Evaluation of the diagnostic management of deep vein thrombosis in the emergency department of a tertiary hospital in Santa Catarina, Brazil: a cross-sectional study.

Background: Venous thromboembolism is an entity that encompasses both deep vein thrombosis and pulmonary thromboembolism. Although protocols for the diagnosis of these diseases are well defined, there is evidence of inappropriate use of diagnostic resources. Objectives: To define the epidemiological profiles of patients admitted to the emergency department with suspected deep vein thrombosis, to determine rates of inappropriate ordering of D-dimer assays and color venous Doppler echocardiography of the lower limbs, and to identify whether these requests followed the recommendations contained in the 2015 Brazilian Society of Angiology and Vascular Surgery guidelines. Methods: We conducted a cross-sectional observational study that retrospectively evaluated 168 patients with suspected deep vein thrombosis for whom D-dimer assays were requested. The most common risk factors were measured and the pretest probability was calculated with the Wells score. The epidemiological profile of these patients and the rates of inappropriate D-dimer testing were assessed using descriptive statistics. Results: The D-dimer requests were inadequate in 55 (32.7%) patients. Venous color Doppler ultrasound was used to examine the lower limbs of 14 (8.3%) of the patients with a low probability according to the Wells score and a negative D-dimer result. No additional diagnostic methods were used in 19 (11.3%) of those with a low probability according to the Wells score and a high D-dimer result. There was unnecessary use of CDUS in 35 (20.8%) cases. The overall rate of inappropriate workup was 53.5%. Conclusions: Differences were found between clinical practice and the recommendations for diagnostic evaluation of patients with suspected deep vein thrombosis, with inappropriate use of diagnostic tests.

Avaliação do manejo diagnóstico de trombose venosa profunda no departamento de emergência de um hospital terciário em Santa Catarina: um estudo transversal / Evaluation of the diagnostic management of deep vein thrombosis in the emergency department of a tertiary hospital in Santa Catarina, Brazil: a cross-sectional study

Resumo Contexto O tromboembolismo venoso é uma entidade que compreende a trombose venosa profunda e o tromboembolismo pulmonar. Embora os protocolos para diagnóstico dessas doenças estejam bem definidos, evidências têm demonstrado uso inadequado de recursos diagnósticos. Objetivos Definir o perfil epidemiológico dos pacientes com suspeita de trombose venosa profunda admitidos na emergência, determinar taxas de inadequação nas solicitações de D-dímero e eco-Doppler colorido venoso de membros inferiores e identificar se essas solicitações seguiram as recomendações da diretriz da Sociedade Brasileira de Angiologia e Cirurgia Vascular de 2015. Métodos Estudo observacional transversal que avaliou retrospectivamente 168 pacientes com suspeita de trombose venosa profunda, aos quais foi solicitado D-dímero. Foram mensurados os fatores de risco mais comuns e a probabilidade pré-teste pelo escore de Wells. O perfil epidemiológico desses pacientes, assim como as taxas de inadequação, foram avaliados por meio de uso de estatística descritiva. Resultados Em 55 (32,7%) casos, as solicitações de D-dímero foram inadequadas. Em 14 (8,3%) pacientes com baixa probabilidade no escore de Wells e D-dímero negativo, houve uso desnecessário de eco-Doppler colorido venoso de membros inferiores, sendo que, em 19 (11,3%) daqueles com baixa probabilidade no escore de Wells e D-dímero elevado, não houve complementação diagnóstica. O uso de eco-Doppler colorido venoso foi inadequado em 35 (20,8%) casos. A taxa global de inadequação foi de 53,5%. Conclusões Constataram-se divergências entre a prática clínica e as recomendações propostas para avaliação diagnóstica nos pacientes com suspeita de trombose venosa profunda devido ao uso inadequado de testes diagnósticos.

