Dissertations / Theses on the topic 'Wound assessment'

This study was conducted to examine the unexplored area of surgical wound assessment and nurses’ expectations of a surgical wound assessment tool in Vietnamese hospitals. The identified research problem was then examined to develop a surgical wound assessment tool and to psychometrically test it and to identify whether this tool was suitable for use in Vietnam. Findings from this research project are the first step to confirm that the surgical wound assessment tool is reliable and valid for monitoring the status of surgical wound healing and detecting early factors that may increase the risk of surgical wound complications. The use of surgical wound assessment tool not only provides baseline data and beneficial information that can assist nurses to identify short and long-term goals of care but also acts as an educational tool to assist inexperienced wound care nurses to complete an accurate assessment.

Orientador: Neusa Maria Costa Alexandre
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Enfermagem
Made available in DSpace on 2018-08-25T10:29:43Z (GMT). No. of bitstreams: 1 Kaizer_UiaraAlinedeOliveira_M.pdf: 3272414 bytes, checksum: 532238ba510651e5d48be0d723dd5510 (MD5) Previous issue date: 2014
Resumo: Para a mensuração da qualidade de vida utilizam-se instrumentos de medida genéricos ou específicos. O Freiburg Life Quality Assessment ¿ Wound (FLQA-wk) é um questionário específico que analisa a qualidade de vida de pessoas com feridas, sendo composto por vinte e quatro itens e seis domínios: sintomas físicos, vida diária, vida social, bem-estar psicológico, tratamento e satisfação. Para a utilização de instrumentos de medida de forma válida e confiável esses instrumentos devem ser avaliados em relação às suas propriedades psicométricas. Estudos sobre a avaliação psicométrica de instrumentos de avalição de feridas no Brasil são escassos. Dessa forma, o objetivo dessa pesquisa foi avaliar as propriedades psicométricas do Freiburg Life Quality Assessment- wound (FLQA-wk) em pacientes queimados. Os dados foram obtidos por meio da entrevista a 100 sujeitos queimados de um Hospital de Referência do interior de São Paulo. A confiabilidade foi verificada por meio da consistência interna utilizando-se o alfa de Cronbach. A validade de constructo foi analisada pela validade convergente, correlacionando os resultados do instrumento com o Burns Specific Health Scale-Revised (BSHS-R), com o Instrumento abreviado de avaliação da qualidade de vida (WHOQOL-abreviado) e com a pontuação da escala visual analógica do Estado de Saúde e Qualidade de vida do FLQA-wk. A responsividade foi analisada comparando-se os resultados do escore total e as três escalas visuais analógicas do FLQA-wk considerando-se um intervalo de tempo de uma semana. Foi realizada análise descritiva para traçar o perfil dos participantes. Verificou-se a validade de constructo por meio do Coeficiente de correlação de Spearman e a responsividade por meio do teste da soma de postos sinalizados de Wilcoxon. Os resultados demostraram um alfa de Cronbach de 0,85 indicando alta precisão da medida. As correlações entre o FLQA-wk e os domínios do BHSH-R e do WHOQOL e das suas duas escalas visuais analógicas foram significativas (p < 0,05) e variaram de satisfatória a forte magnitude, sendo a maior parte delas negativas e de forte magnitude (-0,51 a -0,76). A responsividade mostrou-se satisfatória, pois houve mudanças após uma semana de intervenção terapêutica, com evidências de diferença estatisticamente significante. Portanto, o processo de avaliação das propriedades psicométricas do Freiburg Life Quality Assessment Wound em queimados evidenciou resultados satisfatórios que indicam qualidades psicométricas adequadas do questionário, permitindo assim que este possa ser utilizado em estudos de qualidade de vida com pacientes queimados como uma medida de avaliação de intervenções e tratamentos propostos, despertando o pensamento crítico sobre a qualidade da prática dos profissionais de saúde
Abstract: Generic or specific measurement tools are used to measure Quality of life. The "Freiburg Life Quality Assessment ¿ Wound" (FLQA-wk) is a specific questionnaire that evaluates the quality of life of whose people that live with wounds. This questionnaire has 24 items arranged in six domains: symptoms physical, daily life, social life, psychological well-being and treatment satisfaction. Before use a measurement questionnaire, it is important to have the psychometric properties evaluated in order to know if it is valid and reliable. Psychometric evaluation studies about wound assessment questionnaires are rare in Brazil. The aim of this study was to evaluate the psychometric properties of the Freiburg Life Quality Assessment- wound (FLQA-wk) in burned patients. We interviewed 100 burned patients in a Reference Hospital located in a São Paulo city. The reliability was assessment using the Cronbach¿s alpha to verify internal consistency. Convergent validity was used in order to verify the Construct validity: The results of FLQA-wk were compared with: the Burns Specific Health Scale-Revised (BSHS-R), The short quality of life assessment tool (WHOQOL-bref ) and with the FLQA-wk scale score of visual analogue Health Status and Quality of life. Considering a time interval of one week, we compared the total score results with the three visual analogue scales of FLQA-wk in order to evaluate the responsiveness property. Aiming to identify the subject profiles, we also performed the descriptive analysis. The construct validity was verified by Spearman¿s correlation coefficient and the responsiveness by the sum test of Wilcoxon Signed-Rank. The results showed a 0.85 for Cronbach¿s alpha which indicates high measurement accuracy. The correlations between FLQA-wk, BSHS-R, WHOQOL-bref and the two analogue scales were significant (p<0.05). They ranged from satisfactory up to strong magnitude. The most of them coefficiants negative and was strong (-0.51 to -0.76). The responsiveness property was satisfactory. There were statistically significant differences between the first and the second interview. It was expected since there were changes after a week of therapeutic intervention. Therefore, the psychometric properties evaluation process of the Freiburg Life Quality Assessment Wound among burned people showed satisfactory results. This indicates that this questionnaire is adequate and that it can be used in studies that evaluate quality of life of burned out patients. It can be a measurement tool to evaluate interventions and proposed treatments in order to arouse critical thinking about quality practices of the health professionals
Mestrado
Enfermagem e Trabalho
Mestra em Ciências da Saúde

Surgical site infection (SSI) is the most common healthcare-associated infection. Approximately 2% to 14% of surgical patients are diagnosed with SSI, which may extend length of stay in the hospital or lead to readmission and may necessitate another surgical procedure. Patient readmission due to SSI costs health care industries about $3,000 to $29,000 per case and a total of $10 billion per year. The purpose of this quantitative cross-sectional retrospective study was to examine the association between SSI and teaching status, hospital ownership, and number of beds in the hospital. The epidemiological triad was used as a framework to describe the relationship between the person (hospital is the unit of analysis), place (regional location), and time (one year of data). The dataset used in this study was retrieved from Centers for Medicare & Medicaid Services. A hospital was classified as having a high SSI rate if its rate was in the highest third. Contingency tables were used to test the relationships. The chi-square tests revealed that teaching hospitals were more likely to have high SSI rates than were nonteaching hospitals. Forty percent of teaching hospitals had high SSI rates compared to 26% of nonteaching hospitals (p < 0.001). Hospital ownership, bed size, and region were not significant predictors of high SSI rates. Findings from this study may lead toward further reductions in SSI by guiding infection control efforts toward hospitals with higher rates.

Non-healing wounds is a growing medical problem, often associated with pathological conditions such as diabetes and peripheral ischemia. A non-healing wound entails a large amount of suffering for the patient, and demands extensive health care resources. In this thesis, a new drug treatment paradigm for wound healing was developed by transforming Limosilactobacillus reuteri R2LC with a plasmid encoding CXCL12 (LB_CXCL12). The drug candidate was tested for safety and biological effects following topical administration to full thickness wounds in both mice and minipigs. In parallel, different techniques, including 2D and 3D measurements, planimetry, and ultrasound, for assessing wound healing were developed and evaluated.   Murine wounds treated with LB_CXCL12 demonstrated increased proliferation of dermal cells, and an increased density of macrophages of which a larger fraction expressed TGF-β. If macrophages were depleted prior to wounding, the accelerated effect on healing was abolished demonstrating a macrophage-dependent mechanism of action. Importantly, the LB_CXCL12 treatment also accelerated wound healing in mice with impaired healing as a result of hyperglycemia or peripheral ischemia, conditions that in humans are associated with development of non-healing wounds. Wounds in minipigs treated with the freeze-dried formulation of LB_CXCL12, upon resuscitation referred to as ILP100, showed accelerated healing both by increased granulation tissue formation and accelerated re-epithelialization. The treatment with ILP100 was well tolerated with no treatment-related deviations in haematology, urinalysis, and histopathology. Further, we found improved detection of thin layers if newly formed epithelial using planimetry and ultrasound compared to 2D photographs, whereas 3D scans accounting for surface curvatures yielded larger wound areas than 2D photographs of the same wounds.  Development of topical treatments for non-healing wounds are limited by the proteolytic environment of the wound that cause degradation of applied molecules. Our developed technology, a new-in-class candidate, overcomes this by continuous on-site delivery and increased bioavailability of CXCL12, resulting in prolonged instruction of local immune cells to stimulate wound healing.

The aim of this study was to differentiate Australian Centella species using morphological, genetic and phytochemical methods, and to evaluate their antiglycation and cell protection activities in relation to diabetic wound healing. The morphometric multivariate analysis successfully grouped the samples into three clusters: C. asiatica, C. cordifolia and C. erecta. Inter Simple Sequence Repeat (ISSR) genetic markers classified the samples according to the three species where C. erecta was the most genetically distinct. Multivariate chemometrics of HPTLC profiles of saponins and phenolics separated C. erecta from other two species. The total triterpene and phenolic content as well as chlorogenic acid were higher in C. cordifolia and lower in C. erecta. Ethyl acetate fraction of C. cordifolia exerted the most potent antioxidant and antiglycation activities. It ameliorated the MGO-induced inhibition of endothelial cells, fibroblasts and keratinocytes adhesion on extracellular matrix proteins. The results indicate that ISSR molecular techniques combined with morphological examination and phytochemical analysis are effective for quality assessment and systematic studies of Centella. These methods have enabled the differentiation of three Centella species in Australia. C. cordifolia is a potential candidate for further development as a medicinal product for diabetic wound healing.

Preclinical assessment procedures for wound dressings have been established with the clinical situation in mind, taking into account the important parameters of tensile mechanical properties, conformability to body surfaces, water vapour transmission rate (WVTR) and gaseous transmission (GTR) to 0₂ and CO₂. The mechanical (tensile) properties, the WVTR and the GTR's are measured by modified international standards. These are ASTM D882-81, ASTM E96-81 and BS 2782 respectively. The mechanical test is basically a uniaxial test taken to failure, from which the stress-strain characteristics and the ultimate strength of the material are determined. The WVTR is determined by measuring the rate of water loss from a container, covered with the dressing being evaluated, under controlled humidity conditions. Gaseous transmission, to both oxygen and carbon dioxide, is determined by the British Standard Vacuum technique. This method was used only for the assessment of the hydrophobic dressings. A liquid to gas technique was employed to assess the hydrophilic (water containing) dressings in respect to their transmission characteristics. Conformability is measured by an inflation test. At a pressure of 40 mmHg, a radius of curvature is calculated from the incremental change in height of the central point of a disc of the material under test. Viscoelastic tests were carried out to determine if any of the materials showed viscoelastic behaviour. These properties are of importance in the application of pretensioned dressings. A series of commercial and experimental materials were evaluated using the techniques described above. Some of the materials were assessed as a bi-laminate form, with a Mefix (adhesive bandage) top layer. Such a layer generally proved beneficial with regard to their possible clinical performance. Clinical studies were carried out for both in situ water vapour transmission and conformability. Such studies were carried out to provide a correlation between the laboratory and clinical situations. By providing an indication of possible clinical problems, preclinical assessment is of importance to clinicians and manufacturers.

