Sildenafil na hipertensão pulmonar persistente do recém-nascido associada a hérnia diafragmática congénita

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

The (In)visibility of Psychodiagnosticians' Expertise

This study investigates decision making in mental health care. Specifically, it compares the diagnostic decision outcomes (i.e., the qualityof diagnoses) and the diagnostic decision process (i.e., pre-decisional information acquisition patterns) of novice and experienced clinicalpsychologists. Participants’ eye movements were recorded while they completed diagnostic tasks, classifying mental disorders. In line withprevious research, our findings indicate that diagnosticians’ performance is not related to their clinical experience. Eye-tracking data pro-vide corroborative evidence for this result from the process perspective: experience does not predict changes in cue inspection patterns. Forfuture research into expertise in this domain, it is advisable to track individual differences between clinicians rather than study differenceson the group level.

An 18th century understanding of migraine - Samuel Tissot (1728-1797)

During the period 1778-1780 the Swiss physician Samuel A A D Tissot (1728-1797) published his Traite des nerfs et de leur maladies, a work which continued to be available and widely influential until at least the middle of the following century. It contained a long chapter dealing with migraine, based on the earlier literature on the topic and on Tissot's own clinical experience. The work appeared at the beginning of the modern era of interest in migraine, and provided the first reasonably adequate and systematic account of the disorder to become widely available. Its descriptions of migraine phenomena have an enduring validity, though Tissot's ideas on the pathogenesis of the disorder, viz. that it usually arose from stomach disturbance, were not founded on satisfactory evidence and are long since superseded. (C) 2003 Elsevier Science Ltd. All rights reserved.

Ethical issues in using a cocaine vaccine to treat and prevent cocaine abuse and dependence

A cocaine vaccine'' is a promising immunotherapeutic approach to treating cocaine dependence which induces the immune system to form antibodies that prevent cocaine from crossing the blood brain barrier to act on receptor sites in the brain. Studies in rats show that cocaine antibodies block cocaine from reaching the brain and prevent the reinstatement of cocaine self administration. A successful phase 1 trial of a human cocaine vaccine has been reported. The most promising application of a cocaine vaccine is to prevent relapse to dependence in abstinent users who voluntarily enter treatment. Any use of a vaccine to treat cocaine addicts under legal coercion raises major ethical issues. If this is done at all, it should be carefully trialled first, and only after considerable clinical experience has been obtained in using the vaccine to treat voluntary patients. There will need to be an informed community debate about what role, if any, a cocaine vaccine may have as a way of preventing cocaine addiction in children and adolescents.

A retrospective lyrical analysis of songs written by adolescents with anorexia nervosa

Song-writing plays a central role in music therapy with adolescents. A retrospective lyrical analysis of songs written by adolescents with anorexia nervosa was undertaken in order to identify common themes solicited through song-writing interventions. Fifteen participants contributed 17 songs, from which 368 lyrical units were identified. A modified content analysis approach was used with each lyrical unit being categorised to one of six themes determined from the literature and clinical experience. The theme of 'identity' was used most frequently (28%), with the sub-theme of 'exploring new behaviours, positive self-talk' being addressed most often (12.5% of total). The dominance of the developmentally important theme of 'identity' may reflect the relationship between adolescents, music and identity or may be related to the way in which anorexia nervosa has been theorised to assist the adolescent in managing challenges to the emerging sense of self. Copyright (c) 2006 John Wiley & Sons, Ltd and Eating Disorders Association.

A decade of silicone hydrogel development:surface properties, mechanical properties, and ocular compatibility

Since the initial launch of silicone hydrogel lenses, there has been a considerable broadening in the range of available commercial material properties. The very mobile silicon–oxygen bonds convey distinctive surface and mechanical properties on silicone hydrogels, in which advantages of enhanced oxygen permeability, reduced protein deposition, and modest frictional interaction are balanced by increased lipid and elastic response. There are now some 15 silicone hydrogel material variants available to practitioners; arguably, the changes that have taken place have been strongly influenced by feedback based on clinical experience. Water content is one of the most influential properties, and the decade has seen a progressive rise from lotrafilcon-A (24%) to efrofilcon-A (74%). Moduli have decreased over the same period from 1.4 to 0.3 MPa, but not solely as a result of changes in water content. Surface properties do not correlate directly with water content, and ingenious approaches have been used to achieve desirable improvements (e.g., greater lubricity and lower contact angle hysteresis). This is demonstrated by comparing the hysteresis value of the earliest (lotrafilcon-A, >40°) and most recent (delefilcon-A, <10°) coated silicone hydrogels. Although wettability is important, it is not of itself a good predictor of ocular response because this involves a much wider range of physicochemical and biochemical factors. The interference of the lens with ocular dynamics is complex leading separately to tissue–material interactions involving anterior and posterior lens surfaces. The biochemical consequences of these interactions may hold the key to a greater understanding of ocular incompatibility and end of day discomfort.

