Improving Critical Thinking and Clinical Reasoning With a Continuing Education Course

Background: Continuing education courses related to critical thinking and clinical reasoning are needed to improve the accuracy of diagnosis. Method: This study evaluated a 4-day, 16-hour continuing education course conducted in Brazil. Thirty-nine nurses completed a pretest and a posttest consisting of two written case studies designed to measure the accuracy of nurses` diagnoses. Results: There were significant differences in accuracy from pretest to posttest for case 1 (p = .008) and case 2 (p = .042) and overall (p = .001). Conclusion: Continuing education courses should be implemented to improve the accuracy of nurses` diagnoses. J Contin Educ Nurs 2009;40(3):121-127.

Use of Hyaluronidase to Prevent Perineal Trauma During Spontaneous Births: A Randomized, Placebo-Controlled, Double-blind, Clinical Trial

Introduction: The purpose of this study was to compare the frequency and severity of perineal trauma during spontaneous birth with or without perineal injections of hyaluronidase (HAase). Methods: A randomized, placebo-controlled, double-blind clinical trial was conducted in a midwife-led, in-hospital birth center in Sao Paulo, Brazil. Primiparous women (N = 160) were randomly assigned to an experimental (n = 80) or control (n = 80) group. During the second stage of labor, women in the experimental group received an injection of 20.000 turbidity-reducing units of HAase in the posterior region of the perineum, and those in the control group received a placebo injection. The assessment of perineal outcome was performed by 2 independent nurse-midwives. A 1-tailed Fisher exact test was performed, and a P value < .025 was considered statistically significant. Results: Perineal integrity occurred in 34.2% of the experimental group and in 32.5% of the control group, which was not a statistically significant difference (P = .477). First-degree laceration was the most common trauma in the posterior region of the perineum in women in both groups (experimental = 56%, control = 42.6%). Severe perineal trauma occurred in 28.9% of the experimental group and 38.8% of the control group, which also was not a statistically significant difference (P =. 131). The depth of second-degree perineal lacerations in the experimental and control groups, measured by the Peri-Rule, was 1.9 cm and 2.3 cm, respectively. An episiotomy was performed in 11 women (experimental group = 3, control group = 8), and 4 (all in control group) had third-degree lacerations. Discussion: The use of injectable HAase did not increase the proportion of intact perineum and did not reduce the proportion of severe perineal trauma in our sample. J Midwifery Womens Health 2011; 56: 436-445 (C) 2011 by the American College of Nurse-Midwives.

Clinical relationships and ethical problems in primary care, Sao Paulo, SP, Brazil

Objectives: Main Objective: to identify ethical problems in primary care according to nurses` and doctors` perceptions. Secondary Objective: to know ethical issues of patient-professional relationships in primary care. Design: Synthesis to integrate and reinterpret primary results of qualitative studies. Setting: Primary healthcare centers, Sao Paulo, SP, Brazil. Participants and/or context: Incidental sample of 34 nurses and 36 medical doctors working in primary healthcare centers selected by convenience. Methods: Individual, semi-structured interviews to identity situations considered as sources of ethical problems. The sample is socially representative of primary care health centers and professionals. Data collection assured discourse saturation. Hermeneutic-dialectical discourse analysis was used to study the results. Results: Patient-professional relationships and team work were the main sources of ethical problems. The most important problems were patient information, privacy, confidentiality, interpersonal relationship, linkage and patient autonomy. These issues reflect the recent changes in clinical relation ships and show the peculiarities of primary care with its continuous care which lasts a long time. Healthcare involves multiprofessional team work in the midst of the patient claims for autonomy. Good care of patients needs requires a relationship based on communication and cooperation, and includes feelings and values, with communication skills. Conclusions: Ethical problems in primary care are common situations. For quality and humane primary care the relationship should consist of dialogue, trust and cooperation. (C) 2009 Elsevier Espana, S.L. All rights reserved.

Ringo: Discordance between the molecular and clinical manifestation in a Golden Retriever Muscular Dystrophy dog

Of the various genetic homologues to Duchenne Muscular Dystrophy (DMD), the Golden Retriever Muscular Dystrophy (GRMD) dog, which presents a variable but usually severe and progressive muscle weakness, has the closest relevance to DMD in both clinical severity and histopathological change. Among 77 GRMD dogs born in our colony in Brazil, we have identified a very mildly affected dog, Ringo, born July 2003. Among his descendants, at least one male, Suflair, is also showing a mild course. In an attempt to better characterize these two dogs, we studied the pattern of muscle proteins expression in Ringo and Suflair, as compared to severely affected and normal control dogs. Dystrophin was absent in both and utrophin was overexpressed in a pattern similar to the observed in severely affected dogs. Understanding the mechanism that is protecting Ringo and Suflair from the deleterious effect of the dystrophin gene mutation is of utmost interest, In addition it points out that the clinical impact of therapeutic trials should be interpreted with caution. (C) 2009 Elsevier B.V. All rights reserved.

