A literatura mundial jà vem demonstrando, hà bastante tempo, que a assistÃncia mÃdica em obstetrÃcia trouxe benefÃcios incalculÃveis aos partos distÃcicos. Por outro lado, as tecnologias utilizadas para a assistÃncia ao parto normal, a nÃvel hospitalar, vÃm sendo questionada e, intervenÃÃes, como a episiotomia, o uso abusivo de ocitÃcicos para abreviar o perÃodo de dilataÃÃo, e a posiÃÃo horizontal (deitada) da parturiente, durante o perÃodo expulsivo do parto, estÃo sendo analisadas e criticadas por um largo nÃmero de pesquisadores. O presente estudo visou testar a hipÃtese de que a assistÃncia ao parto normal na posiÃÃo vertical (sentada), durante o perÃodo expulsivo, seria mais apropriada, por ser fisiolÃgica. AlÃm disso, nÃo se usou o procedimento da episiotomia e observou-se a influÃncia da sucÃÃo do mamilo materno pelo RN no tempo de delivramento e perdas sanguÃneas, sem o uso de ocitÃcicos. A diferenÃa mÃdia de 3,4 minutos em favor da menor duraÃÃo do perÃodo expulsivo, para as parturientes que foram assistidas sentadas, merece destaque, apesar da significÃncia do dado estar em seu limiar estatÃstico, ao nÃvel de 95% (p=0,06). A maioria das parturientes delivraram espontaneamente atà 25 minutos depois do parto, nÃo importando se assistidas na vertical, ou na horizontal; as perdas sanguÃneas tambÃm tiveram equivalÃncias estatÃsticas(p=0,52). A sucÃÃo do mamilo materno mostrou alguma influÃncia mas nÃo logrou significÃncia estatÃstica em relaÃÃo a perdas sanguÃneas (p=0,19) e ao tempo de delivramento (vertical: p=0,08; horizontal: p=0,52). Mesmo sem o procedimento da episiotomia, as laceraÃÃes vulvo-perineais se mantiveram em 44,1% e 47,1% para as mulheres que pariram na vertical e horizontal, respectivamente (incidÃncia mais baixa do que os 52,3% que se encontra na literatura), sendo que mais de 80% em ambos os grupos, a laceraÃÃo foi de 1 grau e o restante apenas de 2 grau. NÃo ficou evidenciada qualquer vantagem na posiÃÃo vertical sobre a posiÃÃo horizontal materna durante o perÃodo expulsivo do parto e delivramento, sendo portanto indicado que se permita a livre escolha da parturiente. A abstenÃÃo do uso de ocitÃcicos e de episiotomia nÃo acarretou prejuÃzo Ãs mÃes que pariram, em qualquer das duas posiÃÃes. Assim, os achados do estudo nÃo apontam para a necessidade de intervenÃÃes obstÃtricas de rotina, na assistÃncia ao parto normal; indicando, outrossim, que elas sejam mais criteriosas, evitando-se iatrogenias e promovendo assistÃncia de melhor qualidade e mais humanizada. / Since a long time, world literature has been demonstrating that medical assistance brought large benefits to complications on deliveries. In the other hand, overused obstetric technologies on normal delivery assistance in hospitals are being questioned. Interventions such as episiotomy, the abuse of oxytocic to shorten the dilatation period and the laying down posture imposed to women during labor are being criticized by a large number of researchers. This study intended to find out if the sitting position to assist the second period of womenâs delivery is more appropriate for it is considered physiological. Besides that, no episiotomy has been performed and immediate breastfeeding consequences on blood loss and on the delivery of placenta were observed. The 3.4 minutes difference on favor of the length of time expulsion period to the group of women who delivered on vertical position versus horizontalâs was considered important but not statistic significant (p=0.06). The great majority of mothers has delivered the placenta within the first 25 minutes, regardless they were on the upright (sitting) or neutral (laying down) position. Blood loss was also equivalent on both groups (p=0.52) and breastfeeding did not show any influence on that (p=0.19) and on the time for delivering the placenta (sitting-p=0.08; laying down-p=0.52). The incidence of perineal trauma was 44.1% and 47.0% for women who delivered on vertical and horizontal position, respectively (this incidence was even lower than the 52.3% which is reported on literature). More than 80% of the spontaneous injuries were 1st degree posterior perineal trauma and the rest was just 2nd degree ones, for both groups. It was not evident any advantage of the vertical position over the horizontalâs, during the expulsion period of labor and delivery of placenta. So, mothers could be given the choice in the posture to be assumed during parturition. The absence of oxytocic and episiotomy did not bring any harm to women delivering in any of the two positions. The outcomes do not support medical intervention should be used as routine on normal delivery and for that, those interventions could have a better criteria, avoiding more harm than good and offering a more humanized delivery assistance.

