Sistema muscular do Pé

Porto Medical Tourism

Porto Medical Tourism 

---

24-09-2013 

Hospital da Boavista recebeu a apresentação do projeto Porto Medical Tourism, que resulta de um protocolo entre a Câmara Municipal do Porto, a Associação de Turismo do Porto, a Travel Health Experience.

Ao consultar a plataforma - http://porto-medical-tourism.stepvalue.com/ - o turista que procura cuidados de saúde pode conhecer várias informações sobre o procedimento pretendido, nomeadamente o preço, unidade hospitalar e descrição da intervenção sem qualquer compromisso. Após aprovação da proposta apresentada, é iniciado o plano de viagem, podendo ainda conhecer o médico previamente e receber alguns conselhos clínicos ou pedir informações antes de viajar. Aquando da chegada a Portugal é recebido por um colaborador devidamente credenciado que o levará ao Hospital ou Hotel, mediante plano de viagem.

A gestão e a operacionalização logística de todo o processo relacionado com o circuito do cliente, nomeadamente no que concerne à articulação entre todos os intervenientes e à articulação do setor saúde com o setor do turismo fica a cargo da THE - Travel Health Experience. É, também, da sua responsabilidade providenciar a assistência e os cuidados pré ou pós-hospitalares e promover a manutenção do site oficial através do qual será possível desencadear todo o processo de prestação do serviço pretendido. 

Alegria no trabalho, pois. Mas como?

Un poco de historia de la Fisioterapia Manual

Esquema resumen de los orígenes y evolución de la FisioterapiaManualOrtopédica (OMT).
Cortesía de Freddy Kaltenborn (1)

Este año se celebran los 200 años de la aparición de los directores gimnásticos del Royal Central Institute of Gymnastics (RCIG) de Estocolmo, dirigido por Per Henrik Ling como los precursores de la fisioterapia moderna. Aprovechando la efeméride tendrá lugar la celebración del II Congreso Internacional de OMT-España con la mesa que lo abre: “Historia no contada de la Fisioterapia Manual como profesión moderna estructurada.” en la que tendré la oportunidad de realizar una comunicación oral sobre la “Influencia de los entornos digitales en el desarrollo de la fisioterapia en España: Fisioterapia 2.0″. 

Para tener una idea más amplia sobre los comienzos de nuestra profesión se ha publicado en la revista CUESTIONES DE FISIOTERAPIA un monográfico con esta línea argumental, y algunos aspectos que “casualmente” son conocidos por pocos fisioterapeutas que afectan directamente a las situaciones y “conflictos” identitarios que en ocasiones nos planteamos.

Fue Wiston Churchill el que sentenció que “la historia la escriben los vencedores”, y si la damos por buena, sería posible pensar que la fisioterapia perdió “la guerra”. Muchos se quedan en que la fisioterapia en España nace de “una costilla” de la enfermería y aunque este hecho es en la práctica una realidad, no es del todo cierto que ese fuese el origen primero de nuestra profesión. Sin embargo gracias a los estudios de enfermería tuvimos en su momento el marco legal y académico para poder desarrollarse en España. Recuerdo una entrada  en el antiguo blog de Carlos Castaño, escrita por Manel Domingo de título:”la fisioterapia en un saco” que explica este fenómeno de una manera muy particular .

Os recomiendo que leáis en profundidad el monográfico publicado, porque es esclarecedor en algunas cuestiones, y ya conocéis la famosa frase de “quien no conoce su historia, está condenado a repetirla”. Espero veros a muchos en el Congreso en Zaragoza el día 28 de junio.

Bibliografía:

1. Silvia Pérez-Guillén, César Hidalgo-García, Juan C. Palacio Albertín, María Fortún-Agud, José Miguel Tricás-Moreno, Anders Ottosson. ¿Se ha manipulado la Historia de la Manipulación? Cuest. fisiot. 2013, 42(E). Monografía. Historia de la evolución de la Fisioterapia (1813-2013): 197-213.

