INTRODUÇÃO: A deglutição é um processo complexo que se inicia ainda no período intra-uterino e deve ser funcional em neonatos saudáveis nascidos a termo. A etiologia da disfagia orofaríngea em crianças é multifatorial. A presença de cardiopatia congênita, bem como fatores relacionados à sua evolução e tratamento está entre os fatores de risco para ocorrência de disfagia orofaríngea na infância. A incidência de cardiopatia congênita é de seis a dez a cada 1000 nascidos vivos e estima-se que 25% dos acometidos necessitam de cirurgia no primeiro ano de vida. Os recentes avanços na medicina aumentaram a expectativa de vida nesta população, contudo observam-se necessidades especiais nos sobreviventes, entre elas, relacionadas à alimentação. Estima-se que 22% a 50% dos cardiopatas congênitos submetidos à cirurgia cardíaca apresentem distúrbios na alimentação. OBJETIVO: identificar os preditores clínicos do risco para broncoaspiração em crianças com cardiopatia congênita no pós-operatório de cirurgia cardíaca. MÉTODOS: foi realizado um estudo retrospectivo observacional, por meio da análise de dados de crianças entre 1 a 12 meses de idade, submetidas a procedimentos cirúrgicos cardíacos, encaminhadas para avaliação fonoaudiológica e avaliadas com oferta de líquido fino em mamadeira. A coleta de dados envolveu: dados demográficos e clínicos, avaliação específica da deglutição (Protocolo de Avaliação da Disfagia Pediátrica) e classificação do risco de mortalidade cirúrgica (Escala de Risco Ajustado para Cirurgia em Cardiopatias Congênitas RACHS-1). RESULTADOS: a amostra final consistiu de 108 sujeitos. Para análise estatística os sujeitos foram agrupados de acordo com a gravidade da disfagia: 27 no grupo com disfagia orofaríngea leve (DOL) e 81 no grupo com disfagia moderada a grave ou grave (DOMG/G). Foi observado que os sinais mais graves de disfagia estão associados a um aumento do tempo de internação hospitalar (p = 0,005); aumento do número e tempo de intubação orotraqueal (p = 0,022 e 0,005, respectivamente); um aumento do tempo entre a admissão hospitalar e a avaliação fonoaudiológica (p = 0,003); um aumento do tempo entre o procedimento cirúrgico e a avaliação de deglutição (0,043); e um maior número de sessões fonoaudiológicas para retirada da via alternativa de alimentação e garantir uma alimentação oral segura (p < 0,001). Além disso, pacientes com DOMG/G estão mais propensos a receber alta hospitalar sem resolução do quadro de disfagia. Não foram observadas correlações entre o risco de mortalidade cirúrgica e os sinais alterados na avaliação de deglutição. CONCLUSÕES: Em um serviço com alta demanda de pacientes para assistência fonoaudiológica, pacientes no pósoperatório de cirurgia cardíaca com tempo prolongado de internação, histórico de intubação orotraqueal prolongada ou maior número de intubações, e uso prolongado de via alternativa de alimentação deveriam ser priorizados / INTRODUCTION: Swallowing is a complex process that begins in the uterine period and should be functional in healthy newborns at term. The etiology of oropharyngeal dysphagia in children is multifactorial. The presence of congenital heart disease, as well as factors related to its evolution and treatment are among the risk factors for the occurrence of oropharyngeal dysphagia in childhood. The incidence of congenital heart disease is six to ten per 1000 live births and it is estimated that 25% of those affected need surgery in the first year of life. Recent advances in medicine have increased life expectancy in this population, however special needs are observed in survivors, including those related to food. It is estimated that 22% to 50% of congenital heart patients undergoing cardiac surgery present feeding disorders. PURPOSE: to identify clinical predictors of risk for bronchoaspiration in children with congenital heart disease in the postoperative period of cardiac surgery. METHODS: a retrospective observational study was performed, through data analysis of children between 1 and 12 months of age, who underwent cardiac surgical procedures, referred for speech-language evaluation and evaluated with a thin liquid bottle. Data collection included: demographic and clinical data, specific swallowing evaluation (Pediatric Dysphagia Evaluation Protocol) and surgical mortality risk score (Risk Adjustment for Congenital Heart Surgery 1). RESULTS: the final study sample consisted of 108 patients. For statistical purposes, patients were grouped according to dysphagia severity: 27 patients with mild dysphagia (MD) and 81 patients with moderate-severe and severe dysphagia (MS/SD). Important findings were: the more severe signs of dysphagia are associated to an increased length of hospital stay (p = 0.005); an increased