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El siguiente ensayo es una discusión acerca de la posibilidad de conceptualizar a la salud desde la discapacidad; para ello se realizó una revisión acerca de las nociones actuales de la salud y de la discapacidad. El concepto de salud ha transitado por un continuo proceso de significación que alcanzó su momento clave en 1948, en la definición que adoptó la Organización Mundial de la salud. Actualmente no existe una definición única alrededor de las aspiraciones del nivel de vida que las personas aspiran alcanzar, por ello, cualquier nueva definición de la salud deberá ser ecológica, sistémica, dinámica y positiva. A más de sesenta años de la definición de la salud, la realidad es que hay problemas relacionados con los estados de salud como es la discapacidad que se han venido midiendo invariablemente desde el modelo biomédico; en tal sentido, pareciera que es imposible entender a la discapacidad más allá de la eterna enfermedad. Tras la aprobación en el 2001 de la Clasificación Internacional del Funcionamiento, la Salud y la Discapacidad, se abrió un nuevo panorama en el tema, como la reorientación de la visión de la discapacidad, relativa a las expectativas colocadas sobre el funcionamiento de las personas y de las interacciones multidireccionales que se plantean entre las personas, su contexto donde se desenvuelve con autonomía. Para ello, se planteó una conceptualización de la salud, que transciende del plano de lo estrictamente corpóreo y que involucre factores como las representaciones y las relaciones socioambientales.

La inclusión es un principio social y político construido alrededor del ideal de igualdad que se materializa en el reconocimiento de la equidad y en la garantía en el acceso a las oportunidades. La educación, en sus diferentes niveles de cobertura, es un puente que conecta ambos aspectos. La educación inclusiva es un proceso de transformación y de acompañamiento en el cual las personas se forman con autonomía, calidad y participación, a pesar de la diversidad. Este estudio forma parte de una línea de investigación que aspira, a través del uso de la metodología cualitativa con enfoque fenomenológico, comprender, desde el discurso de once estudiantes con discapacidad y seis profesores, cómo se viene desenvolviendo su ingreso en los espacios de una institución de educación superior pública en Venezuela. Para ello, se utilizó la entrevista semiestructura, el análisis de contenido a través del Atlas. Ti y la triangulación de datos. Surgieron cuatro categorías de análisis (“Ingreso” “Discapacidad física e intelectual, una línea indisoluble”, “Me dijeron” y “Me dejaron por fuera”). Los hallazgos exponen una visión compartida entre los actores acerca del reconocimiento de la igualdad jurídica en el tema del ingreso, pero en el caso del profesorado, condicionada por la exigencia de una exhibición de una garantía de éxito y a la escogencia asistida de la carrera. Se reportaron prácticas de exclusión y de discriminación en el ingreso, las cuales suceden de manera intangible en las relaciones que se establecen a lo interno y que requieren ser revisadas. Las mayores dificultades pareciera que están alrededor de la prosecución y no en el ingreso. Ambos actores coinciden en la visión de una institución asistencialista y exigente en el ingreso; pero descuidada en el acompañamiento y la transformación que deben caracterizar un proceso de educación inclusiva.

This field-scale study evaluates the seasonal effectiveness of employing nature-based solutions (NBSs), particularly surface flow and horizontal subsurface flow constructed wetland configurations, as tertiary treatment technologies for the removal of antibiotics (ABs) and antibiotic resistance genes (ARGs) compared to a conventional treatment involving UV and chlorination. Out of the 21 monitored ABs, 13 were detected in the influent of three tertiary wastewater treatments, with concentrations ranging from 2 to 1218 ng·L -1 . The ARGs sul1 and dfrA1 exhibited concentrations ranging from 1 × 10 5 to 9 × 10 6 copies/100 mL. NBSs were better at reducing ABs (average 69 to 88 %) and ARGs (2-3 log units) compared to the conventional tertiary system (average 36 to 39 % and no removal to 2 log units) in both seasons. Taxonomic compositions in influent water samples shifted from wastewater-impacted communities (Actinomycetota and Firmicutes) to a combination of plant rhizosphere-associated and river communities in NBS effluents (Alphaproteobacteria). In contrast, the conventional technology showed no substantial differences in community composition. Moreover, NBSs substantially reduced the ecotoxicological risk assessment (cumulative RQs). Furthermore, NBSs reduced the ecotoxicological risk (cumulative RQs) by an average of over 70 % across seasons, whereas the benchmark technology only achieved a 6 % reduction. In conclusion, NBSs present a robust alternative for minimizing the discharge of ABs and ARGs into surface water bodies., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Study Design: Narrative review., Objective: To address the gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing., Methods: This review did not involve patient care or any clinical prospective or retrospective review of patient information and thus did not warrant institutional review board approval. The available literature of PubMed, Medline, and OVID was utilized to review the existing literature., Results: Studies have shown that the forces through the lumbar spine in the modern-era golf swing are like other contact sports. Methods of protecting the lumbar spine include proper swing mechanics, abdominal and paraspinal musculature strengthening and flexibility as well as physical fitness. There are a variety of treatment options available to treat lumbar spine pathology each with a different return to play recommendations from doctors in the field., Conclusions: With the introduction of a high impact, modern-era swing to the game of golf, the pathology is seen in the lumbar spine of both young, old, professional, and amateur golfers with low back pain are similar to other athletes in contact sports. Surgery is effective in returning athletes to a similar level of play even though no protocols exist for an effective and safe return. There have been many studies conducted to determine appropriate treatment and return to play for these injuries, but there is a gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing. As return to competitive play is important, especially with professional golfers, studies combining the use of swing mechanics changes, rehabilitation regimens and the type of surgery performed would be able to provide some insight into this topic now that golf may begin to be considered a contact sport.

