Clinical practice guidelines in Portugal : quantitative and qualitative evaluation

RESUMO: Introdução As normas de orientação clínica são ferramentas úteis na translação de conhecimentos desde a investigação para a prática clínica diária. Estratégias ativas de implementação de normas de orientação clínica requerem elevado esforço organizacional e financeiro. Quando os recursos são escassos, as estratégias passivas podem ser a única opção de disseminação. Desde 2011 a Direção Geral da Saúde publicou cento e cinquenta e nove normas de orientação clínica. Nesta Tese é feita uma avaliação do impacto que estratégias de disseminação de normas de orientação clínica têm no padrão de prescrição dos médicos e uma avaliação qualitativa do processo das normas de orientação clínica em Portugal. Métodos: O primeiro artigo é um estudo quasi experimental usando uma série de análises temporais interrompida para comparar os níveis observados e esperados de prescrição de inibidores da ciclooxigenasa-2, antes e depois da publicação da norma de orientação clínica sobre a utilização de anti-inflamatórios não esteroides. O segundo estudo é um artigo de opinião e debate no qual numa primeira parte contextualiza o processo das normas da Direcção Geral da Saúde, na segunda parte aponta virtudes e defeitos no processo e a terceira parte constitui uma contribuição com vista à melhoria do processo. Discussão A produção de normas de orientação clínica requer metodologia rigorosa e complexa. A literatura médica revela que a translação de conhecimento é uma tarefa árdua. Estratégias de implementação ativas requerem recursos financeiros e organizacionais sólidos. Estratégias de implementação passivas podem representar uma solução aceitável se os recursos financeiros e organizacionais escasseiam. Pouco é conhecido sobre a eficácia destas estratégias fora do contexto de investigação. Com esta Tese pretendo contribuir para a clarificação desta resposta, outros países e instituições podem ver utilidade nesta informação, bem como pretendo contribuir para a discussão e melhoria do processo das normas de orientação clínica em Portugal. ------------------ ABSTRACT: Introduction Clinical practice guidelines can help address the failure to translate research findings into clinical practice. Active clinical practice guidelines implementation strategies require active efforts from organizations and are resource and financially demanding. Passive implementation strategies may represent the only option if resources are scarce. Out of research environment, real world efficacy of passive implementation strategies is still undetermined. Since 2011 the Portuguese General Health Directorate published one hundred and fifty nine guidelines. In this Thesis I evaluate the impact of passive dissemination of clinical practice guideline in clinician’s prescription behavior and review, from a qualitative point of view, the Portuguese clinical practice guideline process. Methods The first study is a quasi-experimental study using a retrospective interrupted time-series analysis design to compare the observed and expected prescription of cyclooxygenase-2 before and after the non steroidal antiinflammatory guideline publication. The second study is an opinion and debate article in which I firstly review the General Health Directorate guideline process. The second part states positive and negative aspects in the process and the third part is a contribution aimed at improving the process in the future. Discussion Clinical practice guidelines production demands a rigorous and complex methodology. medical iterature reveals that knowledge translation is a difficult task. Active implementation strategies demand solid financial and organizational resources. Passive implementation strategies may represent an acceptable solution if financial and organizational resources are scarce. Little is known about the efficacy of these strategies out of the research context. With this Thesis I intend to contribute to clarify this question, other countries and institutions with similar conditions may find this information useful, and also to contribute for the discussion and general improvement of national clinical practice guidelines process.

Relatório de estágio na Federação Portuguesa de Futebol

This report aims to present and describe in detail the internship held in the Legal Division of the Portuguese Football Federation (FPF) from February, 15th to June, 15th 2015, in order to obtain a Master degree in Law. This internship had, as prior objective, to understand the work of the Legal Division and what its role in the organizational structure of FPF. Initially, and in order to acquaintance with the greatest diversity possible of topics on which the Legal Division has to pronounce, we proceed with the analysis and resolution of several questions that have been presented to us. In a second phase, and after deepen the study of a particular subject - the Intermediate – we sought to clarify the procedure that needed to be adopted after the entry into force of the two new Regulations on the matter - the FIFA Regulations and the FPF Regulations. The transfer of the responsibility for regulation of this matter from FIFA to the National Federations, has raised a new challenge, which this report aims help solving, becoming a quasi-instruction manual on the procedures involving intermediaries, in order to facilitate the role of those involved.