Chronic venous leg ulcers are a detrimental health issue plaguing our society, resulting in long term pain, immobility and decreased quality of life for a large proportion of sufferers. The frequency of these chronic wounds has led current research to focus on the wound environment to provide important information regarding the prolonged, fluctuated or static healing patterns of these wounds. Disruption to the normal wound healing process results in release of multiple factors in the wound environment that could correlate to wound chronicity. These biochemical factors can often be detected through non-invasively sampling chronic wound fluid (CWF) from the site of injury. Of note, whilst there are numerous studies comparing acute and chronic wound fluids, there have not been any reports in the literature employing a longitudinal study in order to track biochemical changes in wound fluid as patients transition from a non-healing to healed state. Initially the objective of this study was to identify biochemical changes in CWF associated with wound healing using a proteomic approach. The proteomic approach incorporated a multi-dimensional liquid chromatography fractionation technique coupled with mass spectrometry (MS) to enable identification of proteins present in lower concentrations in CWF. Not surprisingly, many of the proteins identified in wound fluid were acute phase proteins normally expressed during the inflammatory phase of healing. However, the number of proteins positively identified by MS was quite low. This was attributed to the diverse range in concentration of protein species in CWF making it challenging to detect the diagnostically relevant low molecular weight proteins. In view of this, SELDI-TOF MS was also explored as a means to target low molecular weight proteins in sequential patient CWF samples during the course of healing. Unfortunately, the results generated did not yield any peaks of interest that were altered as wounds transitioned to a healed state. During the course of proteomic assessment of CWF, it became evident that a fraction of non-proteinaceous compounds strongly absorbed at 280 nm. Subsequent analyses confirmed that most of these compounds were in fact part of the purine catabolic pathway, possessing distinctive aromatic rings and which results in high absorbance at 254 nm. The accumulation of these purinogenic compounds in CWF suggests that the wound bed is poorly oxygenated resulting in a switch to anaerobic metabolism and consequently ATP breakdown. In addition, the presence of the terminal purine catabolite, uric acid (UA), indicates that the enzyme xanthine oxidoreductase (XOR) catalyses the reaction of hypoxanthine to xanthine and finally to UA. More importantly, the studies provide evidence for the first time of the exogenous presence of XOR in CWF. XOR is the only enzyme in humans capable of catalysing the production of UA in conjunction with a burst of the highly reactive superoxide radical and other oxidants like H2O2. Excessive release of these free radicals in the wound environment can cause cellular damage disrupting the normal wound healing process. In view of this, a sensitive and specific assay was established for monitoring low concentrations of these catabolites in CWF. This procedure involved combining high performance liquid chromatography (HPLC) with tandem mass spectrometry and multiple reaction monitoring (MRM). This application was selective, using specific MRM transitions and HPLC separations for each analyte, making it ideal for the detection and quantitation of purine catabolites in CWF. The results demonstrated that elevated levels of UA were detected in wound fluid obtained from patients with clinically worse ulcers. This suggests that XOR is active in the wound site generating significant amounts of reactive oxygen species (ROS). In addition, analysis of the amount of purine precursors in wound fluid revealed elevated levels of purine precursors in wound fluid from patients with less severe ulcers. Taken together, the results generated in this thesis suggest that monitoring changes of purine catabolites in CWF is likely to provide valuable information regarding the healing patterns of chronic venous leg ulcers. XOR catalysis of purine precursors not only provides a method for monitoring the onset, prognosis and progress of chronic venous leg ulcers, but also provides a potential therapeutic target by inhibiting XOR, thus blocking UA and ROS production. Targeting a combination of these purinogenic compounds and XOR could lead to the development of novel point of care diagnostic tests. Therefore, further investigation of these processes during wound healing will be worthwhile and may assist in elucidating the pathogenesis of this disease state, which in turn may lead to the development of new diagnostics and therapies that target these processes.

Aim - Veterinarians have frequently to deal with wounds to the skin, subcutis and underlying muscle. The aim was to explore the application of Hyaluronic Acid (HA) -containing dressing on open skin wounds in dogs. The progress of healing was assessed by wound area reduction and two scoring scales applied in human medicine. Materials and Methods - Ten client-owned dogs with 12 cutaneous open wounds healed by second intention were included. All wounds were treated using available in commerce HA-containing wound dressing from admission to complete re-epithelialization. At every clinical examination, wound area and scale scoring assessments were performed. Results - After debridement an increased wound size was obtained while an improvement was determined by both grading systems. The median numbers of return to clinic for bandage change was 5 times. The median time to complete wound healing was 34.5 days. The mean wound area at day 7,14,21 and 28 were respectively 90.4%, 47.7%, 22.4% and 14.8% of the original size (for linear measurement) and 95.5%, 54.4%, 23.10% and 14.8% of the original size (for software measurement). Regarding wound healing assessment tools, the agreement between two operators was considered high for both scales. Conclusions - HA-containing dressing may be a possible wound treatment for cutaneous open wounds in dogs. The assessment of wound quality using scale scoring system could be useful especially in the earlier healing period and to direct clinical decision-making process.

Published Article
In 2005 the third-year facilitators of the generic degree in nursing embarked on an action research initiative within a service learning pedagogy to revitalise the nursing process related to wound care.As a result of the action research a unique wound care project unfolded. This project embraced an integrated assessment approach in order to assess the competence related to wound care and to develop health care practitioners with generic- and field-specific competencies. Action research as mode of delivery for this project created an opportunity for producing Mode 2 knowledge where all participants contributed to the production of knowledge relevant to the wound care context.

Burn injuries are heterogeneous and dynamic problems. Accurate assessment and early intervention through calculation of the extent of the burn injury, implementation of cooling (first aid), and providing appropriate treatment of the wound, can limit progression of the burn injury and achieve wound healing. The aim of this clinically-based research was to validate the efficacy of the components of assessment and early intervention for burn injuries within New South Wales, Australia, and make recommendations for future burn care. The first study examined the accuracy of burn size estimation in a large series of adult burn injured patients that required retrieval and transfer to a specialised Burns Unit. Accuracy was found to be poor, and overestimation occurred at an alarming rate, indicating that current methods of burn size assessment are ineffective and should be challenged. The effect of cooling (first aid) as an early intervention was examined in a large series of both minor outpatient-based burns and severe burn injuries. Significant benefits were seen in a reduction in wound depth, body surface area burned, healing times, and decreased skin grafting requirements. These human cohort studies are the first to clinically corroborate landmark experimental animal studies. Practices of treating the acute burn wound were assessed by way of two clinical studies. Results indicated that multiple treatments are efficacious for the acute burn wound, and that perhaps the optimal treatment is prompt referral to the specialised Burns Unit where expertise in wound care and the use of bioengineered skin substitutes exists. This thesis has reviewed multiple phases of the assessment of and early intervention for burn injuries in New South Wales, Australia, and has provided a clinically-oriented evidence base for early burn care which was previously limited. Implications for clinical practice include novel methods to achieve definitive burn size calculation as well as further education of health care providers in hospital settings, global dissemination of first aid recommendations, and development of burn care models or pathways that involve early (within 12 hours) retrieval or transfer of partial thickness burn injuries to specialised Burn Units to facilitate burn wound treatment.

Whilst surgical procedures are considered safe, complications such as surgical wound dehiscence (SWD) may occur despite advances in surgical techniques, infection control practices and wound care. A SWD risk assessment tool was developed from identified risk factors based on a review of the literature and a retrospective case control study. A prospective clinical validation of the tool yielded a predictive power of 71% with an interrater reliability of 100%.

Orientador: Neusa Maria Costa Alexandre
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
Made available in DSpace on 2018-08-23T00:34:52Z (GMT). No. of bitstreams: 1 Domingues_ElaineAparecidaRocha_M.pdf: 4577350 bytes, checksum: f80761f458c94b4e1cb0e338f6cfcf63 (MD5) Previous issue date: 2013
Resumo: Feridas crônicas são aquelas que cicatrizam em um período superior a seis semanas e acometem milhões de indivíduos no mundo. A demora na cicatrização e o elevado índice de recidivas afetam a qualidade de vida do indivíduo com ferida. No Brasil há uma escassez de questionários específicos para analisar a qualidade de vida de pessoas com feridas de qualquer etiologia. Dessa forma, o presente estudo apresenta como objetivo adaptar o "Freiburg Life Quality Assessment - Wound" para a língua portuguesa do Brasil e avaliar suas propriedades psicométricas. A adaptação cultural foi realizada seguindo as etapas de tradução, síntese das traduções, retro-tradução, comitê de especialista, préteste e grupo focal. Participaram da pesquisa 200 indivíduos com idade média de 59 anos (±14,0), predominaram o sexo feminino (62%) e com maior frequência no ensino fundamental (48,2%) e com úlcera de etiologia venosa (45%). A confiabilidade foi avaliada pela consistência interna e estabilidade. O alfa de Cronbach foi de 0,86 e o teste reteste, apresentou uma elevada correlação de 0,92. A validade convergente foi obtida por meio da correlação dos domínios do índice de Qualidade de Vida Ferrans e Powers- versão feridas (IQVFP- VF) e com a pontuação de qualidade de vida da escala visual analógica (EVA). Os domínios do IQVFP- VF apresentaram correlações significativas, com valores entre -0,24 a - 0,48. Em relação a correlação com o escore de qualidade de vida da EVA o valor obtido foi de -0,38. Os resultados indicaram que a versão adaptada apresentou medidas psicométricas confiáveis e válidas para a população com feridas crônicas da cultura brasileira
Abstract: Chronic wounds are those that heal over six weeks period and affect million people all over the world. The healing delay and the high number of reappearance affect the quality of Life of the person with wounds. There is a lack of specific questionnaires in Brazil to analyze the quality of Life of people with wounds of any etiology. Thus, this study presents as object the adaptation of the "Freiburg Life Quality Assessment - Wound" to Brazilian Portuguese and assess its psychometric properties. The cultural adaptation was done following the translation steps, the summary of the translations, retro-translation, experts committee, pre-test and focal group. 200 people took part in the survey with an average of 59 years old (±14,0), the female gender prevailed with (62%) and with high school (48,2%) and with venous ulcers (45%). The reliability was evaluated for stability and internal consistency. The alpha of cronbach was of 0,86, and the test retest, presented a high correlation of 0,92. The convergent validity was obtained through the correlation of the domain of the Quality of Life index Ferrans and Powers- wounds version (IQVFP-VF) and with scores of quality of life visual analog scale (VAS). The domains IQVFP-VF showed significant correlations, with value between -0.24 to -0.48. Regarding the correlation with quality of life scores of the VAS value was - 0.38. The results indicated that the adapted version presented reliable and valid psychometrics measurements to the population with chronic wounds of the Brazilian culture
Mestrado
Enfermagem e Trabalho
Mestra em Ciências da Saúde

Chronic leg ulcers are a major health problem that affect 1-3% of adults over 65 and are a financial burden on healthcare systems worldwide. In this study biochemical assays were performed on sequential samples collected from both healing and non-healing ulcers. The results demonstrated that inflammatory resolution was necessary for ulcers to heal. Interestingly, in healing ulcers, proteins associated with dampening inflammation did not change over time whilst those keeping the wound in an inflammatory state decreased, suggesting an alternative mechanism for resolution of inflammation.