2. Silvia Pérez-Guillén, Pablo Fanlo-Mazas, Natalia Pascual-Lanuza, Martín E. Barra-López, José Miguel Tricás-Moreno, Anders Ottosson  200 años de evolución de la Fisioterapia Manual  Cuest. fisiot. 2013, 42(E). Monografía. Historia de la evolución de la Fisioterapia (1813-2013): 187-196

- See more at: http://www.fisioenap.com/2013/06/un-poco-de-historia.html#sthash.AyfuY5me.dpuf

La Fisioterapia en Atención Primaria y el modelo biopsicosocial, ¿Es posible?

Parece que la respuesta a la pregunta: “¿Es posible realizar un enfoque biopsicosocial en fisioterapia de atención primaria?” a priori es un “SÍ” rotundo, no es solo posible sino imprescindible, y los que trabajáis en AP estaréis pensando que es quizá nuestro entorno el perfecto para desarrollar este modelo asistencial. Sin embargo yo me planteo como influye la organización actual de las unidades de fisioterapia de AP en la aplicación del modelo biopsicosocial en el día a día.

Durante la consulta de valoración no solo hacemos (o no deberíamos hacer) preguntas sobre el problema en cuestión, sino que incluimos aspectos de como afecta el problema a su desempeño habitual, como interfiere en sus relaciones personales y familiares, en su trabajo, en su tiempo de ocio, etc. Utilizar los apartados codificados en la CIF puede resultarnos de ayuda. Una muestra de algo distinto, aunque similar a lo que podemos hacer, esta bien descrito en la tabla extraída del artículo de Turabián JL et al. ¹ en las ITU durante el embarazo, salvando las distancias, por supuesto..

Esta información nos resulta útil para plantear los objetivos de tratamiento y pautar las intervenciones y cambios que el paciente debe hacer en su entorno diario para la resolución del problema, pero en aquellos casos en los que el entorno realmente esta siendo clave en la perpetuación del problema de nuestros pacientes nos vemos atados de manos. Estos procesos requieren de una continuidad asistencial de la que no disponemos los fisioterapeutas de AP, podemos pautar revisiones, pero en algunos casos, una vez dado el alta, se producen recidivas o recaídas del mismo proceso que no podemos atender como corresponde, ya que no hay manera humana de que (legalmente) el paciente vuelva directamente a nosotros. NO EXISTE EL ACCESO DIRECTO. Se nos sigue considerando operativamente “aplicadores de técnicas”, actualmente somos los únicos profesionales de AP que no disponen de consultas a demanda. Es necesario un rediseño del modelo asistencial que permita mantener la continuidad asistencial que se requiere en Atención Primaria, y poder desarrollar las habilidades como agentes sanitarios que tenemos.

La reflexión para alcanzar la conclusión de que el no tener acceso directo impide realizar un abordaje biopsicosocial como se exige, es mucho más amplia, pero dejo aquí la muestra para que lleguemos a conclusiones en los comentarios. ¿Pensáis que la imposibilidad de acceso directo a demanda influye en el tratamiento de los pacientes de este tipo?

- See more at: http://www.fisioenap.com/2013/08/la-fisioterapia-en-ap-y-el-modelo-biopsicosocial-es-posible.html#sthash.0NF5j9TP.dpuf

Alzheimer disease

Alzheimer disease (AD) is an acquired disorder of cognitive and behavioral impairment that markedly interferes with social and occupational functioning. It is an incurable disease with a long and progressive course. In AD, plaques develop in the hippocampus, a structure deep in the brain that helps to encode memories, and in other areas of the cerebral cortex that are used in thinking and making decisions. Whether plaques themselves cause AD or whether they are a by-product of the AD process is still unknown.