Ion-beam sources based on superionic solid electrolytes

An ion emitter consisting of a sharp silver tip covered in RbAg4I5 solid electrolyte film has been developed and studied. An accelerating potential is applied and Ag+ ions are emitted from the tip’s apex by field evaporation. The emitted ions are collected by a Faraday cup, producing a current on the pico/nanoampere level which is read by an electrometer. The tips were produced mechanically by sandpaper polishing. The sharpest tip produced had a 2:4 m apex radius. Two deposition methods were studied: thermal vacuum and pulsed laser deposition. The best tip produced a peak current value of 96nA at 180oC, and a quasi-stable 4nA emission current at 160oC, both using an extraction potential of 10kV . The emission dependence on time, temperature and accelerating potential has been studied. Deposited films were characterized by X-ray diffraction (XRD), profilometry, optical and Scanning Electron Microscope (SEM) and Secondary Ion Mass Spectroscopy (SIMS) measurements. Several ion emitters were developed, the latter ones were all able to maintain stable high ion emissions for long periods of time. This investigation was a continuation of an ongoing project backed by the European Space Agency, with the objective of making a proof of concept of this kind of ion emitter with potential application on ion thrusters for orbiting satellites. Going forward, it would be interesting to make a finer analysis of the electrolyte’s conductivity at high temperatures, explore Wien Effect-based emission and to further develop a multi-tip ion emitter prototype.

Envelhecimento ativo : qualidade de vida relacionada com a saúde em idosos praticantes de atividade física : Gigong

RESUMO - Racional : A proporção da população nacional de idosos regista uma tendência crescente e as suas consequências a nível humano, social e económico são preocupantes para os gestores dos serviços de saúde. O Qigong, componente da Medicina Tradicional Chinesa, compreende a realização de movimentos suaves, controlo da respiração e meditação. Objetivos e hipóteses: No âmbito da prática de atividade física enquanto estratégia de um envelhecimento ativo, investigou-se a hipótese do Qigong contribuir para a melhoria da Qualidade de Vida Relacionada com a Saúde dos idosos participantes nesta investigação. Pretendeu-se igualmente investigar a contribuição do Qigong na redução das Frequências Respiratória e Cardíaca. Métodos: Tratou-se de um estudo quasi-experimental, antes e depois da prática de Qigong, caraterizando-se os idosos, avaliando-se a Qualidade de Vida Relacionada com a Saúde através do Questionário SF-12v2 e as Frequências Respiratória e Cardíaca, antes e depois das sessões de Qigong. Resultados: Observou-se uma adesão ao programa de 46%, constatando-se uma tendência global para a melhoria da Qualidade de Vida Relacionada com a Saúde após a prática de Qigong, com diferença estatisticamente significativa na dimensão Função Social do questionário (p = 0,046) e na redução da Frequência Respiratória (p = 0,031). Nas dimensões Desempenho Emocional e Medida Sumário Mental, observou-se um nível de tendência sugestivo de efeito (p <0,10). Foram demonstrados benefícios sentidos por parte dos idosos, decorrentes da prática de Qigong. Conclusão: O Qigong demonstrou efetividade na melhoria da qualidade de vida social e redução da Frequência Respiratória, sugerindo melhoria ao nível mental e emocional dos idosos.

Magnetotransport properties of metal/LaAlO3/SrTiO3 heterostructures

The quasi two-dimensional electron gas (q2DEG) hosted in the interface of an epitaxially grown lanthanum aluminate (LaAlO3) thin film with a TiO2-termi-nated strontium titanate (SrTiO3) substrate (001) has been massively studied in the last few years. The confinement of mobile electrons to within a few nanome-ters from the interface, superconductive behavior at low temperatures and elec-tron mobility exceeding 1000 cm2/(V.s) make this system an interesting candi-date to explore the physics of spin injection and transport. However, due to the critical thickness for conduction of 4 unit cells (uc) of LaAlO3, a high tunneling resistance hampers electrical access to the q2DEG, preventing proper injection of spin polarized current. Recently, our group found that depositing a thin overlayer of Co on LaAlO3 reduces the critical thickness, enabling conduction with only 1 uc of LaAlO3. Two scenarios arise to explain this phenomenon: a pinning of the Fermi level in the metal, inducing charge transfer in the SrTiO3; the creation of oxygen vacancies at the interface between LaAlO3 and the metal, leading to an n-type doping of the SrTiO3. In this dissertation, we will report on magnetotransport of metal/LaAlO3/SrTiO3 (metal: Ti, Ta, Co, Py, Au, Pt, Pd) heterostructures with 2 uc of LaAlO3 studied at low temperatures (2 K) and high magnetic fields (9 T). We have analyzed the transport properties of the gas, namely, the carrier concen-tration, mobility and magnetotransport regime and we will discuss the results in the light of the two scenarios mentioned above.