The vestibular system senses head motion and facilitates gaze stabilization, allowing for clear vision during movement. The vestibulo-ocular reflex (VOR) causes the eyes to move opposite head motion, thus maintaining focus on a target. Consequently, uncompensated loss of vestibular function leads to reduced VOR function resulting in dizziness, nausea, and visual disturbance. Different testing methods have been developed to measure VOR loss. These tests generally require bulky, expensive equipment, and must be performed by a trained examiner. A newly developed digital form of the dynamic visual acuity (DVA) test requires less equipment, is cost-effective, and may be performed at home making it more accessible. The purpose of this study was to determine the validity and test-retest reliability of the digital DVA test and provide normative data for healthy adults. Fifteen adults – 10 female and 5 male (mean age = 22.0 ± 3.1, range: 19-31 years) – completed the study. Exclusion criteria included age older than 49 years, history of vestibular or neurological disorders, and history of significant head injury. Subjects were screened for normal vestibular function using video head impulse testing. The study consisted of two visits, 3-15 days apart. Participants underwent DVA testing with both the validated NeuroCom (InVision software) system and newly developed digital DVA during the initial visit and the digital DVA during the second visit. The digital DVA system consists of a laptop computer paired with a head/eye tracker (Tobii Eye Tracker 5) and Health in Motion software (Blue Marble Health Company). Outcome measures of interest were the difference between static and dynamic visual acuity measured in LogMAR (DVA loss) for rightward and leftward head movement. Pearson Product-Moment bivariate correlations were used to determine validity of the digital DVA outcomes compared to NeuroCom outcomes. Intraclass correlation coefficients (ICCs) were calculated to determine test-retest reliability of the digital DVA. Pearson correlation coefficients for validity were r = 0.025 and r = -0.015 for left and right DVA loss, respectively. ICCs for test-retest reliability were r = 0.366 and r = 0.313 for left and right DVA loss, respectively. Mean values across both sessions for left and right DVA loss measured by digital DVA were 0.26 ± 0.13 and 0.26 ± 0.11, respectively. Correlations between the digital DVA and standard computerized DVA were poor indicating the need for further development of the current digital system/software. Test-retest reliability for the digital DVA system in its current state was also poor. Tobii sensor used in the software is limited by a 200 ms delay in reporting head motion to the software. Future development of a digital DVA may need to consider other sensors. The current digital DVA will not replace the computerized system; however, it may provide important information for clinicians who do not have access to computerized DVA.