Using XML and XSLT for flexible elicitation of mental-health risk knowledge

Current tools for assessing risks associated with mental-health problems require assessors to make high-level judgements based on clinical experience. This paper describes how new technologies can enhance qualitative research methods to identify lower-level cues underlying these judgements, which can be collected by people without a specialist mental-health background. Content analysis of interviews with 46 multidisciplinary mental-health experts exposed the cues and their interrelationships, which were represented by a mind map using software that stores maps as XML. All 46 mind maps were integrated into a single XML knowledge structure and analysed by a Lisp program to generate quantitative information about the numbers of experts associated with each part of it. The knowledge was refined by the experts, using software developed in Flash to record their collective views within the XML itself. These views specified how the XML should be transformed by XSLT, a technology for rendering XML, which resulted in a validated hierarchical knowledge structure associating patient cues with risks. Changing knowledge elicitation requirements were accommodated by flexible transformations of XML data using XSLT, which also facilitated generation of multiple data-gathering tools suiting different assessment circumstances and levels of mental-health knowledge. © 2007 Informa UK Ltd All rights reserved.

Investigating the influence of African American and African Caribbean race on primary care doctors' decision making about depression

This paper explores differences in how primary care doctors process the clinical presentation of depression by African American and African-Caribbean patients compared with white patients in the US and the UK. The aim is to gain a better understanding of possible pathways by which racial disparities arise in depression care. One hundred and eight doctors described their thought processes after viewing video recorded simulated patients presenting with identical symptoms strongly suggestive of depression. These descriptions were analysed using the CliniClass system, which captures information about micro-components of clinical decision making and permits a systematic, structured and detailed analysis of how doctors arrive at diagnostic, intervention and management decisions. Video recordings of actors portraying black (both African American and African-Caribbean) and white (both White American and White British) male and female patients (aged 55 years and 75 years) were presented to doctors randomly selected from the Massachusetts Medical Society list and from Surrey/South West London and West Midlands National Health Service lists, stratified by country (US v.UK), gender, and years of clinical experience (less v. very experienced). Findings demonstrated little evidence of bias affecting doctors' decision making processes, with the exception of less attention being paid to the potential outcomes associated with different treatment options for African American compared with White American patients in the US. Instead, findings suggest greater clinical uncertainty in diagnosing depression amongst black compared with white patients, particularly in the UK. This was evident in more potential diagnoses. There was also a tendency for doctors in both countries to focus more on black patients' physical rather than psychological symptoms and to identify endocrine problems, most often diabetes, as a presenting complaint for them. This suggests that doctors in both countries have a less well developed mental model of depression for black compared with white patients. © 2014 The Authors.

Glasgow antipsychotic side-effects scale for Clozapine - development and validation of a clozapine-specific side-effects scale

OBJECTIVE: The authors developed and validated a clozapine-specific side-effects scale capable of eliciting the subjectively unpleasant side-effects of clozapine. METHODS: Questions from the original Glasgow Antipsychotic Side-effects Scale (GASS) were compared to a list of the most commonly reported clozapine side-effects and those with a significant subjective burden were included in the GASS for Clozapine (GASS-C). The original authors of the GASS and a group of mental health professionals from the UK and Ireland were enlisted to comment on the questions in the GASS-C based on their clinical experience. 110 clozapine outpatients from two sites completed the GASS-C, the original GASS and a repeat GASS-C. Statistical analyses were performed using SPSS for Windows version 19. RESULTS: The GASS-C was shown to have construct validity, in that Spearman's correlation coefficient was 0.816 (p<0.001) with the original GASS, whilst Cohen's kappa coefficient was >0.77 (p<0.001) for one question and >0.81 (p<0.001) for remaining relevant questions. GASS-C was also shown to have strong test-retest reliability, in that Cronbach's alpha coefficient was >0.907 (p<0.001), whilst Cohen's kappa coefficient was >0.81 (p<0.001) for 12 questions and >0.61 (p<0.001) for the remaining four questions. CONCLUSION: The GASS-C is a valid and reliable clinical tool to enable a systematic assessment of the subjectively unpleasant side-effects of clozapine. Future research should focus on how the scale can be utilised as a clinical tool to improve real-world outcomes such as adherence to clozapine therapy and quality of life.