Produção de resíduos hospitalares na prestação de cuidados domiciliários

RESUMO - Os resíduos hospitalares (RH) perigosos — Grupos III e IV — produzidos na prestação de cuidados domiciliários (CD), dada a sua composição, infecciosidade, toxicidade, mobilidade e persistência, constituem um perigo relevante. A exposição a estes resíduos traduz-se num risco importante para os profissionais de saúde, doentes e seus familiares. Dado que em muitas situações estes resíduos ficam no domicílio dos doentes, sendo posteriormente depositados nos contentores camarários, o risco é alargado ao público em geral, aos catadores e aos profissionais de recolha de resíduos sólidos urbanos dos municípios. Através de um estudo observacional, transversal, com componente analítica, da produção de RH pretende-se determinar e caracterizar os quantitativos dos Grupos III e IV produzidos na prestação de CD em 2003 no concelho da Amadora, identificando também o seu destino final. Utiliza- se uma amostra aleatória do universo de doentes submetidos a tratamento domiciliário em 2003 e efectua-se a análise da associação estatística das variáveis peso do Grupo III e peso do Grupo IV com as variáveis relativas às características do doente (sexo, idade e doença), do tratamento (duração e periodicidade) e sazonais (época do ano). A média do peso produzido dos RH por acto prestado é de 213,1 g para o Grupo III e de 3,8 g para o Grupo IV. Estima--se uma produção de RH do Grupo III na prestação de CD, em 2003, no concelho da Amadora entre 8,8 e 11,4 t e para os RH do Grupo IV um valor de 10,2 kg. Verifica-se que, por acto prestado, a produção média de resíduos do Grupo III é maior nos doentes mais idosos, nas úlceras varicosas, no pé diabético, na escara de pressão, nas situações de maior duração do tratamento e nos doentes submetidos a três tratamentos por semana. Também por acto prestado, a produção média de RH do Grupo IV é maior nos doentes mais novos, na patologia osteo-articular, na infecção, no acidente, no pós-operatório, nas situações de menor duração do tratamento e nos doentes submetidos a seis tratamentos por semana (o que está relacionado com as patologias em causa). As produções médias, por acto prestado, de ambos os grupos não apresentam relação com as variáveis idade e época do ano. Todos os RH produzidos nos actos prestados em CD, em 2003, no concelho da Amadora foram depositados nos contentores municipais. Recomendam-se acções de formação e de informação dirigidas aos profissionais de saúde e ao público em geral, a criação de condições para que os RH produzidos nos CD sejam transportados, em condições adequadas, para os centros de saúde e uma articulação entre os órgãos de gestão dos centros de saúde, a autarquia, os operadores de gestão de RH e os serviços de saúde pública no sentido de serem encontradas soluções apropriadas e inovadoras relativamente à gestão dos RH produzidos na prestação de CD.

Application of wavelets to the study of political history

\The idea that social processes develop in a cyclical manner is somewhat like a `Lorelei'. Researchers are lured to it because of its theoretical promise, only to become entangled in (if not wrecked by) messy problems of empirical inference. The reasoning leading to hypotheses of some kind of cycle is often elegant enough, yet the data from repeated observations rarely display the supposed cyclical pattern. (...) In addition, various `schools' seem to exist which frequently arrive at di erent conclusions on the basis of the same data." (van der Eijk and Weber 1987:271). Much of the empirical controversies around these issues arise because of three distinct problems: the coexistence of cycles of di erent periodicities, the possibility of transient cycles and the existence of cycles without xed periodicity. In some cases, there are no reasons to expect any of these phenomena to be relevant. Seasonality caused by Christmas is one such example (Wen 2002). In such cases, researchers mostly rely on spectral analysis and Auto-Regressive Moving-Average (ARMA) models to estimate the periodicity of cycles.1 However, and this is particularly true in social sciences, sometimes there are good theoretical reasons to expect irregular cycles. In such cases, \the identi cation of periodic movement in something like the vote is a daunting task all by itself. When a pendulum swings with an irregular beat (frequency), and the extent of the swing (amplitude) is not constant, mathematical functions like sine-waves are of no use."(Lebo and Norpoth 2007:73) In the past, this di culty has led to two di erent approaches. On the one hand, some researchers dismissed these methods altogether, relying on informal alternatives that do not meet rigorous standards of statistical inference. Goldstein (1985 and 1988), studying the severity of Great power wars is one such example. On the other hand, there are authors who transfer the assumptions of spectral analysis (and ARMA models) into fundamental assumptions about the nature of social phenomena. This type of argument was produced by Beck (1991) who, in a reply to Goldstein (1988), claimed that only \ xed period models are meaningful models of cyclic phenomena".We argue that wavelet analysis|a mathematical framework developed in the mid-1980s (Grossman and Morlet 1984; Goupillaud et al. 1984) | is a very viable alternative to study cycles in political time-series. It has the advantage of staying close to the frequency domain approach of spectral analysis while addressing its main limitations. Its principal contribution comes from estimating the spectral characteristics of a time-series as a function of time, thus revealing how its di erent periodic components may change over time. The rest of article proceeds as follows. In the section \Time-frequency Analysis", we study in some detail the continuous wavelet transform and compare its time-frequency properties with the more standard tool for that purpose, the windowed Fourier transform. In the section \The British Political Pendulum", we apply wavelet analysis to essentially the same data analyzed by Lebo and Norpoth (2007) and Merrill, Grofman and Brunell (2011) and try to provide a more nuanced answer to the same question discussed by these authors: do British electoral politics exhibit cycles? Finally, in the last section, we present a concise list of future directions.

