Como implementar uma diretriz - da teoria à prática: exemplo da profilaxia para Tromboembolismo Venoso

The objective of this manuscript is to discuss the existing barriers for the dissemination of medical guidelines, and to present strategies that facilitate the adaptation of the recommendations into clinical practice. The literature shows that it usually takes several years until new scientific evidence is adopted in current practice, even when there is obvious impact in patients' morbidity and mortality. There are some examples where more than thirty years have elapsed since the first case reports about the use of a effective therapy were published until its utilization became routine. That is the case of fibrinolysis for the treatment of acute myocardial infarction. Some of the main barriers for the implementation of new recommendations are: the lack of knowledge of a new guideline, personal resistance to changes, uncertainty about the efficacy of the proposed recommendation, fear of potential side-effects, difficulties in remembering the recommendations, inexistence of institutional policies reinforcing the recommendation and even economical restrains. In order to overcome these barriers a strategy that involves a program with multiple tools is always the best. That must include the implementation of easy-to-use algorithms, continuous medical education materials and lectures, electronic or paper alerts, tools to facilitate evaluation and prescription, and periodic audits to show results to the practitioners involved in the process. It is also fundamental that the medical societies involved with the specific medical issue support the program for its scientific and ethical soundness. The creation of multidisciplinary committees in each institution and the inclusion of opinion leaders that have pro-active and lasting attitudes are the key-points for the program's success. In this manuscript we use as an example the implementation of a guideline for venous thromboembolism prophylaxis, but the concepts described here can be easily applied to any other guideline. Therefore, these concepts could be very useful for institutions and services that aim at quality improvement of patient care. Changes in current medical practice recommended by guidelines may take some time. However, if there is a broader participation of opinion leaders and the use of several tools listed here, they surely have a greater probability of reaching the main objectives: improvement in provided medical care and patient safety.

Confronting dark energy models using galaxy cluster number counts

The mass function of cluster-size halos and their redshift distribution are computed for 12 distinct accelerating cosmological scenarios and confronted to the predictions of the conventional flat Lambda CDM model. The comparison with Lambda CDM is performed by a two-step process. First, we determine the free parameters of all models through a joint analysis involving the latest cosmological data, using supernovae type Ia, the cosmic microwave background shift parameter, and baryon acoustic oscillations. Apart from a braneworld inspired cosmology, it is found that the derived Hubble relation of the remaining models reproduces the Lambda CDM results approximately with the same degree of statistical confidence. Second, in order to attempt to distinguish the different dark energy models from the expectations of Lambda CDM, we analyze the predicted cluster-size halo redshift distribution on the basis of two future cluster surveys: (i) an X-ray survey based on the eROSITA satellite, and (ii) a Sunayev-Zeldovich survey based on the South Pole Telescope. As a result, we find that the predictions of 8 out of 12 dark energy models can be clearly distinguished from the Lambda CDM cosmology, while the predictions of 4 models are statistically equivalent to those of the Lambda CDM model, as far as the expected cluster mass function and redshift distribution are concerned. The present analysis suggests that such a technique appears to be very competitive to independent tests probing the late time evolution of the Universe and the associated dark energy effects.

Constraints on cold dark matter accelerating cosmologies and cluster formation

We discuss the properties of homogeneous and isotropic flat cosmologies in which the present accelerating stage is powered only by the gravitationally induced creation of cold dark matter (CCDM) particles (Omega(m) = 1). For some matter creation rates proposed in the literature, we show that the main cosmological functions such as the scale factor of the universe, the Hubble expansion rate, the growth factor, and the cluster formation rate are analytically defined. The best CCDM scenario has only one free parameter and our joint analysis involving baryonic acoustic oscillations + cosmic microwave background (CMB) + SNe Ia data yields (Omega) over tilde = 0.28 +/- 0.01 (1 sigma), where (Omega) over tilde (m) is the observed matter density parameter. In particular, this implies that the model has no dark energy but the part of the matter that is effectively clustering is in good agreement with the latest determinations from the large- scale structure. The growth of perturbation and the formation of galaxy clusters in such scenarios are also investigated. Despite the fact that both scenarios may share the same Hubble expansion, we find that matter creation cosmologies predict stronger small scale dynamics which implies a faster growth rate of perturbations with respect to the usual Lambda CDM cosmology. Such results point to the possibility of a crucial observational test confronting CCDM with Lambda CDM scenarios through a more detailed analysis involving CMB, weak lensing, as well as the large-scale structure.