Essential update: Memory tests plus brain imaging help detect early, asymptomatic AD

A study of 129 cognitively normal adults aged 65-87 years (mean, 73.7 years), presented at the Alzheimer's Association International Conference (AAIC) 2013, indicated that a combination of memory tests and brain imaging may help identify the earliest stages of AD before symptoms appear.^[1] In this study, poor episodic memory in the context of synaptic dysfunction and elevated amyloid identified subjects who were at high risk for progression to AD dementia.
Study subjects underwent testing of memory and executive function along with fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) and amyloid deposition with C 11 Pittsburgh Compound B (PiB PET).^[1] The researchers found that amyloid burden and synaptic dysfunction independently predicted episodic memory performance. Subjects with worse memory performance had higher PiB deposition and lower FDG metabolism in regions of the brain commonly affected in AD.
Some individuals had worse memory scores and lower FDG metabolism (synaptic dysfunction) but a normal PiB scan (no amyloid deposition), which indicated that not all memory changes were a result of amyloid plaques.^[1] Individuals who performed worse on nonmemory executive function tests also had lower FDG metabolism but a normal PiB scan. More highly educated individuals had normal performance on memory tests despite lower FDG metabolism and higher PiB retention.

Signs and symptoms

Preclinical Alzheimer disease
A patient with preclinical AD may appear completely normal on physical examination and mental status testing. Specific regions of the brain (eg, entorhinal cortex, hippocampus) probably begin to be affected 10-20 years before any visible symptoms appear.
Mild Alzheimer disease
Signs of mild AD can include the following:

• Memory loss
• Confusion about the location of familiar places
• Taking longer to accomplish normal, daily tasks
• Trouble handling money and paying bills
• Compromised judgment, often leading to bad decisions
• Loss of spontaneity and sense of initiative
• Mood and personality changes; increased anxiety

Moderate Alzheimer disease
The symptoms of this stage can include the following:

• Increasing memory loss and confusion
• Shortened attention span
• Problems recognizing friends and family members
• Difficulty with language; problems with reading, writing, working with numbers
• Difficulty organizing thoughts and thinking logically
• Inability to learn new things or to cope with new or unexpected situations
• Restlessness, agitation, anxiety, tearfulness, wandering, especially in the late afternoon or at night
• Repetitive statements or movement; occasional muscle twitches
• Hallucinations, delusions, suspiciousness or paranoia, irritability
• Loss of impulse control: Shown through behavior such as undressing at inappropriate times or places or vulgar language
• Perceptual-motor problems: Such as trouble getting out of a chair or setting the table

Severe Alzheimer disease
Patients with severe AD cannot recognize family or loved ones and cannot communicate in any way. They are completely dependent on others for care, and all sense of self seems to vanish.
Other symptoms of severe AD can include the following:

• Weight loss
• Seizures, skin infections, difficulty swallowing
• Groaning, moaning, or grunting
• Increased sleeping
• Lack of bladder and bowel control

In end-stage AD, patients may be in bed much or all of the time. Death is often the result of other illnesses, frequently aspiration pneumonia.
See Clinical Presentation for more detail.

Diagnosis

Means of diagnosing AD include the following:

• Clinical examination: The clinical diagnosis of AD is usually made during the mild stage of the disease, using the above-listed signs
• Lumbar puncture: levels of tau and phosphorylated tau in the cerebrospinal fluid are often elevated in AD, whereas amyloid levels are usually low; at present, however, routine measurement of CSF tau and amyloid is not recommended except in research settings
• Imaging studies: Imaging studies are particularly important for ruling out potentially treatable causes of progressive cognitive decline, such as chronic subdural hematoma or normal-pressure hydrocephalus^[2]

See Clinical Presentation and Workup for more detail.

Management

All drugs approved by the US Food and Drug Administration (FDA) for the treatment of AD are symptomatic therapies that modulate neurotransmitters, either acetylcholine or glutamate. The standard medical treatment for AD includes cholinesterase inhibitors (ChEIs) and a partial N-methyl-D-aspartate (NMDA) antagonist.^{[3, 4]}
The following classes of psychotropic medications have been used to treat the secondary symptoms of AD, such as depression, agitation, aggression, hallucinations, delusions, and sleep disorders^[5] :

• Antidepressants
• Anxiolytics
• Antiparkinsonian agents
• Beta-blockers
• Antiepileptic drugs: For their effects on behavior
• Neuroleptics

Prevention
There are no proven modalities for preventing AD,^[3] but evidence, largely epidemiologic, suggests that healthy lifestyles can reduce the risk of developing the disease; the following may be protective^{[6, 7]} :

• Physical activity
• Exercise
• Cardiorespiratory fitness
• Diet: Although no definitive dietary recommendations can be made, in general, nutritional patterns that appear beneficial for AD prevention fit the Mediterranean diet

See Treatment and Medication for more detail.