number and duration of orotracheal intubation (p = 0.022 and p = 0.005 respectively); an increased time between hospital admission and swallowing assessment (p = 0.003); an increased time between the surgical procedure and swallowing assessment (p = 0.043); an increased time between the swallowing assessment and the clinical outcome (p = 0.028); an increased number of speech-language pathologist sessions until the clinical outcome (p = 0.001); and an increased number of speech-language pathologist sessions to remove alternate feeding methods and warrant safe oral feeding (p < 0.001). Moreover, patients with MS/SD are more likely to be discharged from hospital without resolving dysphagia. No correlations were observed between the infant\'s risk of mortality and the altered sings on the clinical swallowing assessment. Conclusion: In a hospital with a high demand for patients for speech therapy, patients in the postoperative period of cardiac surgery with prolonged hospitalization, history of prolonged orotracheal intubation or greater number of intubations, and prolonged use of alternate feeding methods should be prioritized

This study examines college students, studying their final year of their bachelors’ in social work at Gävle Collage, Sweden, and their aspirations for their future after graduating. The students are immigrants to Sweden and they come from less fortunate family backgrounds. As the results demonstrate, the family background of the students and their collage experiences, shape their aspirations. To demonstrate this, the study draws to the anthropological research of Arjun Appadurai (2004). He argues that the individuals’ capacity to aspire is a navigational capacity, which is determined by the individuals access to various resources. My results show that despite the students’ difficult backgrounds, they have developed the resources to confidently orient their future. A further analysis suggests that the students’ aspirations, despite their less fortunate backgrounds, are reasonable in today’s Swedish society. / Studien uppmärksammar högskolestudenter, som läser sista året på ett socialvetenskapligt kandidatprogram på Gävle högskola, och deras förhoppningar för framtiden. Studenterna har utländsk bakgrund och kommer från resurssvagare uppväxtförhållanden. Studieresultaten visar att studenternas förhoppningar för framtiden både formas efter studenternas uppväxtförhållanden och deras erfarenheter från utbildningen. För att illustrera detta, jämförs studenternas förhoppningar för framtiden med antropologisk forskning av Arjun Appadurais (2004). Appadurai menar att individers förhoppningar om framtiden formas efter hennes tillgänglighet till olika resurser. Mina resultat visar att studenterna, trots sina resurssvagare bakgrunder, har under utbildningen tillgodogjort sig nya resurser om hur de ska möta sin framtid.  Avslutningsvis föreslår studien att studenternas förhoppningar för framtiden, trots deras svagare förutsättningar, är sannolika i dagens Sverige.

Objetivo: Caracterizar os aspectos funcionais de deglutição na população com trauma cranioencefálico (TCE) de um hospital de grande porte, considerando as características clínicas e a gravidade dos indivíduos no momento da admissão hospitalar, utilizando sistemas prognósticos usualmente aplicados no ambiente das unidades de terapia intensiva. Métodos: Participaram do estudo 113 adultos, admitidos em um hospital terciário, com diagnóstico de TCE, submetidos à avaliação fonoaudiológica à beira-leito. As etapas de coleta de dados envolveram: a avaliação fonoaudiológica clínica do risco de broncoaspiração, determinação do nível funcional da deglutição (American Speech-Language-Hearing Association National Outcome Measurement System), determinação da gravidade do indivíduo de acordo com a Escala de Coma de Glasgow no momento da avaliação fonoaudiológica, Sequential Organ Failure Assessment (SOFA) no momento da admissão na Unidade de Terapia Intensiva e no dia da avaliação fonoaudiológica. Foram realizadas duas análises com a mesma população: análise 1- de acordo com a gravidade do TCE, análise 2- de acordo com a funcionalidade da deglutição. Resultados: Indicaram que as pontuações baixas na Escala de Coma de Glasgow têm relação com o aumento do tempo de intubação orotraqueal e na piora da funcionalidade da deglutição na avaliação fonoaudiológica. Houve associação entre o maior tempo de intubação, maior tempo de hospitalização, maior número de atendimentos fonoaudiológicos até a reintrodução da dieta via oral e pior funcionalidade da deglutição. A tosse e o escape extraoral foram os sinais clínicos preditores de broncoaspiração no TCE. Após a intervenção fonoaudiológica, o grupo com pior Glasgow apresentou piores resultados