RESUMO
BACKGROUND: The Choosing Wisely initiative aims to promote discussions among healthcare professionals and patients about low-value, or potentially harmful, health practices. OBJECTIVES: To describe the process of development of the Brazilian Choosing Wisely list for musculoskeletal physical therapy. METHODS: The Brazilian Choosing Wisely list was developed in accordance with the recommendations of the American Board of Internal Medicine. A three-step procedure was used. First, an expert panel was selected, and a modified Delphi approach was used to obtain a list of evidence-based statements. Second, members of the research team performed content analysis. Third, a national survey was conducted to present selected statements to a sample of physical therapists. Participants were invited to vote considering the level of importance of selected statements for physical therapists and patients. RESULTS: The expert panel comprised 17 physical therapists. The median age of the expert panel was 33 [interquartile range (IQR) 29 to 37; range 26 to 60] years and the median length of professional experience was 12 (IQR 10 to 18) years. A list of eight recommendations was presented to a national sample composed of 1127 physical therapists. The median length of professional experience of the national sample was 10 (IQR 5 to 15) years. Based on the number of votes, the five most important recommendations were included in the Brazilian Choosing Wisely list for musculoskeletal physical therapy. Descriptive and frequency analysis were used to report the results. CONCLUSION: The Brazilian Choosing Wisely list for musculoskeletal physical therapy provides an opportunity for physical therapists, patients, society and policy makers to collaboratively discuss tests and treatments that are unnecessary or potentially harmful.
Assuntos
Fisioterapeutas , Adulto , Brasil , Humanos , Modalidades de Fisioterapia , Estados UnidosRESUMO
Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.
Assuntos
Anestesia , Doença da Artéria Coronariana , Procedimentos Desnecessários , Adulto , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Feminino , Cardiopatias , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/diagnóstico , Procedimentos Desnecessários , Anestesia , Programas de Rastreamento , Estudos Retrospectivos , Fatores de Risco , Medição de Risco , CardiopatiasRESUMO
Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.
Assuntos
Atitude , Cardiologistas/estatística & dados numéricos , Ecocardiografia/estatística & dados numéricos , Cardiopatias/diagnóstico , Procedimentos Desnecessários/psicologia , Atitude do Pessoal de Saúde , Cardiologistas/psicologia , Ecocardiografia/normas , Escolaridade , Feminino , Cardiopatias/psicologia , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Inquéritos e QuestionáriosRESUMO
Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Ecocardiografia/estatística & dados numéricos , Atitude , Procedimentos Desnecessários/psicologia , Cardiologistas/estatística & dados numéricos , Cardiopatias/diagnóstico , Índice de Gravidade de Doença , Ecocardiografia/normas , Atitude do Pessoal de Saúde , Inquéritos e Questionários , Escolaridade , Cardiologistas/psicologia , Cardiopatias/psicologiaRESUMO
OBJECTIVE: To test the hypothesis that ophthalmic artery Doppler velocimetry is predictive of the development of pre-eclampsia (PE). METHODS: This was a prospective cohort study that included pregnant women in the second trimester who had risk factors for PE. Seven ophthalmic artery Doppler parameters, in addition to uterine artery (UtA) Doppler and clinical variables, were investigated for their prognostic value with respect to PE. RESULTS: A total of 347 women were recruited, of whom 40 developed PE. A comparison of the mean ophthalmic artery Doppler parameter values between women with and those without PE showed statistically significant differences in several parameters: peak systolic velocity, end-diastolic velocity, mean velocity, peak mesodiastolic velocity (PMDV) and peak ratio. After adjusting for confounding variables, only PMDV remained statistically significant (P < 0.001), with an area under the receiver-operating characteristics curve (AUC) of 0.73. The best cut-off for predicting PE was a PMDV of > 22.11 cm/s, with sensitivity of 70%, specificity of 75%, positive likelihood ratio of 2.8, negative likelihood ratio of 0.4, positive predictive value of 28% and negative predictive value of 95%. The AUC increased from 0.72 to 0.78 when the PMDV was incorporated into a prediction model based on clinical variables, demonstrating that this marker increased the discriminatory capability of the model. The performance of ophthalmic artery Doppler was similar to that of UtA Doppler for predicting PE. Additionally, the AUC increased significantly from 0.82 to 0.88 when the PMDV was incorporated into the model containing clinical variables and UtA Doppler indices. CONCLUSION: A high ophthalmic artery PMDV in the second trimester of pregnancy is an independent predictor of PE that increases the discriminatory ability of clinical markers, as well as of models that include clinical variables and UtA Doppler indices.
Assuntos
Artéria Oftálmica/diagnóstico por imagem , Pré-Eclâmpsia/diagnóstico por imagem , Reologia/métodos , Ultrassonografia Doppler/métodos , Adolescente , Adulto , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Gravidez , Segundo Trimestre da Gravidez , Estudos Prospectivos , Fatores de Risco , Sensibilidade e Especificidade , Artéria Uterina/diagnóstico por imagem , Adulto JovemRESUMO
OBJECTIVE: To assess safety and efficacy of coronary angioplasty with stent implantation in unstable coronary syndromes. METHODS: Retrospective analysis of in-hospital and late evolution of 74 patients with unstable coronary syndromes (unstable angina or infarction without elevation of the ST segment) undergoing coronary angioplasty with stent placement. These 74 patients were compared with 31 patients with stable coronary syndromes (stable angina or stable silent ischemia) undergoing the same procedure. RESULTS: No death and no need for revascularization of the culprit artery occurred in the in-hospital phase. The incidences of acute non-Q-wave myocardial infarction were 1.4% and 3.2% (p = 0.6) in the unstable and stable coronary syndrome groups, respectively. In the late follow-up (11.2 +/- 7.5 months), the incidences of these events combined were 5.7% in the unstable coronary syndrome group and 6.9% (p = 0.8) in the stable coronary syndrome group. In the multivariate analysis, the only variable with a tendency to significance as an event predictor was diabetes mellitus (p = 0.07; OR = 5.2; 95% CI = 0.9-29.9). CONCLUSION: The in-hospital and late evolutions of patients with unstable coronary syndrome undergoing angioplasty with intracoronary stent implantation are similar to those of the stable coronary syndrome group, suggesting that this procedure is safe and efficacious when performed in unstable coronary syndrome patients.
