Clinicians and hospital administrators are increasingly challenged to achieve efficient evidence-based care. Clinical decision support (CDS) tools are being introduced into the clinical setting to facilitate the bridging of knowledge gaps at the point of care. Order sets are one of the tools used to facilitate this knowledge translation. Using the realist review methodology and a focus group of interview participants, this thesis explored retrospectively some of the causal relationships that lead to effective and successful order set adoption. Findings demonstrate the need for in-depth and regular review of context and order set adoption. Technology can offer some enhancements in the form of delivery tools, but it also introduces new and complex challenges for development and implementation. Ongoing software development is needed to improve delivery formats as well as incorporate effective tools to allow for efficient continuous quality improvement supports. / Graduate / 0769 / 0566 / hallsm.77@gmail.com

Background: The PHQ-4 is a widely used open access screening instrument for depression and anxiety in different health care and community settings; however, empirical evidence of its psychometric quality in Colombia is lacking. The objectives of the current study were to generate normative data and to further investigate the construct validity and factorial structure of the PHQ-4 in the general population. Methods: A nationally representative face-to-face household survey was conducted in Colombia in 2012 (n = 1,500). The item characteristics of the PHQ-4 items, including the inter-item correlations and inter-subscale correlations, were investigated. To measure the scale’s reliability, the internal consistency (Cronbach’s α) was assessed. For factorial validity, the factor structure of the PHQ-4 was examined with confirmatory factor analysis (CFA). Results: The Cronbach’s alpha coefficient for the PHQ-4 was 0.84. The confirmatory factor analysis supported a two-factor model, which was structurally invariant between different age and gender groups. Normative data for the PHQ-4 were generated for both genders and different age levels. Women had significantly higher mean scores compared with men [1.4 (SD: 2.1) vs. 1.1 (SD: 1.9), respectively]. The results supported the discriminant validity of the PHQ-4. Conclusions: The normative data provide a framework for the interpretation and comparisons of the PHQ-4 with other populations in Colombia. The evidence supports the reliability and validity of the two-factor PHQ-4 as a measure of anxiety and depression in the general Colombian population.

This research explores literacy as a medium for deepening student's awareness of their world and the impact of the Ontario Secondary School Literacy Test (OSSLT). Standardized testing is analyzed as a fundamental paradigm to our school culture. Ethnography is explored as a method for describing one group of students and their teacher as they prepare for the OSSLT. The findings conclude that the test occupies time, dominates definitions of literacy and undermines student and teacher agency. The conclusion considers reasons for why we seem to accept a testing paradigm that may be a direct affront to democratic practice in schools.

Thesis (doctoral)--Universiẗat Köln, 2005. / Includes bibliographical references (p. 187-204).

Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro / O propósito do presente trabalho foi investigar a participação da proliferação celular e da expressão dos componentes da matriz extracelular na cascata de eventos do processo de reparo da fratura óssea, empregando as técnicas histológica, imunohistoquímica e morfométrica, em um modelo experimental padronizado para a indução da lesão na tíbia de ratos a partir do método empregado por Yuehuei e Friedman7. É importante padronizar um modelo de indução da fratura, para posterior investigação da participação das células e dos componentes da matriz extracelular no processo de reparo da fratura, considerando que o tempo de consolidação depende significantemente da natureza e do tipo da lesão produzida. Quarenta (n = 40) ratos Wistar foram submetidos a fratura . Os animais foram avaliados em oito (n = 8) grupos de cinco (n = 5) animais, cada grupo emperimental com 12, 24, 48, 72, 96, 144, 192 e 240 horas após a fratura (12h até 10 dias). As fraturas foram classificadas de acordo com o sistema de classificação internacional de fratura de Muller100, AO (Associação para Osteosíntese). Foram encontradas fraturas simples em 86% do total, sendo 68% de fraturas transversas e 18% de fraturas obliquas, 14% do total de fraturas foram complexas, sendo 8% de fraturas irregulares e 6% de fraturas segmentares. Esses resultados demonstram que o aparelho permite padronizar radiológicamente o tipo de fratura, caracterizado pela linha que separa os fragmentos ósseos. Os resultados qualitativos dos componentes da matriz extracelular para TGF-β, VEGF, colágeno I e II, osteopontina, proteoglicanos, fibras do sistema elástico com a coloração de resorcina funcsina de Weigert, e para proliferação celular pelo PCNA, assim como os resultados morfométricos, sugerem que a modulação da expressão dos componentes da matriz extracelular e a proliferação celular durante o processo de reparo da fratura não é homogênea para todos os componentes teciduais, dependendo significantemente das tensões locais geradas pelo tipo da linha de fratura que pode ser determinante no tempo de regeneração do osso e na qualidade da restauração das propriedades biomecânica. Nossos achados podem contribuir para melhor compreensão da reparo de fratura óssea e para novas abordagens terapêuticas que considerem as propriedades biomecânicas do tecido ósseo em reparo nas suas diferentes etapas / The purpose of this study was to investigate the role of cells proliferation and extracellular matrix components expression in the process of bone fracture repair. To do so it used histological techniques, immunohistochemistry and morphometric analysis as well as a standardized experimental model for the induction of injury to the tibia of rats as proposed by Yuehuei and Friedman7. It is important to standardize a model of fracture induction for further investigation of the involvement of cells and extracellular matrix components in the fracture repair process, whereas the healing time depends significantly on the nature and type of lesion produced. Forty (n = 40) Wistar rats were subjected to fracture. The animals were divided into eight (n = 8) groups of five (n = 5). Each subgroup was observed after 12, 24, 48, 72, 96, 144, 192 and 240 hours of fracture (12 to 10 days). Immediately afterwards, the fractures were classified according to the system of international classification of fracture by Muller100, AO (Association for Osteosynthesis). Simple fractures were found in 86% of the total, among them, 68% were transverse and 18% were oblique. Complex fractures were found in 14% of the cases, among them 8% were irregular and 6% were segmental. These results demonstrated that the device enables researchers to standardize the type of fracture by X-ray, marked by the line separating the bone fragments. The qualitative results of the cells and extracellular matrix components of TGF-β, VEGF, PCNA, collagen I and II, osteopontin, proteoglycans, elastic fibers system with resorcin funcsin of Weigert, as well as the morphometric results suggest that the repair process of the fracture is not homogeneous for all components. Expression of the extracellular matrix components and cell proliferation modulation significantly depends on the local stresses generated by the type of the fracture. Such type can be decisive in determining time duration for bone regeneration and quality of the biomechanical properties restoration. Our findings may contribute to better understanding of bone fracture repair and for new therapeutic approaches that consider the biomechanical properties of bone tissue in repair in its different stages

Orientador: Vania dos Santos Nunes Nogueira / Resumo: Objetivo: esta revisão sistemática da literatura e metanálise comparou a taxa da mortalidade na acromegalia com a taxa esperada na população geral dos estudos publicados antes de 2009 versus estudos publicados após. Métodos: foram criadas três estratégias de busca gerais e adaptáveis às bases de dados eletrônicas na área da saúde: Embase (1980–2015), Pubmed (1966–2016) e Biblioteca Virtual da Saúde (1982–2016). Foram incluídos estudos observacionais em que a mortalidade na acromegalia foi comparada à da população geral, por meio do número de mortes observadas nessa doença em comparação à taxa de mortalidade esperada para população geral (O/E). A partir do O/E, recalculamos todos os Standardized Mortality Ratio (SMR) e os seus respectivos intervalos de confiança (IC) que foram plotados em uma metanálise. Resultados: foram identificadas 1005 referências, dois revisores independentemente leram os títulos e resumos desses artigos. Dos 27 estudos potencialmente elegíveis, 23 foram incluídos e quatro foram excluídos por não preencherem os critérios de elegibilidade. A mortalidade geral na acromegalia foi significativamente superior a da população geral (SMR: 1,66, IC 1,44 - 1,93, p < 0,00001, I2 84%). Separando os artigos publicados a partir de 2009, a mortalidade na acromegalia não foi significativamente diferente 1,29 (IC 0,95-1,76, p=0,10, I2 86%). Nas análises por subgrupo de acordo com o status da doença, sete estudos consideraram como curados os pacientes que apresentaram a n... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Objective: This systematic literature review and meta-analysis compared the mortality rate in acromegaly with the expected rate in the general population of studies published before 2009 versus studies published after. Methods: three general and adaptive search strategies were created from the electronic databases in the health area: Embase (1980-2015), Pubmed (1966-2016) and Virtual Health Library. Observational studies were included in which the mortality in acromegaly was compared to the general population, the number of deaths observed compared to the expected mortality rate in the general population (O/E). From O/E, we recalculated all the Standardized Mortality Ratio (SMR) and their respective confidence intervals (CI) that were plotted in a meta-analysis. Results: 1005 references were identified and two reviewers independently read the titles and abstracts of these articles. Of the 27 potentially eligible studies, 23 were included and four were excluded because they did not meet the eligibility criteria. Overall mortality in acromegaly was significantly higher than the general population (SMR: 1.66, CI 1.44 - 1.93, p <0.00001, I² 84%). Analyzing articles published as of 2009, the mortality in acromegaly was not significantly different, SMR 1.29 (CI 0.95-1.76, p = 0.10, I² 86%). In subgroup analyzes according to disease status, seven studies considered patients with IGF-1 normalization associated with random GH <2.5 ng / mL as cured. In these individuals, the SMR was 0.... (Complete abstract click electronic access below) / Mestre