na evolução da funcionalidade da deglutição. Em relação ao escore SOFA, os sistemas orgânicos respiratório, cardiovascular e neurológico foram as principais alterações encontradas na população com TCE. É importante entender os mecanismos do TCE nos aspectos neurológico, cognitivo e comportamental para poder utilizar as melhores estratégias na identificação dos indivíduos com pior funcionalidade da deglutição e com necessidade de terapia fonoaudiológica precoce. Conclusão: Ao estabelecer os parâmetros clínicos que podem prever os aspectos relacionados à funcionalidade da deglutição durante a internação hospitalar, é possível auxiliar no gerenciamento e planejamento da reabilitação / Objective: to characterize the swallowing functional aspects in the severe traumatic brain injury (TBI) population in a large hospital considering the clinical features and the subjects\' severity at the moment of hospital admission adopting prediction models usually applied in the intensive care unit environment. Methods: 113 adults participated in the study; they were admitted at a tertiary referral hospital with a TBI diagnosis and were submitted to a bedside speech-language assessment. The data collection steps included: a clinical speech-language assessment for risk of bronchoaspiration, determination of swallowing functional level (American Speech-Language-Hearing Association National Outcome Measurement System), determination of individual\'s severity according to the Glasgow Coma Scale at the moment of the speech-language assessment, Sequential Organ Failure Assessment (SOFA) at the moment of admission at the intensive care unit and on the day of the speech-language assessment. Two analyses were carried out with the same population: analysis 1 - according to the trauma severity, analysis 2 - according to the swallowing functionality. Results: The results indicated that low scores in the Glasgow Coma Scale are related to higher orotracheal intubation time and worsening of swallowing functionality in the speech-language assessment. There was a link between higher intubation and hospitalization periods, higher number of speech-language therapies until the reintroduction of oral diet and worse swallowing functionality. Cough and extraoral escape were found as clinical risk factors for bronchoaspiration in the TBI. After the speech-language intervention, the group with worst Glasgow presented worst results in the swallowing functionality progress. With regard to the SOFA score, the respiratory, cardiovascular and neurological organic systems were the main alterations found in the TBI population. It is important to understand the TBI mechanisms in the neurological, cognitive and behavioral aspects to adopt the best strategies in the identification of the subjects with worst swallowing functionality and in need of early speech-language therapy. Conclusion: By establishing the clinical parameters that may foresee aspects related to the swallowing functionality during hospitalization, it is possible to help in the management and planning of rehabilitation

Os nódulos de tireoide são frequentemente encontrados na prática clínica e, com o auxílio de ultrassonografia de alta resolução, podem ser identificados em 17 a 67% da população. A alta prevalência desses nódulos causa preocupação frequente aos pacientes e aos clínicos devido ao risco de malignidade, o que, por sua vez, leva a investigações laboratoriais de alto custo, invasivas e, eventualmente, a cirurgias desnecessárias. A punção aspirativa com agulha fina (PAAF) é o método diagnóstico pré-operatório mais preciso para identificação de um nódulo maligno de tireoide, mas não consegue excluir malignidade nos casos de citologia inadequada, nódulos com diagnóstico citológico de lesão folicular ou atipia de significado indeterminado e nas citologias sugestivas de neoplasia folicular. O objetivo deste estudo foi analisar as características clínicas, laboratoriais, ultrassonográficas e citológicas de uma população de pacientes com nódulos de tireoide submetidos a tireoidectomia e a relação entre estes achados e o risco de malignidade. Além disto, em relação aos nódulos malignos, verificar se o valor de TSH esteve associado a um estadiamento mais avançado da doença. Foram avaliados prontuários de 353 pacientes submetidos a tireoidectomia, acompanhados no Hospital das Clínicas da FMUSP de São Paulo, no período de fevereiro de 2002 a abril de 2010. O número total de nódulos nestes pacientes foi 392. As características clínicas e laboratoriais analisadas em cada paciente foram idade, sexo, valores séricos de TSH e T4 livre, presença de anticorpo anti-tireoperoxidase (anti- TPO) e anti-tireoglobulina (anti-TG). Foram avaliadas a presença de características ultrassonográficas