Racionalização para a técnica de proteção pulpar direta

Projeto de Pós-Graduação/Dissertação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Medicina Dentária

Adaptive Neural Networks for Control of Movement Trajectories Invariant under Speed and Force Rescaling

This article describes two neural network modules that form part of an emerging theory of how adaptive control of goal-directed sensory-motor skills is achieved by humans and other animals. The Vector-Integration-To-Endpoint (VITE) model suggests how synchronous multi-joint trajectories are generated and performed at variable speeds. The Factorization-of-LEngth-and-TEnsion (FLETE) model suggests how outflow movement commands from a VITE model may be performed at variable force levels without a loss of positional accuracy. The invariance of positional control under speed and force rescaling sheds new light upon a familiar strategy of motor skill development: Skill learning begins with performance at low speed and low limb compliance and proceeds to higher speeds and compliances. The VITE model helps to explain many neural and behavioral data about trajectory formation, including data about neural coding within the posterior parietal cortex, motor cortex, and globus pallidus, and behavioral properties such as Woodworth's Law, Fitts Law, peak acceleration as a function of movement amplitude and duration, isotonic arm movement properties before and after arm-deafferentation, central error correction properties of isometric contractions, motor priming without overt action, velocity amplification during target switching, velocity profile invariance across different movement distances, changes in velocity profile asymmetry across different movement durations, staggered onset times for controlling linear trajectories with synchronous offset times, changes in the ratio of maximum to average velocity during discrete versus serial movements, and shared properties of arm and speech articulator movements. The FLETE model provides new insights into how spina-muscular circuits process variable forces without a loss of positional control. These results explicate the size principle of motor neuron recruitment, descending co-contractive compliance signals, Renshaw cells, Ia interneurons, fast automatic reactive control by ascending feedback from muscle spindles, slow adaptive predictive control via cerebellar learning using muscle spindle error signals to train adaptive movement gains, fractured somatotopy in the opponent organization of cerebellar learning, adaptive compensation for variable moment-arms, and force feedback from Golgi tendon organs. More generally, the models provide a computational rationale for the use of nonspecific control signals in volitional control, or "acts of will", and of efference copies and opponent processing in both reactive and adaptive motor control tasks.

Hospital clinicians information behaviour and attitudes towards the 'Clinical Informationist': an Irish survey

Background: Hospital clinicians are increasingly expected to practice evidence-based medicine (EBM) in order to minimize medical errors and ensure quality patient care, but experience obstacles to information-seeking. The introduction of a Clinical Informationist (CI) is explored as a possible solution. Aims:  This paper investigates the self-perceived information needs, behaviour and skill levels of clinicians in two Irish public hospitals. It also explores clinicians perceptions and attitudes to the introduction of a CI into their clinical teams. Methods: A questionnaire survey approach was utilised for this study, with 22 clinicians in two hospitals. Data analysis was conducted using descriptive statistics. Results: Analysis showed that clinicians experience diverse information needs for patient care, and that barriers such as time constraints and insufficient access to resources hinder their information-seeking. Findings also showed that clinicians struggle to fit information-seeking into their working day, regularly seeking to answer patient-related queries outside of working hours. Attitudes towards the concept of a CI were predominantly positive. Conclusion: This paper highlights the factors that characterise and limit hospital clinicians information-seeking, and suggests the CI as a potentially useful addition to the clinical team, to help them to resolve their information needs for patient care.