Recurring venous leg ulcers are a serious health problem and it is difficult to predict when they are likely to recur. This research discovered new predictors of recurrence and found a checklist developed to assist in identifying the person's level of risk of recurrence, to be accurate more than 70% of the time. Prevention of recurrence is important and knowledge about the likelihood of these ulcers recurring can assist in preventing this from happening. This research has contributed knowledge to a topic which has had little previous research and has provided evidence to be further examined in large studies.

Bone healing involves a variety of different cell types and biological processes. Although certain key molecules have been identified, the molecular interactions of the healing progress are not completely understood. Moreover, a clinical routine for predicting the quality of bone healing after a fracture in an early phase is missing. This is mainly due to a lack of techniques to comprehensively screen for cytokines, growth factors and metabolites at their local site of action. Since all soluble molecules of interest are present in the fracture hematoma, its in-depth assessment could reveal potential markers for the monitoring of bone healing. Here, we describe an approach for sampling and quantification of cytokines and metabolites by using microdialysis, combined with solid phase extractions of proteins from wound fluids. By using a control group with an isolated soft tissue wound, we could reveal several bone defect-specific molecular features. In bone defect dialysates the neutrophil chemoattractants CXCL1, CXCL2 and CXCL3 were quantified with either a higher or earlier response compared to dialysate from soft tissue wound. Moreover, by analyzing downstream adaptions of the cells on protein level and focusing on early immune response, several proteins involved in the immune cell migration and activity could be identified to be specific for the bone defect group, e.g. immune modulators, proteases and their corresponding inhibitors. Additionally, the metabolite screening revealed different profiles between the bone defect group and the control group. In summary, we identified potential biomarkers to indicate imbalanced healing progress on all levels of analysis.

Bone healing involves a variety of different cell types and biological processes. Although certain key molecules have been identified, the molecular interactions of the healing progress are not completely understood. Moreover, a clinical routine for predicting the quality of bone healing after a fracture in an early phase is missing. This is mainly due to a lack of techniques to comprehensively screen for cytokines, growth factors and metabolites at their local site of action. Since all soluble molecules of interest are present in the fracture hematoma, its in-depth assessment could reveal potential markers for the monitoring of bone healing. Here, we describe an approach for sampling and quantification of cytokines and metabolites by using microdialysis, combined with solid phase extractions of proteins from wound fluids. By using a control group with an isolated soft tissue wound, we could reveal several bone defect-specific molecular features. In bone defect dialysates the neutrophil chemoattractants CXCL1, CXCL2 and CXCL3 were quantified with either a higher or earlier response compared to dialysate from soft tissue wound. Moreover, by analyzing downstream adaptions of the cells on protein level and focusing on early immune response, several proteins involved in the immune cell migration and activity could be identified to be specific for the bone defect group, e.g. immune modulators, proteases and their corresponding inhibitors. Additionally, the metabolite screening revealed different profiles between the bone defect group and the control group. In summary, we identified potential biomarkers to indicate imbalanced healing progress on all levels of analysis.

Background: Silica is the common name for silicon dioxide (SiO2) materials and exists in both crystalline and amorphous forms. While crystalline silica is known for its severe health effects, amorphous silica has been considered safe and applied in many areas. However, some recent studies have showed evidence of their toxicity, raising concerns about its use as nanomaterial for biomedical applications. When nanomaterials enter the body, they are enveloped in biological fluids rich in biomolecules, which compete for binding to the nanomaterial. Such effect could alter their surface chemistry and therefore affect their bio-distribution and interaction with cells. Aim and objectives: As part of the EU-funded NANODRUG network programme, the aim of this project was the in vitro toxicity assessment of commercially-sourced fumed and colloidal amorphous silica particles in relation to their physico-chemical properties and potential application as carriers for drug delivery. The objectives were 1) characterization of silica particles hydrodynamic (Hd) size and dispersity in different cell culture media; 2) in vitro toxicological assessment of silica particles in human skin cells; 3) delineation of toxicity mechanisms in relation to their size; 4) assessment of the influence of Foetal Bovine Serum (FBS) on particle Hd size and toxicity; and 5) contributing to the overall objective of the NANODRUG programme - development of safe nanodrugs for skin application - through collaborations with different partners.

This study attempted to investigate the impact of new technology, specifically tele-advice on community nurses' care of leg ulcers. Firstly, a stratified randomised controlled study was designed to measure the impact of using this technology on their levels of wound knowledge and confidence. An individual self-test questionnaire and an attitudinal scale measured nurses' knowledge and confidence respectively both pre and post-intervention. Secondly, a new visual wound assessment tool was designed to represent the state of the wound by a single numerical value; the State of the Wound Index (SWI). Thirdly, the impact of nurses' knowledge, confidence and patient variables was explored to assess their impact on the state of the wound as represented by SWI. The sample consisted of thirty-eight registered primary care nurses from two local NHS trusts in South Wales and their corresponding 38 patients with venous leg ulcers. Nurses were stratified according to their qualifications into experimental or control groups. Both groups were shown to have comparable levels of knowledge and confidence pre-intervention. Nurses in the experimental group received expert tele-advice by a Clinical Nurse Specialist (CNS) over a 12 week period regarding the care of their patient's leg ulcer, whilst those in the control group continued to care for their leg ulcer patients in the traditional way. hi the experimental group, nurses' level of knowledge increased significantly (p=0.02) whilst no improvement was observed for the control group. In terms of confidence, the experimental group reached near significance when extremely positive statements were excluded with no improvement observed for the control group. Results show that the intervention had a positively significant impact on nurses' wound care knowledge and level of confidence. A set of 18 tele-transmittable wound factors was identified by a panel of wound experts. These factors were ranked by another independent panel of leg ulcer experts and no significance could be established in their order of importance. These factors were then examined for their highest and lowest possible estimates for every wound in the sample both pre and post intervention using a Visual Analogue Scale (VAS). These estimated values formed the basis for 95% confidence interval estimates from which 100 virtual nurse assessed values were generated. These values were then used to generate SWI. This new index ranged from 0 (best possible state) to 100 (worse possible) and was seen to reliably increase when the wound deteriorated and decrease as the wound improved. Linear regression models were built to establish the relationship between SWI, patient variables and nurses' knowledge and confidence levels pre and post-intervention. These indicated that knowledge and confidence can have a positive impact on the healing process. This study has shown that there is great potential for the use of tele-advice in community nurses' care of leg ulcers. For this to succeed, it is recommended that further pre and post registration nurse training is provided to enhance their knowledge in wound care, especially in the areas of physiology and wound assessment.

Esta pesquisa tem como objeto de estudo a análise do processo de acompanhamento dos clientes portadores de feridas na atenção primária do município de Angra dos Reis. Os objetivos são: verificar a existência de processo de acompanhamento de clientes portadores de feridas nas unidades de atenção primária do município de Angra dos Reis; analisar as dificuldades inerentes ao processo de acompanhamento de clientes portadores de feridas nas unidades de atenção primária do município de Angra dos Reis. O método foi descritivo, o tipo é de levantamento e de natureza quantitativa. O instrumento de coleta de dados foi o formulário, tendo como sujeitos do estudo a população de enfermeiros atuantes na atenção primária do município de Angra dos Reis e que assinaram o Termo de Consentimento Livre e Esclarecido, conforme disposto na Resolução 196/96 do Conselho Nacional de saúde. O cenário utilizado foi o município de Angra dos Reis. A pesquisa foi aprovada pelo Comitê de Ética em Pesquisa do Instituto de Medicina Social da UERJ, através da Plataforma Brasil em 28/06/2013. A análise demonstrou que mais de 93% dos enfermeiros realizam curativos durante sua atuação profissional na atenção primária, destes, 80% realizam algum tipo de acompanhamento de clientes portadores de feridas. Este acompanhamento nem sempre é contínuo, por contada dificuldade técnica do próprio profissional, da interrupção do fornecimento de materiais por parte do almoxarifado, da baixa adesão do cliente e da inexistência de uma rotina institucionalizada. A insuficiência de produtos disponíveis no município para a realização de curativos também foi um fator descrito pelos sujeitos como prejudicador no processo de acompanhamento destes pacientes. Foi verificado que a utilização de produtos de segunda geração para realização de curativos, quando indicados de forma correta e respeitando o prazo de troca, proporciona uma economia nos fastos do município no que se refere ao tratamento tópico de feridas, economia esta que pode chegar à metade dos gastos. Este estudo foi relevante para a otimização do processo de acompanhamento de clientes portadores de feridas no município, bem como reorganização defluxos, rotinas e do cuidado prestado.
This research aims to study the analysis of the monitoring of clients with wounds in primary care in the municipality of Angra dos Reis. The objectives are: to verify the existence of monitoring clients with wounds in primary care units of the municipality of Angra dos Reis process, to analyze the inherent difficulties in the monitoring clients with wounds process in the p primary care units of the municipality of Angra dos Reis. The method was descriptive, is the type of survey and quantitative nature. The instrument for data collection was the form, with the population of nurses working in primary care in the municipality of Angra dos Reis as subjects of study that signed the consent for, as defined in Resolution 196/96 of the National Council Health. The scenario used was the municipality of Angra dos Reis. The study was approved by Ethics Committee in Research of the UERJs Institute of Social Medicine by Brazil on 28/06/2013 Plataform. The analysis showed that more than 93% of nurses do dressing during their professional careers in primary care, of which 80% use some type of monitoring clients with wounds. This monitoring is not always continuous, due to the technical difficulty of the professional himself, the interruption of the supply of material from warehouse, the low adherence of the client and the lack of an institutionalized routine. The failure of products available in the county for holding dressings was also described by subjects as a factor that harms in clinical patient management process. It was found that the use of second-generation products to perform curative when given correctly and respecting the exchange term, provides a saving in expenditure of the municipality with regard to topical treatment of wounds, this economy that can reach the half of the expenses. This study was relevant for optimizing the treatment of clients with wounds in the city process and reorganization of flows and routines of the care provided.