sugestivas de benignidade (presença de halo periférico hipoecoico, aparência espongiforme, aspecto isoecóico ou hiperecoico) e de malignidade (nódulo sólido hipoecoico, contornos irregulares, presença de microcalcificações). Baseados nestas características, os nódulos foram classificados em benignos, indeterminados e suspeitos para malignidade. O diagnóstico citológico foi classificado em benigno, indeterminado, suspeito e maligno, e a análise combinada das características ultrassonográficas e citológicas também foi avaliada. Ao exame histopatológico, 200 nódulos eram malignos e 192 nódulos eram benignos. Os nossos resultados mostraram que sexo, idade, valores séricos de TSH e T4 livre e presença de anticorpo anti-TPO e anti-TG não estiveram associados a uma maior chance de malignidade. O valor de TSH sérico também não esteve associado a maior risco de recorrência ou estadiamento mais avançado nos pacientes com câncer Os nódulos maiores estiveram mais associados a benignidade quando avaliamos toda amostra. Na análise multivariada de toda amostra, após regressão logística, apenas a citologia maligna, hipoecogenicidade e presença de microcalcificações foram associados a malignidade. Já, a classificação ultrassonográfica que não se baseia em apenas uma característica mas em um conjunto de características, apresentou um alto valor preditivo de benignidade e foi útil na identificação de nódulos com citologia indeterminada. A classificação ultrassonográfica tem o potencial de reduzir o número de cirurgias para nódulos com citologia indeterminada / Thyroid nodules are often encountered in clinical practice, and with the use of high-resolution ultrasound may be identified in 17 to 67% of the population. The high prevalence of these nodules cause frequent concern to patients and clinicians due to the risk of malignancy, wich in turn leads on costly investigations, use of invasive diagnostic methods and sometimes unnecessary surgeries. Fine needle aspiration biopsy (FNAB) is the most accurate preoperative diagnostic method to identify a malignant thyroid nodule. However, FNAB cannot rule out malignancy in cases of inadequate cytology, follicular lesions, atypia of undetermined significance, and in cytology suggestive of follicular neoplasm. The aim of this study was to analyze clinical, laboratory, ultrasound and cytopathologic characteristics of a group of patients with thyroid nodules undergoing thyroidectomy and the relationship between serum levels of TSH and the risk of malignancy. In nodules found to be malignant in this cohort, we analyzed the association of TSH levels with advanced disease stage and risk of recurrence. We analyzed the records of 353 patients who were followed at Hospital das Clínicas - São Paulo Medical School, between February 2002 and April 2010, and who subsequently underwent thyroidectomy. The total number of nodules in these patients was 392. The clinical and laboratory characteristics included in the analysis were age, gender, serum levels of TSH and free T4, and presence of serum thyroid anti-peroxidase (anti-TPO) and anti-thyroglobulin (anti-TG) antibodies. We evaluated the presence of ultrasonographic features suggestive of benignity (isoechoic or hyperechoic appearance, presence of hypoechoic peripheral halo, spongiform appearance) and malignancy (hypoechoic appearance, irregular border, presence of microcalcifications). Based on these ultrasonographic characteristics, we classified the nodules as benign, indeterminate or suspicious for malignancy. According to the FNAB cytology, we also subdivided the nodules into benign, indeterminate, suspicious and malignant. The combined analysis of ultrasonographic features and cytopathology was also evaluated. On histopathology, 200 nodules were malignant and 192 were benign. Our results showed that gender, age, serum levels of TSH and free T4, as well as the presence of anti-TPO and anti-TG were not associated with increased risk of malignancy. Similarly, serum TSH value was not associated with increased risk of recurrence or more advanced stage in patients with thyroid cancer. A large nodule size was associated with benignity. In multivariate analysis, after logistic regression, only malignant cytology, hypoechoic appearance and presence of microcalcifications were associated with malignancy. Furthermore, the ultrasonographic classification, wich was not based in only one feature but in a set of characteristics, showed a high predictive value for benignity and seems to be useful in identifying nodules with indeterminate cytology at risk for malignancy. The use of ultrassonographic classification has the potential to reduce the number of surgeries for nodules with indeterminate cytology

No description available.