Assuntos
Angioplastia Coronária com Balão/métodos , Isquemia Miocárdica/terapia , Complicações Pós-Operatórias/epidemiologia , Stents , Angina Pectoris/terapia , Angina Instável/terapia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/terapia , Estudos Retrospectivos , Síndrome , Resultado do TratamentoRESUMO
Infernão Lake, located within the Jataí Ecological Station in Luiz Antônio Municipal district (São Paulo State, Brazil), is one of the most typical ox-bow lake of the Mogi-Guaçu River, and it presents, as the main feature, its great quantity of aquatic macrophytes, whose intensive development, in the last years practically covered the whole mirror of water. With the purpose to point out the composition and to establish the relative participation of the phytophilic zoocoenosis that inhabits the different macrophytes of that lake, a collection program of the main vegetation stands was established. The collections, were carried out randomly, during dry season (1994), in stands of Salvinia auriculata, Utricularia sp., Cabomba piauhyensis, Eichhornia azurea and Scirpus cubensis being used specific methodology for each vegetable type. The analysis of the different macrophytes showed the presence of 4,130 macroinvertebrates of 28 families, in which Chironomidae (Diptera) and Naididae (Oligochaeta) were the most representative, contributing on the average with 51 percent and 25 percent of the total fauna. Asheum, Beardius, Chironomus, Goeldichironomus, Parachironomus and Polypedilum were the most abundant Chironomidae genera. Species of the genus Dero (Dero) and D. (Aulophorus) represented the most typical Naididae of the phytofauna. With clear faunistic gradient from the shore to the center of the lake, the taxocoenosis indicated low similarity (PSc < 50 percent), evidencing its own characteristics of each biotope. On the contrary, there was a high similarity (PSc > 60 percent) among the associated communities on different vegetables, when grouped into feeding guilds, with expressive participation, in most of the macrophytes, of the collector-gatherers category, except on S. auriculata, whose predators (> 50 percent) and collector-filterers (> 20 percent) dominance turned that zoocoenosis distinct from the others
Assuntos
Animais , Dípteros/classificação , Ecossistema , Água Doce/análise , Oligoquetos/classificação , Plantas , BrasilRESUMO
Infernão Lake, located within the Jataí Ecological Station in Luiz Ant nio Municipal district (São Paulo State, Brazil), is one of the most typical ox-bow lake of the Mogi-Guaçu River, and it presents, as the main feature, its great quantity of aquatic macrophytes, whose intensive development, in the last years practically covered the whole mirror of water. With the purpose to point out the composition and to establish the relative participation of the phytophilic zoocoenosis that inhabits the different macrophytes of that lake, a collection program of the main vegetation stands was established. The collections, were carried out randomly, during dry season (1994), in stands of Salvinia auriculata, Utricularia sp., Cabomba piauhyensis, Eichhornia azurea and Scirpus cubensis being used specific methodology for each vegetable type. The analysis of the different macrophytes showed the presence of 4,130 macroinvertebrates of 28 families, in which Chironomidae (Diptera) and Naididae (Oligochaeta) were the most representative, contributing on the average with 51% and 25% of the total fauna. Asheum, Beardius, Chironomus, Goeldichironomus, Parachironomus and Polypedilum were the most abundant Chironomidae genera. Species of the genus Dero (Dero) and D. (Aulophorus) represented the most typical Naididac of the phytofauna. With clear faunistic gradient from the shore to the center of the lake, the taxocoenosis indicated low similarity (PSc < 50%), evidencing its own characteristics of each biotope. On the contrary, there was a high similarity (PSc > 60%) among the associated communities on different vegetables, when grouped into feeding guilds, with expressive participation, in most of the macrophytes, of the collector-gatherers category, except on S. auriculata, whose predators (> 50%) and collector-filterers (> 20%) dominance turned that zoocoenosis distinct from the others.
Assuntos
Dípteros , Ecossistema , Água Doce , Oligoquetos , Plantas , Animais , Brasil , Dípteros/classificação , Oligoquetos/classificaçãoRESUMO
PURPOSE: To evaluate the clinical efficacy and safety of subcutaneous (SC) low molecular weight heparin (LMWH) compared to intravenous (IV) non fractioned heparin (NFH) in unstable angina, acute myocardial infarction and post-percutaneous transluminal coronary angioplasty. METHODS: From September/92 to April/94, 314 patients were randomized in two groups. Group I-- 154 patients treated with SC LMWH, using in the 1st phase SC LMWH with a dosage of 160 UaXa IC/kg/day (group IA--92 patients), and in the 2nd, a dosage of 320 UaXa IC/kg/day (group IB--62 patients). Group II--160 patients treated with IV NFH 100UI/kg (bolus), followed by 1000UI/h with adjusted dosage by activated partial thromboplastin time. RESULTS: There was not a statistically significant difference among the three groups in relation to cardiac events, hemorrhagic complications and deaths. CONCLUSION: The clinical efficacy and safety of SC LMWH in patients with unstable angina, acute myocardial infarction and post-percutaneous transluminal coronary angioplasty were similar to IV NFH with the dosages used in this study.