A seca que assola o norte de Minas Gerais é um desencadeante de severos impactos socioambientais. Mudanças na distribuição das precipitações, ou mesmo a redução no volume de chuvas é fator suficiente para a desorganização da atividade econômica regional. Neste contexto, este trabalho analisou a distribuição espaço-temporal da seca/estiagem no norte de Minas Gerais, entre 2003 a 2014. A metodologia consistiu na elaboração de série temporal de anomalia padronizada de NDWI utilizando imagens de reflectância MOD13Q1/MODIS. Para a realização das análises utilizou-se como base: os decretos de anormalidade por motivo de seca/estiagem, dados de perdas e danos, de precipitação e de variação de água da subsuperfície das soluções GRACE. Foram realizadas correlações entre NDWI e precipitação e entre anomalia padronizada de NDWI e anomalia de precipitação, considerando dados sem e com 30 dias de defasagem. Foi aplicado teste de médias, teste t de Student, para a anomalia padronizada de NDWI e a anomalia de precipitação, em um intervalo de confiança de 95%. Os resultados demonstraram que a anomalia padronizada de NDWI identificou de forma satisfatória três períodos de seca/estiagem na região. Estes corroboram com os dados de decretos de emergência e calamidade pública, sendo observado um maior número de decretos, principalmente, nestes períodos. Dois períodos identificados como de seca/estiagem foram noticiados como de estiagem severa no norte de Minas Gerais. Esse fato corrobora os dados de anomalia padronizada de NDWI com a situação ocorrida na região. O quantitativo de áreas afetadas por seca também evidencia o mesmo período de maiores números de ocorrências de seca/estiagem e deficiência na distribuição da precipitação. No entanto, o emprego de anomalia padronizada de NDWI na identificação seca/estiagem, por si só, pode não ser suficiente para essa identificação, uma vez que, o fenômeno pode ocorrer e causar danos e prejuízos, em meio a uma paisagem verde, como constatado para 2010. As análises estatísticas mostraram que existem correlações com graus de intensidade melhores entre o NDWI e a precipitação com uma defasagem de 30 dias. Fato também observado para os dados de anomalia padronizada de NDWI e anomalia de precipitação, todavia, foram observadas correlações de fraca a moderada. O teste de médias apresentou diferenças entre as médias apenas para o ano de 2014. Apesar de em todos os outros períodos as médias não serem estatisticamente diferentes entre si, foram verificados baixos valores de p-value, com excessão do período entre 2008 e 2011, onde são verificados p-value entre 0,4 a 0,9. Ainda que os testes estatísticos não apresentaram uma ótima significância, a variação temporal dos dados de anomalia padronizada de NDWI e de anomalia de precipitação evidencia uma relação similar entre esses dados. Por fim, a comparação com dados das soluções GRACE, identificou os mesmos períodos verificados com a anomalia padronizada de NDWI, sendo então, observado que estes dados corroboram entre si na identificação de seca/estiagem no norte de Minas Gerais. / The drought that affects the north of Minas Gerais State causes severe socio-environment impacts. Changes on the precipitation distribution or even the reduction of the raining amount is enough reason for regional disorganization. In this context, this work analyzed the drought spatial-temporal distribution in the north of Minas Gerais State, between 2003 and 2014. The methodology consisted on the elaboration of time series of standardized anomaly NDWI using images of reflectance MOD13Q1/MODIS. For the analysis it was used the following basis: the abnormality decrees caused by drought, damage and losses data, precipitation and the water subsurface range on GRACE solution. Correlations were conducted between NDWI and precipitation, as well as between standardized anomaly NDWI and precipitation anomaly, considering data with and without 30 days of gap. It was applied average test, the Student t-test, for the standardized anomaly NDWI and precipitation anomaly, with a confidence range of 95%. Results demonstrated that standardized anomaly NDWI satisfactorily identified three seasons of drought in this region. It corroborates with emergency decrees and public calamity data, in what it was observed a higher number of decrees, especially in these periods. Two seasons identified as drought were reported as severe drought in the north of Minas Gerais State. This fact validates the standardized anomaly NDWI data with the situation occurred in the region. The quantity of affected areas drought, also evidences the same period of larger numbers of occurrences drought and disability in the distribution of precipitation. However, the use of standardized anomaly NDWI by itself on the identification of drought may not be enough evidence for this association, since the phenomenon can occur and cause damages and losses among a green landscape, as seen in 2010. Statistical analysis demonstrated that there are correlations with better intensity degrees between the NDWI and the precipitation with a gap of 30 days. This fact was also observed for the standardized anomaly NDWI and precipitation anomaly data, however, mild to moderate correlations were observed. Student t-test demonstrated differences between the averages only for the year of 2014. Despite for all other periods averages were not statistically different, they were observed p-value low values, with the exception of the period between 2008 and 2011, which are verified p-value between 0.4 and 0.9. Although statistical tests did not demonstrated a great significance, the temporal variation of standardized anomaly NDWI data and precipitation anomaly evidenciate a similar relationship between these data. Lastly, the comparison with data from GRACE solutions, identified the same periods verified with the standardized anomaly NDWI, being then observed that these data corroborates between them in the identification of draught in the north of Minas Gerais State.