Submitted by Erika Demachki (erikademachki@gmail.com) on 2015-05-07T20:24:41Z No. of bitstreams: 2 Dissertação - Queiliene Rosa dos Santos - 2014.pdf: 5935624 bytes, checksum: d66f43d89d744af5d9b6b18d6328e494 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5)
Approved for entry into archive by Erika Demachki (erikademachki@gmail.com) on 2015-05-07T20:26:47Z (GMT) No. of bitstreams: 2 Dissertação - Queiliene Rosa dos Santos - 2014.pdf: 5935624 bytes, checksum: d66f43d89d744af5d9b6b18d6328e494 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5)
Made available in DSpace on 2015-05-07T20:26:47Z (GMT). No. of bitstreams: 2 Dissertação - Queiliene Rosa dos Santos - 2014.pdf: 5935624 bytes, checksum: d66f43d89d744af5d9b6b18d6328e494 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2014-06-26
INTRODUCTION: Vascular ulcers are a major public health problem, affecting around 1% of the general population, with a higher prevalence among the aged. Treatment is time consuming and costly, they can cause physical, social, economic and emotional problems. They are considered complex and difficult to heal, have a high number of relapses, and most of them are critically colonized or infected. Service to people with vascular ulcers is challenging to both health professionals and the public administration by virtue of its complexity, including the absence of public policies for this population, structuring services, access to care, professional qualification, and appropriate resources. GENERAL OBJECTIVE: To analyze the outcomes of healthcare for people with vascular ulcers treated in the examination rooms of the primary care system from the perspective of the evolution of healing over a period of six months. METHODOLOGY: Analytic longitudinal study with nested cross-sectional studies, in the examination rooms of the public health service of the city of Aparecida de Goiania, Goias, Brazil, from August 2012 to October 2013. Population consists of users receiving treatment by nurses, and professionals who provided nursing care in the study setting. Data collection occurred through structured nonparticipant observation, interview, physical examination, and use of Pressure Ulcer Scale for Healing (PUSH), planigraphy of ulcers, and photographic record. Absolute frequencies and percentages were used for data collection. The study complies with guidelines for research ethics, being approved under protocol 085/2012. RESULTS: The three rooms designed to care for people with vascular ulcers in the studied scenario showed non-washable walls, windows not screened, without adequate hand hygiene resources, without proper procedures for cleaning and disinfection of the environment, and lack of essential resources and inconsistent supply thereof. As for users, there was gender parity, prevalence among 60 years or older, and social and economic conditions in the lower middle class and below. The majority had lesions for more than one year, which were usually painful. Microbiological examination showed predominantly Gram-negative rods, including Pseudomonas aeruginosa. Among professionals, most were females, aged between 18 and 36 years and "reasonable experience" in treating people with vascular ulcers. CONCLUSION: Conditions were inadequate for serving people with vascular ulcers and contribute to care not compliant with current recommendations, which creates a discontinuity of care and diminished capacity to resolve these issues. Therefore, it is necessary to structure the service with respect to people with chronic ulcers, and maintain supplies and appropriate resources for care.
INTRODUÇÃO: As úlceras vasculares constituem um importante problema de saúde pública, afetam em torno de 1% da população em geral, sendo mais presentes entre os idosos. Seu tratamento é demorado e oneroso. Podem acarretar problemas físicos, sociais, econômicos e emocionais. Consideradas feridas complexas e de difícil cicatrização, apresentam elevado número de recidivas, e, a maioria delas é colonizada criticamente ou infectada. A assistência a pessoas com úlceras vasculares constitui um desafio aos profissionais de saúde e para o poder público, em virtude de sua complexidade, que abrange ausência de políticas públicas voltadas para essa população, estruturação dos serviços, acesso ao atendimento, qualificação profissional, insumos apropriados. OBJETIVO GERAL: Analisar a resolutividade da assistência à saúde a pessoas com úlceras vasculares atendidas em salas de curativo da rede de atenção primária, na perspectiva de evolução da cicatrização no período de seis meses. METODOLOGIA: Estudo analítico longitudinal, com estudos transversais nele aninhados, nas salas de curativo da rede municipal de saúde de Aparecida de Goiânia, Goiás, Brasil, no período de agosto de 2012 a outubro de 2013. A população consiste de usuários que receberam atendimento de enfermagem e profissionais que prestaram o atendimento de enfermagem no cenário de estudo. A coleta de dados se deu por meio da observação estruturada não participante, entrevista, exame físico, utilização da Pressure Ulcer Scale for Healing (PUSH), planigrafia das úlceras e registro fotográfico. Para análise de dados utilizaram-se frequências absolutas e percentuais. O estudo atende às diretrizes de ética em pesquisa, sendo aprovado sob protocolo 085/2012. RESULTADOS: As três salas destinadas ao atendimento de pessoas com úlceras vasculares no cenário estudado apresentaram paredes não laváveis, janelas não teladas, sem recursos adequados à higienização das mãos, sem padronização adequada de higienização e desinfecção do ambiente e desabastecidas de insumos indispensáveis e com suprimento descontinuado. Quanto aos usuários, houve paridade de gênero, predominância entre os de 60 anos ou mais e condições sociais e econômicas compatíveis com as classes C e D. A maioria das lesões possuía duração superior a um ano e geralmente dolorosas. Ao exame microbiológico predominaram os bastonetes Gram-negativos, entre os quais Pseudomonas aeruginosa. Quanto aos profissionais, a maioria era do gênero feminino, com faixa etária entre 18 e 36 anos e “razoável experiência” no atendido a pessoas com úlceras vasculares. CONCLUSÃO: O cenário estudado não apresenta condições adequadas para atendimento a pessoas com úlceras vasculares e corroboram uma prática assistencial discordante com as recomendações atuais, o que implica na descontinuidade do cuidado e diminuição da resolutividade da assistência à saúde. Diante disso, é necessário estruturar o serviço voltado para pessoas com úlceras crônicas, qualificação profissional e manter insumos e recursos apropriados para atendimento.

The present study attempts to further define the neuropsychological characteristics associated with mild, moderate, and severe closed head injuries (CHI). The Dean-Woodcock Neuropsychological Assessment System (D-WNAS), a new neuropsychological battery, was administered to 119 CHI patients. The scores of the cognitive portion of the D-WNAS were then analyzed via cluster analysis in an attempt to further delineate neuropsychological impairment into more specific classifications occurring within types of brain trauma.Results suggested that the cognitive portion of the D-WNAS was effective in separating 4 subtypes within CHI, which are best interpreted as "profiles" or characteristics associated with "levels" of impairment. These levels of impairment were characterized by distinctly different subtest profiles, and were labeled as mild/high functioning, mild, moderate, and severe. The highest performing group, mild/high functioning, showed no neuropsychological deficits. The most severely impaired group was characterized by many deficits in short-term memory, visual stimuli, new learning, processing speed, visual-spatial abilities, abstract reasoning, attention/concentration, and remote memory tasks. A multivariate analysis showed that educational level was significant in differentiating between the subtypes and suggested that, depending on the severity of injury, educational level might also protect individuals from obtaining a poorer prognosis.From this investigation, the cognitive portion of the D-WNAS appears to offer valuable utility in identifying CHI patients and in further classifying their varied neuropsychological characteristics. Implications for diagnosing and differentiating between different levels or profiles of CHI was discussed.
Department of Educational Psychology

Thesis (MOccTher)--Stellenbosch University, 2014.
ENGLISH ABSTRACT: Introduction: This research was conducted to establish the assessment practices of occupational therapists working with clients with upper limb injuries and/or conditions. This was done to get an updated account of frequency and variation in the use of various assessment tools as well as reasons offered for infrequent use. Methodology: A quantitative cross-sectional survey design was used. A convenience sample of therapists attending courses was recruited for the study. A questionnaire was developed for the study and face and content validity established through pilot testing. The questionnaire consisted of three sections containing demographic information and questions about upper limb assessment practices. Descriptive statistics were calculated for numerical and categorical data to describe the demographic characteristics and to identify the measurement tools that were used most frequently. The Chi-Square test of associations was used to determine whether there were any associations between frequency of use and demographic factors. Results: Questionnaires were completed by 81 (71%) respondents. Twenty-two (27.2%) of the respondents had more than five years’ experience in the field of hand therapy while the remainder (n=52, 64.2%) had less than five years. The more experienced therapists worked in the private sector (n=49, 60.5%) with two (0.03%) experienced therapists being employed in the public sector. The diagnoses that were seen most commonly were nerve injuries (90.1%), fractures (88.8%) and tendon injuries (85.1%). Of the 81 respondents 15 (18.5%) held post graduate qualifications in the field of hand therapy. Goniometry (68 of 81, 84.0%), manual muscle testing (62 of 81, 76.5%) and testing for flexor digitorum profundus and superficialis function (61 of 81, 76.3%) were used most frequently. Performance tests were used infrequently or not at all. The most common reasons for non-use of performance tests were that they were not available in the practice setting or respondents were not familiar with them. Significant associations were found between frequency of using measurement tools and practice setting, years of experience and holding a post graduate qualification in the field of hand therapy. There was a significant association between working in the private sector and using a dynamometer (p < 0.001), and working in government settings and frequent use of the test for localisation (p = 0.021). Therapists with more than five years’ experience in the field of hand therapy were significantly more likely to use Semmes Weinstein monofilaments (p = 0.034) as were those holding a post graduate qualification in hand therapy (p <0.001). Conclusion: The results of this study have serious implications in terms of the upper limb assessment practices of occupational therapists, especially in the context of evidence-based practice which has become crucial not only for the credibility of the profession, but also for its survival. Information obtained through this research could aid to guide education and training at an undergraduate and post graduate level and assist to direct a research focus for hand therapy in the South African context.
AFRIKAANSE OPSOMMING: Inleiding: Hierdie navorsing is uitgevoer om die bepalingspraktyke van arbeidsterapeute wat werk met kliënte met boonste ledemaat beserings en/of toestande vas te stel om sodoende ‘n beeld te verkry van die frekwensie en variasie van die gebruik van bepalingsinstrumente. Redes aangebied vir ongereelde gebruik hiervan is ook ondersoek. Metode: 'n Kwantitatiewe deursnee-opname-ontwerp is gebruik. ’n Gerieflikheidssteekproef van terapeute wat kursusse bygewoon het, is gewerf vir die studie. ‘n Vraelys is ontwikkel vir die studie, en voorkoms- en inhoudsgeldigheid is bepaal deur ‘n loodstudie. Die vraelys het bestaan uit drie afdelings met demografiese inligting en vrae oor boonste ledemaat bepalingspraktyke. Beskrywende statistiek is bereken vir numeriese en kategoriese data ten einde die demografiese eienskappe te beskryf en die bepalingsmetodes wat die meeste gebruik is, te identifiseer. Die Chi-kwadraat toets is gebruik om te bepaal of daar enige assosiasies tussen die frekwensie van gebruik en demografiese faktore bestaan. Resultate: Vraelyste is deur 81 (71%) respondente voltooi. Twee-en-twintig (27,2%) van die respondente het meer as vyf jaar ondervinding in die veld van handterapie gehad, terwyl die res (n = 52, 64.2%) minder as vyf jaar gehad het. Die meer ervare terapeute het gewerk in die privaatsektor (n = 49, 60.5%) met twee (0,03%) ervare terapeute in diens van die staat. Senuweebeserings (90.1%), frakture (88,8%) en tendonbeserings (85.1%) was die meeste gesien. Van die 81 respondente het 15 (18,5%) ‘n nagraadse kwalifikasie in die veld van handterapie gehad. Goniometer (68 van 81, 84.0%), spiertoetsing (62 van 81, 76,5%) en die toetse vir fleksor digitorum profundus en superficialis funksie (61 van 81, 76,3%) is die meeste gebruik. Vaardigheidstoetse is selde of glad nie gebruik nie. Die mees algemene redes aangevoer vir die feit dat vaardigheidstoetse nie gebruik is nie, was dat dit óf nie beskikbaar is in die respondent se werksarea nie, óf dat respondente nie vertroud is met die toetse nie. Beduidende assosiasies is gevind tussen die frekwensie van die gebruik van bepalingsmetodes en werksarea, jare ervaring in handterapie en 'n nagraadse kwalifikasie in die veld van die handterapie. Daar was 'n beduidende assosiasie tussen terapeute werksaam in privaatpraktyk en die gebruik van 'n dinamometer (p < 0,001) en terapeute werksaam in die staat en gereelde gebruik van die lokalisasie toets (p = 0.021). Terapeute met meer as vyf jaar ondervinding, sowel as diegene met ’n nagraadse kwalifikasie in handterapie was beduidend meer geneig om Semmes Weinstein monofilaments te gebruik (p = 0,034 en p < 0,001 respektiewelik). Gevolgtrekking : Die bevindinge van hierdie studie het ernstige implikasies in terme van die arbeidsterapie bepalingspraktyke van die boonste ledemaat, veral in die konteks van bewys-gebaseerde praktykvoering (evidence based practice) wat noodsaaklik geword het nie net vir die geloofwaardigheid van die beroep nie, maar ook vir die oorlewing daarvan. Inligting wat verkry is deur middel van hierdie navorsing kan help met onderrig en opleiding op 'n voor-en nagraadse vlak. Dit kan ook help om navorsing in handterapie te rig binne die Suid- Afrikaanse konteks.