Image library

Systematic reviews of the effectiveness of day care for people with severe mental disorders: (1) acute day hospital versus admission; (2) vocational rehabilitation; (3) day hospital versus outpatient care.

Autor: Marshall M, Crowther R, Almaraz-Serrano A, Creed F, Sledge W, Kluiter H, Roberts C, Hill E, Wiersma D, Bond GR, Huxley P, Tyrer P.

Source

University of Manchester, Guild Trust, Preston, UK.

Abstract

***ACUTE DAY HOSPITAL VERSUS ADMISSION FOR ACUTE PSYCHIATRIC DISORDERS***

BACKGROUND:

Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals.

OBJECTIVE:

The aim of this review was to assess the effectiveness and feasibility of day hospital versus inpatient care for people with acute psychiatric disorders. METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials of day hospital versus inpatient care for people with acute psychiatric disorders. Studies were excluded if they were primarily concerned with elderly people, children, or patients with a diagnosis of organic brain disease or substance abuse. METHODS - DATA SOURCES: We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: Data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risk (RR) and 95% confidence intervals (CIs) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise the data. Individual patient data were therefore sought so that outcomes could be re-analysed using a common format.

RESULTS:

Nine trials met the inclusion criteria (involving 1568 randomised patients and 2268 assessed for suitability of day hospital treatment). Individual patient data were obtained for four trials (involving 594 people). A sensitivity analysis of combined data suggested that day hospital treatment was feasible for at worst 23.2% (n = 2268; 95% CI, 21.2 to 25.2) and at best 37.5% (n = 1768; 95% CI, 35.2 to 39.8) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in the number of days in hospital (combining day hospital days and inpatient days) between day hospital patients and controls (n = 465; weighted mean difference (WMD) = -0.38 days/ month; 95% CI, -1.32 to 0.55). However, compared with controls, patients randomised to day hospital care spent significantly more days in day hospital care (n = 265; WMD = 2.34 days/month; 95% CI, 1.97 to 2.70) and significantly fewer days in inpatient care (n = 265; WMD = -2.75 days/month; 95% CI, -3.63 to -1.87). There was no difference between readmission rates for day hospital and control patients (n = 667; RR = 0.91; 95% CI, 0.72 to 1.15). Individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (n = 407; c2 = 9.66; p = 0.002), but not social functioning (n = 295; c2 = 0.006; p = 0.941) amongst day hospital patients. Four of five trials demonstrated that day hospital care was cheaper than inpatient care (with overall cost reductions ranging from 20.9% to 36.9%).

CONCLUSIONS:

Acute day hospitals are an attractive option in situations where demand for inpatient care is high and facilities exist that are suitable for conversion. They are a less attractive option when demand for inpatient care is low and where effective alternatives already exist. The interpretation of day hospital research would be enhanced if future trials made use of the common set of outcome measures used in this review. It is important to examine how acute day hospital care can be most effectively integrated into a modern community-based psychiatric service. ***VOCATIONAL REHABILITATION FOR PEOPLE WITH SEVERE MENTAL DISORDERS***

BACKGROUND:

People who are disabled by severe mental disorders experience high rates of unemployment, but most want to work. Prevocational training (PVT) is the traditional approach to helping such people to return to work. PVT assumes that a period of preparation is required before those with a severe mental disorder can enter into competitive employment. Supported Employment (SEm) is a new approach that places clients in competitive employment without extended preparation. Both PVT and SEm are widely practised, but it is unclear which is the most effective.

