wage, and the rest, with the exception of 1 patient, received up to 3 wages. These data are similar to the median monthly income of 600.00 reais (about 137 US Dollars) for men residing in Acre, which is below the national average of 1,200.00 reais (about 275 US Dollars)(2020 Instituto Brasileiro de Geografia e Estatística-IBGE. Censo Demográfico 2010 - Resultados dos Rendimentos[Internet]. Rio de Janeiro - IBGE. 2011[cited 2019 Jan 27]. Available from: _preliminares/rendimentos_preliminares_tab_pdf.shtm ). A similar study shows that the level of education and low income can be an impediment in the search for diagnosis, adequate treatment, knowledge of risks and health care, in addition to prolonging the search for adequate therapy and, consequently, presenting a higher risk of aggravating the health(2121 Tavares DMS, Bolina AF, Dias FA, Santos NMF. Qualidade de vida de idosos com incontinência urinária. Rev Eletrôn Enferm. 2011;13(4):695-702. doi: 10.5216/ree.v13i4.12488 ).


Among the patients who had difficulty urinating 75% had BPH and of these 96.9% used drug treatment to control the disease, however they often did not empty the bladder completely after urinating, used the bathroom several times in 24 hours, had a urinary stream weak, and 34.4% reported an episode of significant urinary retention. The prevalence of BPH increases markedly in men and the continued growth of the prostate is a risk factor for progression of LUTS and an increased risk of clinical progression of BPH, urinary retention and need for prostate surgery(2525 Yue L, Wang T, Ge Y, Ge M, Zhang C, Hou Q, et al. Prevalence and heritability of benign prostatic hyperplasia and LUTS in men aged 40 years or older in Zhengzhou rural areas. Prostate. 2018;79(3):312-9. doi: 10.1002/pros.23737 ). Studies have shown that men with difficulty urinating experience discomfort, difficulty sleeping, problems in social life, decreased QoL, changes in psychological status and even depression(2626 Rhee SJ, Kim EY, Kim SW, Kim SH, Lee HJ, Yoon DH, et al. Longitudinal study of the relationship between lower urinary tract symptoms and depressive symptoms. J Psychosom Res. 2019;116(4):100-5. doi: 10.1016/j.jpsychores.2018.12.006 -2727 Pinto JDO, He HG, Chan SWC, Toh PC, Esuvaranathan K, Wang W. Health-related quality of life and psychological well-being in patients with benign prostatic hyperplasia. J Clin Nurs. 2014;24(3-4):511-22. doi: 10.1111/jocn.12636 ).


More than half of the patients who used the urinary catheter reported needing help to perform care with it. A study conducted at Wisconsin University Hospital in the United States found that 75% of patients did not receive adequate education on indwelling urinary catheters. One hundred percent of patients reported that alternative methods of excretion were not discussed, and 65% of patients received no information information about the risks of having an indwelling urinary catheter(3131 Safdar N, Codispoti N, Purvis S, Knobloch MJ. Patient perspectives on indwelling urinary catheter use in the hospital. Am J Infect Control [Internet]. 2016 [cited 2019 Oct 8];44(3):e23-4. Available from: ).


Another aspect of the study that concerns patients using indwelling urinary catheter is that 75% of patients did not use a closed and adequate system for urine drainage (urine collector with drainage system and anti-reflux valve). In this group, the bag was replaced by syringes to close the catheter outlet, 43.8% of the cases, glass ampoules in 28.1% and 3.1% used a nylon cord to tie the catheter and prevent urine output. This finding contradicts the scientific evidence and national and international recommendations on maintaining a closed drainage system after aseptic insertion to avoid the risk of urinary tract infection associated with the catheter(2424 Ministério da Saúde (BR). Agência Nacional de Vigilância Sanitária (ANVISA). Medidas de prevenção de infecção relacionada à assistência a saúde [Internet]. Brasília (DF): MS ; 2017 [cited 2019 Mar 31]. Available from: +4+-+Medidas+de+Preven%C3%A7%C3%A3o+de+Infec%C3%A7%C3%A3o+Relacionada+%C3%A0+Assist%C3%AAncia+%C3%A0+Sa%C3%BAde/a3f23dfb-2c54-4e64-881c-fccf9220c373 ,3232 Bradley SM, Schweon SJ, Mody L, Mahajan D, Olmsted RN. Identifying safe practices for use of the urinary leg bag drainage system in the postacute and long-term care setting: An integrative review. Am J Infect Control [Internet]. 2018 [cited 2019 Sep 12];46(9):973-9. Available from: ). It is worth mentioning that the service had a urine collection bag, but the fact that patients did not use the bag may be associated with the lack of guidance from the health team or perhaps because of body image, an unproven inference.


The QoL scores of patients who used a urinary catheter or had difficulty urinating were low and significantly lower, in the first group, in five domains: Functional Capacity, Physical Aspects, General Health Status, Vitality, and Social Aspects; similar in the Pain and Mental Health domains, and also very low in the Emotional Aspects domain. Studies have shown that the QoL of patients with urinary problems is compromised in almost all domains(1919 Kim TH, Han DH, Ryu DS, Lee KS. The impact of lower urinary tract symptoms on quality of life, work productivity, depressive symptoms, and sexuality in Korean men aged 40 years and older: a population-based survey. Int Neurourol J. 2015;19(2):120-9. doi: 10.5213/inj.2015.19.2.120 ,3333 Khalaf KM, Coyne KS, Globe DR, Malone DC, Armstrong EP, Patel V, et al. The impact of lower urinary tract symptoms on health-related quality of life among patients with multiple sclerosis. Neurourol Urodyn [Internet]. 2016 [cited 2019 Jan 17];35(1):48-54. Available from: ). However, a research carried out in Africa, with 32 patients who used an indwelling urinary catheter, showed that catheter use did not change the QoL of patients, as they reported that its use provided relief to the LUTS(3434 Okeke LI, Aisuodionoe-Shadrach OI. Self-Reported Quality of Life Measures of Patients With Benign Prostatic Hyperplasia on Indwelling Urethral Catheters. Vol. 12, African J Urology. 2006 [cited 2019 Feb 13];12:15-23. Available from: ). 041b061a72


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