Red blood cells are a scarce resource whose demand often exceeds its supply. Intraoperative red cell salvage has proven to be a highly effective blood conservation strategy, as it can reduce the need for allogeneic blood transfusion. However, the use of cell saver alone is not sufficient. Without specific blood ordering guidelines, the amount of allogeneic blood product requested and cross&ndash;matched is often much greater than the real level of consumption. Efficient blood ordering guidelines have been developed in the past, and have succeeded in providing a more accurate prediction of actual need for intraoperative blood transfusion and minimizing waste. Few studies attempted to examine the blood ordering and utilization pattern with an emphasis on surgical cases that involve the use of intraoperative cell salvage. With the use of intraoperative cell salvage devices to reduce the amount of blood bank products required during surgery, considerable change in the practice of ordering cross&ndash;matched blood should be made. We retrospectively assessed the effectiveness of one Standardized Clinical Assessment and Management Plan (SCAMP) in improving the efficiency of blood utilization and reducing waste. This SCAMP was introduced at our Boston Children's Hospital in July 2012 as a blood ordering guideline for all pediatric orthopedic patients who are scheduled for intraoperative cell salvage. We retrospectively compared demographic variables, clinical characteristics, and blood utilization patterns of patients who underwent orthopedic procedure and received cell saver blood during the 17 months prior to the introduction of SCAMP (n = 455) and those who underwent similar procedures during the 15 months after the introduction of SCAMP (n = 487). Results suggested that demographic variables including age, weight, and sex were similar between the pre&ndash;SCAMP and post&ndash;SCAMP groups. It also demonstrated that after the introduction of SCAMP, the mean percentage utilization of blood (number of units used/number of units ordered x 100%) increased by 24.4% (p < 0.001), while the difference between the number of units ordered and number of units used reduced by 0.5 units (p < 0.001). In conclusion, the introduction of a SCAMP for blood product ordering has led to an increase in the efficiency of blood utilization and a reduction in blood waste. However, further evaluation and modification of the SCAMP need to be made in order to better predict actual level of utilization of blood products.