The dissertation, with a collected papers approach, focused on evaluating the implementation of MI curriculum in high school Biology I classes in south Florida. The dissertation included the development and validation of the Biology Identity and Persistence Survey (BIPS), the connection of instructors’ teaching practices with students’ biology identities, evolution identities, and career aspirations, and the connection of instructors’ teaching practice with students’ conceptual understanding in evolution. In the first part of the dissertation study, the BIPS was validated through expert review and student cognitive interviews for its face and content validity. Confirmatory factor analysis addressed the construct validity of the final version of the BIPS, after removing four problematic items. The Cronbach’s alpha and test-retest reliability analysis indicated that the BIPS was a reliable instrument in terms of its internal reliability and stability. In the second part of the dissertation study, the comparison between the MI and non-MI classes indicated that there was no detectable significant difference between the MI classes and non-MI classes in students’ development of biology identities and evolution identities, and shifts in career aspirations. Using the analysis of the MI and non-MI instructors’ teaching practices, it was suggested that the use of intentional lack of inquiry closure, seeding, small-group collaboration, whole-class discussion, and Socratic questioning might contribute to students’ biology/evolution identity development. In the third part of the dissertation study, the Evolution Concept Inventory was demonstrated as an invalid and unreliable research instrument. Qualitative analysis of instructors’ teaching practices suggested that interactions between MI instructional materials and MI pedagogical techniques, including student-centered teaching, small-group collaboration, student-student interaction, whole-class discussion, and Socratic questioning, might contribute to students’ gain of conceptual understanding in evolution. On the basis of the research findings, this dissertation provided suggestions for high school biology MI instructors and high school biology MI workshops.

Purpose: The purpose of this thesis is to investigate Stena Metall’s values and how they are communicated within the organization. Background: In the Fall of 2008, the world was shocked by the worst financial crisis in decades. The crisis had deep effects on the Swedish economy, and many companies suffered heavily. The recycling and environmental service company Stena Metall experienced their first negative result in 30 years, and 900 employees had to leave the company. An action program, including an altered culture was established with the purpose to adapt the operations to the new business environmental conditions. Values, which are a part of the organizational culture, were decided to be an important part of the change. To implement these in the entire organization a well-structured communication process is needed. Within these subjects; values and communication, a qualitative study at Stena Metall has been conducted. Method: To fulfill the purpose, a qualitative method has been used. Thirteen interviews were conducted to collect data from different levels of the organization. The interviews were designed differently based on the employee’s level of responsibility in the organization. The theoretical framework used when analyzing the empirical material includes earlier research in the areas of culture, with emphasis on values, and communication. Conclusion: Two set of values have been identified, core values and aspiration values. The findings indicate a gap in the communicational process at Stena Metall. Part of the new information communicated about Stena Metall´s values is lost on its way from the management to the lower levels in the organization. The perception of what the values mean, both core and aspiration values, differs depending on level in the organization.

本研究旨在以理工科系大學生為樣本，探討並建構家庭社經地位、成就抱負與預期薪資之理論模型。研究以胡悅倫（2008）建構之資料庫為樣本，抽取1,084名理工科系大學生為研究對象，以變異數分析、卡方考驗及結構方程模式建構其路徑關係模式。研究結果顯示： 一、家庭社經地位對個體的成就抱負與預期薪資有正向的影響。父母職業聲望和教育程度較高者有較高的成就抱負和預期薪資。 二、家庭社經地位會透過成就抱負為中介，間接影響個體的預期薪資。 三、男女性在成就抱負上無顯著差異，但在預期薪資中男性的預期薪資會高於女性的預期薪資。 四、男性會進入男性化職業，女性會進入女性化職業。 五、預期進入男性化職業工作者的預期薪資高於進入女性化職業的工作者，而這樣的差距是跨性別存在。 最後，研究者根據研究結果提出建議，供實務工作者與後續研究者參考。 / The purpose of this study is to investigate and build a model on how family socioeconomic status affects achievement aspiration and anticipated salary. Participants are 1,084 Science and Engineering students from the database compiled by Yueh-Luen Hu (2008). Data analysis includes one-way ANOVA, t-test, chi-square test, and structural equation modeling. Results of the study are as follows: 1. Family socioeconomic status had significant positive effects on achievement aspiration and anticipated salary. Participants who are of higher socioeconomic status also had higher achievement aspiration and anticipated salary. 2. Achievement aspiration acted as a mediator between family socioeconomic status and anticipated salary. Achievement aspiration had significant indirect effects on anticipated salary. 3. The gender differences in achievement aspiration are non-significant. However, Men’s pay expectations are higher than of the women’s. 4. Males prefer to enter male-dominated jobs, while females prefer to enter female-dominated jobs. 5. Those who hold female-dominated jobs expect to gain less pay than those pursuing male-dominated jobs. The gap exists for both men and women. Results of the study shall serve as a point of reference for future researches.

