O parto por cesariana no Hospital de Cascais : análise de taxas, indicações, procedimentos e complicações

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

Safety of oral tenofovir disoproxil fumarate-based pre-exposure prophylaxis for HIV prevention: prospective studies in HIV-uninfected men and women

Thesis (Ph.D.)--University of Washington, 2016-06

Achieving better in-hospital and after-hospital care of patients with acute cardiac disease

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after hospital care, patient self-care, and hospital-community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital-community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before-after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and beta-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF. Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, beta-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P=0.06) and from 13.4% to 10.1% (P= 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P= 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression

Objective: Antidepressant drugs and cognitive-behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness - Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression. Method: The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods. Results: All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below $A10 000 per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from $A17 000 to $A20 000 per DALY) but still well below $A50 000, which is considered the affordable threshold. Conclusions: A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.

Adoption of a sedation scoring system and sedation guideline in an intensive care unit

Aim. The paper presents a study assessing the rate of adoption of a sedation scoring system and sedation guideline. Background. Clinical practice guidelines including sedation guidelines have been shown to improve patient outcomes by standardizing care. In particular sedation guidelines have been shown to be beneficial for intensive care patients by reducing the duration of ventilation. Despite the acceptance that clinical practice guidelines are beneficial, adoption rates are rarely measured. Adoption data may reveal other factors which contribute to improved outcomes. Therefore, the usefulness of the guideline may be more appropriately assessed by collecting adoption data. Method. A quasi-experimental pre-intervention and postintervention quality improvement design was used. Adoption was operationalized as documentation of sedation score every 4 hours and use of the sedation and analgesic medications suggested in the guideline. Adoption data were collected from patients' charts on a random day of the month; all patients in the intensive care unit on that day were assigned an adoption category. Sedation scoring system adoption data were collected before implementation of a sedation guideline, which was implemented using an intensive information-giving strategy, and guideline adoption data were fed back to bedside nurses. After implementation of the guideline, adoption data were collected for both the sedation scoring system and the guideline. The data were collected in the years 2002-2004. Findings. The sedation scoring system was not used extensively in the pre-intervention phase of the study; however, this improved in the postintervention phase. The findings suggest that the sedation guideline was gradually adopted following implementation in the postintervention phase of the study. Field notes taken during the implementation of the sedation scoring system and the guideline reveal widespread acceptance of both. Conclusion. Measurement of adoption is a complex process. Appropriate operationalization contributes to greater accuracy. Further investigation is warranted to establish the intensity and extent of implementation required to positively affect patient outcomes.

The tiered model of psychosocial intervention in cancer: A community based approach

Clinical practice guidelines for the management of psychosocial distress in people with cancer have been produced ill Australia and North America and these provide direction for the provision of psychosocial care for patients with cancer and their families. This report describes a tiered intervention model to operationalise psychosocial care ill oncology in the community and Outlines a framework for integrating services across sectors. Copyright (c) 2005 John Wiley & Soils, Ltd.

Diagnosing primary ciliary dyskinesia: an international patient perspective

Primary ciliary dyskinesia (PCD) is a rare genetic disorder characterised by progressive sinopulmonary disease, with symptoms starting soon after birth. A European Respiratory Society (ERS) Task Force aims to address disparities in diagnostics across Europe by providing evidence-based clinical practice guidelines. We aimed to identify challenges faced by patients when referred for PCD diagnostic testing. A patient survey was developed by patient representatives and healthcare specialists to capture experience. Online versions of the survey were translated into nine languages and completed in 25 countries. Of the respondents (n=365), 74% were PCD-positive, 5% PCD-negative and 21% PCD-uncertain/inconclusive. We then interviewed 20 parents/patients. Transcripts were analysed thematically. 35% of respondents visited their doctor more than 40 times with PCD-related symptoms prior to diagnostic referral. Furthermore, the most prominent theme among interviewees was a lack of PCD awareness among medical practitioners and failure to take past history into account, leading to delayed diagnosis. Patients also highlighted the need for improved reporting of results and a solution to the “inconclusive” diagnostic status. These findings will be used to advise the ERS Task Force guidelines for diagnosing PCD, and should help stakeholders responsible for improving existing services and expanding provision for diagnosis of this rare disease.