We describe a patient who developed hemolysis and methemoglobinemia due to rasburicase (RBU) and was found to have glucose-6-phosphate dehydrogenase (G6PD) deficiency. This is a rare clinical scenario that provides valuable insight into complex diagnosis and management of these life-threatening complications. A 59-year-old male presented to the VA Medical Center with 11 days of epigastric abdominal pain radiating to the back and flank, associated with bloating and lower extremity edema. He was transferred to our facility for percutaneous nephrostomy tube (PCN) placement for renal dysfunction (creatinine 5.5). Computed tomography (CT) scan of the abdomen and pelvis revealed 17 cm retroperitoneal mass engulfing major vessels, involving right renal hilum and ureter with moderate-severe right hydronephrosis. CT guided biopsy of the mass showed intermediate-large malignant cells that were CD20, CD23, BCL2 and BCL6 positive; CD10 and MUM1 negative. Fluorescent in-situ hybridization resulted after discharge to reveal no MYC rearrangement, confirming a diagnosis of diffuse large B-cell lymphoma. Positron-emission tomography CT revealed extensive retroperitoneal lymphadenopathy with pelvic extension into internal and external iliac vessels, encasing aorta, inferior vena cava and anteriorly displacing pancreas and bowel and contiguous involvement of the right kidney with hypermetabolic activity. Moderate right sided pleural effusion was also seen. Creatinine improved with PCN. Uric acid was 10.3 with lactate dehydrogenase (LDH) 953. The patient received RBU for tumor lysis syndrome (TLS). However, pulse oximetry showed an oxygen saturation of 70-80%, though the patient had only mild dyspnea. CT pulmonary embolism (CTPE) showed segmental PE. Therapeutic lovenox was initiated. He underwent thoracentesis with symptomatic improvement but continued to desaturate on pulse oximetry. Arterial blood gas on 100% oxygen via non-rebreather revealed methemoglobin of 4.5% without hypoxemia. LDH worsened to 1668 with low haptoglobin and direct hyperbilirubinemia, suggestive of hemolysis. G6PD was deficient at 0.8 U/g. Treatment was conservative with cautious use of red cell transfusions and supplemental oxygen. Due to hyperbilirubinemia, chemotherapy was started with dose-adjusted etoposide, prednisone, oncovin, cyclophosphamide, and rituximab - with adriamycin withheld upfront. As hemolysis improved the patient received dose-reduced adriamycin. RBU is a recombinant urate oxidase used in managing TLS. It converts uric acid to allantoin, producing hydrogen peroxide, which oxidizes hemoglobin to methemoglobin. G6PD deficiency decreases cellular ability to reduce glutathione and thus detoxify hydrogen peroxide. This causes life-threatening methemoglobinemia and hemolysis. Methylene blue is contraindicated due to the risk of worsening hemolysis in G6PD deficiency. Methemoglobinemia is typically treated in such cases with exchange transfusion or hyperbaric oxygen therapy.

No description available.

Intervención médica temprana; programas gente sana; salud pública; estilo de vida saludable; dieta saludable; actividades recreativas. / El proyecto de intervención se realizó en la ciudad de Chachapoyas en la región Amazonas durante el periodo de aislamiento social mayo-junio 2020. De acuerdo al análisis de los indicadores de salud, se puede inferir que el sistema de salud de la provincia es deficiente ya que no cuenta con suficiente personal médico ni recursos. Esto afectaría directamente el estado de salud de la población en el contexto actual debido a la pandemia del virus (SARS-CoV 2). La importancia de este proyecto de intervención es que ha permitido que los integrantes del entorno familiar puedan establecer medidas de promoción y prevención de salud a través de la implementación de un estilo de vida saludable. Se identificaron los problemas principales del entorno familiar a través del análisis de la situación de la salud (ASIS), análisis de involucrados y diagnóstico participativo comunitario (DPC) para luego poder realizar la priorización de problemas e identificar las causas y consecuencias empleando el árbol de problemas y plantear proponer soluciones con el árbol de objetivos. Se planteó como objetivo principal "Mejorar las prácticas saludables manejo de estrés y alimentación saludable en el entorno familiar, en la ciudad de Chachapoyas, durante periodo 2020-1.” Se diseñó, elaboro, supervisó y monitoreó actividades enfocadas en la promoción de la salud. Los resultados encontrados en este proyecto son muy satisfactorios ya que se cumplieron las actividades de elaboración de material, ejecución y monitoreo de actividades. Cabe resaltar que se obtuvo resultados favorables en los indicadores de evaluación, la cobertura y eficacia de todas las actividades al 100%. Se respetó los tiempos estimados de duración media, e inclusive en algunas actividades se obtuvo mayor rendimiento. / The intervention project was carried out in the city of Chachapoyas, in the Amazon region during the period of social isolation, from May to June 2020. According to the analysis of health indicators, it can be inferred that the province's health system is highly deficient. It does not have enough medical personnel nor resources having directly affected the health status of the population, especially in the current context of pandemic (SARS-CoV 2). The relevance of this intervention project is that it has allowed members of families to establish health promotion and prevention measures through the implementation of a healthy lifestyle. The main problems of the family environment were identified through the analysis of the health situation (ASIS), analysis of stakeholders, and participatory community diagnosis (DPC) to prioritize problems and identify the causes and consequences using the tree of problems and suggesting solutions with the objective tree. The main objective was to "Improve healthy stress management and healthy eating practices in the family environment, in the city of Chachapoyas, during the period 2020-1. Activities focused on health promotion were designed, developed, supervised, and monitored. The results found in this project were eminently satisfactory since the activities of material preparation, execution, and monitoring of these were accomplished. It should be noted that favorable results were obtained in the evaluation indicators, the coverage, and the effectiveness of all activities at 100%. Estimated times of average duration were respected, and even in some activities higher performance was achieved. / Trabajo de investigación

