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.

The nature of avidyÄ in Buddhism and VedÄ nta

This thesis deals with the nature of ignorance as it was interpreted in the Upani~adic tradition, specifically in Advaita Vedanta, and in early and Mahayana Buddhism , e specially in the Madhyamika school of Buddhism. The approach i s a historical and comparative one. It examines the early thoughts of both the upanis.a ds and Buddhism abou t avidya (ignorance), shows how the notion was treated by the more speculative and philosphically oriented schools which base d themselves on the e arly works, and sees how their views differ. The thesis will show that the Vedinta tended to treat avidya as a topic for metaphysical s peculation as t he s chool developed, drifting from its initial e xistential concerns, while the Madhyamika remained in contact with the e xistential concerns evident in the first discourses of the Buddha. The word "notion" has been chosen for use in referring t o avidya, even though it may have non-intellectual and emotional connotations, to avoid more popular a lternatives such as "concept" or "idea". In neither the Upani,ads, Advaita Vedanta, or Buddhism is ignorance merely a concept or an idea. Only in a secondary sense, in texts and speech , does it become one. Avidya has more to do with the lived situation in which man finds himself, with the subjectobject separation in which he f eels he exists, than with i i i intel lect ual constr ucts . Western thought has begun to r ealize the same with concerns such as being in modern ontology, and has chosen to speak about i t i n terms of the question of being . Avidya, however, i s not a 'question' . If q ue stions we r e to be put regarding the nature of a vidya , they would be more of t he sort "What is not avidya?", though e ven here l anguage bestows a status t o i t which avidya does not have. In considering a work of the Eastern tradition, we f ace t he danger of imposing Western concepts on it. Granted t hat avidya is customari ly r endered i n English as ignorance, the ways i n which the East and West view i gno rance di f f er. Pedagogically , the European cultures, grounded in the ancient Greek culture, view ignorance as a l ack or an emptiness. A child is i gnorant o f certain t hings and the purpose o f f ormal education , in f act if not in theory, is to fill him with enough knowledge so that he can cope wit h t he complexities and the e xpectations of s ociety. On another level, we feel t hat study and research will l ead t o the discovery o f solutions, which we now lack , for problems now defying solut i on . The East, on the o t her hand, sees avidya in a d i fferent light.Ignorance isn't a lack, but a presence. Religious and philosophical l iterature directs its efforts not towards acquiring something new, but at removing t.he ideas and opinions that individuals have formed about themselves and the world. When that is fully accomplished, say the sages , t hen Wisdom, which has been obscured by those opinions, will present itself. Nothing new has to be learned, t hough we do have t o 'learn' that much. The growing interest in t he West with Eastern religions and philosophies may, in time, influence our theoretical and practical approaches to education and learning, not only in the established educati onal institutions, but in religious , p sychological, and spiritual activities as well. However, the requirements o f this thesis do no t permit a formulation of revolutionary method or a call to action. It focuses instead on the textual arguments which attempt to convince readers that t he world in which they take themselves to exist is not, in essence, real, on the ways i n which the l imitations of language are disclosed, and on the provisional and limited schemes that are built up to help students see through their ignorance. The metaphysic s are provisional because they act only as spurs and guides. Both the Upanisadic and Buddhist traditions that will be dealt with here stress that language constantly fails to encompass the Real. So even terms s uch as 'the Real', 'Absolute', etc., serve only to lead to a transcendent experience . The sections dealing with the Upanisads and Advaita Vedanta show some of the historical evolution of the notion of avidya, how it was dealt with as maya , and the q uestions that arose as t o its locus. With Gau?apada we see the beginnings of a more abstract treatment of the topic, and , the influence of Buddhism. Though Sankhara' S interest was primarily directed towards constructing a philosophy to help others attain mok~a ( l iberation), he too introduced t echnica l t e rminology not found in the works of his predecessors. His work is impressive , but areas of it are incomplete. Numbers of his followers tried to complete the systematic presentation of his insi ghts . Their work focuses on expl anat i ons of adhyasa (superimposition ) , t he locus and object of ignorance , and the means by which Brahman takes itself to be the jiva and the world. The section on early Buddhism examines avidya in the context o f the four truths, together with dubkha (suffering), the r ole it p l ays in t he chain of dependent c ausation , a nd t he p r oblems that arise with t he doctrine of anatman. With t he doct rines of e arly Buddhism as a base, the Madhyamika elaborated questions that the Buddha had said t e nded not t o edi f ication. One of these had to do with own - being or svabhava. Thi s serves a s a centr e around which a discussion o f i gnorance unfolds, both i ndividual and coll ective ignorance. There follows a treatment of the cessation of ignorance as it is discussed within this school . The final secti on tries to present t he similarities and differences i n the natures o f ignorance i n t he two traditions and discusses the factors responsible for t hem . ACKNOWLEDGEMENTS I would like to thank Dr. Sinha for the time spent II and suggestions made on the section dealing with Sankara and the Advait.a Vedanta oommentators, and Dr. Sprung, who supervised, direoted, corrected and encouraged the thesis as a whole, but especially the section on Madhyamika, and the final comparison.

