Ordem para não reanimar? Aspetos éticos de uma decisão de vida

Trabalho final de mestrado integrado em Medicina (Ética Médica), apresentado à Faculdade de Medicina da Universidade de Coimbra.Objetivos – Cerca de 40 anos após a primeira tomada de decisão de não reanimar (DNR) não existe um padrão quanto à sua aplicação no exercício da Medicina. Face ao elevado número de doentes em fase terminal, entre o encarniçamento terapêutico e a medicina paliativa, a DNR constitui um assunto válido e apropriado, mas que levanta muitas questões. O presente trabalho pretende, com base na literatura existente, rever os aspetos clínicos e, a partir destes, abordar os aspetos éticos, particularmente, da DNR em doentes oncológicos, promovendo oportunamente uma reflexão acerca de questões de fim de vida Métodos – Revisão da literatura, nomeadamente de artigos científicos, a partir da base de dados online PubMed. Incluem-se, também, pareceres, obras, convenções e diplomas legais como fontes bibliográficas. Resultados – Foca-se o papel do médico nas questões de fim de vida, segundo os princípios da beneficência e da não maleficência, e a autodeterminação do doente, segundo o princípio do respeito pela sua autonomia. Abordam-se ainda os limites da intervenção terapêutica e aplicação de recursos distributivos face à DRN, segundo o princípio da justiça. Por fim, destaca-se a reflexão em torno da ética das virtudes, integrando-a na aplicação dos princípios hipocráticos. Conclusões - A DNR não constitui matéria consensual, dada a delicadeza que é abordar questões acerca do fim de vida. Assim sendo, é muito importante que se aposte na formação específica nestas áreas, desde logo nas escolas médicas, e se promova a sua discussão clínica e ética, para que a abordagem da DNR possa vir a ser transversal e a sua realização criteriosa e clara.Objectives - Nearly 40 years after the first do-not-resuscitate order, there is no standard regarding its application in the practice of Medicine. Given the high number of terminally ill patients, between the medical futility and palliative care, the do-not-resuscitate order is a valid and appropriate subject, but raises many questions. Based on existing literature, this paper aims to review the clinical and ethical aspects, particularly of the do-not-resuscitate order in cancer patients, opportunely promoting reflection about end of life issues. Methods - Literature review, namely scientific articles from the online database PubMed. Other literature sources used were opinion documents, books, conventions and legislation. Results - The role of the physician in end of life issues is focused on, according to the principles of beneficence and non-maleficence, and the self-determination of the patient, according to the principle of respect for their autonomy. It also reflects on the limits of therapeutic intervention and application of distributive resources due to the do-not-resuscitate orders, according to the principle of justice. Finally, the reflection stands out around the ethics of virtues, integrating it in applying the Hippocratic principles. Conclusions - The do-not-resuscitate order is not a consensual subject according to the delicacy that is to discuss about end of life questions. It is therefore very important to bet on specific training in medical schools and promote their clinical and ethical discussion, so that the do-not-resuscitate discussions may become transverse and its fulfillment careful and clear

Pesquisa de público no Museu Histórico e Cultural de Jundiaí-Jundiaí, São Paulo, SP, Brasil

SIAM. Series Iberoamericanas de Museología. Año 3, Vol.