Monitoring the early stiffness development in epoxy adhesives for structural strengthening

The present work aimed to assess the early-age evolution of E-modulus of epoxy adhesives used for Fibre-Reinforced Polymer (FRP) strengthening applications. The study involved adapting an existing technique devised for continuous monitoring of concrete stiffness since casting, called EMM-ARM (Elasticity Modulus Measurement through Ambient Response Method) for evaluation of epoxy stiffness. Furthermore, monotonic tensile tests according to ISO standards and cyclic tensile tests were carried out at several ages. A comparison between the obtained results was performed in order to better understand the performance of the several techniques in the assessment of stiffness of epoxy resins. When compared to the other methodologies, the method for calculation of E-modulus recommended by ISO standard led to lower values, since in the considered strain interval, the adhesive had a non-linear stress–strain relationship. The EMM-ARM technique revealed its capability in clearly identifying the hardening kinetics of epoxy adhesives, measuring the material stiffness growth during the entire curing period. At very early ages the values of Young׳s modulus obtained with quasi-static tests were lower than the values collected by EMM-ARM, due to the fact that epoxy resin exhibited a significant visco-elastic behaviour.

Out-of-plane behavior of masonry infill walls

In order to investigate the out-of-plane behaviour of masonry infill walls, quasi-static testing was performed on a masonry infill walls built inside a reinforced concrete frame by means of an airbag system to apply the uniform out-of-plane load to each component of the infill. The main advantage of this testing setup is that the out-of-plane loading can be applied more uniformly in the walls, contrarily to point load configuration. The test was performed under displacement control by selecting the mid-point of the infill as control point. Input and output air in the airbag was controlled by using a software to apply a specific displacement in the control point of the infill wall. The effect of the distance between the reaction frame of the airbag and the masonry infill on the effective contact area was previously analysed. Four load cells were attached to the reaction frame to measure the out-of-plane force. The effective contact area of the airbag was calculated by dividing the load measured in load cells by the pressure inside the airbag. When the distance between the reaction walls and the masonry infill wall is smaller, the effective area is closer to the nominal area of the airbag. Deformation and crack patterns of the infill confirm the formation of arching mechanism and two-way bending of the masonry infill. Until collapse of the horizontal interface between infill and upper beam in RC frame, the infill bends in two directions but the failure of that interface which is known as weakest interface due to difficulties in filling the mortar between bricks of last row and upper beam results in the crack opening trough a well-defined path and the consequent collapse of the infill.

Seismic retrofit of masonry-to-timber connections in historical constructions

Tese de Doutoramento em Engenharia Civil.

Development of ductile cementitiuos composites using carbon nanotubes

Concrete is the primary construction material for civil infrastructures and generally consists of cement, coarse aggregates, sand, admixtures and water. Cementitious materials are characterized by quasi-brittle behaviour and susceptible to cracking [1]. The cracking process within concrete begins with isolated nano-cracks, which then conjoin to form micro-cracks and in turn macro-cracks. Formation and growth of cracks lead to loss of mechanical performance with time and also make concrete accessible to water and other degrading agents such as CO2, chlorides, sulfates, etc. leading to strength loss and corrosion of steel rebars. To improve brittleness of concrete, reinforcements such as polymeric as well as glass and carbon fibers have been used and microfibers improved the mechanical properties significantly by delaying (but could not stop) the transformation of micro-cracks into macro forms [2]. This fact encouraged the use of nano-sized fillers in concrete to prevent the growth of nano-cracks transforming in to micro and macro forms. Nanoparticles like SiO2, Fe2O3, and TiO2 led to considerable improvement in mechanical performance and moreover, nano-TiO2 helped to remove organic pollutants from concrete surfaces [3].