Thesis (M. Eng.)--Massachusetts Institute of Technology, Dept. of Materials Science and Engineering, 2007.
"September 2007."
Includes bibliographical references (p. 67-72).
As the number of individuals suffering from tissue loss and end-stage organ failure continues to grow, researchers are turning to tissue engineering to provide better methods of treatment. The field, however, still faces many technical challenges that are limiting its applications. One challenge faced in engineering more complex tissues and organs is the need for inherent microvasculature to supply the tissue with nutrients and oxygen. Researchers at The Charles Stark Draper Laboratory have developed a method for engineering microvascular networks in vitro using various microfabrication techniques. This paper discusses the current state of the research and technical challenges to overcome before commercializing the technology. The feasibility of using the networks in the nearer term application of treating chronic wounds will also be assessed, and a potential business strategy will be laid out.
by Connie Hong-Yee King.
M.Eng.

Ten caucasian male quadriplegics were compared with eight sedentary caucasian male controls in regards to left ventricular dimensions and mass obtained from echocardiograrns. The interventricular septum (IVS), left ventricular posterior wall (LVPW) and left ventricular internal diameter (LVII) were within normal limits for both groups. However, the INS in the SCI were significantly thicker than controls (p <0.05). Myocardial thickness was larger in SCI subjects (p <0.05). Absolute left ventricular mass (LVM) and total left ventricular volume was not different ( p > 0.05), but SCI subjects had significantly greater LVM to lean body mass ratios. Echocardiographically, SCI patients demonstrate concentric hypertrophy. This suggests adaptive response to chronic increase in afterload pressure secondary to their daily activities and muscle spasticity.

Muscle pain is felt during exercise or daily activities for several days after performing unaccustomed exercise, which is referred to as delayed onset muscle soreness (DOMS). Many people experience DOMS, but its underlying mechanisms are not fully understood. One of the challenges in the investigation of DOMS is its subjective nature, which makes the assessment ambiguous, thus establishing a standardised protocol is necessary. The present thesis scrutinised muscle pain assessments (Study 1, Study 2), developed a new assessment of muscle pain focusing on muscle fascia (Study 3), and investigated why DOMS is reduced after the second than the first bout of eccentric exercise (Study 4). From these studies, DOMS was thought to be more associated with connective tissue than muscle fibre damage and inflammation. In Study 1, the relationship between pain level assessed by a visual analogue scale (VAS) and pain sensitivity assessed by pressure pain threshold (PPT) was examined. Thirty-one healthy young men performed 10 sets of 6 maximal isokinetic eccentric contractions with their non-dominant arm. Before and 1 - 4 days after the exercise, muscle pain perceived upon palpation of the biceps brachii at three sites (5, 9, and 13 cm above the elbow crease) was assessed by VAS with a 100 mm line (0 = no pain, 100 = extremely painful), and PPT of the same sites was determined by an algometer. The VAS increased after exercise and peaked two days post-exercise, while the PPT decreased most at 1 day post-exercise and did not return to baseline for 4 days following exercise (P Muscle pain induced by elbow flexor eccentric exercise was investigated using different assessments in Study 2. Ten untrained men performed 10 sets of 6 maximal isokinetic eccentric contractions of the elbow flexors with one arm. Maximal voluntary isometric contraction torque (MVC), range of motion (ROM) and serum creatine kinase (CK) activity were measured before, immediately after, and 1 to 5 days after exercise as indirect markers of muscle damage. PPT of 50 sites over an exercised upper arm, VAS with a 100-mm line for pain level upon static pressure by a cuff and fingers, and palpation of the biceps brachii at three sites (3, 9, and 15 cm above the elbow crease) and different palpation methods (longitudinal, transverse and circular movements) on the mid-belly of biceps were assessed. Large decreases in MVC and ROM, and significant increases in serum CK activity indicated muscle damage. A significant difference (P In Study 3, changes in the electrical pain threshold (EPT) of the biceps brachii fascia, biceps brachii muscle and brachialis fascia following eccentric elbow flexor contractions, and the relationship between EPT and VAS or PPT were investigated. Ten healthy untrained men performed two eccentric exercise bouts (ECC1, ECC2) consisting of 10 sets of 6 maximal isokinetic eccentric contractions of the elbow flexors with the same arm separated by 4 weeks. Changes in MVC, ROM, VAS and PPT were smaller (P The purpose of Study 4 was to investigate the magnitude of muscle lengthening during the first and second bout of eccentric exercise bouts and whether the muscle length changes are associated with the magnitude of DOMS and changes in other indirect markers of muscle damages between bouts. Ten healthy untrained men performed two eccentric exercise bouts (ECC1, ECC2) consisting of 10 sets of 6 maximal isokinetic eccentric contractions of the elbow flexors using the same arm separated by 4 weeks. Changes in MVC, ROM, muscle thickness, ultrasound echo intensity, serum CK activity and muscle soreness (VAS) were smaller (P

Det är känt att ambulanspersonalens omhändertagande av barns smärta kan bli bättre. Akut smärta hos barn är en vanlig orsak till att barn söker ambulanssjukvård. Barn i för- skoleålder utgör en utmaning på grund av bristerna i den språkliga och kognitiva ut- vecklingen, som gör det svårt för dem att kommunicera kring sin egen smärta. Att ge- nomföra en adekvat smärtskattning hos barn är ett sätt att mäta deras smärta och därige- nom utföra en lämplig behandling, samt kunna utvärdera effekten av genomförd be- handling. Idag är VAS det vanligaste smärtskattningsinstrument som används i ambu- lansen, det är endast validerat från barn > 8 år. Syfte: Att undersöka hur smärtskattning av barn i åldrarna tre till sex år inom prehospital akutsjukvård genomförs och vilka för- utsättningar som finns för att genomföra smärtskattning. Studien är en integrativ littera- turstudie. Tio artiklar ingår i studien, åtta kvantitativa och två kvalitativa. Sökning efter vetenskapliga artiklar skedde i databaserna Pubmed, Cinahl och Embase. Artiklarna granskades med SBU:s granskningsmall. Resultatet visar på olika sätt hur ambulansper- sonal försöker förstå barns smärta, men att det i dagsläget finns mer att önska. Smärt- skattning kan utföras oftare men kunskap och erfarenhet saknas om hur och varför man ska smärtskatta. Behandlingsriktlinjer räcker inte för att öka frekvensen samt förbättra utförandet av smärtskattning. I ambulansmiljö saknas det validerade instrument till barn i  förskoleåldern. Förutsättningar för att använda validerade smärtskattningsinstrument visade sig vara kunskap och erfarenhet. Både personalen och verksamheten har ett an- svar för att skapa förutsättningar till smärtskattnings. Det för att öka chansen till en hållbar vårdrelation.

Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

Doctor of Philosophy
Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

The focus of this investigation was an analysis of the work demands being placed on South African automotive industry workers as there is a recognised problem with regard to the prevalence of musculoskeletal disorders (MSDs). Preliminary work was conducted to highlight the dominant risks and areas which elicited higher numbers of MSDs within the chosen automotive plant. An area of concern was highlighted through medical record analysis and the use of risk assessment tools, thereby prioritising the need for ergonomic intervention. In particular, the effects of varying restricted and overhead work heights on the biomechanical, physiological and psychophysical responses of an individual were investigated. Twenty-eight subjects were required to complete sixteen conditions. The conditions consisted of the adoption of restricted and upright overhead static postures, with half requiring the holding of four kilograms of weight in the hands and the remaining eight conditions having no weight. Testing was carried out using an electromyography unit, ergospirometer and a perceptual Body Discomfort Map and Scale. This involved a habituation and testing session. The results of the testing revealed the biomechanical and physiological responses were dependant on the change in height. Body discomfort was also shown to be variable over the changing height conditions. This indicates that there is a significant effect of height on an individual’s responses during overhead work. The extreme restricted (-200mm and -100mm) and upright (+300mm and +400mm) overhead conditions within this study were limiting, as they elicited the highest muscle activation, physiological responses and body discomfort ratings. Positions that are preferable to adopt, which were identified from the results in this study, indicate conditions closer to head height (0mm and +100mm) were favourable. The results therefore illustrate how awkward working postures during work are likely to elicit higher demands from an individual, which could lead to an increased risk for the development of a musculoskeletal disorder. The added factor of weight elicited significant results over all variables, excluding a respiratory The focus of this investigation was an analysis of the work demands being placed on South African automotive industry workers as there is a recognised problem with regard to the prevalence of musculoskeletal disorders (MSDs). Preliminary work was conducted to highlight the dominant risks and areas which elicited higher numbers of MSDs within the chosen automotive plant. An area of concern was highlighted through medical record analysis and the use of risk assessment tools, thereby prioritising the need for ergonomic intervention. In particular, the effects of varying restricted and overhead work heights on the biomechanical, physiological and psychophysical responses of an individual were investigated. Twenty-eight subjects were required to complete sixteen conditions. The conditions consisted of the adoption of restricted and upright overhead static postures, with half requiring the holding of four kilograms of weight in the hands and the remaining eight conditions having no weight. Testing was carried out using an electromyography unit, ergospirometer and a perceptual Body Discomfort Map and Scale. This involved a habituation and testing session. The results of the testing revealed the biomechanical and physiological responses were dependant on the change in height. Body discomfort was also shown to be variable over the changing height conditions. This indicates that there is a significant effect of height on an individual’s responses during overhead work. The extreme restricted (-200mm and -100mm) and upright (+300mm and +400mm) overhead conditions within this study were limiting, as they elicited the highest muscle activation, physiological responses and body discomfort ratings. Positions that are preferable to adopt, which were identified from the results in this study, indicate conditions closer to head height (0mm and +100mm) were favourable. The results therefore illustrate how awkward working postures during work are likely to elicit higher demands from an individual, which could lead to an increased risk for the development of a musculoskeletal disorder. The added factor of weight elicited significant results over all variables, excluding a respiratory individual.

[Truncated abstract] Controlled and automatic processing are broad categories, and how best to measure these constructs and their impact on functioning after mild traumatic brain injury (TBI) remains uncertain. The purpose of this thesis was to examine automatic and controlled processing aspects of attention after mild TBI using the Paced Auditory Serial Addition Task (PASAT) and event-related potentials (ERPs). The PASAT is one of the most frequently used tests to evaluate attentional functioning. It has been demonstrated to be a measure sensitive to both acute and longer-term effects of mild TBI, presumably due to demands for rapid processing and executive attentional control. ERPs provide a noninvasive neurophysiological index of sensory processing and cognitive functions and have demonstrated sensitivity to even minor cognitive dysfunction. The parameters provided by this functional technique may be those most likely to distinguish individuals with mild TBI from controls. Initially, it was hypothesized that successful novice PASAT performance requires the engagement of executive attention to establish novel controlled information processing strategies. Ten individuals who had suffered a mild TBI an average of 15.20 months previously were therefore expected to demonstrate processing abnormalities on the PASAT, relative to 10 healthy matched controls. Although the mild TBI group reported significant intensification of subjective symptoms since their injury, compared to controls, the mild TBI group provided a similar amount of correct PASAT responses. ... In the first experiment a visual search task consisting of an automatic detection and a controlled search condition was developed. In the second experiment the search task was performed concurrently with the PASAT task in a dual-task paradigm. In the mild TBI group, prior failure to establish more efficient forms of information processing with practice was found to significantly interfere with simultaneous performance of the PASAT task and the attention demanding condition of the search task. The pattern of impaired performance was considered to reflect a reduction in processing resources rather than a deficit in resource allocation. Dual-task performance in the control group was not associated with a large interference effect. In general, the results of this thesis suggest that individuals with mild TBI are impaired in their ability to progress from the stage of effortful controlled information processing to a stage of more efficient, automatic processing, and thus suffer a subtle attentional deficit. Following mild TBI, performance levels equivalent to controls may only be achieved with an abnormal expenditure of cognitive effort. As a result of the neuropathologic consequences of injury, individuals who have sustained a mild TBI are less able to benefit from practice, experience difficulty coping with simultaneous performance of secondary task, and are susceptible to distressing subjective symptomatology.