Insulinoma canino: abordagem diagnóstica e terapêutica

O presente relatório foi realizado no âmbito do estágio curricular do Mestrado Integrado em Medicina Veterinária da Universidade de Évora e contém duas componentes. A primeira integra um resumo da casuística acompanhada pela estagiária no Centro Hospitalar Veterinário do Porto ao longo de seis meses, desde 1 de setembro de 2021 até 28 de fevereiro de 2022. A segunda diz respeito a uma monografia acerca do insulinoma canino, seguida da descrição de um caso clínico acompanhado durante o estágio, referente a esta patologia. Os insulinomas são os tumores pancreáticos endócrinos mais comuns em cães. Nestes, as células neoplásicas produzem e secretam insulina, originando situações de hiperinsulinémia e hipoglicemia que podem ser fatais. O diagnóstico é desafiante devido à presença de sinais clínicos e alterações laboratoriais geralmente inespecíficos. A intervenção cirúrgica é frequentemente recomendada e só assim é possível obter a confirmação diagnóstica; Canine Insulinoma: Diagnostic and Therapeutic Approach Abstract: This report was written within the frame of the curricular internship of the integrated master’s degree in Veterinary Medicine of University of Évora and comprises two parts. The first includes a summary of the caseload followed by the intern during the six month internship held in Centro Hospitalar Veterinário at Porto, between September 1st, 2021 and February 28th, 2022. The second contains a monography about canine insulinoma followed by the description of a clinical case, witnessed by the student during the internship and related to this pathology. Insulinomas are the most common pancreatic endocrine tumors in dogs. The neoplastic cells produce and secrete insulin, leading to situations of hyperinsulinemia and hypoglycemia that can be life-threatening. The diagnosis is challenging due to the presence of nonspecific clinical signs and laboratory findings. Surgical intervention is often recommended and it is the only way to get a definitive diagnosis

The impact of wind turbine noise on health

info:eu-repo/semantics/publishedVersio

Use of a High-Power Laser for Wound Healing: A Case Report

Introduction: The use of low-level laser therapy (LLLT) to treat wounds and accelerate tissue healing has been extensively studied in recent years. The aim of this article is to describe a clinical case using an unfocused high-power laser instead of a low-power laser for therapy. Case Report: In the present article, we present the use of a high-power diode laser to treat an extensive knee injury that occurred after surgical treatment for total prosthesis due to border ischemia resulting from prolonged use of autostatic retractors. Conclusion: It is possible to use an unfocused high-power laser at a decreased intensity to accelerate healing as an adjuvant in the treatment of complicated wounds. This procedure results in reduced application time and cost and an excellent tissue response pattern similar to that reported in the literature with low-power lasers

Acoustics and Biological Structures

Within the context of noise-induced health effects, the impact of airborne acoustical phenomena on biological tissues, particularly within the lower frequency ranges, is very poorly understood. Although the human body is a viscoelastic-composite material, it is generally modeled as Hooke elastic. This implies that acoustical coupling is considered to be nonexistent at acoustical frequencies outside of the human auditory threshold. Researching the acoustical properties of mammalian tissue raises many problems. When tissue samples are investigated as to their pure mechanical properties, stimuli are not usually in the form of airborne pressure waves. Moreover, since the response of biological tissue is dependent on frequency, amplitude, and time profile, precision laboratory equipment and relevant physiological endpoints are mandatory requirements that are oftentimes difficult to achieve. Drawing upon the viscoelastic nature of biological tissue and the tensegrity model of cellular architecture, this chapter will visit what is known to date on the biological response to a variety of different acoustic stimuli at very low frequencies

Flowering, fruit production and quality of passion fruit hybrids in Minas Gerais, Brazil