Diabetes mellitus (DM) is a significant public health problem that afflicted approximately 29.1 million Americans in 2012 (CDC, 2014). The estimated cost of diabetes in the United States in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in reduced productivity (ADA, 2013a). To reach a diagnosis of DM, a clinician generally relies on fasting plasma glucose (FPG), the oral glucose tolerance test (OGTT), and/or the Hemoglobin A1c (HbA1c) test (ADA, 2013b). Current noninsulin antidiabetic medications include sulfonylureas, GLP-1 analogues, DPP-4 inhibitors, biguanides, thiazolidinediones, and SGLT2 inhibitors (Kaiser & Oetjen, 2014). Insulin therapies include basal (long-acting insulin analogues), biphasic (premixed insulin analogues), prandial (short-acting insulin analogues), and basal bolus (a combination of long-acting and short-acting insulin analogues) (Esposito et al., 2012). The aim of this study is to review the existing literature on the cost effectiveness of diabetes interventions to develop a standardized protocol for early type 2 diabetes care that can be delivered through primary care providers. The substantial cost effectiveness of preventative measures, including ad campaigns and outreach programs, has already been established (Mendis & Chestnov, 2013). Screening for impaired glucose tolerance early and implementing lifestyle and pharmacological changes at an early stage are also considered cost effective approaches for the long-term management of diabetes mellitus (Gillies et al., 2008). This study utilizes six cost effectiveness analyses on both clinical and non-clinical interventions to determine a standardized protocol for screening, diagnosing, and treating DM. Noninsulin antidiabetic drugs accounted for 78.4% of the 154.4 million prescriptions for antidiabetic drugs filled in 2012 (Hampp et al., 2014). Approximately half of the noninsulin antidiabetic drugs filled in 2012 was for metformin, whereas roughly a quarter of the same category was for sulfonylureas (Hampp et al., 2014). In decreasing order, long-acting human analog insulin and fast-acting human analog insulin were the most popular insulin variants in the insulin antidiabetic drug market (Hampp et al., 2014). Of the noninsulin antidiabetic drugs, the highest proportion of diabetic patients who achieved the HbA1C target of <7% were those taking sustained release exenatide (a GLP-1 analog) (63.2%) (Esposito et al., 2012). Of the insulin varieties, the highest proportion of diabetic patients who achieved the HbA1C target of <7% were those using basal bolus insulin (50.2%) (Esposito et al., 2012). While there are some concerns about the ability of diabetic patients with chronic kidney disease to clear metformin via renal excretion, extensive clinical experience supports its use in diabetic patients with mild to moderate renal impairment (Inzucchi et al., 2014). From the cost effectiveness studies, lifestyle modification (i.e., changes in diet and exercise) beginning at any age was determined to be a cost-effective approach in preventing and treating DM and may be cost saving for adults between the age of 25 to 44 (Herman et al., 2005). Screening for DM beginning at age 45 and repeating every three years if negative provides the best balance of effectiveness and cost effectiveness (Kahn et al., 2010). As a first-line clinical intervention, metformin was established to be cost-effective as well in treating DM (but less so compared to lifestyle modification) (Herman et al., 2005). Bariatric surgery for diabetics with a BMI greater than or equal to 35 kg/m2 has also been established as cost effective (Hoerger et al., 2010). Next, in considering the ideal frequency of clinical consultations, diabetics with a stable condition (assessed as HbA1c ≤7.5%, blood pressure ≤145 mmHg, and total cholesterol ≤201 mg/dL) can safely be seen by a primary care provider every six months compared to every three months with no noticeable decline in long-term health outcomes (Wermeling et al., 2014). For cases of T2D that cannot be simply controlled with metformin, sulfonylurea has shown that it is overall more cost-effective and effective as a second-line therapy when compared to DPP-4 inhibitors and GLP-1 analogs (Zhang et al., 2014). Cost effectiveness analysis of the long-acting analogue insulin detemir across different countries reveals substantially different cost effectiveness for the medication in terms of both nominal and purchasing power terms (Home et al., 2014). The results of these studies were parsed to establish a long-term clinical protocol for primary care providers in screening, diagnosing, and treating type 2 diabetes. Future studies should focus on integrating cost effectiveness and comparative effectiveness research in implementing even more nuanced clinical decisions through a structured protocol. The cost effectiveness of existing and new interventions--both clinical and non-clinical in nature--will also need to be continuously assessed to ensure that the measurements incorporate the most accurate set of assumptions on costs and effectiveness.

Projektet har utförts i samarbete med Schur Pack Sweden AB Kumla, som tillverkar förpackningar till bland annat livsmedelsindustrin. Avsaknaden av efterkontroller av utgående leveranser har orsakat reklamationer. För att kunna kontrollera de utgående leveranserna hade företaget ett önskemål om att införa kvalitetskontroller, detta via standarden SS 02 01 30. Projektet har genomförts med hjälp av etablerade kvalitetsverktyg utvecklat för denna typ av projekt. Studiebesök, möten, intervjuer samt tester har lett till att fel som kan orsaka reklamationer, så kallade feltyper, identifierats och sammanställts till en lista med tillhörande felkvotsvärden. Projektet har resulterat till att en rutin har tagits fram med instruktioner för kvalitetskontroller av utgående produkter. Företaget har efter det genomförda projektet de grundläggande förutsättningarna som krävs för att börja arbeta efter standarden SS 02 01 30. / This project has been taking place at Schur Pack Sweden in Kumla, which manufactures packaging for the food industry. The lack of existing quality control on outbound deliveries has led to complaints. In order to check outbound deliveries, the company had a desire to introduce quality controls, this through a standard named SS 02 01 30. This project has been performed by a method that is established in quality management, developed for this kind of project. To find out what failure that may appear on the products has meetings, study visits and a pilot study been performed. The project has resulted in a routine developed with instructions for quality checks of outbound products, with associated lists of failure types. After that this project is done, the company will have the knowledge to be able to act by the standard SS 02 01 30.