Second Welland Canal - Book 1, Survey Map 1 - Entrance, Lock 1 and Port Dalhousie

Survey map of the Second Welland Canal created by the Welland Canal Company showing the areas in and around Port Dalhousie and Grantham Township. Identified structures associated with the Canal include Lock 1, Lighthouse, Lighthouse Keeper's House, East and West Piers, Harbour, Waste Weir, Store House, Collector's Office, Collector Assistant Office, Lock Tender's House and the new towing path. Features of the First Welland Canal are noted in red ink and includes the old Harbour, old Lock 1, old towing path and the original bed of the Twelve Mile Creek. The surveyors' measurements and notes can be seen in red and black ink and pencil. Local area landmarks and businesses are also identified and include streets and roads (ex. Lock Street and Colonel Clark's Cattle Road), Alex Muir's Dry Dock, RandJ Laurie Flouring Mill, R. Laurie and Company Grist Mill, A. Morrison Saw Mill, Johnson's Tavern, a store and a church. Properties and property owners of note are: Concession 1 Lots 21 and 22, John Christie, John Clark, N. Pawling, William Pawling, W. Carter, G.A. Clark, J. Maven, Mrs. Wood, James Drabble and J. Woodall.

Second Welland Canal - Book 1, Survey Map 2 - Lock 1 and Port Dalhousie

Survey map of the Second Welland Canal created by the Welland Canal Company showing the areas in and around Port Dalhousie and Grantham Township. Identified structures associated with the Canal include Lock 1, East and West Piers, Collector's Office, Lock Tender's House and the new towing path. The surveyors' measurements and notes can be seen in red and black ink and pencil. Local area landmarks and businesses are also identified and include streets and roads (ex. Road to St. Catharines, Side Line, Old Road to Port Dalhousie, Road to Niagara), the Welland Railway and its structures (ex. freight sheds, wood shed, raised platform, elevator, cranes, water tank, turn table, and passenger station), G. A. Clark's Wood Yard, Clark's Wood Office, Alex Muir's Dry Dock, Donald, Andrews and Ross' Dry Dock, RandJ Laurie Flouring Mill, R. Laurie and Company Grist Mill and A. Morrison Saw Mill. A New Road to St. Catharines is featured in red ink. Properties and property owners of note are: Concession 1 Lots 19, 20 and 21, John Christie, and John Clark.

Seasonal Studies on Primary Production and Associated Environmental Parameters in the Indian EEZ

The thesis describes the importance of Indian EEZ, definition and the various factors affecting primary production, general account of phytoplankton and its importance in marine ecosystem etc. In review of literature, general oceanography of Arabian Sea and Bay of Bengal and hydrography of eastern Arabian Sea and western Bay of Bengal. It deals with the distribution patterns of primary production, chlorophyll a, phytoplankton composition and particulate organic carbon in the eastern Arabian Sea and western Bay of Bengal during different seasons. Factors that affect primary productivity are irradiance, temperature, stability of the surface waters, nutrients and zooplankton grazing. The differential biological response of eastern Arabian Sea and western Bay of Bengal to monsoonal regimes. A precise estimation on the primary production of the entire EEZ of India on a regional basis and on a seasonal scale would be the only way to achieve any kind of predictive assessment on the fish stock and their sustainable yield. This study mainly envisages the qualitative and quantitative aspects on the magnitude of phytoplankton standing crop and production of organic carbon and their relationship to environmental characteristics during summer monsoon, Inter monsoon and winter monsoon periods in the east and west coasts of the Indian EEZ.This study revealed that the seasonality exerts a great impact on the biological production in the eastern Arabian Sea and western Bay of Bengal. High biological production may be the reason why most of the fish landings are Concentrated in the west coast of India than east coast. The present data on Phytoplankton production rate and the species composition will provide a meaningful ground for evaluations of exploitable renewable resources of the IndianEEZ