(EN) Introduction: Tobacco dependence is one of the four major risk factors (RF), cardiovascular (CV) disease (CVD). Objective: Analysis of CV risk of patients of our Center for Tobacco-Dependent. Methods: A retrospective assessment of the presence of CVD, RF for CVD and CV risk level according to the method SCORE in our patients - smokers from 2007 - 2009 (N = 1,349, 52.2% males, age range 25-64 years, mean age 44 ± 11, 7). CV risk was also evaluated one year after the baseline visit including newly diagnosed CVD RF, abstinence from smoking was validated by carbon monoxide in expired air. The results were compared to those of smokers in the study postMONICA (N = 1,122, 54.5% men, mean age 46 ± 11). Compared to the general population of smokers (postMONICA) significantly more Center patients had automatically high CV risk and CVD. The prevalence of type 2 diabetes was comparable as well as prevalence of hypertension and dyslipidemia in smokers without automatically high CV risk. Significantly fewer Center patients without automatically high CV risk were obese, family history was also significantly lower risk. Significantly more women with low RF and significantly fewer men aged 55-59 and women aged 55-64 with SCORE ≥ 5% came to the Center. Success rate of Center patients with SCORE < 5 % was 44.3 %...

Substance use disorder (SUD) is a disease that continues to affect the lives of millions of Americans. Access to adequate treatment also continues to be a challenge for many of those suffering from substance use disorder. To better understand the barriers to treatment as well as the social challenges people face in seeking care for their substance use, we designed an observational study to capture demographic data, perceptions of stigma, and self esteem levels at a medication assisted treatment (MAT) facility in Northeast Tennessee. A robust survey was administered to patients at the MAT facility to quantify and analyze these metrics. Results from the survey showed when it came to stigma, respondents felt the highest level of internalized stigma compared to the other two types of measured stigma (enacted and anticipated). This was still the case even after stratifying based on gender. Regarding self esteem, survey results showed that as a whole, most respondents were within the normal range for self esteem, however, differences were appreciated when the data was categorized based on age. Finally, some of the most common reasons respondents selected for not seeking treatment previously were the thought that the problem could be handled alone, the lack of health insurance, and the fact that they were not ready to quit. A greater understanding of these issues is crucial for providers to better serve their patient population and tailor their services to the pertinent issues of the area.

The purpose of this qualitative study was to explore school nurses’ (SN) perceptions of factors influencing their ability to identify, refer, and provide mental health services to students with early signs of mental, emotional, and behavioral (MEB) needs. The National Research Council and Institute of Medicine have urged a preventive public health approach to decrease adverse outcomes of unidentified and untreated MEB needs among children (O’Connell, 2009). Historically and theoretically based in public health, SN have daily contact with students and are in an optimal location for early identification, referral and provision of services, yet little empirical research describing their role is available. Five focus groups with 29 SN were conducted and four themes emerged through analysis of data: Frequent flyers : student visits to SN offices, the observations that alert SN to potential MEB needs; Digging to get the whole picture : the process SN frequently used to collect information necessary to confirm MEB needs; Road to referral : the resources used and barriers encountered within the referral process; and, Safety zone : the important role SN play in the provision of services to students with early signs of MEB needs. Within the provision of services was a collective subtheme across all five focus groups: What we need to better help our kids. In this category SN identified their educational limitations and learning needs, as well as potential strategies to improve provision of services for students with MEB needs. The findings of this study provide a lens into the complex and little explored are of early identification, referral and intervention processes used by SN to care for students with MEB needs. Understanding the role of the SN is a critical first step towards improving outcomes.