Effects of creatine supplementation on renal function: a randomized, double-blind, placebo-controlled clinical trial

Creatine (CR) supplementation is commonly used by athletes. However, its effects on renal function remain controversial. The aim of this study was to evaluate the effects of creatine supplementation on renal function in healthy sedentary males (18-35 years old) submitted to exercise training. A randomized, double-blind, placebo-controlled trial was performed. Subjects (n = 18) were randomly allocated to receive treatment with either creatine (CR) (similar to 10 g day(-1) over 3 months) or placebo (PL) (dextrose). All subjects undertook moderate intensity aerobic training, in three 40-min sessions per week, during 3 months. Serum creatinine, serum and urinary sodium and potassium were determined at baseline and at the end of the study. Cystatin C was assessed prior to training (PRE), after 4 (POST 4) and 12 weeks (POST 12). Cystatin C levels (mg L-1) (PRE CR: 0.82 +/- 0.09; PL: 0.88 +/- 0.07 vs. POST 12 CR: 0.71 +/- 0.06; PL: 0.75 +/- 0.09, P = 0.0001) were decreased over time, suggesting an increase in glomerular filtration rate. Serum creatinine decreased with training in PL but was unchanged with training in CR. No significant differences were observed within or between groups in other parameters investigated. The decrease in cystatin C indicates that high-dose creatine supplementation over 3 months does not provoke any renal dysfunction in healthy males undergoing aerobic training. In addition, the results suggest that moderate aerobic training per se may improve renal function.

Composite materials obtained from textile fiber residue

This article presents the use of fibers residue from textile industry to minimize environmental problems associated with material accumulation. Composite materials utilizing textile fiber residues and high density polyethylene were prepared. Effect of treatment with hot water on fibers to prepare composites was studied to provide an improvement in mechanical properties of these materials. This treatment on fibers was evaluated by X-ray diffraction and scanning electron microscopy techniques. Experimental results of mechanical properties indicated higher mechanical strength for treated fiber composites compared to the untreated fiber composites.

Lumbar Epidural Anesthesia in the Treatment of Discal Lombosciatalgia: A Comparative Clinical Study between Methylprednisolone and Methylprednisolone with Levobupivacaine

Sousa FAEF, Colhado OCG - Lumbar Epidural Anesthesia in the Treatment of Discal Lombosciatalgia: A Comparative Clinical Study between Methylprednisolone and Methylprednisolone with Levobupivacaine. Background and objectives: Lumbar epidural technique has been used in the treatment of lombosciatalgia since 1953. In most cases, methylprednisolone is used along with a local anesthetic, and it is not known whether the isolated use of methylprednisolone is equally effective in relieving symptoms. The objective of this study was to compare the efficacy of two different solutions - methylprednisolone with saline and methylprednisolone with levobupivacaine injected in the epidural space to heal lombosciatalgia secondary to lumbar herniated disk. Methods: Sixty individuals ASA I and II, of both genders, ages 18 to 65 years participated in this randomized, double-blind study over a period of one year. They underwent interlaminar lumbar epidural analgesia without radioscopic control to heal a lombosciatalgia and they were divided into two groups: G-M (methylprednisolone + saline) and G-M + L (methylprednisolone + levobupivacaine + saline) both at a volume of 10 mL. Diagnosis was based on history, physical exam, and imaging exam (MRI). The Visual Analogue Scale (VAS) was applied in a total of two blockades, 15 days apart. Results: A reduction in pain severity was observed in the methylprednisolone-levobupivacaine group, but without statistical significance. Conclusions: The analgesic efficacy of the G-M + L solution was superior to that of the G-M solution in the treatment of discal lombosciatalgia regarding the shorter time to onset of analgesia, but this was not significant at the time of discharge, and both solutions were effective in the treatment of discal lombosciatalgia.