Electronic transport across linear defects in graphene

We investigate the low-energy electronic transport across grain boundaries in graphene ribbons and infinite flakes. Using the recursive Green’s function method, we calculate the electronic transmission across different types of grain boundaries in graphene ribbons. We show results for the charge density distribution and the current flow along the ribbon. We study linear defects at various angles with the ribbon direction, as well as overlaps of two monolayer ribbon domains forming a bilayer region. For a class of extended defect lines with periodicity 3, an analytic approach is developed to study transport in infinite flakes. This class of extended grain boundaries is particularly interesting, since the K and K0 Dirac points are superposed.

Predictors of dropout in a controlled clinical trial of psychotherapy for moderate depression

A significant number of psychotherapy clients remain untreated, and dropping out is one of the main reasons. Still, the literature around this subject is incoherent. The present study explores potential pre-treatment predictors of dropout in a sample of clients who took part in a clinical trial designed to test the efficacy of narrative therapy for major depressive disorder compared to cognitive-behavioral therapy. Logistic regression analysis showed that: (1) treatment assignment did not predict dropout, (2) clients taking psychiatric medication at intake were 80% less likely to drop out from therapy, compared to clients who were not taking medication, and (3) clients presenting anxious comorbidity at intake were 82% less likely to dropout compared to those clients not presenting anxious comorbidity. Results suggest that clinicians should pay attention to depressed clients who are not taking psychiatric medication or have no comorbid anxiety. More research is needed in order to understand this relationship.

O erro médico na imprensa portuguesa: quando os pacientes fazem parte da notícia

Esta investigação aborda a qualidade da produção noticiosa sobre o erro médico, como um fator essencial na construção do conhecimento público sobre o tema, com o objetivo de compreender que características definem tal produção e até que ponto poderão ser explicadas pela periodicidade e orientação editorial dos jornais; que conceito de erro médico é veiculado pela produção noticiosa sobre o tema; e quais são os protagonistas no discurso jornalístico sobre o erro médico. Foram analisadas as edições de três jornais portugueses, de 2008 a 2011, resultando num corpus de 266 (4,2%) artigos, que foram classificados de acordo com as seguintes variáveis: as fontes de informação citadas (o seu estatuto e especialidade, no caso dos médicos); os temas que são tratados; as características de enquadramento da informação publicada (tom, género jornalístico; e a presença e número de fontes de informação). Pela análise de conteúdo quantitativa, apurou-se que esse tema está em crescimento, essencialmente com notícias de tom negativo e fontes de informação habitualmente identificadas. Não há evidência para afirmar que a periodicidade e a orientação editorial expliquem as variações dessas características, a não ser relativamente ao número de fontes citadas. Vigoram as notícias centradas nos resultados dos erros (mortes ou lesões), provocados por "erros de omissão" e por "erros de comissão", envolvendo uma diversidade de protagonistas: são, tal como acontece na informação sobre saúde em geral, fontes oficiais e especializadas do campo da saúde. Destacam-se os médicos e os juristas e é dado relevo aos pacientes.

Fathers’ emotional involvement with the neonate: impact of the umbilical cord cutting experience

Aims. This paper is a report on a study analysing the effect of the umbilical cord cutting experience on fathers’ emotional involvement with their infants. Background. Participation in childbirth offers an opportunity for father and mother to share the childbirth experience, so it is vital that midwives improve the fathers’ participation in this event. Design. A quasi-experimental study with a quantitative methodology was implemented. Methods. One hundred and five fathers were recruited as part of a convenience sample in a Maternity Public Hospital in a Metropolitan City in Portugal, between January and May of 2008. The Bonding Scale, the Portuguese version of the ‘Mother-to-Infant Bonding Scale’ was used to evaluate the fathers’ emotional involvement with the neonate at different moments: before childbirth, first day after childbirth and first month after childbirth. After childbirth, the fathers were divided into three separate groups depending on their umbilical cord cutting experience. Results. The results demonstrate that the emotional involvement between father and child tends to increase during the first days after childbirth and to decrease when evaluated 1 month after birth, for fathers who did not cut the umbilical cord. However, fathers who cut the umbilical cord demonstrate an improvement in emotional involvement 1 month later. Conclusion. Results suggest that the umbilical cord cutting experience benefits the father’s emotional involvement with the neonate, supporting the benefits of his participation and empowerment in childbirth.