Developing leadership in managers to facilitate the implementation of national guideline recommendations : a process evaluation of feasibility and usefulness

Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers’ leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention’s potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers’ behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.

Idoneidade formativa dos campos de prática clínica - caso particular de uma unidade de saúde personalizada

A Ordem dos Enfermeiros (OE) aprovou em Assembleia Geral de 2007 uma proposta de alteração estatutária em termos de regulação e desenvolvimento profissional. Surge assim o Modelo de Desenvolvimento Profissional (MDP) que traz uma nova dimensão à certificação de competências de enfermeiro e enfermeiro especialista. Se até aqui a OE certificava estas competências a partir dos documentos académicos apresentados, a partir desta alteração a certificação passa por uma prática tutelada de exercício profissional e só depois de dará a atribuição do título profissional. O Exercício Profissional Tutelado (EPT) só poderá ocorrer em serviços de saúde com idoneidade formativa acreditada pela OE. Para determinar esta idoneidade formativa dos contextos de prática clínica de enfermagem, é construído um referencial, que parte do documento “Padrões de Qualidade dos Cuidados de Enfermagem”, tendo como eixo organizador o enunciado descritivo sobre “A organização dos cuidados de enfermagem”. Este trabalho reflete o estágio realizado num contexto de prática clínica (Unidade de Cuidados de Saúde Personalizados) onde foi feita uma avaliação em termos de idoneidade formativa. De Abril a Junho de 2011 foi feita observação documental e da prática de enfermagem, aplicada uma grelha de avaliação de idoneidade formativa e entrevistado o enfermeiro chefe. Os resultados apresentados são de não evidência de idoneidade formativa, após o que se tentou estabelecer um Plano de Acção, para cumprimento dos critérios estabelecidos para a certificação. Com base no mesmo enunciado, a organização dos cuidados de enfermagem, foram delineadas algumas intervenções que, a seu tempo, poderão certificar esta unidade para a prática do exercício profissional tutelado. Destacamos o necessário envolvimento de todos os elementos de enfermagem, com uma condução de liderança forte e motivadora, no sentido criar um contexto de prática clínica congruente com as orientações da OE para a certificação e, em simultâneo, melhorar a qualidade dos cuidados de enfermagem prestados.

Le traitement nutritionnel des épisodes d'hypoglycémie dans le diabète de type 1

Les patients atteints de diabète de type 1 (DbT1) semblent sur-traiter leurs hypoglycémies par rapport aux recommandations des Lignes directrices Canadiennes en diabète. Objectifs : 1) Décrire les habitudes des patients DbT1 pour le traitement des hypoglycémies et estimer les impacts sur le profil de risque cardio-métabolique et 2) explorer les excursions glycémiques suite à un traitement d’hypoglycémie qui respecte les recommandations. Méthodologie (analyses secondaires) : Objectif 1 : 121 patients DbT1 ont complété un journal alimentaire et de glycémies de 48 h. Des variables cardio-métaboliques ont été mesurées et un questionnaire sur la peur des hypoglycémies a été complété. Objectif 2 : 57 patients DbT1 ont complété les bras contrôles de notre programme sur le pancréas artificiel (traitement des hypoglycémies standardisé). Les valeurs de glycémie étaient disponibles aux 5 minutes. Résultats : Projet 1 : Les patients ont fait en moyenne 1,45 hypoglycémies/jour et 73% sur-traitaient avec une consommation moyenne de glucides de 32 ± 24 g. Ce sur-traitement est associé avec un plus jeune âge et une peur des hypoglycémies plus importante, mais pas avec un profil de risque cardio-métabolique plus défavorable. Projet 2 : Dans 20% des cas, traiter une hypoglycémie avec 15 g de glucides était efficace pour ramener la glycémie ≥ 4,0 mmol/L en 15 minutes, le temps moyen étant de 24 ± 12 minutes. La proportion d’insuline basale, le temps depuis le dernier repas et la pratique d’activité physique sont les éléments qui semblent avoir le plus d’impact sur l’efficacité du traitement. Conclusion : L’éducation entourant le traitement des hypoglycémies a besoin d’être renforcée et d’autres études sont nécessaires afin de valider les recommandations.