The aim of this work was to characterize flowering aspects, as well as to evaluate the agronomic performance and fruit quality of the main sour passion fruit hybrids. The experimental design was randomized blocks with four replicates and five treatments, consisting of the following commercial hybrids: ‘FB300-Araguary’, ‘FB200-Yellow Master’, ‘BRS Gigante Amarelo, ‘BRS Sol do Cerrado’ and ‘BRS Rubi do Cerrado’ and the experimental unit consisted of three plants. Phenological characterization and the aspects related to flowering were performed through visual observations of the beginning and duration of the events. Hybrid production was determined by weighing all fruits harvested during the production period. For physical and physicochemical variables such as fruit mass, peel mass, seed mass, pulp mass, peel yield, seed yield, pulp yield, peel thickness, number of seeds, longitudinal diameter, transverse diameter, fruit shape, were evaluated, peel firmness, peel and pulp color, pH, total soluble solids, total titratable acidity and TSS/TTA ratio were evaluated. The beginning of flowering and harvesting was 02/22/19 and 04/22/2019, respectively. All studied hybrids had similar production and yield responses, with ideal physical characteristics for processing or fresh consumption.  The aim of this work was to characterize flowering aspects, as well as to evaluate the agronomic performance and fruit quality of the main sour passion fruit hybrids. The experimental design was randomized blocks with four replicates and five treatments, consisting of the following commercial hybrids: ‘FB300-Araguary’, ‘FB200-Yellow Master’, ‘BRS Gigante Amarelo, ‘BRS Sol do Cerrado’ and ‘BRS Rubi do Cerrado’ and the experimental unit consisted of three plants. Phenological characterization and the aspects related to flowering were performed through visual observations of the beginning and duration of the events. Hybrid production was determined by weighing all fruits harvested during the production period. For physical and physicochemical variables such as fruit mass, peel mass, seed mass, pulp mass, peel yield, seed yield, pulp yield, peel thickness, number of seeds, longitudinal diameter, transverse diameter, fruit shape, were evaluated, peel firmness, peel and pulp color, pH, total soluble solids, total titratable acidity and TSS/TTA ratio were evaluated. The beginning of flowering and harvesting was 02/22/19 and 04/22/2019, respectively. All studied hybrids had similar production and yield responses, with ideal physical characteristics for processing or fresh consumption

Estimulação espinhal transcutânea por corrente directa na modulação da excitabilidade do sistema motor