Orientador: José Irineu Gorla
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Educação Física
Made available in DSpace on 2018-08-27T17:57:13Z (GMT). No. of bitstreams: 1 Borges_Mariane_M.pdf: 1121036 bytes, checksum: 9b0d5cc7811b2bb052eac8f395a8074e (MD5) Previous issue date: 2015
Resumo: Pessoas com Lesão na Medula Espinhal (LME) apresentam importantes alterações na composição corporal (CC), como o aumento da massa gorda e redução da massa magra. O monitoramento destas alterações através da avaliação é preponderante tanto para se atingir o desempenho esportivo desejado quanto para a saúde destes indivíduos. No entanto, ainda não existe um consenso sobre métodos de campo confiáveis de avaliação da CC nesta população e existe uma variedade de técnicas para uso em laboratório, que dificulta a proposta de indicadores referenciais. Desta forma, os objetivos do presente estudo foram verificar os principais métodos e alterações da CC em indivíduos com LME através de uma revisão de literatura; verificar o perfil da CC de atletas de handebol e rugby em cadeira de rodas com LME e analisar a aplicabilidade do método de pregas cutâneas em comparação aos resultados obtidos pela densitometria óssea (DXA). Para se atingir o primeiro objetivo os estudos relevantes para a revisão foram levantados nas bases de dados Pubmed e Science Direct até maio de 2014. Sendo que foram incluídos 38 estudos, destes, 29 estudos utilizaram como método de analise da CC a densitometria óssea, considerado um método válido para a análise da CC nesta população. Quanto aos métodos de campo, os estudos indicam que o IMC e as equações de predição subestimam a gordura corporal nesta população já a circunferência abdominal e a relação cintura-quadril podem predizer a gordura visceral e risco de doenças cardiovasculares. No que tange às alterações na composição corporal os estudos apontaram para um aumento significativo da massa (MG) e diminuição da massa magra (MM) corporal e regional devido à inatividade física e atrofia causada por desuso nos membros paralisados. A fim de verificar o perfil da CC de atletas com LME participaram deste estudo 12 indivíduos sendo, oito atletas de rugby em cadeira de rodas com tetraplegia e quatro atletas de handebol em cadeira de rodas com paraplegia. Desta forma pode-se observar acúmulo de gordura na região do tronco e de membros inferiores, sendo que a massa corporal (r=0,75, p=0,00) e o tempo de lesão (r=0,73, p=0,00) se mostraram influenciadores do acúmulo de gordura na região do tronco. A fim de analisar a aplicabilidade do método de pregas cutâneas verificou-se a relação entre as variáveis antropométricas e da composição corporal (DXA) e em seguida as variáveis com correlação ? 0,70 (r) foram incluídas em modelos de regressão linear e as variáveis que apresentaram coeficiente de determinação R² ? 0,70, foram incluídas em gráficos de Bland Altman a fim de verificar a concordância entre os métodos. Desta forma, constatou-se que somente as pregas cutâneas biciptal (r²= 0,71, p= 0,00), subscapular (r²= 0,83, p=0,00) e abdominal (r²= 0,70, p= 0,00) mostraram-se possíveis preditoras da massa gorda do tronco por DXA. Portanto, no que se refere à população estudada, podemos identificar que aparentemente o método antropométrico de pregas cutâneas possui limitações de forma que não estima precisamente os componentes da composição corporal segmentar
Abstract: People with Spinal Cord Injury (SCI) show some changes in body composition (BC) profile, such as the increasing in fat mass and reduced lean body mass. The monitoring of this change by assessing is important both to achieve the desired performance sport for healthy such as individuals. However, there is still no consensus on reliable field assessment methods BC this population and there is a variety of techniques for laboratory use which hinders the proposed reference indicators. Thus, the objectives of this study were to check the main methods and changes of BC in individuals with SCI through a literature review; check the profile of BC handball athletes and rugby wheelchair with SCI and analyze the applicability of the skinfold thickness method of comparing the results obtained by bone densitometry (DXA). To achieve the first objective relevant studies for review were raised in Pubmed and Science Direct until May 2014. Being that were included 38 studies, of these, 29 studies used as BC method of analysis bone densitometry, considered a valid method for the analysis of BC this population. As for field methods, studies indicate that the BMI and the prediction equations underestimate body fat in this population already waist circumference and waist-to-hip ratio may predict visceral fat and risk of cardiovascular disease. Regarding the changes in body composition studies indicated a significant increase in fat mass and decreased lean mass and regional body due to physical inactivity and atrophy caused by disuse in paralyzed limbs. In order to verify the BC profile of athletes with SCI, participated in this study 12 individuals (eight quadriplegic wheelchair rugby athletes and four paraplegic wheelchair handball athletes). Therefore it can be observed accumulation of fat in the trunk and lower limbs and body mass (r = 0.75, p = 0.00) and time of injury (r = 0.73, p = 0.00) proved influencers of fat accumulation in the region trunk. In order to verify the applicability of the skinfold thickness there was a relationship between the anthropometric variables and body composition (DXA), and then the variables with correlation coefficients ? 0.70 (r) were included in the linear regression models and the variables that presented coefficient of determination R² ? 0.70 were included in graphs Bland Altman in order to verify the agreement between the methods. Thus it was found that only the skinfold thickness bicipital (r² = 0.71, p = 0.00), subscapular (r² = 0.83, p = 0.00) and abdominal (r² = 0.70; p = 0.00) were possible predictors of the trunk fat mass by DXA. Therefore, with regard to the study population, we identified that apparently the anthropometric method skinfold thickness has limitations so that not precisely estimates the components of the segmental body composition
Mestrado
Atividade Fisica Adaptada
Mestra em Educação Física

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2017-03-07T18:26:02Z No. of bitstreams: 1 Isabelle Andrade Silveira.pdf: 1744842 bytes, checksum: 517b4f56d05e86c90f2f3978129e864a (MD5)
Made available in DSpace on 2017-03-07T18:26:02Z (GMT). No. of bitstreams: 1 Isabelle Andrade Silveira.pdf: 1744842 bytes, checksum: 517b4f56d05e86c90f2f3978129e864a (MD5) Previous issue date: 2016
Mestrado Acadêmico em Ciências do Cuidado em Saúde
Introdução: O Leg Ulcer Measurement Tool é um instrumento desenvolvido no Canadá especificamente para avaliar úlceras de perna. Composto por 14 itens classificados como domínios avaliados clinicamente e 3 domínios avaliados pelo paciente. A primeira parte do instrumento avalia as características da lesão e a segunda parte avalia a intensidade e frequência da dor e a qualidade de vida. Objetivos: Traduzir e adaptar transculturamente o LUMT para língua portuguesa do Brasil; Validar o conteúdo do instrumento traduzido através do Comitê de Juízes; Avaliar a praticabilidade da versão final do instrumento em pacientes com úlceras de perna. Método: Pesquisa metodológica que seguiu as etapas de tradução e adaptação transcultural recomendadas por Guillemin, Bombardier e Beaton (1993), as quais incluem: tradução inicial; síntese das traduções; retrotradução; avaliação das versões por um comitê de juízes e a realização do pré-teste. O protocolo de pesquisa foi submetido ao Comitê de Ética em Pesquisa da Faculdade de Medicina da Universidade Federal Fluminense e aprovado sob o número 1.585.542, CAAE 56252216.2.0000.5243. Resultados: Na primeira etapa, foram realizadas duas traduções do instrumento e das instruções; na segunda etapa em uma reunião consensual com as duas tradutoras e as autoras desse estudo as discrepâncias entre as traduções iniciais foram resolvidas e gerada uma versão síntese; na terceira etapa, a versão síntese do instrumento e das instruções foram retrotraduzidas para o inglês por duas tradutoras independentes a fim de verificar a equivalência com a versão original e nenhuma destas apresentou discrepâncias importantes em relação ao instrumento original; na quarta etapa, um comitê de juízes analisou a versão síntese e as retrotraduções com relação à equivalência semântica e idiomática e julgou adequada a versão do instrumento em língua portuguesa; na quinta e última etapa o LUMT na língua portuguesa foi aplicado por enfermeiros em pacientes com úlceras de perna e avaliada sua praticabilidade na prática clínica, e o mesmo foi considerado apropriado e aplicável. Conclusão: Atingiu-se o objetivo proposto de realizar a tradução e adaptação transcultural do LUMT para a língua portuguesa do Brasil. Durante as etapas percorridas foi viável perceber a viabilidade da utilização do mesmo na realidade brasileira. Este estudo metodológico contribui para a área da saúde na disponibilização de um instrumento específico para avaliação de úlceras de perna e para a comparação de resultados internacionalmente de forma mais acurada e fidedigna, fortalecendo a homogeneidade dos dados coletados
Introduction: The Leg Ulcer Measurement Tool is a tool developed in Canada specifically to evaluate leg ulcers. Composed of 14 items classified as domains assessed clinically and 3 domains assessed by the patient. The first part of the instrument evaluates the characteristics of the lesion and the second part evaluates the intensity and frequency of pain and quality of life. Objectives: To translate and adapt culturally the LUMT into Portuguese of Brazil; Validate the instrument content translated through the Judges Committee; To evaluate the feasibility of the final version of the instrument in patients with leg ulcers. Method: Methodology research that followed the steps of translation and cultural adaptation recommended by Guillemin, Bombardier and Beaton (1993), which include: initial translation; synthesis of translations; back translation; evaluation of versions by a panel of judges and the pretest. The research protocol was submitted to the Ethics Committee of the Medical School of the Universidade Federal Fluminense and approved under number 1585542, CAAE 56252216.2.0000.5243. Results: In the first stage, there were two translations of the instrument and instructions; in the second stage in a consensus meeting with the two translators and the authors of this study the discrepancies between the initial translations were resolved and generated a summary version; the third step, the synthesis version of the instrument and instructions were back-translated into English by two independent translators to verify the equivalence with the original version and none of them was important discrepancies in the original instrument; the fourth stage, a committee of judges examined the synthesis version and back translations regarding the semantic and idiomatic equivalence and deemed appropriate instrument version in Portuguese; in the fifth and final stage, the LUMT in Portuguese was applied by nurses in patients with leg ulcers and assessed its feasibility in clinical practice, and it was considered appropriate and applicable. Conclusion: It was reached the proposed objective of performing the translation and cultural adaptation of LUMT into Portuguese of Brazil. During the covered steps it was possible to realize the feasibility of using the same in the Brazilian reality. This methodological study contributes to the health sector in the provision of a specific instrument for evaluating leg ulcers and to compare results internationally more accurately and reliably, strengthening the homogeneity of the data collected