Abstract Background Venous thromboembolism is an entity that encompasses both deep vein thrombosis and pulmonary thromboembolism. Although protocols for the diagnosis of these diseases are well defined, there is evidence of inappropriate use of diagnostic resources. Objectives To define the epidemiological profiles of patients admitted to the emergency department with suspected deep vein thrombosis, to determine rates of inappropriate ordering of D-dimer assays and color venous Doppler echocardiography of the lower limbs, and to identify whether these requests followed the recommendations contained in the 2015 Brazilian Society of Angiology and Vascular Surgery guidelines. Methods We conducted a cross-sectional observational study that retrospectively evaluated 168 patients with suspected deep vein thrombosis for whom D-dimer assays were requested. The most common risk factors were measured and the pretest probability was calculated with the Wells score. The epidemiological profile of these patients and the rates of inappropriate D-dimer testing were assessed using descriptive statistics. Results The D-dimer requests were inadequate in 55 (32.7%) patients. Venous color Doppler ultrasound was used to examine the lower limbs of 14 (8.3%) of the patients with a low probability according to the Wells score and a negative D-dimer result. No additional diagnostic methods were used in 19 (11.3%) of those with a low probability according to the Wells score and a high D-dimer result. There was unnecessary use of CDUS in 35 (20.8%) cases. The overall rate of inappropriate workup was 53.5%. Conclusions Differences were found between clinical practice and the recommendations for diagnostic evaluation of patients with suspected deep vein thrombosis, with inappropriate use of diagnostic tests.

Corpo (en)cena: o risco de cada um / The staged body stages: each and every one's risk

Este artigo ilustra a relação dos sintomas do corpo adolescente com o gozo contemporâneo, através de um caso clínico. A fobia e a síndrome de angústia seriam efeito do encobrimento sistemático da condição mortal de nosso corpo por parte dos discursos midiáticos e científico. A arte, pelo contrário, é reveladora do indizível do campo do inconsciente e lugar de elaboração dos traços sintomáticos coletivos. O retorno das artes circenses como caminho de elaboração da imagem do corpo na inclusão de sua condição mortal. (AU)

This article illustrates the relationship between the symptoms of the adolescent body and contemporary enjoyment through a clinical case study. Phobia and the distress syndrome could be the result of the systematic concealment of the mortal condition of our body by media and scientific discourse. Art, on the other hand, reveals what cannot be uttered from the field of the unconscious and the place where collective symptomatic traces appear. The return of the circus arts is here discussed as a way of building the body’s image including its mortal condition. (AU)

Between the ideal and the real: reconsidering the International Classification of Functioning, Disability and Health.

PURPOSE: The World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) is a disability classification and framework that was endorsed in 2001. Despite its endorsement from WHO member states, some rehabilitation researchers have argued that the ICF has been used and requires further inquiry. The purpose of this article is to examine the ICF critically using a feminist theoretical perspective. METHOD: In this commentary, I apply a feminist perspective to identify some of the assumptions that limit the ICF and to illustrate how the principles of feminist science could enhance the ICF. RESULTS: The analysis reveals that although the ICF is premised on the assumptions of biopsychosocial theory (BPS), there are aspects of the classification that contradict the tenets of BPS. Moreover, although the ICF is purported to represent a change in thinking about disability, the stated principles of rehabilitation medicine have the potential to limit the ICF in this regard. CONCLUSION: The ICF has the potential to be a powerful tool for changing the way that we think about disability and to improve the lives of individuals of all abilities. Bringing the ICF into closer alignment with BPS theory is an important step in moving the ICF forward.

Understanding the professional socialization of canadian physical therapy students: a qualitative investigation.

PURPOSE: To understand the professional socialization of physical therapy (PT) students. METHOD: Forty-two students enrolled in our newly developed master's degree programme wrote three-page reflective journals on a critical learning incident after each of three selected clinical experiences. The journals were coded and analyzed, and major themes were identified and described. A separate cohort of 44 students participated in focus groups after the same three clinical experiences to check the trustworthiness of the results. RESULTS: Following the first placement, the main themes coded were emotions, self-confidence, professionalism in the real world, communication, and learning by doing. After the intermediate placement, major themes were idealism versus realism, depth of communication with clients, and breadth of communication with family members and colleagues. Aspects of clinical learning were variable, and self-confidence remained an issue. After the final placement, most students were deeply engaged with their clients and self-confidence had developed to the point of self-efficacy. Tensions increased between the concept of ideal practice and the pragmatics of actual practice, and the concept of self as protégé (rather than as object of the supervisor's evaluation) emerged. The themes were subsequently assembled in a booklet with representative quotations. CONCLUSION: These results contribute to foundational knowledge required by PT educators, including clinical instructors, by explicitly describing the professional socialization of PT students.