Tese de mestrado, Neurociências, Universidade de Lisboa, Faculdade de Medicina, 2016Introdução: A medula espinhal é uma estrutura complexa, que contém circuitos neuronais próprios, complexos, que estão sob a influência de centros superiores, mas que mantêm relevante autonomia, sendo que os mesmos estão envolvidos em diversos processos patológicos. Recentemente, tem surgido um elevado interesse no estudo de técnicas que possam modular a resposta dos circuitos medulares, em particular pela aplicação de correntes percutâneas de baixa intensidade aplicadas em períodos temporais prolongados, a estimulação transcutânea por corrente directa (tsDCS). Estes estudos seguem historicamente a extensa investigação no uso destas mesmas correntes na modulação da resposta cortical, o que tem sido explorado em diversas condições clínicas, desde a reabilitação às doenças psiquiátricas, incorporando as doenças do movimento e a epilepsia - a estimulação transcraniana por corrente directa (tDCS). Sendo a tsDCS uma técnica recente compreende-se que na literatura os resultados publicados sejam muito diversos na metodologia e nos resultados, embora promissores quanto ao potencial desta técnica na modulação das complexas respostas fisiológicas da medula espinhal. Objectivo: Dado ser a tsDCS uma técnica recente e os resultados já publicados inconsistentes, o nosso principal objectivo foi o de verificar o impacto desta técnica nas respostas motoras medulares, pela aplicação de uma metodologia rigorosa, em particular, evitando viés na observação dos resultados por parte do investigador. Para tal, decidimos pela aplicação da tsDCS na região lombar, uma topografia menos investigada. Metodologia: Realizámos um estudo cross-over, duplamente cego e pseudorandomizado, em que foi aplicado tsDCS durante 15 minutos (Sham, anódica e catódica) distribuída ao nível de L2 (2.5 mA, 15 min, 0.001 A/cm2 e carga total de 90 C/cm2) em 15 sujeitos saudáveis. Por estimulação distal do nervo tibial posterior direito com captação da resposta motora no músculo abductor hallucis e por estimulação proximal do nervo tibial posterior direito com captação da resposta motora no músculo solhar foram estudados os seguintes parâmetros: amplitude e latência da onda M; latências (mímima, média e cronodispersão), frequência e amplitudes das Ondas F; e limiar, razão H/M, latência e curva de recrutamento do reflexo H. Por estimulação magnética transcraniana da área motora do membro inferior, foram estudadas: o limiar, as amplitudes motoras (razão MEP/M), e latências das respostas com captação no abductor hallucis direito; e o período silêncio cortical (com o sinal rectificado e não-rectificado) da resposta no músculo tibial anterior direito. Foi ainda avaliada a resposta simpática cutânea plantar direita obtida por estimulação eléctrica súbita, intensa e distal quer no nervo tibial posterior esquerdo quer no nervo mediano esquerdo, com registo da amplitude e da latência. Foram aplicados métodos estatísticos paramétricos e não-paramétricos com correcção de Bonferroni para comparações múltiplas, um valor de p0.05 após correcção de Bonferroni). Discussão: O observado aumento das latências das Ondas F associa-se, provavelmente à imobilidade de cerca de 90 minutos que decorria para os sujeitos durante o protocolo experimental. No entanto não podemos excluir algum efeito da redução na temperatura cutânea, cerca de 1-2ºC. Relativamente à estabilidade dos restantes parâmetros, acreditamos que possa derivar das características do protocolo experimental utilizado em relação às características fisiológicas do sistema motor. Conclusão: Concluímos assim que o protocolo utilizado de tsDCS aplicado, de forma a modular os neurónios motores lombo-sagrados, não condiciona alteração da resposta aos estímulos empregues. Futuros estudos requerem protocolos sólidos sustentados em modelos computacionais.The spinal cord is a complex structure that contains its own neuronal circuits, also complex, under the influence of higher centers. These circuits keep a relevant autonomy and can be involved in many different pathological conditions. Recently, has been growing the interest in the study of technicals that can modulate the output of the spinal circuits, in particular through the application of percutaneous currents of lower intensity delivered over long time – transcutaneous direct current stimulation (tsDCS). These studies follow the extensive research about the use of direct current in cortical excitability modulation – transcranial direct current stimulation (tDCS). This technique has been explored in rehabilitation and in many clinical conditions, like epilepsy, psychiatric and movement illness. Being the tsDCS a new tool, there are different methods and results in literature, but promising about the potential modulation of physiological outputs of the spinal cord. Aim: The primordial aim of this study was to observe the impact of this tool in the motor spinal responses by rigorous methodology, due double blind investigation. We decided to deliver tsDCS on lumbar region, a topography less investigated. Methods: To further explore tsDCS-induced changes in motor spinal responses, we examined, in a double-blind crossover pseudo-randomized study, during which tsDCS was delivered for 15 minutes (anodal, cathodal, and sham) at the L2 level (2.5 mA, 15 min, 0.001 A/cm2; 90 C/cm2) in 15 healthy subjects.Through distal stimulation of the right posterior tibial nerve, with the recorded motor response in the abductor hallucis muscle and by proximal stimulation of the same nerve with recorded motor response of the solear muscle, were study the following parameters: M-wave amplitude and latency; F-Wave latency (minimum, mean and chronodispersion), frequency and amplitude of the F- Wave; H-reflex threshold, ratio H/M, latency and the stimulus-response curves of the soleus H-reflex, before and after the current offset. With transcranial magnetic stimulation on motor area of the lower limb, were study: the motor threshold, the motor amplitude (ratio MEP/M) and the latency of the responses at right abductor hallucis; and the silence cortical period (rectified and non-rectified) of the right anterior tibial muscle response, before and after the current offset.It was also measured the sympathetic sudomotor response plantar of the right side the sympathetic right plantar cutaneous response achieved by sudden, intense and distal electrical stimulation - either in the left posterior tibial nerve, either in the left median nerve - with recording of the latency and amplitude. Were applied parametrics and non-parametrics statistics methods with Bonferroni correction for multiples comparisons. In all tests, statistical significance was assumed if p0.05 after Bonferroni correction) Discussion: The increment of the latency in the F wave is probably due to the 90 minutes where the subjects were mobilized during the experimental protocol. However we cannot exclude any effect by cutaneous temperature decrement, about 1 to 2ºC. In relation to stability of the remaining neurophysiologics parameters, we believe that they can be due to the experimental protocol features, in relation to physiologic characteristics of the motor system. Conlusion: We concluded that the protocol applied, using tsDCS to modulate the lumbarsaccral motor neuron, doesn’t change the response of delivered stimulus. Future studies should have more solid protocols, sustained in computational models of the current density distribution