OBJECTIVES:

The overall objective of this review was to assess the effectiveness of PVT and SEm relative to each other and to standard care (in hospital or the community) for people with severe mental disorders. In addition, the review examined the effectiveness of: (1) special types of PVT ("clubhouse" model) and SEm (individual placement and support model); and (2) modifications for enhancing PVT (e.g. payment or psychological interventions). METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials (RCTs) examining the effectiveness of vocational rehabilitation approaches (PVT and SEm or modifications) for people of working age and suffering from a severe mental disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Schizophrenia Group's specialised register, MEDLINE, EMBASE, CINAHL and PsycLIT, and the reference lists of all identified studies and review articles. Researchers who were active in the field were approached in order to identify unpublished studies. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. Continuous data were excluded if they were collected by using an unpublished scale or were based on a subset of items from a scale. METHODS - DATA SYNTHESIS: For all comparisons, the primary outcome was the number of clients who were in competitive employment at various time points. Secondary outcomes were: other employment outcomes, clinical outcome and costs. The relative risk (RR) and number-needed-to-treat (NNT) were calculated for the relevant categorical outcomes. Continuous data were either presented as in the original trial reports or, where possible, combined across trials as a standardised mean difference score.

RESULTS:

Eighteen RCTs of reasonable quality were identified: PVT versus hospital controls, three RCTs, n = 172; PVT versus community controls, five RCTs, n = 1204; modified PVT, four RCTs, n = 423; SEm versus community controls, one RCT, n = 256; and SEm versus PVT, five RCTs, n = 491). The main finding was that, on the primary outcome (number in competitive employment), SEm was significantly more effective than PVT at all time points (e.g. at 12 months, SEm 34% employed, PVT 12% employed; RR of not being in competitive employment = 0.76, 95% confidence interval 0.69 to 0.84, NNT = 4.5). Clients in SEm also earned more and worked more hours per month than those in PVT.

CONCLUSIONS:

The main finding was that SEm was more effective than PVT for patients suffering from a severe mental disorder who wanted to work. There was no evidence that PVT was more effective than standard community care or hospital care. The implication of these findings is that people suffering from mental disorders who want to work should be offered the option of SEm. Commissioning agencies would be justified in encouraging vocational rehabilitation (VR) providers to develop more SEm schemes. From a research perspective, the cost-effectiveness of SEm should be examined in larger multicentre trials, both within and outside the USA. There is a case for countries outside the USA to survey their existing VR services to determine the extent to which the most effective interventions are being offered. ***DAY HOSPITAL VERSUS OUTPATIENT CARE FOR PATIENTS WITH PSYCHIATRIC DISORDERS***

BACKGROUND:

This review considers the use of day hospitals as an alternative to outpatient care. Two typesof day hospital provision are covered: "day treatment programmes" and "day care centres". Day treatment programmes are day hospitals that are used to enhance the treatment of patients with anxiety or depressive disorders who have failed to respond to outpatient care. Day care centres are day hospitals that offer structured support to patients with long-term severe mental disorders who would otherwise be treated in an outpatient clinic.

OBJECTIVES:

There were two objectives: first, to assess the effectiveness of day treatment programmes versus outpatient care for people with non-psychotic disorders; and, secondly, to assess the effectiveness of day care centres versus outpatient care for people with severe long-term disorders. METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials comparing day hospital care (either a day treatment programme or a day care centre) with outpatient care. Studies were ineligible if they were largely restricted to patients who were aged under 18 or over 65 years or who had a primary diagnosis of substance abuse or organic brain disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of all identified studies and review articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risks and 95% confidence intervals were calculated for dichotomous data. Standardised mean differences were calculated for continuous data.

RESULTS:

There was evidence from two of the five trials identified suggesting that day treatment programmes were superior to continuing outpatient care in terms of improving psychiatric symptoms. There was no evidence to suggest that day treatment programmes were better or worse than outpatient care on any other clinical or social outcome variable or on costs.