Le traitement nutritionnel des épisodes d'hypoglycémie dans le diabète de type 1

Les patients atteints de diabète de type 1 (DbT1) semblent sur-traiter leurs hypoglycémies par rapport aux recommandations des Lignes directrices Canadiennes en diabète. Objectifs : 1) Décrire les habitudes des patients DbT1 pour le traitement des hypoglycémies et estimer les impacts sur le profil de risque cardio-métabolique et 2) explorer les excursions glycémiques suite à un traitement d’hypoglycémie qui respecte les recommandations. Méthodologie (analyses secondaires) : Objectif 1 : 121 patients DbT1 ont complété un journal alimentaire et de glycémies de 48 h. Des variables cardio-métaboliques ont été mesurées et un questionnaire sur la peur des hypoglycémies a été complété. Objectif 2 : 57 patients DbT1 ont complété les bras contrôles de notre programme sur le pancréas artificiel (traitement des hypoglycémies standardisé). Les valeurs de glycémie étaient disponibles aux 5 minutes. Résultats : Projet 1 : Les patients ont fait en moyenne 1,45 hypoglycémies/jour et 73% sur-traitaient avec une consommation moyenne de glucides de 32 ± 24 g. Ce sur-traitement est associé avec un plus jeune âge et une peur des hypoglycémies plus importante, mais pas avec un profil de risque cardio-métabolique plus défavorable. Projet 2 : Dans 20% des cas, traiter une hypoglycémie avec 15 g de glucides était efficace pour ramener la glycémie ≥ 4,0 mmol/L en 15 minutes, le temps moyen étant de 24 ± 12 minutes. La proportion d’insuline basale, le temps depuis le dernier repas et la pratique d’activité physique sont les éléments qui semblent avoir le plus d’impact sur l’efficacité du traitement. Conclusion : L’éducation entourant le traitement des hypoglycémies a besoin d’être renforcée et d’autres études sont nécessaires afin de valider les recommandations.

Weight Loss in the Chiropractic Profession

Background: Excess weight places a significant burden on health. Clinical practice guidelines advise healthcare professionals to provide weight management interventions to patients with overweight and obesity. Chiropractic practice may provide a unique opportunity to deliver weight management interventions to those with overweight and obesity. However, little has been done to address overweight and obesity within the chiropractic profession. Identifying the extent of this evidence-practice gap in chiropractic practice is the first step in addressing this issue. Objectives: This thesis was to assess the clinical practices of weight loss provided by chiropractors. The primary objectives were to 1) determine the prevalence of overweight and obesity in the adult patient population that sought chiropractic care, 2) describe the frequency and distribution of chiropractor directed weight management intervention, 3) identify associations between chiropractor directed weight management interventions and specific patient-level and chiropractor-level variables, and 4) examine the interaction between patient weight and comorbid conditions and whether chiropractors offered weight management interventions. Methods: Data from the Ontario Chiropractic Observational and Analysis Study was used (N = 42 chiropractors, N = 3523 patient encounters). Multilevel logistic regression was performed. Patient-level as well as chiropractor-level variables were investigated and associations with weight management provided by chiropractors were identified. Results: The majority of patients who sought chiropractic were overweight or obese (61.2%). Weight loss was provided to only 5.4% of patients. Chiropractors who graduated between 1995 and 2005 (OR: 0.02, 95% CI: 0.00 - 0.13) or prior to 1995 (OR: 0.08, 95% CI: 0.01 - 0.42) provided weight management significantly less than chiropractors who graduated between 2005 and 2014. No significant interaction was observed between patient adiposity and comorbid conditions with chiropractors directed weight loss. Conclusion: The majority of patients who seek chiropractic care are overweight and obese. Chiropractors are in a unique position to help improve patient health through offering weight management. However, this opportunity has not been fully realized by the chiropractic profession.