Supporting therapist engagement in evidence based practice: Developing a continuing education programme through participatory action research

Therapists find it challenging to integrate research evidence into their clinical decision-making because it may involve modifying their existing practices. Although continuing education (CE) programmes for evidence-based practice (EBP) have employed various approaches to increase individual practitioner’s knowledge and skills, these have been shown to have little impact in changing customary behaviours. To date, there has been little attempt to actively engage therapists as collaborators in developing educational processes concerning EBP. The researcher collaborated with seven clinical therapists (one occupational therapist, four physiotherapists and two speech and language therapists) enrolled in a new post-qualification Implementing Evidence in Therapy Practice (IETP) MSc module to monitor and adapt the learning programme over ten weeks. The participating therapists actively engaged in participatory action research (PAR) iterative cycles of reflecting→ planning→ acting→ observing→ reflecting with the researcher. Mixed methods were used to evaluate the IETP module and its influence on therapists’ subsequent engagement in EBP activities. Data were gathered immediately on completion of the module and five months later. Immediate post-module findings revealed four components as being important to the therapists: 1) characteristics of the learning environment; 2) acquisition of relevant EBP skills; 3) nature of the learning process; and 4) acquiring confidence. The two themes and sub-themes which emerged from individual interviews conducted five months post-module expanded on the four components already identified. Theme 1: Experiencing the learning (sub-themes: module organisation; learning is relational; improving the module); and theme 2: Enacting the learning through a new way of being (sub-themes: criticality and reflection; self agency; modelling EBP behaviours; positioning self in an EB work culture). The therapists’ perspectives had by then shifted from that of a learner to that of a clinician constructing a new sense of self as an evidence-based practitioner. Findings from this study underline the importance of the process of socially constructed knowledge and of empowering learners through collaboratively designed continuing education programmes. In the student-driven learning environment, therapists chose repetitive skill-building and authentic problem-solving activities which reflected the complexity of the environments to which they were expected to transfer their learning. These findings have implications for educators designing EBP continuing education programmes, during which students develop professional ways of being.

Learning to drive: from hazard detection to hazard handling

Hazard perception has been found to correlate with crash involvement, and has thus been suggested as the most likely source of any skill gap between novice and experienced drivers. The most commonly used method for measuring hazard perception is to evaluate the perception-reaction time to filmed traffic events. It can be argued that this method lacks ecological validity and may be of limited value in predicting the actions drivers’ will take to hazards encountered. The first two studies of this thesis compare novice and experienced drivers’ performance on a hazard detection test, requiring discrete button press responses, with their behaviour in a more dynamic driving environment, requiring hazard handling ability. Results indicate that the hazard handling test is more successful at identifying experience-related differences in response time to hazards. Hazard detection test scores were strongly related to performance on a driver theory test, implying that traditional hazard perception tests may be focusing more on declarative knowledge of driving than on the procedural knowledge required to successfully avoid hazards while driving. One in five Irish drivers crash within a year of passing their driving test. This suggests that the current driver training system does not fully prepare drivers for the dangers they will encounter. Thus, the third and fourth studies in this thesis focus on the development of two simulator-based training regimes. In the third study participants receive intensive training on the molar elements of driving i.e. speed and distance evaluation. The fourth study focuses on training higher order situation awareness skills, including perception, comprehension and projection. Results indicate significant improvement in aspects of speed, distance and situation awareness across training days. However, neither training programme leads to significant improvements in hazard handling performance, highlighting the difficulties of applying learning to situations not previously encountered.

Training in and assessment of the procedural skills required to perform peripheral nerve blockade

The training and ongoing education of medical practitioners has undergone major changes in an incremental fashion over the past 15 years. These changes have been driven by patient safety, educational, economic and legislative/regulatory factors. In the near future, training in procedural skills will undergo a paradigm shift to proficiency based progression with associated requirements for competence-based programmes, valid, reliable assessment tools and simulation technology. Before training begins, the learning outcomes require clear definition; any form of assessment applied should include measurement of these outcomes. Currently training in a procedural skill often takes place on an ad hoc basis. The number of attempts necessary to attain a defined degree of proficiency varies from procedure to procedure. Convincing evidence exists that simulation training helps trainees to acquire skills more efficiently rather than relying on opportunities in their clinical practice. Simulation provides a safe, stress free environment for trainees for skill acquisition, generalization and transfer via deliberate practice. The work described in this thesis contributes to a greater understanding of how medical procedures can be performed more safely and effectively through education. The effect of feedback, provided to novices in a standardized setting on a bench model, based on knowledge of performance was associated with an increase in the speed of skill acquisition and a decrease in error rate during initial learning. The timing of feedback was also associated with effective learning of skill. A marked attrition of skills (independent of the type of feedback provided) was demonstrable 24 hrs after they have first been learned. Using the principles of feedback as described above, when studying the effect of an intense training program on novices of varied years of experience in anaesthesia (i.e. the present training programmes / courses of an intense training day for one or more procedures). There was a marked attrition of skill at 24 hours with a significant correlation with increasing years of experience; there also appeared to be an inverse relationship between years of experience in anaesthesia and performance. The greater the number of years of practice experience, the longer it required a learner to acquire a new skill. The findings of the studies described in this thesis may have important implications for the trainers, trainees and training bodies in the design and implementation of training courses and the formats of delivery of changing curricula. Both curricula and training modalities will need to take account of characteristics of individual learners and the dynamic nature of procedural healthcare.