Var transcription profiling of Plasmodium falciparum 3D7: assignment of cytoadherent phenotypes to dominant transcripts

Background: Cytoadherence of Plasmodium falciparum-infected red blood cells is mediated by var gene-encoded P. falciparum erythrocyte membrane protein-1 and host receptor preference depends in most cases on which of the 50-60 var genes per genome is expressed. Enrichment of phenotypically homogenous parasites by panning on receptor expressing cells is fundamental for the identification of the corresponding var transcript. Methods: P. falciparum 3D7 parasites were panned on several transfected CHO-cell lines and their var transcripts analysed by i) reverse transcription/PCR/cloning/sequencing using a universal DBL alpha specific oligonucleotide pair and ii) by reverse transcription followed by quantitative PCR using 57 different oligonucleotide pairs. Results: Each cytoadherence selected parasite line also adhered to untransfected CHO-745 cells and upregulation of the var gene PFD995/PFD1000c was consistently associated with cytoadherence to all but one CHO cell line. In addition, parasites panned on different CHO cell lines revealed candidate var genes which reproducibly associated to the respective cytoadherent phenotype. The transcription profile obtained by RT-PCR/cloning/sequencing differed significantly from that of RT-quantitative PCR. Conclusion: Transfected CHO cell lines are of limited use for the creation of monophenotypic cytoadherent parasite lines. Nevertheless, 3D7 parasites can be reproducibly selected for the transcription of different determined var genes without genetic manipulation. Most importantly, var transcription analysis by RT-PCR/cloning/sequencing may lead to erroneous interpretation of var transcription profiles.

Hidden vorticity in binary Bose-Einstein condensates

We consider a binary Bose-Einstein condensate (BEC) described by a system of two-dimensional (2D) Gross-Pitaevskii equations with the harmonic-oscillator trapping potential. The intraspecies interactions are attractive, while the interaction between the species may have either sign. The same model applies to the copropagation of bimodal beams in photonic-crystal fibers. We consider a family of trapped hidden-vorticity (HV) modes in the form of bound states of two components with opposite vorticities S(1,2) = +/- 1, the total angular momentum being zero. A challenging problem is the stability of the HV modes. By means of a linear-stability analysis and direct simulations, stability domains are identified in a relevant parameter plane. In direct simulations, stable HV modes feature robustness against large perturbations, while unstable ones split into fragments whose number is identical to the azimuthal index of the fastest growing perturbation eigenmode. Conditions allowing for the creation of the HV modes in the experiment are discussed too. For comparison, a similar but simpler problem is studied in an analytical form, viz., the modulational instability of an HV state in a one-dimensional (1D) system with periodic boundary conditions (this system models a counterflow in a binary BEC mixture loaded into a toroidal trap or a bimodal optical beam coupled into a cylindrical shell). We demonstrate that the stabilization of the 1D HV modes is impossible, which stresses the significance of the stabilization of the HV modes in the 2D setting.

Observation of double electron-positron pair production by gamma rays reexamined

An experiment was conducted to observe triple- and quadruple-escape peaks, at a photon energy equal to 6.128 MeV, in the spectra recorded with a high-purity Ge detector working in coincidence with six bismuth germanate detectors. The peak intensities may be explained having recourse to only the bremsstrahlung cascade process of consecutive electron-positron pair creation; i.e., the contribution of simultaneous double pair formation (and other cascade effects) is much smaller. The experimental peak areas are in reasonably good agreement with those predicted by Monte Carlo simulations done with the general-purpose radiation-tran sport code PENELOPE.

