Critérios de adequação em ecocardiografia e a repercussão clinica no outcome do paciente: a realidade do Lister Hospital - East and North Hertfordshire NHS Trust, Reino Unido

RESUMO - Introdução: Os critérios de adequação (Appropriate Use Criteria - AUC) em Ecocardiografia Transtorácica (ETT) foram publicados com o intuito de permitir o uso racional da ecocardiografia, de influenciar decisões clinicas, prestar cuidados de saúde de elevada qualidade e melhorar o outcome dos pacientes. A relação entre a adequação destes e o seu impacto clinico ainda não se encontra largamente estudada. Objectivo: Neste estudo pretendeu-se avaliar o grau de adesão aos AUC em ETT, em diferentes contextos de atendimento e de acordo com diferentes especialidades, bem como o impacto clínico do exame no outcome do paciente, num hospital público terciário no Reino Unido. Metodologia: 859 ETTs realizados consecutivamente no mês de Janeiro de 2014, foram revistos por forma a avaliar a sua adequação e foram classificados como adequados, incertos ou inadequados de acordo com as guidelines de 2011. De seguida os registos dos pacientes foram revistos com o intuito de avaliar o impacto clinico dos ETTs e foram classificados de acordo com uma das 3 seguintes categorias: (1) alteração ativa dos cuidados – por continuação ou descontinuação dos cuidados como resultado do ETT, (2) continuação dos cuidados – sem continuação ou descontinuação dos cuidados, mas comunicação ao paciente dos resultados do ETT, (3) sem alteração dos cuidados – os cuidados ao paciente já estavam a ser aplicados previamente ao resultado do ETT, causa de sintomas já estabelecida no momento da requisição para exame, exame prévio explicativo dos sintomas e sem indicação aguda para novo ETT, terapêutica não alterada ou inexistência de documentação relativa aos achados ecocardiográficos. Pacientes cujos registos não se encontravam disponíveis foram excluídos (259). Todas as classificações foram avaliadas por uma cardiologista independente, sem relação direta com o estudo. Resultados: A nossa amostra apresentou uma média de idades de 63 ± 17 anos, com uma equilíbrio de géneros. A maioria dos exames foi solicitada em contexto de ambulatório (81,4%), pela Cardiologia (50,3%) e pela Medicina Geral e Familiar (13,4%). Relativamente aos achados ecocardiográficos dos exames, 7,6% demonstraram disfunção sistólica do ventrículo esquerdo moderada a grave, 4,0% revelaram doença valvular grave e 5,1% hipertensão pulmonar significativa. Em relação à adequação dos pedidos para ETTs, 76,5% foram adequados, 7,1% inadequados e 12,6% incertos. Relativamente ao impacto clínico dos ETTs, 42,7% dos exames revelaram uma alteração ativa nos cuidados, 15,6% mostraram uma continuação dos cuidados e 11,5% demonstraram não haver alteração nos cuidados. A idade (P=0,05), o contexto de atendimento (P<0,01) e o pedido realizado pela especialidade medicina geral e familiar (MGF) (P=0,02) foram os preditores mais importantes de uma alteração ativa nos cuidados. Numa perspectiva de prestação de cuidados a uma população mais idosa, o contexto de atendimento, a presença de achados ecocardiográficos significativos e a não alteração dos cuidados apresentam uma relação significativa com a idade. Conclusões: Os dados demonstram que quase 8 em cada 10 ETTs foram considerados adequados e que 4 em cada 10 exames não apresentaram alteração ativa dos cuidados.

Relatório de atividade profissional

Relatório de atividade profissional de mestrado em Optometria Avançada

Modelos de gestão pública e as opções de reforma do XIX governo constitucional: análise do discurso

Dissertação de Mestrado em Gestão e Políticas Públicas

Alternatives to Aerobic Exercise Prescription in Patients with Chronic Heart Failure