Communication practices in physician decision-making for an unstable critically ill patient with end-stage cancer.

BACKGROUND: Shared decision-making has become the standard of care for most medical treatments. However, little is known about physician communication practices in the decision making for unstable critically ill patients with known end-stage disease. OBJECTIVE: To describe communication practices of physicians making treatment decisions for unstable critically ill patients with end-stage cancer, using the framework of shared decision-making. DESIGN: Analysis of audiotaped encounters between physicians and a standardized patient, in a high-fidelity simulation scenario, to identify best practice communication behaviors. The simulation depicted a 78-year-old man with metastatic gastric cancer, life-threatening hypoxia, and stable preferences to avoid intensive care unit (ICU) admission and intubation. Blinded coders assessed the encounters for verbal communication behaviors associated with handling emotions and discussion of end-of-life goals. We calculated a score for skill at handling emotions (0-6) and at discussing end of life goals (0-16). SUBJECTS: Twenty-seven hospital-based physicians. RESULTS: Independent variables included physician demographics and communication behaviors. We used treatment decisions (ICU admission and initiation of palliation) as a proxy for accurate identification of patient preferences. Eight physicians admitted the patient to the ICU, and 16 initiated palliation. Physicians varied, but on average demonstrated low skill at handling emotions (mean, 0.7) and moderate skill at discussing end-of-life goals (mean, 7.4). We found that skill at discussing end-of-life goals was associated with initiation of palliation (p = 0.04). CONCLUSIONS: It is possible to analyze the decision making of physicians managing unstable critically ill patients with end-stage cancer using the framework of shared decision-making.

Using fractal downscaling of satellite precipitation products for hydrometeorological applications

The objective of spatial downscaling strategies is to increase the information content of coarse datasets at smaller scales. In the case of quantitative precipitation estimation (QPE) for hydrological applications, the goal is to close the scale gap between the spatial resolution of coarse datasets (e.g., gridded satellite precipitation products at resolution L × L) and the high resolution (l × l; L»l) necessary to capture the spatial features that determine spatial variability of water flows and water stores in the landscape. In essence, the downscaling process consists of weaving subgrid-scale heterogeneity over a desired range of wavelengths in the original field. The defining question is, which properties, statistical and otherwise, of the target field (the known observable at the desired spatial resolution) should be matched, with the caveat that downscaling methods be as a general as possible and therefore ideally without case-specific constraints and/or calibration requirements? Here, the attention is focused on two simple fractal downscaling methods using iterated functions systems (IFS) and fractal Brownian surfaces (FBS) that meet this requirement. The two methods were applied to disaggregate spatially 27 summertime convective storms in the central United States during 2007 at three consecutive times (1800, 2100, and 0000 UTC, thus 81 fields overall) from the Tropical Rainfall Measuring Mission (TRMM) version 6 (V6) 3B42 precipitation product (~25-km grid spacing) to the same resolution as the NCEP stage IV products (~4-km grid spacing). Results from bilinear interpolation are used as the control. A fundamental distinction between IFS and FBS is that the latter implies a distribution of downscaled fields and thus an ensemble solution, whereas the former provides a single solution. The downscaling effectiveness is assessed using fractal measures (the spectral exponent β, fractal dimension D, Hurst coefficient H, and roughness amplitude R) and traditional operational scores statistics scores [false alarm rate (FR), probability of detection (PD), threat score (TS), and Heidke skill score (HSS)], as well as bias and the root-mean-square error (RMSE). The results show that both IFS and FBS fractal interpolation perform well with regard to operational skill scores, and they meet the additional requirement of generating structurally consistent fields. Furthermore, confidence intervals can be directly generated from the FBS ensemble. The results were used to diagnose errors relevant for hydrometeorological applications, in particular a spatial displacement with characteristic length of at least 50 km (2500 km2) in the location of peak rainfall intensities for the cases studied. © 2010 American Meteorological Society.