<p><strong>Purpose: </strong>The purpose of this thesis is to investigate Stena Metall’s values and how they are communicated within the organization.</p><p><strong>Background: </strong>In the Fall of 2008, the world was shocked by the worst financial crisis in decades. The crisis had deep effects on the Swedish economy, and many companies suffered heavily. The recycling and environmental service company Stena Metall experienced their first negative result in 30 years, and 900 employees had to leave the company. An action program, including an altered culture was established with the purpose to adapt the operations to the new business environmental conditions. Values, which are a part of the organizational culture, were decided to be an important part of the change. To implement these in the entire organization a well-structured communication process is needed. Within these subjects; values and communication, a qualitative study at Stena Metall has been conducted.</p><p><strong>Method: </strong>To fulfill the purpose, a qualitative method has been used. Thirteen interviews were conducted to collect data from different levels of the organization. The interviews were designed differently based on the employee’s level of responsibility in the organization. The theoretical framework used when analyzing the empirical material includes earlier research in the areas of culture, with emphasis on values, and communication.</p><p><strong>Conclusion: </strong>Two set of values have been identified, core values and aspiration values. The findings indicate a gap in the communicational process at Stena Metall. Part of the new information communicated about Stena Metall´s values is lost on its way from the management to the lower levels in the organization. The perception of what the values mean, both core and aspiration values, differs depending on level in the organization.</p>

Darbų apžvalgoje nagrinėjami sergamumo skydliaukės vėžiu pokyčiai Lietuvoje 1978 – 2003 metais bei sergamumo sąsajos su diagnostika. Sergamumas skydliaukės vėžiu Lietuvoje 1978-2003 metais didėjo ir vidutinis metinis pokytis vyrams siekė 4,2% (p<0,0001), o moterims - 6,1% (p<0,0001). Standartizuotas vyrų sergamumo rodiklis padidėjo nuo 0,7 atvejo 100 000 gyventojų 1978 metais iki 2,5 atvejo 100 000 gyventojų 2003 metais, o moterų – atitinkamai nuo 1,5 iki 11,4 atvejo 100 000 gyventojų. Mirtingumas nuo skydliaukės vėžio nagrinėjamu laikotarpiu nepakito. Nustatytas papilinės skydliaukės karcinomos padidėjimas 1978 – 2003 metų laikotarpiu. Didžiausią įtaką susirgimo skaičiaus pokyčiams turėjo skydliaukės vėžio atvejai diagnozuoti ankstyvosiose stadijose. Žymų sergamumo skydliaukės vėžiu padidėjimą 2002-2003 metais Lietuvoje galima susieti su pokyčiais skydliaukės mazgų diagnostikoje, tobulesnių ultragarsinių technologijų panaudojimu bei aktyviu ultragarsu kontroliuojamų aspiracinių biopsijų plona adata pritaikymu klinikinėje praktikoje. / The aim of this study is to analyse changes in thyroid cancer incidence trends in Lithuania during the period of 1978–2003 and the relationship between incidence and diagnostic strategies. Annual percentage changes in the age-standardized rates over this period were 4.2% (p<0.0001) and 6.1% (p<0.0001) for men and women, respectively, for all carcinomas combined. During study period the age-standardized incidence rates increased in males from 0.7 to 2.5 cases per 100000 and in females from 1.5 to 11.4 per 100000. Mortality due to thyroid cancer did not change during the period of 1978–2003. By histopathology, number of papillary thyroid carcinoma cases increased in 1998-2003. Also, there was increase in the number of early stages of thyroid cancer. The increase in thyroid cancer incidence in Lithuania seems to be mainly due to the changes in the management of thyroid nodules and increased usage of ultrasound guided fine needle aspiration biopsy in clinical practice.