Development of the Daily Activities of Infants Scale: a measure supporting early motor development.

We describe the development and preliminary psychometric testing of the Daily Activities of Infants Scale (DAIS), a parent-completed measure of opportunities parents provide infants for development of postural control and movement. First we obtained 1300 photographs of typical activities from 17 families with infants aged 4 to 11 months. Through consensus we established nine dimensions of activities, graded across three levels of opportunity for development. Pilot testing supported content validity of the DAIS. Subsequently, 50 parents of infants born preterm aged 4 to 11 months participated in psychometric testing. There were 25 male and 25 female infant participants with a mean gestational age of 29.4 weeks (SD 3.6) and a mean birthweight of 1266 grams (SD 635). We found that completion of the DAIS over 1 day was representative of data collected over 3 sequential days. Older infants obtained significantly higher DAIS scores than younger infants, providing preliminary evidence for discriminant validity. The DAIS scores demonstrated a part-correlation of 0.20 (p<0.01) with scores on the Alberta Infant Motor Scale obtained concurrently, providing some evidence for convergent validity. The intraclass correlation coefficients reflecting interrater reliability and test-retest reliability of the total DAIS score were 0.76 (95% confidence interval [CI] 0.60-0.86) and 0.77 (95% CI 0.60-0.87) respectively. The DAIS has sufficient reliability and validity for use in clinical practice and research.

A angústia da dança adolescente

Este texto traz a Dança como inscrição do corpo adolescente no campo do Outro em direção à sexuação. Essa travessia requer uma escritura que refaça o corpo para coreografá-lo no ritmo da Voz do Pai e não mais no embalo materno

Children with severe developmental disabilities and behavioral disorders have increased special healthcare needs.

We studied whether children with severe developmental disabilities (SDDs) who have a comorbid behavioral disorder also have higher rates of special healthcare needs (SHCNs). We used a matched-comparison control group design to establish whether SHCNs were higher in children with SDDs with behavioral disorders versus children with SDDs without behavioral disorders. Thirty-six children were matched for age (mean 12 y 6 mo; range 5 y 2 mo-18 y 8 mo), sex (24 males, 12 females), ethnicity (22 non-white), mental retardation level (22 moderate, eight severe, six profound), and Diagnostic and Statistical Manual of Mental Disorders, 4th edition axis I diagnosis (18 autism spectrum disorder, 10 specified syndrome, eight mental retardation not otherwise specified). Measures included the Achenbach Child Behavior Checklist, behavioral observation, health status examination, and Childhood Health Questionnaire (CHQ). Children with SDDs with behavioral disorders had significantly higher levels of SHCN, as measured by the CHQ and health status examination. Children with SDDs with behavioral disorders had a twofold higher incidence of SHCNs than children with SDDs without behavioral disorders. No difference was observed in the number or types of prescription medication that children received. The findings suggest that SHCNs contribute to the occurrence and/or intensity of behavioral disorders in children with SDD and may require interdisciplinary care coordination.

A comparison of the International Classification of Functioning, Disability, and Health to the disability tax credit.

BACKGROUND: The Disability Tax Credit (DTC) Certification is an assessment tool used to provide Canadians with disability tax relief The International Classification of Functioning, Disability and Health (ICF) provides a universal framework for defining disability. PURPOSE: The purpose of this study was to evaluate the DTC and familiarize occupational therapists with the process of mapping measures to the ICF classification system. METHOD: Concepts within the DTC were identified and mapped to appropriate ICF codes (Cieza et al., 2005). RESULTS: The DTC was linked to 45 unique ICF codes (16 Body Functions, 19 Activities and Participation, and 8 Environmental Factors). IMPLICATIONS: The DTC encompasses various domains of the ICF; however, there is no consideration of Personal Factors, Body Structures, and key aspects of Activities and Participation. Refining the DTC to address these aspects will provide an opportunity for fair and just determinations for those who experience disability.