Medical education as moral formation: an Aristotelian account of medical professionalsim.

The medical professionalism movement, bolstered by many influential medical organizations and institutions, has in the last decade produced a number of conceptual definitions of professionalism and a number of concrete proposals for its measurement and teaching. These projects, however laudable, are misguided when they treat professionalism as a unitary descriptive concept rather than as a contested and therefore primarily evaluative one; when they conceive professionalism as a domain of medical practice separable in principle from other domains; and when they treat professionalism as, in principle, a specifiable goal or product of sufficiently well designed educational curricula. The logic of professionalism-as-product corresponds to the logic of techne (art or practical skill) in Aristotle's Nicomachean Ethics. Aristotle provides a cogent argument, however, that the moral excellences denoted by "professionalism" cannot be "produced" or even prespecified in the concrete; rather, they must be acquired through long practice under the careful concrete guidance of teachers who themselves embody these moral excellences. Phronesis (practical wisdom) rather than techne must therefore be the guiding logic of educational initiatives in medical professional formation, with particular emphasis on close mentorship and on the moral character both of students and of those who teach them.

VERSATILITY IN THE MODERN PERFORMER: THREE DIVERSE OPERA ROLES

This dissertation project consisted of performances of three diverse operatic roles. The goal was to examine the challenges and benefits of performing diverse repertoire (baroque, classical, and romantic opera, in this case) and to observe how vocal and acting techniques might adjust to different styles and voice classifications. On December 3, 5, 11, and 13,2003, I performed a composite role in Fatal Song, directed by Leon Major, in the Robert & Arlene Kogod Theatre. This opera pastiche, premiered in 1996, contains spoken dialogue, and the music originates from famous eighteenth and nineteenth-century operas. I explored the challenges and benefits of playing three different, well-known opera characters within the same opera, performing four different languages within the same opera, and performing spoken dialogue in an opera. My roles in this pastiche of famous opera included Lucia from Lucia di Lammermoor by Gaetano Donizetti, Manon from Manon by Jules Massenet, and Pamina from Die ZauberJlote by W.A. Mozart. On January 28 and 29, 2005, I performed the role of Nice in Eurilla e Alcindo, a serenata by Antonio Vivaldi, in Homer Ulrich Recital Hall; musical direction by Joseph Gascho and stage direction by Kate Vetter Cain. I explored the challenges and benefits of preparing baroque ornamentation, singing without a conductor, performing an unknown work, staging a work that is not traditionally staged, singing with minimal sets and costumes, and singing with period instruments. On April 16,20, and 24,2005, I performed the role of Musetta in Giacomo Puccini's La BohBme, directed by Pat Diamond and conducted by Jeffrey Rink, in the Ina & Jack Kay Theatre. I examined the challenges and benefits of singing with a large orchestra of modem instruments, singing Puccini rubato and coordinating this with the conductor, and singing a role in one of the most well-known operas in today's repertoire. As a result of this investigation, I concluded that singing different styles, and singing outside one's voice classification, within reason, is beneficial. The knowledge, skill, confidence and insight I acquired by becoming more versatile benefited me as a performer and as a teacher.