Clinical indicators of ineffective airway clearance in children with congenital heart disease

To analyse the sensitivity and specificity of clinical indicators of ineffective airway clearance in children with congenital heart disease and to identify the indicators that have high predictive power. The precise establishment of nursing diagnoses has been found to be one of the factors contributing to higher quality of care and cost reduction in healthcare institutions. The use of indicators to diagnose ineffective airway clearance could improve care of children with congenital heart disease. Longitudinal study. Participants consisted of 45 children, <= 1 year of age, with congenital heart disease, who had not had definitive or palliative surgical correction. Six assessments were made at 2-day intervals. Each clinical indicator was defined based on previously established operational criteria. Sensitivity, specificity and positive and negative predictive values of each indicator were calculated based on a model for the longitudinal data. A nursing diagnosis of ineffective airway clearance was made in 31% of patients on the first assessment, rising to 71% on the last assessment, for a 40% increase. Sensitivity was highest for Changes in Respiratory Rates/Rhythms (0.99), followed by Adventitious Breath Sounds (0.97), Sputum Production (0.85) and Restlessness (0.53). Specificity was higher for Sputum Production (0.92), followed by Restlessness (0.73), Adventitious Breath Sounds (0.70) and Changes in Respiratory Rates/Rhythms (0.17). The best positive predictive values occurred for Sputum Production (0.93) and Adventitious Breath Sounds (0.80). Adventitious Breath Sounds followed by Sputum Production were the indicators that had the best overall sensitivity and specificity as well as the highest positive predictive values. The use of simple indicators in nursing diagnoses can improve identification of ineffective airway clearance in children with congenital heart disease, thus leading to early treatment of the problem and better care for these children.

Upper limb assessment in tetraplegia: clinical, functional and kinematic correlations

The aim of this study was to correlate clinical and functional evaluations with kinematic variables of upper limp reach-to-grasp movement in patients with tetraplegia. Twenty chronic patients were selected to perform reach-to-grasp kinematic assessment using a target placed at a distance equal to the arm`s length. Kinematic variables (hand peak velocity, movement time, percent time-to-maximal velocity, index of curvature, number of peaks, and joint range of motion) were correlated to clinical (Standard Neurological Classification of Spinal Cord Injury-American Spinal Injury Association) and functional [Functional Independence Measure (FIM) and Spinal Cord Independence Measure II (SCIM II)) evaluation scores. Twenty control participants were also selected to obtain normal reference parameters. There was a positive correlation between total motor index and FIM (r=0.6089; P=0.0044) and SCIM II (r=0.5229; P=0.018). Both functional scores showed positive correlation with each other (r=0.8283; P<0.0001). A correlation was also observed between the right and left motor indices, the motor AM, and the SCIM II in most of the reach-to-grasp kinematic variables studied (hand peak velocity, movement time, index of curvature, and number of peaks). In contrast, for the joint range of motion (shoulder, elbow, and wrist), only the wrist in the horizontal plane showed correlation with clinical variables. This study shows that muscle strength assessed by the American Spinal Injury Association motor index influences the reach-to-grasp kinematic variables of patients with tetraplegia. However, the functional assessments did not present the same influence.

Experimental analysis of active-passive vibration control using viscoelastic materials and extension and shear piezoelectric actuators

Hybrid active-passive damping treatments combine the reliability, low cost and robustness of viscoelastic damping treatments and the high-performance, modal selective and adaptive piezoelectric active control. Numerous hybrid damping treatments have been reported in the literature. They differ mainly by the relative positions of viscoelastic treatments, sensors and piezoelectric actuators. In this work we present an experimental analysis of three active-passive damping design configurations applied to a cantilever beam. In particular, two design configurations based on the extension mode of piezoelectric actuators combined with viscoelastic constrained layer damping treatments and one design configuration with shear piezoelectric actuators embedded in a sandwich beam with viscoelastic core are analyzed. For comparison purposes, a purely active design configuration with an extension piezoelectric actuator bonded to an elastic beam is also analyzed. The active-passive damping performance of the four design configurations is compared. Results show that active-passive design configurations provide more reliable and wider-range damping performance than the purely active configuration.

Non-linear boundary element formulation with tangent operator to analyse crack propagation in quasi-brittle materials

This work deals with analysis of cracked structures using BEM. Two formulations to analyse the crack growth process in quasi-brittle materials are discussed. They are based on the dual formulation of BEM where two different integral equations are employed along the opposite sides of the crack surface. The first presented formulation uses the concept of constant operator, in which the corrections of the nonlinear process are made only by applying appropriate tractions along the crack surfaces. The second presented BEM formulation to analyse crack growth problems is an implicit technique based on the use of a consistent tangent operator. This formulation is accurate, stable and always requires much less iterations to reach the equilibrium within a given load increment in comparison with the classical approach. Comparison examples of classical problem of crack growth are shown to illustrate the performance of the two formulations. (C) 2009 Elsevier Ltd. All rights reserved.