Studies On The Biology And Fishery Of The Fishes Of The Family Priacanthidae (Pisces : Perciformes) Of Indian Waters

Preliminary investigations revealed that 3. hamrur is the predominant species along the east and west coasts of India while other species are sparsely distributed and occur sporadically. In the present investigation, aspects such as population parameters, breeding and feeding biology, fishery etc. of _l:. hamrur of the north east coast of India (Fig.1) are dealt with. Studies on the distribution, abundance and stock size of priacanthids all along the Indian waters were undertaken. Taxonomic studies of the priacanthid species encountered during the study from the Indian waters is also attempted

Molecular Approaches For Characterization And Determination Of Pathogenicity Of Vibrios With Special Reference To Vibrio Harveyi From Penaeus Monodon Larval Production Systems

The present study focuses on vibrios especially Vibrio harveyi isolated from shrimp (P. monodon) larval production systems from both east and west coasts during times of mortality. A comprehensive approach has been made to work out their systematics through numerical taxonomy and group them based on RAPD profiling and to segregate the virulent from non- virulent isolates based on the presence of virulent genes as well as their phenotypic expression. The information gathered has helped to develop a simple scheme of identification based on phenotypic characters and segregate the virulent from non virulent strains of V. harveyi.

Personal status laws in Morocco and Tunisia: A comparative exploration of the possibilities for equality-enhancing reform in Bangladesh

This paper focuses on successful reform strategies invoked in parts of the Muslim world to address issues of gender inequality in the context of Islamic personal law. It traces the development of personal status laws in Tunisia and Morocco, exploring the models they offer in initiating equality-enhancing reforms in Bangladesh, where a secular and equality-based reform approach conflicts with Islamic-based conservatism. Recent landmark family law reforms in Morocco show the possibility of achieving ‘women-friendly’ reforms within an Islamic legal framework. Moreover, the Tunisian Personal Status Code, with its successive reforms, shows that a gender equality-based model of personal law can be successfully integrated into the Muslim way of life. This study examines the response of Muslim societies to equality-based reforms and differences in approach in initiating them. The paper maps these sometimes competing approaches, locating them within contemporary feminist debates related to gender equality in the East and West.

Role of mammalian lignans in the prevention and treatment of prostate cancer

Prostate cancer is poised to become the most prevalent male cancer in the Western world. In Japan and China, incidence rates are almost 10-fold less those reported in the United States and the European Union. Epidemiological data suggest that environmental factors such as diet can significantly influence the incidence and mortality of prostate cancer. The differences in lifestyle between East and West are one of the major risk factors for developing prostate cancer. Traditional Japanese and Chinese diets are rich in foods containing phytoestrogenic compounds, whereas the Western diet is a poor source of these phytochemicals. The lignan phytoestrogens are the most widely occurring of these compounds. In vitro and in vivo reports in the literature indicate that lignans have the capacity to affect the pathogenesis of prostate cancer. However, their precise mechanism of action in prostate carcinogenesis remains unclear. This article outlines the possible role of lignans in prostate cancer by reviewing the current in vitro and in vivo evidence for their anticancer activities. The intriguing concept that lignans may play a role in the prevention and treatment of prostate cancer over the lifetime of an individual is discussed.

Economic commodity or environmental crisis? An interdisciplinary approach to analysing the bushmeat trade in central and west Africa

Bushmeat is a large but largely invisible contributor to the economies of west and central African countries. Yet the trade is currently unsustainable. Hunting is reducing wildlife populations, driving more vulnerable species to local and regional extinction, and threatening biodiversity. This paper uses a commodity chain approach to explore the bushmeat trade and to demonstrate why an interdisciplinary approach is required if the trade is to be sustainable in the future.