Background: Exercise is essential for patients with heart failure as it leads to a reduction in morbidity and mortality as well as improved functional capacity and oxygen uptake (v̇O2). However, the need for an experienced physiologist and the cost of the exam may render the cardiopulmonary exercise test (CPET) unfeasible. Thus, the six-minute walk test (6MWT) and step test (ST) may be alternatives for exercise prescription. Objective: The aim was to correlate heart rate (HR) during the 6MWT and ST with HR at the anaerobic threshold (HRAT) and peak HR (HRP) obtained on the CPET. Methods: Eighty-three patients (58 ± 11 years) with heart failure (NYHA class II) were included and all subjects had optimized medication for at least 3 months. Evaluations involved CPET (v̇O2, HRAT, HRP), 6MWT (HR6MWT) and ST (HRST). Results: The participants exhibited severe ventricular dysfunction (ejection fraction: 31 ± 7%) and low peak v̇O2 (15.2 ± 3.1 mL.kg-1.min-1). HRP (113 ± 19 bpm) was higher than HRAT (92 ± 14 bpm; p < 0.05) and HR6MWT (94 ± 13 bpm; p < 0.05). No significant difference was found between HRP and HRST. Moreover, a strong correlation was found between HRAT and HR6MWT (r = 0.81; p < 0.0001), and between HRP and HRST (r = 0.89; p < 0.0001). Conclusion: These findings suggest that, in the absence of CPET, exercise prescription can be performed by use of 6MWT and ST, based on HR6MWT and HRST

Nouveautés en médecine ambutatoire: dépistage, traitement et iatrogénicité [Innovations in ambulatory care: screening, treatment and iatrogenicity]

Cette année, six études utiles pour la pratique ont été retenues. L'indication à la mammographie entre 40 et 49 ans devrait être évaluée individuellement et en tenant compte des risques/bénéfices de cet examen. Au-delà de 65 ans, un dépistage systématique de la fibrillation auriculaire avec prise de pouls puis ECG (si pouls irrégulier) pourrait être réalisé de manière systématique. Les risques de complications postcolonoscopie existent, particulièrement suite à des biopsies/polypectomies, et ce risque devrait être discuté. Les inhibiteurs de la pompe à protons au long court sont un facteur de risque de fracture de hanche. S'il est important de prendre en charge des pressions artérielles élevées au-delà de 80 ans, il faut être prudent (orthostatisme). Une corticothérapie précoce suite à une paralysie faciale périphérique est efficace. This year we have selected six studies useful for the day to day practice. A mammography in women 40 to 49 years of age should be evaluated taking into account the patient's profile and the possible risks and benefits of this exam. In patients over 65 years of age, a systematic atrial fibrillation screening, with pulse rate measuring then ECG (if irregular beat) should be realised on a regular basis. The risks for complications following colonoscopies do exist, especially after biopsies/polypectomies and this risk should be discussed. Long term proton pump inhibitor treatment is a risk factor for hip fracture. It is important to treat high blood pressure problems in the elderly, but the orthostatic risks should be adressed. A corticoid treatment started quickly for Bell's palsy is efficient

Cancer mortality inequalities in urban areas: a Bayesian small area analysis in Spanish cities

Background Intra-urban inequalities in mortality have been infrequently analysed in European contexts. The aim of the present study was to analyse patterns of cancer mortality and their relationship with socioeconomic deprivation in small areas in 11 Spanish cities. Methods It is a cross-sectional ecological design using mortality data (years 1996-2003). Units of analysis were the census tracts. A deprivation index was calculated for each census tract. In order to control the variability in estimating the risk of dying we used Bayesian models. We present the RR of the census tract with the highest deprivation vs. the census tract with the lowest deprivation. Results In the case of men, socioeconomic inequalities are observed in total cancer mortality in all cities, except in Castellon, Cordoba and Vigo, while Barcelona (RR = 1.53 95%CI 1.42-1.67), Madrid (RR = 1.57 95%CI 1.49-1.65) and Seville (RR = 1.53 95%CI 1.36-1.74) present the greatest inequalities. In general Barcelona and Madrid, present inequalities for most types of cancer. Among women for total cancer mortality, inequalities have only been found in Barcelona and Zaragoza. The excess number of cancer deaths due to socioeconomic deprivation was 16,413 for men and 1,142 for women. Conclusion This study has analysed inequalities in cancer mortality in small areas of cities in Spain, not only relating this mortality with socioeconomic deprivation, but also calculating the excess mortality which may be attributed to such deprivation. This knowledge is particularly useful to determine which geographical areas in each city need intersectorial policies in order to promote a healthy environment.