Challenges in improving the quality of osteoporosis care for long-term glucocorticoid users: a prospective randomized trial.

BACKGROUND: In light of widespread undertreatment for glucocorticoid-induced osteoporosis (GIOP), we designed a group randomized controlled trial to increase bone mineral density (BMD) testing and osteoporosis medication prescribing among patients receiving long-term glucocorticoid therapy. METHODS: Using administrative databases of a large US health plan, we identified physicians who prescribed long-term glucocorticoid therapy to at least 3 patients. One hundred fifty-three participating physicians were randomized to receive a 3-module Web-based GIOP intervention or control course. Intervention modules focused on GIOP management and incorporated case-based continuing medical education and personalized audit and feedback of GIOP management compared with that of the top 10% of study physicians. In the year following the intervention, we compared rates of BMD testing and osteoporosis medication prescribing between intervention and control physicians. RESULTS: Following the intervention, intent-to-treat analyses showed that 78 intervention physicians (472 patients) vs 75 control physicians (477 patients) had similar rates of BMD testing (19% vs 21%, P = .48; rate difference, -2%; 95% confidence interval [CI], -8% to 4%) and osteoporosis medication prescribing (32% vs 29%, P = .34; rate difference, 3%; 95% CI, -3% to 9%). Among 45 physicians completing all modules (343 patients), intervention physicians had numerically but not significantly higher rates of BMD testing (26% vs 16%, P =.04; rate difference, 10%; 95% CI, 1%-20%) and bisphosphonate prescribing (24% vs 17%, P =.09; rate difference, 7%; 95% CI, -1% to 16%) or met a combined end point of BMD testing or osteoporosis medication prescribing (54% vs 44%, P =.07; rate difference, 10%; 95% CI, -1% to 21%) compared with control physicians. CONCLUSIONS: In the main analysis, a Web-based intervention incorporating performance audit and feedback and case-based continuing medical education had no significant effect on the quality of osteoporosis care. However, dose-response trends showed that physicians with greater exposure to the intervention had higher rates of GIOP management. New cost-effective modalities are needed to improve the quality of osteoporosis care.

Advancing rehabilitation research: an interactionist perspective to guide question and design.

The purpose of this position statement is to propose an interactionist framework to bring together the existing literature and provide a unifying direction for rehabilitation research. The framework comprises three components: the conceptual model, the research question, and the research design. The interactionist conceptual model has been adapted from the World Health Organization International Classification of Functioning, Disability, and Health. The model forms the starting point that guides the specification of the research question, which, in turn, guides the selection of research design. This approach demands that the question takes precedence and that there be an extensive repertoire of research designs, each of which is valued for its 'goodness-of-fit' with the question, rather than an a priori, single hierarchical ordering of designs. Research designs must be appropriate for questions that examine the disability experience, development over the lifespan, multifaceted interventions, low incidence conditions, and development of new interventions. Analytical challenges include dealing with confounding, mediating, and moderating variables. Rehabilitation researchers--and those who fund their work--should consider and value the use of diverse research methods to best answer the questions posed from the interactionist perspective.

Expression profiling of glial genes during Drosophila embryogenesis.