The 2012 update to the anticholinergic cognitive burden scale

Background: In 2008, the Anticholinergic Cognitive Burden (ACB) scale was generated through a combination of laboratory data, literature review, and expert opinion. This scale identified an increased risk in mortality and worsening cognitive function in multiple populations, including 13,000 older adults in the United Kingdom. We present an updated scale based on new information and new medications available to the market. Methods: We conducted a systematic review for publications recognizing medications with adverse cognitive effects due to anti-cholinergic properties and found no new medications since 2008.Therefore we identified medications from a review of newly ap-proved medications since 2008 and medications identified throughthe clinical experience of the authors. To be included in the updatedACB scale, medications must have met the following criteria; ACBscore of 1: evidence from in vitro data that the medication has antag-onist activity at muscarinic receptors; ACB score of 2: evidence fromliterature, prescriber’s information, or expert opinion of clinical anti-cholinergic effect; ACB score of 3: evidence from literature, pre-scriber’s information, or expert opinion of the medication causingdelirium. Results: The reviewer panel included two geriatric pharmacists,one geriatric psychiatrist, one geriatrician, and one hospitalist.Twenty-three medications were eligible for review and possible inclu-sion in the updated ACB scale. Of these, seven medications were ex-cluded due to a lack of evidence for anticholinergic activity. Of the re-maining 16 medications, ten had laboratory evidence ofanticholinergic activity and added to the ACB list with a score of one.One medication was added with a score of two. Five medicationswere included in the ACB scale with a score of three.Conclusions: The revised ACB scale provides an update of med-ications with anticholinergic effects that may increase the risk of cog-nitive impairment. Future updates will be routinely conducted tomaintain an applicable library of medications for use in clinical andresearch environments.

The use of treatment theories and procedures for postural control in adult with hemiplegia: A national survey

This study investigated the use of treatment theories and procedures for postural control training used by Occupational Therapists (OTs) when working with hemiplegic adults who have had cerebrovascular accident (CVA) or traumatic brain injury (TBI). The method of data collection was a national survey of 400 randomly selected physical disability OTs with 127 usable surveys returned. Results showed that the most common used treatment theory was neurodevelopmental treatment (NDT), followed by motor relearning program (MRP), proprioceptive neuromuscular facilitation (PNF), Brunnstrom's approach, and the approach of Rood. The most common treatment posture used was sitting, followed by standing, mat activity, equilibrium reaction training, and walking. The factors affecting the use of various treatment theories procedures were years certified, years of clinical experience, work situation and work status. Pearson correlation coefficient analyses found significant positive relationships between treatment theories and postures. There were significant high correlations between usage of all pairs of treatment procedures. ^

Ethics in the provision of removable partial dentures

Aim: To investigate the construction of cobalt-chromium removable partial dentures by commercial private dental laboratories. Methods: Ninety master casts for fabrication of cobalt-chromium removable partial dentures were obtained from three commercial laboratories randomly selected. Casts were assessed for dental arch treated, Kennedy classification, cast surveying, denture design information provided by the dentist, and mouth preparation (rest seat, guiding plane and retentive area). Dental technicians answered a questionnaire regarding qualification of assisted dentists, monthly number of framework castings, and use of dental surveyor. Mouth preparation was compared among laboratories using Kruskal-Wallis test (α=0.05). Results: The percentage of Kennedy class I was 16%, class II 19%, class III 56%, and class IV 9%. The majority of master cats (51%) examined was sent to dental laboratories without any design information and did not comply with ethical guidelines in the provision of RPD. Approximately half of the casts were considered “inappropriate” for guiding planes and retentive areas. One of the laboratories presented all casts “inappropriate” for rest seat distribution (p<0.001). Conclusions: Mouth preparation frequently failed for guiding planes, retentive areas and distribution of rest seats. It is necessary to provide students with adequate clinical experience at the dental school environment, which will actually be carried into the practice of dentistry.

Ethics in the provision of removable partial dentures

Aim: To investigate the construction of cobalt-chromium removable partial dentures by commercial private dental laboratories. Methods: Ninety master casts for fabrication of cobalt-chromium removable partial dentures were obtained from three commercial laboratories randomly selected. Casts were assessed for dental arch treated, Kennedy classification, cast surveying, denture design information provided by the dentist, and mouth preparation (rest seat, guiding plane and retentive area). Dental technicians answered a questionnaire regarding qualification of assisted dentists, monthly number of framework castings, and use of dental surveyor. Mouth preparation was compared among laboratories using Kruskal-Wallis test (α=0.05). Results: The percentage of Kennedy class I was 16%, class II 19%, class III 56%, and class IV 9%. The majority of master cats (51%) examined was sent to dental laboratories without any design information and did not comply with ethical guidelines in the provision of RPD. Approximately half of the casts were considered “inappropriate” for guiding planes and retentive areas. One of the laboratories presented all casts “inappropriate” for rest seat distribution (p<0.001). Conclusions: Mouth preparation frequently failed for guiding planes, retentive areas and distribution of rest seats. It is necessary to provide students with adequate clinical experience at the dental school environment, which will actually be carried into the practice of dentistry.

Nutrition

This new edition of The Perioperative Medicine Consult Handbook provides useful information, advice, and guidelines based on a combination of clinical experience and evidence-based medicine.