Physical and mental integrity of an individual represents one of the components of a human personality, which may be regarded as a personal sphere of everyone and which is protected by the law against any unauthorized interference. Legislation regarding the interference with the integrity of an individual is based on the principle of inviolability of a human being, according to which no one is entitled to interfere with the integrity of another individual without his consent, except as provided by law. The consent of the individual concerned is therefore the most fundamental circumstance excluding illegality of the interference. The aim of this diploma thesis is to analyse current legislation regarding the interference with the integrity of an individual, especially relevant provisions of the new civil code, and to point out its potential deficiencies or problematic aspects. It focuses on particular circumstances under which it is possible to interfere with the integrity of an individual, or which represent the reasons for such interference and therefore exclude its illegality. Even though the thesis aims to elaborate the topic from the point of view of civil law, with regard to the fact that most of the serious interferences with the integrity of an individual occur when health services are...

Ces travaux s’inscrivent dans le cadre de la navigation endovasculaire assistée par ordinateur. L’objectif principal est d’étudier et de proposer de nouvelles solutions pour la localisation et le suivi des dispositifs endovasculaires en mouvement par rapport aux structures anatomiques, considérées comme immobiles ou mobiles. Il s’agit à terme de faciliter le geste interventionnel, en maximisant la précision et la fiabilité des procédures, tout en minimisant le recours aux rayons X et au produit de contraste. Les travaux et résultats obtenus concernent : - L’étude d’approches de recalage permettant de fusionner des données 3D pré-opératoires décrivant les structures anatomiques et des données intra-opératoires de localisation 3D électromagnétique (positions d’un cathéter équipé d’un capteur magnétique en son extrémité). Dans le contexte du traitement des anévrismes aortiques abdominaux, deux méthodes de recalage ne nécessitant pas de marqueur externe et exploitant uniquement les trajectoires endovasculaires (avec hypothèse de correspondance totale ou partielle) ont été proposées. Les tests ont été réalisés sur fantôme physique. Bien que la précision de localisation des systèmes électromagnétiques soit encore limitée, ceux-ci pourraient être utilisés pour aider la navigation endovasculaire, comme par exemple, lors du cathétérisme d’artères collatérales. - L’élaboration d’une méthode de tracking des calcifications et de repères dans les séquences d’images fluoroscopiques, dans le contexte des procédures d’implantation endovasculaire de valve aortique (TAVI). Nous avons proposé une méthode de tracking par modèle d’apparence adaptatif (TMAA). L'approche a été évaluée sur 13 séquences fluoroscopiques dans le cadre des procédures TAVI valve native et 5 séquences fluoroscopiques dans le cadre des procédures TAVI valve-in-valve. Elle fournit une erreur de localisation moyenne inférieure à 1 mm et un temps de traitement de 32,23 ms/trame. L’évaluation de cette méthode et son application sur données patients ont permis de montrer la précision et la compatibilité du tracking avec une utilisation clinique. / This work is part of computer-assisted endovascular navigation. The aim of this thesis is to study and to propose new solutions for the localization and the tracking of moving endovascular devices within anatomical structures, which can be considered fixed or moving. The objective is to facilitate the endovascular intervention, by maximizing the accuracy and reliability of procedures, while minimizing the use of X-rays and contrast agents. The works concern : - The study of registration approaches to align pre-operative 3D data describing the anatomical structures and intra-operative 3D electromagnetic data (positions of a catheter equipped with a magnetic sensor at its tip). In the context of the treatment of abdominal aortic aneurysms (AAA), two fiducial-free registration methods that exploit only the endovascular trajectories (with total or partial correspondence hypothesis) have been proposed. The tests were performed on an AAA phantom. Although the localization accuracy of electromagnetic systems is still limited, these could be used to assist endovascular navigation (e.g., catheterization of collateral arteries). - The elaboration of a method to track calcifications and markers in fluoroscopic sequences, in the context of transcatheter aortic valve implantation (TAVI) procedures. We proposed a method of tracking by adaptive appearance model (TMAA). The approach was evaluated on 13 fluoroscopic sequences as part of TAVI native valve procedures and 5 fluoroscopic sequences as part of TAVI valve-in-valve procedures. The average localization error was less than 1 mm and the average processing time was 32.23 ms/frame. The evaluation of this method and its application on patient data has made it possible to show the precision and the compatibility of the tracking with a clinical use.