R Markdown: Integrating A Reproducible Analysis Tool into Introductory Statistics

Nolan and Temple Lang argue that “the ability to express statistical computations is an es- sential skill.” A key related capacity is the ability to conduct and present data analysis in a way that another person can understand and replicate. The copy-and-paste workflow that is an artifact of antiquated user-interface design makes reproducibility of statistical analysis more difficult, especially as data become increasingly complex and statistical methods become increasingly sophisticated. R Markdown is a new technology that makes creating fully-reproducible statistical analysis simple and painless. It provides a solution suitable not only for cutting edge research, but also for use in an introductory statistics course. We present experiential and statistical evidence that R Markdown can be used effectively in introductory statistics courses, and discuss its role in the rapidly-changing world of statistical computation.

Comparison of dynamic balance in adolescent male soccer players from rwanda and the United States.

PURPOSE/BACKGROUND: Dynamic balance is an important component of motor skill development. Poor dynamic balance has previously been associated with sport related injury. However, the vast majority of dynamic balance studies as they relate to sport injury have occurred in developed North American or European countries. Thus, the purpose of this study was to compare dynamic balance in adolescent male soccer players from Rwanda to a matched group from the United States. METHODS: Twenty-six adolescent male soccer players from Rwanda and 26 age- and gender-matched control subjects from the United States were screened using the Lower Quarter Y Balance Test during their pre-participation physical. Reach asymmetry (cm) between limbs was examined for all reach directions. In addition, reach distance in each direction (normalized to limb length, %LL) and the composite reach score (also normalized to %LL) were examined. Dependent samples t-tests were performed with significant differences identified at p<0.05. RESULTS: Twenty-six male soccer players from Rwanda (R) were matched to twenty-six male soccer players from the United States (US). The Rwandan soccer players performed better in the anterior (R: 83.9 ± 3.2 %LL; US: 76.5 ± 6.6 %LL, p<0.01), posterolateral (R: 114.4 ± 8.3 %LL ; US: 106.5 ± 8.2 %LL, p<0.01) and composite (R: 105.6 ± 1.3 %LL; US: 97.8 ± 6.2 %LL, p<0.01) reach scores. No significant differences between groups were observed for reach asymmetry. CONCLUSIONS: Adolescent soccer players from Rwanda exhibit superior performance on a standardized dynamic balance test as comparison to similar athletes from the United States. The examination of movement abilities of athletes from countries of various origins may allow for a greater understanding of the range of true normative values for dynamic balance. LEVELS OF EVIDENCE: 3b.

The Oud Across Arabic Culture

This study is a compilation and compendium of information on the oud, the most important instrument in Arabic classical music. It has grown out of my own long-time involvement in studying and playing the oud, and in particular out of my interest in the lack of sources and knowledge available to the vast majority of oud players and researchers, as well as for the readers. My own path started from an intensive study of the oud, which included exposure to several treaties; some housed in museums around the globe, and some only available in the Arabic language. The study combines archival research (including Arabic poetry and pre-Islamic Era and medieval treaties), symbolism, new archaeological discoveries, field interviews, and analysis of existing scholarship, and draws on my professional performance experience for detailed stylistic analysis of the oud's performance practice and its historical development. The study consists of participant observation, personal performance, and interviews conducted in person, via telephone, and/or via e-mail, according to the choice of the performers. The performers have been selected from networks of musicians who perform regularly at lounges, concert halls, and private events. These performers have been chosen according to their musical knowledge, technical skill, experience, and activity in Arabic music and oud performance. Chapter one deals with the purpose of this study and the methods of investigation, as well as giving a brief overview of the history of the oud. In addition, there will be an introduction to the Arabic musical system (mâqâm), which is primarily based on the mechanics and sound production of the oud. Chapter two deals with the oud in Arabic sources: the first source is Arabic poetry in the pre-Islamic Era. The second source is Arabic poetry in the medieval era, in which I found a significant number of poets who allude to the oud, providing accurate descriptions of the player, singers, and the scenes within the contexts of oud performance. The third source is the Arab scholars' intensive treatises with meticulous accounts of the instrument's apparatii, including descriptions and measurements of the parts, strings, and tuning. While chapter three deals with the classification, the development of the oud, chapter four deals with topics such as: the symbolism of the oud and its relation to cosmology, astronomy, mathematics and anatomy. In most of the pertinent Arabic writings, philosophers mention a significant correlation between the oud and the other sciences. Chapter five deals with recreating the performance practice of the oud. A case study of the oud performers focuses on their style, technique, training, and personal experiences. Topics such as improvisation and ornamentation, the oud in the Arabic musical ensemble, the social uses and functions, and gender in musical performance practices will be included in detailed analysis. Other important topics will be analyzed such as traditional vs. modern technique, and the repertoire of the oud. Specifically, in regard to technique, the study outline the style of the music, the role of the oud in Arabic ensembles, the function of the oud in music composition, and the form of the ensembles in Arabic performance and practice.