Analytical formulae for electromechanical effective properties of 3-1 longitudinally porous piezoelectric materials

A unidirectional fiber composite is considered here, the fibers of which are empty cylindrical holes periodically distributed in a transversely isotropic piezoelectric matrix, The empty-fiber cross-section is circular and the periodicity is the same in two directions at an angle pi/2 or pi/3. Closed-form formulae for all electromechanical effective properties of these 3-1 longitudinally periodic porous piezoelectric materials are presented. The derivation of such expressions is based on the asymptotic homogenization method as a limit of the effective properties of two-phase transversely isotropic parallel fiber-reinforced composites when the fibers properties tend to zero. The plane effective coefficients satisfy the corresponding Schulgasser-Benveniste-Dvorak universal type of relations, A new relation among the antiplane effective constants from the solutions of two antiplane strains and potential local problems is found. This relation is valid for arbitrary shapes of the empty-fiber cross-sections. Based on such a relation, and using recent numerical results for isotropic conductive composites, the antiplane effective properties are computed for different geometrical shapes of the empty-fiber cross-section. Comparisons with other analytical and numerical theories are presented. (c) 2008 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Sorption aspects for unconsolidated materials of the Sao Carlos region (SP), Brazil

The transport of liquid and gaseous pollutants through porous geological media depends on the physical and chemical characteristics of the unconsolidated material, rocks and water associated with the characteristics of the pollutants. Of these characteristics, the sorption aspect is of fundamental importance and is a function of the mineral proportions, pH, Eh and void aspects encountered in the porous media. In the Sao Carlos region, located in the eastern-central part of the 9 ate of Sao Paulo, Brazil, there are basically two types of unconsolidated materials: the first is a residual from sandstones cemented with fines and the secondarily composed of claystones, siltstones and conglomerates from the Cretaceous Period that constitute the Itaqueri Formation; the second is a sandy sediment of the Tertiary Period. These geological conditions are found in areas where chemical products are disposed of characterized as either diffuse or point pollutions sources. Because of this situation, a study was developed to evaluate the sorption aspects of some inorganic cations that are frequently found in these sources, in varied concentrations. Taken into consideration were their physical/chemical properties, such as: specific weight, grain size, mineralogy, cationic exchange capacity, pH, hydraulic conductivity. Batch tests were run using solutions of KCl, ZnCl(2) and CuCl center dot H(2)O at three different pH values, and then with a combined solution (KCl + ZnCl(2) + CuCl center dot H(2)O), also at three different pH values.

Performance evaluation and phylogenetic characterization of anaerobic fluidized bed reactors using ground tire and pet as support materials for biohydrogen production

This study evaluated two different support materials (ground tire and polyethylene terephthalate [PET]) for biohydrogen production in an anaerobic fluidized bed reactor (AFBR) treating synthetic wastewater containing glucose (4000 mg L(-1)). The AFBR, which contained either ground tire (R1) or PET (R2) as support materials, were inoculated with thermally pretreated anaerobic sludge and operated at a temperature of 30 degrees C. The AFBR were operated with a range of hydraulic retention times (HRT) between 1 and 8 h. The reactor R1 operating with a HRT of 2 h showed better performance than reactor R2, reaching a maximum hydrogen yield of 2.25 mol H(2) mol(-1) glucose with 1.3 mg of biomass (as the total volatile solids) attached to each gram of ground tire. Subsequent 16S rRNA gene sequencing and phylogenetic analysis of particle samples revealed that reactor R1 favored the presence of hydrogen-producing bacteria such as Clostridium, Bacillus, and Enterobacter. (C) 2010 Elsevier Ltd. All rights reserved.

Anaerobic degradation of linear alkylbenzene sulfonate (LAS) in fluidized bed reactor by microbial consortia in different support materials

Four anaerobic fluidized bed reactors filled with activated carbon (R1), expanded clay (R2), glass beads (R3) and sand (R4) were tested for anaerobic degradation of LAS. All reactors were inoculated with sludge from a UASB reactor treating swine wastewater and were fed with a synthetic substrate supplemented with approximately 20 mg l(-1) of LAS, on average. To 560 mg l(-1) COD influent, the maximum COD and LAS removal efficiencies were mean values of 97 +/- 2% and 99 +/- 2%, respectively, to all reactors demonstrating the potential applicability of this reactor configuration for treating LAS. The reactors were kept at 30 degrees C and operated with a hydraulic retention time (HRT) of 18 h. The use of glass beads and sand appear attractive because they favor the development of biofilms capable of supporting LAS degradation. Subsequent 16S rRNA gene sequencing and phylogenetic analysis of samples from reactors R3 and R4 revealed that these reactors gave rise to broad microbial diversity, with microorganisms belonging to the phyla Bacteroidetes, Firmicutes, Actinobacteria and Proteobacteria, indicating the role of microbial consortia in degrading the surfactant LAS. (C) 2010 Elsevier Ltd. All rights reserved.