Introdução: O Trauma and Injury Severity Score (TRISS) é considerado padrão ouro na análise de probabilidade de sobrevida do doente traumatizado, apesar de suas limitações. Vários têm sido os esforços na tentativa de torná-lo mais acurado, tendo em vista seu importante papel nos Programas de Melhoria de Qualidade em Trauma. Objetivos: Propor três novos ajustes à equação do TRISS e comparar suas performances com o TRISS e o TRISS-like originais e com esses índices e o NTRISS com coeficientes ajustados à população do estudo; identificar se a técnica de imputação múltipla aumenta a acurácia das equações derivadas de bancos de dados com perdas e comparar o desempenho dos novos modelos quando derivados e aplicados em diferentes grupos de vítimas traumatizadas. Método: Trata-se de um estudo multicêntrico, retrospectivo, com vítimas de trauma internadas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC FMUSP) e no Centro de Trauma da Universidade da Califórnia San Diego Medical Center (UCSD MC), no período de 1º de janeiro de 2006 a 31 de dezembro de 2010. As informações dos doentes foram agrupadas em Bancos de Dados Derivação e Teste, sendo o primeiro utilizado para derivar as equações e o segundo para validar as equações geradas. Os coeficientes dos modelos foram estabelecidos pela análise de regressão logística. A curva Receiver Operating Characteristics (ROC) foi utilizada para avaliar a performance dos modelos e o algoritmo de DeLonge et al. para comparar as áreas sob as curvas (AUC). Resultados: A casuística foi composta de 2.416 doentes do HC FMUSP (São Paulo, Brasil) e 8.172 participantes do UCSD MC (San Diego, EUA). Os novos modelos propostos foram o NTRISS-like, que incluiu as variáveis Melhor Resposta Motora (MRM), Pressão Artéria Sistólica (PAS), New Injury Severity Score (NISS) e idade; o TRISS SpO2, com as variáveis Escala de Coma de Glasgow, PAS, saturação periférica de oxigênio (SpO2), Injury Severity Score, além da idade e o NTRISSlike SpO2 (MRM + PAS + SpO2 + NISS + idade). Todas as equações tiveram coeficientes ajustados para trauma contuso e penetrante. A técnica de imputação múltipla aplicada à derivação das equações não melhorou a acurácia dos modelos. Os modelos TRISS original, TRISS, TRISS-like e NTRISS com coeficientes ajustados e as novas propostas não apresentaram diferença estatisticamente significativa em sua performance. As novas equações ajustadas aos dados de São Paulo e as geradas com informações de San Diego apresentaram diferentes AUC ao serem aplicadas nos dois grupos de doentes dessas localidades. A acurácia sempre foi maior quando as equações foram aplicadas na população de San Diego. Conclusões: Os novos modelos apresentaram boa acurácia (cerca de 89,5%) e desempenho similar a outros ajustes do índice TRISS anteriormente publicados; portanto, podem ser utilizados nas avaliações de qualidade da assistência ao traumatizado. Os ajustes dos índices de probabilidade de sobrevida à realidade local de sua aplicação não melhoraram seu desempenho, resultado que reforça a incerteza sobre a necessidade desses ajustes, conforme o local de aplicação do índice.
Introduction: Trauma and Injury Severity Score (TRISS) is considered the \"gold standard\" in the analysis of survival probability of trauma patients, despite its limitations. There have been several efforts to make it more accurate because of its important role in Trauma Quality Improvement Programmes. Objectives: To propose three new adjustments to the TRISS equation and compare their performances with the TRISS and TRISS-like originals and these indices and NTRISS with coefficients adjusted to the study population; identify if the multiple imputation technique increases the accuracy of the equations derived from databases with missing; and to compare the performance of the new models when derivatives and applied to different groups of trauma patients. Methods: This is a multicenter, retrospective study with trauma victims admitted to the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC FMUSP) and the Trauma Center at the University of California San Diego Medical Center (UCSD MC) for the period between January 1st, 2006 and December 31st, 2010. The information of patients were grouped into two different databases: derivation and testing; the first one served to derive the equations and the second was used to validate the equations generated. The model coefficients were established by logistic regression analysis. Receiver Operating Characteristic curve (ROC) was used to evaluate the performance of the models and De Long et al. algorithm to compare the areas under the curves (AUC). Results: The casuistic consisted of 2,416 patients from HC FMUSP (São Paulo, Brazil) and 8,172 participants from UCSD MC (San Diego, USA). The new models proposed were NTRISS-like which included the variables Best Motor Response (BMR), Systolic Blood Pressure (SBP), New Injury Severity Score (NISS) and age; TRISS SpO2 that included the variables Glasgow Coma Scale, SBP, saturation of peripheral oxygen (SpO2), Injury Severity Score and age; and NTRISS-like SpO2 (BMR + SBP + SpO2 + NISS + age). All equations had adjusted coefficients for blunt and penetrating trauma. The multiple imputation technique applied in the derivation of the equations did not improve the accuracy of the models. The original TRISS, and TRISS, TRISS-like and NTRISS with adjusted coefficients and the new proposals showed no statistically significant difference in performance. The new equations fitted to the São Paulo data and generated with information from San Diego showed different AUC when applied in the two patient groups in these localities. The accuracy was always higher when the equations were applied to the population of San Diego. Conclusions: The new models demonstrated good accuracy (about 89.5%) and similar performance to other TRISS adjustments previously published, and may be used in assessments of quality of care for traumatized. The survival probability scores adjustments to the local reality of its application did not improve its performance, a result that reinforces the uncertainty about the need for such adjustments, as the application site index.

Introdução: A avaliação da dor, constitui uma intervenção de enfermagem fundamental para o estabelecimento do tratamento adequado da dor. Portanto, os profissionais de enfermagem devem considerar o uso de instrumentos de avaliação de dor apropriados para as crianças. Dentre os instrumentos de avaliação encontram-se os instrumentos multidimensionais, porém evidenciou-se escassez destes instrumentos em idioma espanhol para a avaliação da dor em crianças com feridas por profissionais de enfermagem Colombianos. Objetivo: Adaptar culturalmente e encontrar evidências de validade do Instrumento Cartões de qualidade da Dor (ICQD) em crianças com feridas para a língua espanhola da Colômbia. Método: Estudo metodológico e transversal, que foi desenvolvido em duas etapas. Etapa 1: adaptação cultural e validação de conteúdo que esteve composta por seis fases; tradução, síntese das traduções, retrotradução, avaliação da versão por um comitê de juízes, avaliação por crianças na escola e no hospital, e pré-teste da versão final; Etapa 2: evidências de validade baseadas no constructo e no critério externo do ICQD, com 90 crianças em idade escolar hospitalizadas portadoras de feridas. O estudo foi realizado em um hospital pediátrico da cidade de Bogotá Colômbia, com previa aprovação do Comitê de ética da EEUSP e do hospital pediátrico. Os dados foram processados através do software IBM-SPSS 19.0 com nível de significância de 5% (p<0.005). Resultados: Todos as fases pertencentes à etapa de adaptação cultural foram realizadas satisfatoriamente, obtendo uma versão do ICQD adaptado. Foram encontradas evidências fortes baseadas no conteúdo com um IVC total de 0,92; PABAK de 0,79 em representatividade; 0,69 em clareza e 0,74 em dimensão teórica mostrando concordância substancial segundo avaliação dos juízes. No pré-teste, o ICQD versão adaptada mostrou ser clara para mais de 70% de crianças escolares hospitalizadas portadoras de feridas. Na etapa de evidências no critério externo, as variáveis de diagnóstico médico, tipo de ferida, localização de ferida, infecção da ferida, mobilidade e intensidade de dor mostraram resultados significativos. Conclusões: O Instrumento Cartões de Qualidade da Dor (ICQD) versão espanhol, mostrou-se adaptado culturalmente em crianças escolares com feridas no contexto Colombiano apresentando evidências de validade baseadas no conteúdo e no critério externo.
Introduction: Pain assessment, is a fundamental nursing intervention to stablish an adequate pain management. Therefore, nursing professionals should consider the use of appropriate pain assessment tools for children. Among the assessment tools are multidimensional instruments, but it became clear the shortage of these instruments in Spanish for assessing pain in injured children by Colombian nursing professionals. Objective: To translate to the Colombian Spanish language and culturally adapt the Pain Quality Cards Instrument (PQCI) and find evidence of its validity for school age children with wounds. Method: methodological and transversal study, which was developed in two phases. phase 1: cultural adaptation, was composed of six stages translation, synthesis of translations, back translation, evaluation of the resulting version by a panel of judges, evaluation by children in school and in hospital, and pretesting of the final version; phase 2: evidence of validity based on the construct and external criterion PQCI, with a sample of 90 school age children hospitalized with wounds. The study was conducted in a pediatric hospital in Bogotá - Colombia, with anticipated approval of the Ethics Committee of EEUSP and a pediatric hospital. Data were processed through the IBM-SPSS 19.0 with a significance level of 5% (p <0.005). Results: All the stages of the cultural adaptation were performed satisfactorily, obtaining a version adapted PQCI. Strong evidence-based content was found with a total CVI of 0.92; PABAK 0.79 in representativeness; 0.69 in clarity and 0.74 in theoretical dimension shows a substantial agreement as assessed by judges. In the pre-test, the adapted PQCI version proved to be clear to over 70% of school age children hospitalized with wounds. In the phase of external criterion validity evidence the variables medical diagnosis, type of wound, wound location, wound infection, mobility and pain intensity showed significant results. Conclusions: Pain Quality Cards Instrument (PQCI) Spanish version proved to be culturally adapted in injured school age children in the Colombian context showing evidence of validity based on the content and external criterion.