Spectra of identified high-p(T) pi(+/-) and p((p)over-bar ) in Cu + Cu collisions at root s(NN)=200 GeV

We report new results on identified (anti) proton and charged pion spectra at large transverse momenta (3 < p(T) < 10 GeV/c) from Cu + Cu collisions at root s(NN) = 200 GeV using the STAR detector at the Relativistic Heavy Ion Collider (RHIC). This study explores the system size dependence of two novel features observed at RHIC with heavy ions: the hadron suppression at high-p(T) and the anomalous baryon to meson enhancement at intermediate transverse momenta. Both phenomena could be attributed to the creation of a new form of QCD matter. The results presented here bridge the system size gap between the available pp and Au + Au data, and allow for a detailed exploration of the onset of the novel features. Comparative analysis of all available 200 GeV data indicates that the system size is a major factor determining both the magnitude of the hadron spectra suppression at large transverse momenta and the relative baryon to meson enhancement.

Consistency restrictions on maximal electric-field strength in quantum field theory

Quantum field theory with an external background can be considered as a consistent model only if backreaction is relatively small with respect to the background. To find the corresponding consistency restrictions on an external electric field and its duration in QED and QCD, we analyze the mean-energy density of quantized fields for an arbitrary constant electric field E, acting during a large but finite time T. Using the corresponding asymptotics with respect to the dimensionless parameter eET(2), one can see that the leading contributions to the energy are due to the creation of particles by the electric field. Assuming that these contributions are small in comparison with the energy density of the electric background, we establish the above-mentioned restrictions, which determine, in fact, the time scales from above of depletion of an electric field due to the backreaction.

One-loop energy-momentum tensor in QED with electriclike background

We have obtained nonperturbative one-loop expressions for the mean-energy-momentum tensor and current density of Dirac's field on a constant electriclike back-round. One of the goals of this calculation is to give a consistent description of backreaction in such a theory. Two cases of initial states are considered: the vacuum state and the thermal equilibrium state. First, we perform calculations for the vacuum initial state. In the obtained expressions, we separate the contributions due to particle creation and vacuum polarization. The latter contribution,, are related to the Heisenberg-Euler Lagrangian. Then, we Study the case of the thermal initial state. Here, we separate the contributions due to particle creation, vacuum polarization, and the contributions due to the work of the external field on the particles at the initial state. All these contributions are studied in detail, in different regimes of weak and strong fields and low and high temperatures. The obtained results allow us to establish restrictions on the electric field and its duration under which QED with a strong constant electric field is consistent. Under such restrictions, one can neglect the backreaction of particles created by the electric field. Some of the obtained results generalize the calculations of Heisenberg-Euler for energy density to the case of arbitrary strong electric fields.

Structural and optical properties of rare earth-doped (Ba(0.77)Ca(0.23))(1-x)(Sm, Nd, Pr, Yb)(x)TiO(3)

The structural, dielectric, and vibrational properties of pure and rare earth (RE)-doped Ba(0.77) Ca(0.23)TiO(3) (BCT23; RE = Nd, Sm, Pr, Yb) ceramics obtained via solid-state reaction were investigated. The pure and RE-doped BCT23 ceramics sintered at 1450 degrees C in air for 4 h showed a dense microstructure in all ceramics. The use of RE ions as dopants introduced lattice-parameter changes that manifested in the reduction of the volume of the unit cell. RE-doped BCT23 samples exhibit a more homogenous microstructure due to the absence of a Ti-rich phase in the grain boundaries as demonstrated by scanning electron microscopy imaging. The incorporation of REs led to perturbations of the local symmetry of TiO(6) octahedra and the creation of a new Raman mode. The results of Raman scattering measurements indicated that the Curie temperature of the ferroelectric phase transition depends on the RE ion and ion content, with the Curie temperature shifting toward lower values as the RE content increases, with the exception of Yb(3+) doping, which did not affect the ferroelectric phase transition temperature. The phase transition behavior is explained using the standard soft mode model. Electronic paramagnetic resonance measurements showed the existence of Ti vacancies in the structure of RE-doped BCT23. Defects are created via charge compensation mechanisms due to the incorporation of elements with a different valence state relative to the ions of the pure BCT23 host. It is concluded that the Ti vacancies are responsible for the activation of the Raman mode at 840 cm(-1), which is in agreement with lattice dynamics calculations. (c) 2011 American Institute of Physics. [doi:10.1063/1.3594710]