Board examination for anatomical pathology in Switzerland: two intense days to verify professional competence.

About 15 years ago, the Swiss Society of Pathology has developed and implemented a board examination in anatomical pathology. We describe herein the contents covered by this 2-day exam (autopsy pathology, cytology, histopathology, molecular pathology, and basic knowledge about mechanisms of disease) and its exact modalities, sketch a brief history of the exam, and finish with a concise discussion about the possible objectives and putative benefits weighed against the hardship that it imposes on the candidates.

Vestibulo-ocular reflex characteristics in patients with unilateral Ménière's disease.

OBJECTIVE: The pathophysiologic concept of Ménière's disease assumes that endolymphatic hydrops is the cause of the symptoms via increased pressure in the endolymphatic space and/or ionic disorder due to ruptured membrane. The goal of this study was to assess whether the vestibulo-ocular reflex (VOR) properties in patients with Ménière's disease were consistent with the classical theory. MATERIAL AND METHODS: We studied 34 patients (19 women, 15 men) presenting with unilateral Ménière's disease divided into 2 groups according to the duration of the disease: 18 were in the early stage (< 12 mo), and 16 were in the late stage (> or = 12 mo). Nineteen patients were examined during an attack. Eight of them and the 15 other patients were tested during the interval between attacks. Their characteristics were compared with those of a group of 22 normal subjects. The VOR function was evaluated via standard caloric and impulse rotatory tests (velocity step). A mathematic model of vestibular function was used to characterize the VOR response to rotational stimulation. Dynamic VOR parameters (sensitivity coefficient, time constant, gain, and asymmetries between the 2 directions of rotation) were statistically compared between the 2 groups of patients during and between attacks and between the patients and controls. RESULTS: All dynamic VOR parameters showed no statistically significant difference both with normal controls and among the patients during and between attacks (p > 0.05) except for gain asymmetry (p < or = 0.008). During attacks, patients with early Ménière's disease displayed a higher gain in rotation toward the affected ear, the opposite being observed in patients with late disease. Caloric test revealed a moderate canal paresis on the affected side during the crisis and a slight asymmetry between attacks. CONCLUSION: During attacks in patients with early Ménière's disease, the VOR gain toward the affected side is higher than that toward the intact side, supporting the fact that that the sensitivity of the cupuloendolymphatic system on the affected ear is increased. This observation is in agreement with a mechanical pressure effect of hydrops on the vestibular organs.

Margaret Glassford fonds, 1941, 1951, 1961, 1971, 1973-1975, 1977-1984, 1986-2000, 2002, 2005, n.d.

Margaret was an only child who grew up on a farm just east of Cayuga, Ontario. After high school, Margaret attended Hamilton Teacher’s College and took a position with Grantham Public School Board and taught at Power Glen school. Margaret was married in 1962 and had 2 children, a daughter and a son in 1963 and 1964, respectively. Margaret left her teaching job to raise her children. Margaret was very creative and artistic and during this time, focused on these talents, which included painting, graphic arts and sewing. Margaret was also an accomplished pianist. In her 40’s, Margaret enrolled at Brock University and in 1989 obtained a Honors Bachelor of Arts degree with First-Class Honors in Sociology. In partial fulfillment of her Honors B.A. she completed her thesis that is entitled ; The State and Liberal Feminism: The Ontario Government’s “Business Ownership For Women Program”. While living in St. Catharines, Margaret attended York University and graduated with a Master of Arts in Sociology in 1992 where her studies focused on women’s issues. Margaret received a scholarship from York University and was a teaching assistant. Margaret stayed on at York University and completed her academic requirements for a Doctorate degree in Sociology. Her dissertation was on self employed women in St. Catharines at the beginning of WWII -- not the” Rosie the Riveters” who took over jobs formerly held by men who had to go off to fight World War II, but women who ran their own businesses when that was still unusual. Margaret completed the research for her thesis but did not complete her written thesis as she made a difficult decision to put her academic work on hold in the mid-1990’s and she returned to her love for the arts, although she always remained a voracious reader and interested in women’s issues. In the last decade of her life, she took up quilting with a passion, which she referred to as fabric arts. Margaret loved colour and being non-traditional. Margaret had been a quilting instructor at the Flemington College for Fine Arts in Haliburton. In 1997, Margaret founded Project Smile in the St. Catharines region, a non-profit group who make quilts for children with cancer. Margaret was also the President of the Niagara Heritage Quilters’ Guild in 2006-2007 and was very involved with the Local Council of Women.