A GLOBAL SAMPLING OF PIANO MUSIC FROM 1978 TO 2005

Pianists of the twenty-first century have a wealth of repertoire at their fingertips. They busily study music from the different periods -- Baroque, Classical, Romantic, and some of the twentieth century -- trying to understand the culture and performance practice of the time and the stylistic traits of each composer so they can communicate their music effectively. Unfortunately, this leaves little time to notice the composers who are writing music today. Whether this neglect proceeds from lack of time or lack of curiosity, I feel we should be connected to music that was written in our own lifetime, when we already understand the culture and have knowledge of the different styles that preceded us. Therefore, in an attempt to promote today’s composers, I have selected piano music written during my lifetime, to show that contemporary music is effective and worthwhile and deserves as much attention as the music that preceded it. This dissertation showcases piano music composed from 1978 to 2005. A point of departure in selecting the pieces for this recording project is to represent the major genres in the piano repertoire in order to show a variety of styles, moods, lengths, and difficulties. Therefore, from these recordings, there is enough variety to successfully program a complete contemporary recital from the selected works, and there is enough variety to meet the demands of pianists with different skill levels and recital programming needs. Since we live in an increasingly global society, music from all parts of the world is included to offer a fair representation of music being composed everywhere. Half of the music in this project comes from the United States. The other half comes from Australia, Japan, Russia, and Argentina. The composers represented in these recordings are: Lowell Liebermann, Richard Danielpour, Frederic Rzewski, Judith Lang Zaimont, Samuel Adler, Carl Vine, Nikolai Kapustin, Akira Miyoshi and Osvaldo Golijov. With the exception of one piano concerto, all the works are for solo piano. This recording project dissertation consists of two 60 minute CDs of selected repertoire, accompanied by a substantial document of in-depth program notes. The recordings are documented on compact discs that are housed within the University of Maryland Library System.

Selbstorganisierte Projektgruppen von Studierenden. Neue Wege bei der Kompetenzentwicklung an Hochschulen

In diesem Beitrag weisen wir auf die Bedeutung hin, die selbstorganisierte Projektgruppen von Studierenden für das (Aus-)Bildungsziel der überfachlichen Kompetenzentwicklung haben können. Nach einem kurzen Überblick über den aktuellen Stand der Förderung überfachlicher Kompetenzen an Hochschulen stellen wir am Beispiel des Augsburger „Begleitstudiums Problemlösekompetenz“ einen Ansatz zur Kompetenzentwicklung vor, der auf der Partizipation in studentischen Praxisgemeinschaften beruht. Wir erläutern vor diesem Hintergrund, wie sich selbstorganisierte Projektgruppen von Studierenden von anderen Gruppenformen im Rahmen von Lehrveranstaltungen unterscheiden, und machen anhand eines Beispiels deutlich, welchen Mehrwert diese Praxisgemeinschaften gegenüber anderen Ansätzen zur überfachlichen Kompetenzförderung an Hochschulen haben. (DIPF/ Orig.)