Three-vortex configurations in trapped Bose-Einstein condensates

We report on the creation of three-vortex clusters in a (87)Rb Bose-Einstein condensate by oscillatory excitation of the condensate. This procedure can create vortices of both circulations, so that we are able to create several types of vortex clusters using the same mechanism. The three-vortex configurations are dominated by two types, namely, an equilateral-triangle arrangement and a linear arrangement. We interpret these most stable configurations respectively as three vortices with the same circulation and as a vortex-antivortex-vortex cluster. The linear configurations are very likely experimental signatures of predicted stationary vortex clusters.

Dynamical Casimir effect for a massless scalar field between two concentric spherical shells with mixed boundary conditions

In this work we analyze the dynamical Casimir effect for a massless scalar field confined between two concentric spherical shells considering mixed boundary conditions. We thus generalize a previous result in literature [Phys. Rev. A 78, 032521 (2008)], where the same problem is approached for the field constrained to the Dirichlet-Dirichlet boundary conditions. A general expression for the average number of particle creation is deduced considering an arbitrary law of radial motion of the spherical shells. This expression is then applied to harmonic oscillations of the shells, and the number of particle production is analyzed and compared with the results previously obtained under Dirichlet-Dirichlet boundary conditions.

Dynamical Casimir effect for a massless scalar field between two concentric spherical shells

In this work we consider the dynamical Casimir effect for a massless scalar field-under Dirichlet boundary conditions-between two concentric spherical shells. We obtain a general expression for the average number of particle creation, for an arbitrary law of radial motion of the spherical shells, using two distinct methods: by computing the density operator of the system and by calculating the Bogoliubov coefficients. We apply our general expression to breathing modes: when only one of the shells oscillates and when both shells oscillate in or out of phase. Since our results were obtained in the framework of the perturbation theory, under resonant breathing modes they are restricted to a short-time approximation. We also analyze the number of particle production and compare it with the results for the case of plane geometry.

Awaking the Vacuum in Relativistic Stars

Void of any inherent structure in classical physics, the vacuum has revealed to be incredibly crowded with all sorts of processes in relativistic quantum physics. Yet, its direct effects are usually so subtle that its structure remains almost as evasive as in classical physics. Here, in contrast, we report on the discovery of a novel effect according to which the vacuum is compelled to play an unexpected central role in an astrophysical context. We show that the formation of relativistic stars may lead the vacuum energy density of a quantum field to an exponential growth. The vacuum-driven evolution which would then follow may lead to unexpected implications for astrophysics, while the observation of stable neutron-star configurations may teach us much on the field content of our Universe.

Gravity-Induced Vacuum Dominance

has been widely believed that, except in very extreme situations, the influence of gravity on quantum fields should amount to just small, subdominant contributions. This view seemed to be endorsed by the seminal results obtained over the last decades in the context of renormalization of quantum fields in curved spacetimes. Here, however, we argue that this belief is false by showing that there exist well-behaved spacetime evolutions where the vacuum energy density of free quantum fields is forced, by the very same background spacetime, to become dominant over any classical energy-density component. By estimating the time scale for the vacuum energy density to become dominant, and therefore for back-reaction on the background spacetime to become important, we argue that this (infrared) vacuum dominance may bear unexpected astrophysical and cosmological implications.