In the central nervous system of Drosophila, the induction of the glial cell fate is dependent on the transcription factor glial cells missing (gcm). Though a considerable number of other genes have been shown to be expressed in all or in subsets of glial cells, the course of glial cell differentiation and subtype specification is only poorly understood. This prompted us to design a whole genome microarray approach comparing gcm gain-of-function and, for the first time, gcm loss-of-function genetics to wildtype in time course experiments along embryogenesis. The microarray data were analyzed with special emphasis on the temporal profile of differential regulation. A comparison of both experiments enabled us to identify more than 300 potential gcm target genes. Validation by in situ hybridization revealed expression in glial cells, macrophages, and tendon cells (all three cell types depend on gcm) for 70 genes, of which more than 50 had been unknown to be under gcm control. Eighteen genes are exclusively expressed in glial cells, and their dependence on gcm was confirmed in situ. Initial considerations regarding the role of the newly discovered glial genes are discussed based on gene ontology and the temporal profile and subtype specificity of their expression. This collection of glial genes provides an important basis for the clarification of the genetic network controlling various aspects of glial development and function.

Documented tuberculin skin testing among infliximab users following a multi-modal risk communication interventions.

PURPOSE: Following its licensure, tuberculosis (TB) was reported as a potential adverse effect of infliximab. Subsequently, the product circular was changed to recommend tuberculin skin testing before patients received infliximab, which was reinforced by several risk communication efforts. The aim of this study was to evaluate patterns and predictors of documented tuberculin skin testing in patients before and after manufacturer, federal, and academic risk communications. METHODS: Patients administered infliximab were identified from 11 health plans located throughout the United States, and claims data were examined to determine whether the patients had received a tuberculin skin test. Patients were divided into three cohorts depending on the timing of their first infliximab treatment in relation to the risk communication efforts. RESULTS: The overall tuberculin skin testing rate doubled from 15.4% in the first cohort to 30.9% in the last cohort, while the rate of pre-infliximab treatment testing increased from 0 to 27.7% (Chi-squared test for trend, p < 0.0001 for both). Tuberculin skin testing rates were significantly higher in women, those with a diagnosis of rheumatoid or psoriatic arthritis, and those with a rheumatologist as prescriber. After multivariable analysis, only rheumatologist remained significantly associated with tuberculin skin testing. CONCLUSIONS: Although the tuberculin skin testing rate was relatively low overall, tuberculin skin testing doubled over 30 months of ongoing risk communication efforts and under ascertainment likely occurred. We also found variation in the tuberculin skin testing rate associated with physician specialty. This study demonstrates a significant change in patient care following risk communication efforts.

Regulation of the expression of histone H3.3 by differential polyadenylation.

Previously we have shown that the 3' untranslated regions (UTRs) of the replacement histone genes H3.3.A and H3.3B of Drosophila melanogaster differ in their nucleotide sequences and have different polyadenylation sites. To understand their functional relevance, which might explain the presence and evolutionary conservation of 2 different H3.3 genes, green fluorescent protein (GFP) constructs with different 3' UTR sections were studied by the expression of GFP as a marker protein. Here we show that the polyadenylation signals modify the cell-specific translation of the histone replacement variants in testes and ovaries. The H3.3A gene may be required to provide postmeiotic histone H3.3 in the male germ line in transition to chromatin packaging in sperm.

Longitudinal patterns in the prevention of osteoporosis in glucocorticoid-treated patients.

OBJECTIVE: To evaluate patient and physician factors associated with prevention of glucocorticoid-induced osteoporosis and to describe temporal trends in screening and prevention of glucocorticoid-induced osteoporosis. METHODS: Using databases from a national managed care organization, enrollees who had been prescribed glucocorticoids (taken for at least 60 days) during an 18-month period were identified. Administrative data from January 2001 through June 2003 and linked survey data from October 2003 were examined for measurement of bone mass, prescription of antiresorptive medication, and use of over-the-counter calcium and/or vitamin D treatment. Factors associated with screening and bone-protective therapies were identified using multivariable logistic regression, focusing on physician specialty and survey respondent ethnicity. Trends in glucocorticoid-induced osteoporosis prevention were assessed using administrative data from 2001-2003 versus 1995-1998. RESULTS: We identified 6,281 patients who were prescribed glucocorticoids in 2001-2003 (mean +/- SD prescribed prednisone-equivalent dosage 16 +/- 14 mg/day). Forty-two percent underwent bone mass measurement and/or were prescribed bone-protective medication; rates were lowest for men (25%). Compared with patients of internists, the odds of bone mass measurement were lowest among patients prescribed glucocorticoids by family physicians (odds ratio [OR] 0.56 [95% confidence interval] [95% CI] 0.30-1.04) and highest among patients prescribed glucocorticoids by rheumatologists (OR 1.48 [95% CI 1.06-2.08]). Patients prescribed glucocorticoids by gastroenterologists were less likely to be treated with antiresorptive agents (OR 0.49 [95% CI 0.28-0.86]). African American patients were less likely than white patients to be screened (OR 0.55 [95% CI 0.40-0.75]) or treated (OR 0.71 [95% CI 0.51-0.98]). The frequency of bone mass measurement among glucocorticoid-treated patients in 2001-2003 increased 3-fold compared with 1995-1998, and the use of prescription antiresorptive medication increased approximately 2-fold. CONCLUSION: Despite significant temporal increases in the frequency of screening for and treatment of glucocorticoid-induced osteoporosis, absolute rates remain low, especially among men, African Americans, and patients of certain physician specialties.