Introdução: Entre as lesões traumáticas, a lesão axonal difusa (LAD) tem sido apontada como a que ocasiona os piores desfechos. Destacam-se entre as consequências dessa lesão as mudanças comportamentais das vítimas que frequentemente rompem o equilíbrio em sua vida social e de seus familiares. Logo, conhecer as mudanças de comportamento dessas vítimas e os fatores relacionados foi relevante para contribuir para uma reabilitação adequada que facilitasse a reintegração das vítimas de LAD à sociedade, além de fundamentar uma melhor assistência aos familiares. Objetivos: Descrever as mudanças comportamentais das vítimas após LAD segundo informações de familiares, nos períodos de 3, 6 e 12 meses após o trauma, e identificar fatores associados a essas mudanças e a sua evolução. Método: Foram incluídas no estudo vítimas de LAD de 18 a 60 anos de idade, atendidas em hospital referência para lesões traumáticas na cidade de São Paulo e incluídas em serviço ambulatorial específico para seu tratamento. Foi realizado um estudo de coorte prospectivo com três abordagens às vítimas e familiares: 3, 6 e 12 meses após LAD. Para avaliar as mudanças comportamentais foi aplicado um questionário elaborado para identificar tais mudanças segundo percepção de familiares. A diferença da pontuação na Escala Likert desse questionário, antes e após o trauma, permitiu identificar as mudanças comportamentais das vítimas. Foi aplicado o modelo de efeitos mistos para identificar as mudanças comportamentais significativas e o efeito do tempo na sua evolução. Esse modelo também foi utilizado para verificar associações entre variáveis sociodemográficas, gravidade da LAD e mudanças comportamentais. Resultados: Mudanças comportamentais desfavoráveis foram observadas na grande maioria dos participantes deste estudo (81,2% a 91,6%). Alterações favoráveis foram menos frequentes, apontadas em torno de 50% dos casos. Predominaram entre os comportamentos com mudanças desfavoráveis a irritabilidade, o esquecimento e a dependência, presentes em 54,6% dos casos, seguidos pela ansiedade (45,8%), depressão (39,6%) e oscilação de humor (31,2%). Quanto às mudanças favoráveis, foram mais frequentes a impulsividade (18,7%), a irritabilidade (16,7%), a oscilação de humor (16,7%) e o temperamento explosivo (14,6%). Entre antes e após o trauma, houve diferença estatisticamente significativa (p0,05) para ansiedade, dependência, depressão, irritabilidade, esquecimento e oscilação de humor. Para esses comportamentos, as médias da intensidade das alterações foram sempre negativas, evidenciando a tendência de mudança desfavorável após LAD. A análise da evolução desses comportamentos mostrou que as mudanças observadas após a lesão mantiveram-se na mesma intensidade até 12 meses após trauma. Na análise de fatores associados, observou-se relação entre depressão e renda per capita familiar mensal, bem como entre idade e irritabilidade. A gravidade da LAD se associou com dependência e com a evolução da ansiedade entre 3 e 12 meses após trauma. Conclusão: Mudanças comportamentais foram consequências muitíssimo frequentes para as vítimas de LAD e não foi notada melhora dessas alterações até 12 meses após lesão. A irritabilidade, o esquecimento e a dependência foram comportamentos alterados na maioria dos casos, gerando impacto negativo sobre a participação dos indivíduos na comunidade. A renda per capita familiar mensal, a idade e gravidade da LAD tiveram relação com as alterações comportamentais.
Introduction: Among traumatic injuries, diffuse axonal injury (DAI) has been reported as the one that causes the worst outcomes. Behavioral changes are consequences of this injury that frequently break the balance between victims social life and their families. Thus, learning about behavioral changes of these victims and the related factors was relevant to contribute to a suitable rehabilitation that facilitates the reintegration of the victims of DAI in the society besides providing a better assistance to relatives. Objectives: Describe behavioral changes of DAI victims according to relatives information in the periods of 3, 6 and 12 months after trauma and identify associated factors to these changes and its course. Method: The study included victims of DAI, aged between 18 and 60 years old, assisted in a referral hospital for traumatic injuries in Sao Paulo and included in specific ambulatory service for treatment. A prospective cohort study of three assessments was carried out with victims and relatives: 3, 6 and 12 months after DAI. To evaluate behavioral changes, a questionnaire was designed as per identify such changes according to the perception of family members. The difference in the Likert Scale Score based on this questionnaire, before and after trauma, lead to identify behavioral changes of the victims. The mixed effects model was used to identify significant behavioral changes and the effect of time on the evaluation. This model was also used to verify associations with sociodemographic variables, severity of DAI and behavior changes. Results: Unfavourable behavioral changes were observed in the majority of the participants of this study (81.2% to 91.6%). Favourable changes were less frequent, indicated in around 50% of the cases. Irritability, memory deficits and dependence were prevalent among the behaviours with unfavourable changes in 54.6% of the cases, followed by anxiety (45.8%), depression (39.6%) and liability of mood (31.2%). When it comes to favourable changes, impulsivity (18.7%), irritability (16.7%), liability of mood (16.7%) and explosive temperament (14.6%) were more frequent. Comparing before and after trauma, there was significant statistical difference (p0,05) in anxiety, dependence, depression, irritability, memory deficits and liability of mood. Regarding these behaviours the alterations in intensity means were always negative, demonstrating the tendency of unfavourable changes after DAI. The analysis of the evolution of these behaviours showed that the changes observed after injury remained at the same intensity up to 12 months post trauma. In the analysis of the associated factors, there was relationship between depression and monthly family per capita income, age and irritability, and the severity of DAI was associated to dependence and anxiety evolution between 3 and 12 months after trauma. Conclusion: Behavioral changes were frequent consequences for DAI victims and no improvement of these alterations was noticed until 12 months after injury. Irritability, memory deficits and dependence were changed behaviours in most cases, generating a negative impact on the participation of individuals in the community. Monthly per capita family income, age and severity of DAI were related to behavioral changes

Mestrado em Enfermagem de Saúde Familiar
No âmbito do 3º semestre do 2º ano do Mestrado em Enfermagem de Saúde Familiar foi desenvolvido um estágio de natureza profissional na Unidade de Saúde Familiar Flor de Sal (ACeS Baixo Vouga) por se considerar ser o contexto de excelência para o exercício das competências do enfermeiro de família. O campo de estágio serviu de contexto à realização de um trabalho de investigação baseado na problemática do envelhecimento da população que conduz ao aumento das doenças crónicas, aumento da incapacidade funcional, da dependência e consequente aumento do risco de úlceras por pressão, com impacto na família e nos serviços de saúde. A avaliação do risco nutricional é um dos parâmetros mais frágeis da escala de Braden que é o principal instrumento recomendado para avaliação do risco de desenvolvimento de úlceras por pressão. Dada a importância da nutrição como fator de risco de aparecimento destas lesões, a avaliação do risco nutricional deve ser considerado pelos enfermeiros de família. Este trabalho procurou descrever e fazer uma análise critico-reflexiva das competências desenvolvidas, dificuldades e situações marcantes do estágio, bem como, no âmbito da investigação, verificar se a avaliação do risco de úlceras por pressão dos idosos com dependência na mobilidade da USF Flor de Sal englobava uma correta avaliação do risco nutricional por parte dos enfermeiros e, ao mesmo tempo, avaliar o risco nutricional desses índivíduos. Realizou-se um estudo de natureza quantitativa que envolveu um dos ciclos do método de investigação-ação, já que após um diagnóstico inicial, se procurou implementar uma intervenção/formação de forma a verificar o seu efeito na prática dos enfermeiros na avaliação do risco nutricional, através da escala de Braden. Na avaliação foi utilizada a Mini Nutritional Assessment como instrumento de avaliação nutricional e, ainda, um questionário de caracterização sociodemográfica da amostra de idosos. Foi feita a análise descritiva para caracterizar e descrever a relação entre as variáveis, avaliadas nos dois momentos de recolha de dados. As amostras de idosos obtidas (inicial e pós-intervenção) apresentavam uma média de 80 anos e eram sobretudo do sexo feminino. Em ambos os momentos apresentaram maioritariamente risco de desenvolvimento de úlceras por pressão. A avaliação do risco nutricional realizada pelos enfermeiros, através da escala de Braden, mostrou percentagens relativamente equilibradas entre indivíduos “nutridos” e “desnutridos”, encontrando-se os primeiros em maior número em ambos os momentos de avaliação. A avaliação da investigadora com a Mini Nutritional Assessment apresentou uma diferença relevante, revelando, claramente, uma maior percentagem de idosos “desnutridos”. As competências esperadas para o estágio foram, genericamente desenvolvidas. Concluímos com o estudo que a intervenção/formação realizada não obteve os resultados esperados já que as discrepâncias existentes entre as avaliações do risco nutricional dos enfermeiros e da investigadora se mantiveram na 2ªavaliação.
Under the 3rd semester of the 2nd year of the Master in Family Health Nursing a professional traineeship was developed at the USF Flor de Sal (ACeS Baixo Vouga) as it was considered to be the context of excellence for the exercise of family nursing skills. The training field served as the context for carrying out a research work based on population ageing reality that contributed to increase of chronic diseases, functional disability, dependency and the consequent increased risk of pressure ulcers, with an impact on family and health services. The assessment of nutritional risk is one of the weakest parameters of the Braden scale which is the primary recommended tool for assessing risk of pressure ulcer development. Considering the importance of nutrition as the risk factor for the appearance of these injuries, the assessment of nutritional risk should be considered by family nurses. This study tries to describe and make a critical and reflective analysis of the skills developed, difficulties and striking situations experienced on the traineeship, as well as verify, by the research, if the assessment of the risk of pressure ulcers of elderly patients dependents on mobility in USF Flor Sal includes a correct assessment of nutritional risk by nurses and, at the same time, assess the nutritional risk of these individuals. It was conducted a quantitative study, that involved one of the cycles of the research-action method, because, after an initial diagnosis, an intervention/training was implemented in order to check its effect in practice of nurses in assessment of nutritional risk, by the Braden scale. The researcher used the Mini Nutritional Assessment as nutritional assessment tool and also a sociodemographic questionnaire to characterize the elderly sample. The data processing was made by descriptive analysis to characterize and describe the relationship between variables, collected at both assessment moments. The elderly samples obtained (initial and post-intervention) had an average of 80 years and were mostly female. Both initial and post-intervention samples mostly presented risk of developing pressure ulcers. The assessment of nutritional risk, made by nurses through the Braden scale, showed relatively balanced percentages among individuals "nourished" and "malnourished", showing the first classification in greater numbers in both assessment periods. The assessment of the researcher with the Mini Nutritional Assessment showed an important difference, showing, clearly, a higher percentage of elderly patients "malnourished". The expected skills to be developed in the traineeship were generally achieved. The study concludes that the intervention/training carried out did not get the expected results due to the discrepancies between the assessments of nutritional risk, made by nurses and the researcher remained in the 2nd assessment.

博士
國立臺灣大學
生醫電子與資訊學研究所
107
Numerous patients suffer from chronic wounds and wound infections nowadays. Until now, the care for wounds after surgery still remain a tedious and challenging work for the medical personnel and patients. As a result, with the help of the hand-held mobile devices, there is high demand for the development of a series of algorithms and related methods for wound infection early detection and wound self-monitoring. This research proposed an automated way to perform (1) wound image segmentation and (2) wound infection assessment after surgical operations. The first part describes an edge-based self-adaptive threshold detection image segmentation method to exclude nonwounded areas from the original images. The second part describes a wound infection assessment method based on machine learning approach. In this method, the extraction of feature points from the suture area and an optimal clustering method based on unimodal Rosin threshold algorithm that divides feature points into clusters are introduced. These clusters are then merged into several regions of interest (ROIs), each of which is regarded as a suture site. Notably, a support vector machine (SVM) can automatically interpret infections on these detected suture site. This research also propose a surgical wound assessment system. The proposed system is designed to enable patients capture surgical wound images themselves by using a mobile device and upload these images for analysis. Combining image-processing and machine-learning techniques, the proposed method is composed of four phases. First, images are segmented into superpixels where each superpixel contains pixels with similar color distribution. Second, these superpixels corresponding to the skin are identified and the area of connected skin superpixels is derived. Third, surgical wounds will be extracted from this area based on the observation of the texture difference between skin and wounds. Lastly, state and symptoms of surgical wound will be assessed. In this research, I had developed a wound analysis APP to allow patients and medical professionals to capture the wound area and upload those images onto the system for further analysis.

No
Knowledge of clinically and cost-effective wound management is an obvious requirement for surgeons, yet wound care education rarely features within the medical curriculum. As a result surgical trainees are often poorly placed to join in multidisciplinary wound management and may feel threatened when asked to manage wound complications. A vast range of dressing products exists yet robust evidence of the function and effectiveness of individual products is often lacking. An understanding of wound pathophysiology, a defined treatment goal and regular wound assessment combined with knowledge of basic wound dressing categories will provide guidance on product selection for different clinical situations and wound types.

No
Knowledge of clinically and cost-effective wound management is an obvious requirement for surgeons, yet wound care education rarely features within the medical curriculum. As a result surgical trainees are often poorly placed to join in multidisciplinary wound management and may feel threatened when asked to manage wound complications. A vast range of dressing products exists yet robust evidence of the function and effectiveness of individual products is often lacking. An understanding of wound pathophysiology, a defined treatment goal and regular wound assessment combined with knowledge of basic wound dressing categories will provide guidance on product selection for different clinical situations and wound types.