Concordancia en la interpretación de los gases arteriales entre residentes de medicina de emergencias y el intensivista

Se desconoce en la actualidad en Colombia la calidad de la interpretación de los gases arteriales por parte de los residentes de medicina de emergencias. Los gases arteriales es una de las ayudas diagnósticas de más rápida consecución en el servicio de urgencias y más utilizadas por ser indispensable en la valoración de patologías de alta prevalencia como son las enfermedades respiratorias y la sepsis. Su mala interpretación puede llevar a mal direccionamiento del manejo de pacientes en estado crítico por lo que es indefectible que los residentes logren un buen entrenamiento en la interpretación de los mismos. Por esta razón se realiza este estudio analítico de concordancia con recolección prospectiva, de corte transversal que busca determinar el grado de concordancia en la interpretación de gases arteriales de los residentes del programa de Medicina de Emergencias de la Universidad del Rosario y especialista en cuidado crítico, así como la interpretación entre ellos según su nivel de entrenamiento y describir cuáles son los hallazgos que encuentran en la interpretación de los mismos. Se recolectaron 60 gases arteriales realizados a paciente hospitalizados en la unidad de cuidados intensivos de la Fundación Santa Fe de Bogotá y se halló la concordancia entre la lectura de los residentes del programa de Medicina de Emergencias y un intensivista. Encontrando una concordancia moderada (r 0.445 y 0.442, ) en las respuestas identificadas en los residentes de segundo y tercer año de residencia(p:0,000y0,01).(MESH: Blood Gas Análisis, Emergency Medical Services, Education, Medical, Graduate)

MA17xexam01

Exam questions and solutions in LaTex. Diagrams for the questions are all together in the support.zip file, as .eps files

MA17xexam01pdf

Exam questions and solutions in PDF

Qualidade dos empregos e a carcinicultura marinha nos laboratórios da praia de Barreta/RN

To present research had for objective to study the quality of the employment in the maturation Laboratories and larviculture of the Beach of Barreta/RN, adopting for so much the criteria used by Reinecke(1999) to characterize a quality employment: surrender, benefits non salary, regularity and work reliability and of the wage, contractual status, social protection, work day, intensity of the work, risk of accidents and of occupational diseases, involvement in linked decisions to the section work, possibility for the development of professional qualifications. Of the exam of the data it was verified that the generated employments are considered employments of good quality. However, this result should be analyzed to the light of a context of extreme informality and of precarization of the work. Therefore, the results should be relativized. He/she/you imports to retain that one of the limitations of the study resides in the impossibility of generalizing the data for the whole section of the sea carcinicultura. In spite of that fact, he/she is considered that the objectives of the research were assisted fully and that the characterization of the profile of the employment generated by the section of the shrimpculture it is extremely important for the drawing of public politics gone back to foment this activity.

Construir frondoso :uma herança esquecida?

This dissertation of master degree was presented to Post-Graduation Program in Architecture and Planning at UFRN, Brazil. It evaluates 45 one-family housings in the Metropolitan Area of Recife, whose architects consider them to be in conformity with the recommendations contained in Armando de Holanda's book: A Guide to build in the Brazilian Northeast: Architecture as a pleasant place in the sunny tropics , published in 1976 by UFPE. For a long time, it used to be reference in many Architecture and Planning Schools of the Northern Region of Brazil. The research s methodological procedures are based on the Post- Occupancy Evaluation (P.O.E.) with emphasis on the users' thermal comfort of the houses that make part of the sample. Therefore, it has been done technical analyses of the projects, when possible; interviews with the architects; building s inspections; and form applications to the users. The collected data analysis was based on the project recommendations of Holanda s book, they can be synthesized in the principle of Building Leafy". It can not be affirmed that all the houses present the recommendations contained in the guide, but, in many different ways, they exist, sometimes more intensely and sometimes more shyly. However, it can be noticed that in the 45 projects, that the architects perceived the importance of "Building Leafy" on the climatic reality of the Metropolitan Region of Recife