Adolescência e instituições: a mímesis como transmissão possível

Este escrito examina os processos de transmissão de uma geração à outra como modo de constituir filiação e possibilidades identificatórias. Problematiza determinadas posturas educativas que são predominantemente assistencialistas e moralizadoras, que tem como fundamento uma ética do Bem. Esta se traduz como a nostalgia dos lugares imaginários onde, no passado a autoridade estava representada pela figura de um patriarca. Uma nostalgia de um mundo idealizado, que tinha como representantes chefes totalitários também idealizados. O tão falado declínio da autoridade na passagem do modernismo para a contemporaneidade é efeito da impossibilidade em se constituir narrativas tradicionais, já que não existem mais referências universais. O reconhecimento coletivo de novos estilos narrativos a partir de novas imagens matrizes é o que possibilita refazer laços e sustentar a transmissão de uma lei simbólica. O conceito de mímesis é o que permite transpor a incomunicabilidade entre as gerações e dar, portanto, abertura a novos traços identificatórios. Como paradigma do sujeito contemporâneo, a adolescência, entre a família e as instituições, é a que melhor representa estes movimentos de passagem. Uma instituição transitória de adolescentes ilustra estas investigações e oferece exemplos que possibilitam pensar o cotidiano das relações entre adolescência e autoridade. As possibilidades em constituir parentalidade no campo público iniciam-se por legitimar pequenos traços de narrativas criativas e singulares, num espaço nem tão privado, nem tão público, mas coletivo. Este é o caso das instituições de abrigagem. Ao contrário de uma ética do bem, a ética do desejo, que é a da psicanálise sustenta o conflito, mas tenta escutá-lo na sua versão criativa. O adolescente é o instigador da dialética no processo de transmissão; ele mantém a oposição necessária, para que o salto adiante possa acontecer. A mímesis da condição adolescente é a aposta deste escrito na possibilidade de que embora escapando aos projetos bem intencionados, a transmissão se faça sem dissolver o enigma ou a utopia (AU)

A Model Substrate for Ellipsometry Studies of Lipoprotein Deposition at the Endothelium.

Endothelial cell layers from umbilical cords were grown on methylated silica surfaces. Fluorescence microscopy showed this layer to be confluent and to consist of living cells. Initial ellipsometry measurements were performed to illustrate both the stability of the model surface in ellipsometry measurements and the Ca(2+)-dependent binding of lipoproteins at the cell-based substrate. The present substrate holds promise as a model substrate for in vitro investigations of lipoprotein deposition at the endothelium surface under close to in vivo conditions. Copyright 2001 Academic Press.

O szondi-test no processo de selecao

O presente artigo trata da utilizacao da tecnica projetiva de Szondi no processo de selecao de vendedores, vigilantes e motoristas de uma empresa do setor de comercio de Porto Alegre. Este estudo contribui com sugestoes sobre o uso deste instrumento na selecao de pessoal, oferecendo dados para uma melhor investigacao e observacao de caracteristicas de cada perfil no trabalho do psicologo.