Weight Loss in the Chiropractic Profession

Background: Excess weight places a significant burden on health. Clinical practice guidelines advise healthcare professionals to provide weight management interventions to patients with overweight and obesity. Chiropractic practice may provide a unique opportunity to deliver weight management interventions to those with overweight and obesity. However, little has been done to address overweight and obesity within the chiropractic profession. Identifying the extent of this evidence-practice gap in chiropractic practice is the first step in addressing this issue. Objectives: This thesis was to assess the clinical practices of weight loss provided by chiropractors. The primary objectives were to 1) determine the prevalence of overweight and obesity in the adult patient population that sought chiropractic care, 2) describe the frequency and distribution of chiropractor directed weight management intervention, 3) identify associations between chiropractor directed weight management interventions and specific patient-level and chiropractor-level variables, and 4) examine the interaction between patient weight and comorbid conditions and whether chiropractors offered weight management interventions. Methods: Data from the Ontario Chiropractic Observational and Analysis Study was used (N = 42 chiropractors, N = 3523 patient encounters). Multilevel logistic regression was performed. Patient-level as well as chiropractor-level variables were investigated and associations with weight management provided by chiropractors were identified. Results: The majority of patients who sought chiropractic were overweight or obese (61.2%). Weight loss was provided to only 5.4% of patients. Chiropractors who graduated between 1995 and 2005 (OR: 0.02, 95% CI: 0.00 - 0.13) or prior to 1995 (OR: 0.08, 95% CI: 0.01 - 0.42) provided weight management significantly less than chiropractors who graduated between 2005 and 2014. No significant interaction was observed between patient adiposity and comorbid conditions with chiropractors directed weight loss. Conclusion: The majority of patients who seek chiropractic care are overweight and obese. Chiropractors are in a unique position to help improve patient health through offering weight management. However, this opportunity has not been fully realized by the chiropractic profession.

Variability in the international normalised ratio (INR) in patients with antiphospholipid syndrome and positive lupus anticoagulant: should the INR targets be higher?

El síndrome antifosfolípido es un desorden autoinmune caracterizado por hipercoagulabilidad que requiere terapia anticoagulante como pilar fundamental, siendo la warfarina el tratamiento de elección en los casos que requieren manejo por largos periodos. Sin embargo, los pacientes con anticoagulante lúpico positivo representan un reto porque tienen mayor riesgo de presentar eventos trombóticos, sumado a que el seguimiento con el International Normalized Ratio (INR) no es confiable, ya que estos anticuerpos generan interferencia con las pruebas de laboratorio basadas en fosfolípidos, como es el caso del tiempo de protrombina (PT) con INR basal prolongado, incluso antes del inicio de la terapia anticoagulante. Por tal razón, se ilustra el caso de una paciente con síndrome antifosfolípido primario y anticoagulante lúpico positivo quien ha presentado múltiples episodios trombóticos, a pesar de recibir terapia anticoagulante. Además se hace una revisión de la literatura disponible y se postulan nuevas metas de INR en estos pacientes diferentes de las que se plantean actualmente.

Primary Joint Arthroplasty Surgery: Is the Risk of Major Bleeding Higher in Elderly Patients? A Retrospective Cohort Study

Increased risk of bleeding after major orthopedic surgery (MOS) has been widely documented in general population. However, this complication has not been studied in elderly patients. The purpose of this study is to determine whether the risk of major bleeding after MOS is higher in elderly patients, compared with those operated at a younger age. Methods: This retrospective cohort study included total hip and total knee arthroplasty patients operated during 5 consecutive years. The main outcome was the occurrence of major bleeding. Patients with other causes of bleeding were excluded. Relative risks (RRs) and confidence intervals (CIs) were calculated, anda multivariate analysis was performed. Results: A total of 1048 patients were included, 56% of patients were hip arthroplasties. At the time of surgery, 553 (53%) patients were older than 70 years. Patients aged >70 years showed an increased risk of major bleeding (RR: 2.42 [95% CI: 1.54-3.81]). For hip arthroplasty, the RR of bleeding was 2.61 (95%CI: 1.50-4.53) and 2.25 (95% CI: 1.03-4.94) for knee arthroplasty. After multivariate analysis, age was found to be independently associated with higher risk of major bleeding. Conclusion: According to European Medicines Agency criteria, patients aged 70 years are at a higher risk of major bleeding after MOS, result of a higher frequency of blood transfusions in this group of patients. Standardized protocols for blood transfusion in these patients are still required.