Doctors have two ethical duties: to cure disease or ease suffering and, also, to do no harm. The ethical duty to "Do No Harm" has been used to justify two sides of a pendulum swing in the philosophy of opioid prescribing for pain. In the 1990s, it was invoked to expand prescribing, and more recently to justify dramatic reductions in prescription opioid use. In this Article, we explore whether prescribing opioids for pain presents challenges that differ from the ordinary mandate physicians face as they balance the call for action with the imperative to do no harm [DNH].We argue that the treatment of pain differs in three important ways. First, the fact that pain is present and occurrent reduces uncertainty about the need for action, and thus strengthens the reasons to act. Second, while DNH applies to both physicians and policymakers, each has distinct duties: physicians have a duty to the individual patient; policymakers have a duty to society. As a result, harm from drug diversion should weigh little when clinicians decide how to treat individual patients. Public health officials, by contrast, rightly consider societal effects. However, in doing so, they must adopt policies that mitigate the ethical burdens placed on physicians, respect the testimony of patients in pain, and pay particular attention to how policy guidance is likely to be implemented by others. Finally, we address what duties are owed to patients who are currently taking opioid medication, given evidence that they are experiencing significant barriers in receiving healthcare. We argue that once treatment has been initiated, there are special duties to these patients.

Extreme urban heat is a powerful environmental stressor which poses a significant threat to human health and well-being. Exacerbated by the urban heat island phenomenon, heat events are expected to become more intense and frequent as climate change progresses, though we have limited understanding of the impact of such events on vulnerable populations at a neighborhood or census block group level. Focusing on the City of Portland, Oregon, this study aimed to determine which socio-demographic populations experience disproportionate exposure to extreme heat, as well as the level of access to refuge in the form of public cooling centers or residential central air conditioning. During a 2014 heat wave, temperature data were recorded using a vehicle-traverse collection method, then extrapolated to determine average temperature at the census block group level. Socio-demographic factors including income, race, education, age, and English speaking ability were tested using statistical assessments to identify significant relationships with heat exposure and access to refuge from extreme heat. Results indicate that groups with limited adaptive capacity, including those in poverty and non-white populations, are at higher risk for heat exposure, suggesting an emerging concern of environmental justice as it relates to climate change. The paper concludes by emphasizing the importance of cultural sensitivity and inclusion, in combination with effectively distributing cooling centers in areas where the greatest burden befalls vulnerable populations., Competing Interests: The authors declare no conflict of interest.

The associations of family, home visitor and site characteristics with family engagement within the first 6 months were examined. The variation in family engagement was also explored. Home visiting program participants were drawn from 21 Healthy Families America sites (1707 families) and 9 Nurse-Family Partnership sites (650 families) in New Jersey. Three-level nested generalized linear mixed models assessed the associations of family, home visitor and site characteristics with family receipt of a high dose of services in the first 6 months of enrollment. A family was considered to have received a high dose of service in the first 6 months of enrollment if they were active at 6 months and had received at least 50% of their expected visits in the first 6 months. In general, both home visiting programs engaged, at a relatively high level (Healthy Families America (HFA) 59%, Nurse-Family Partnership (NFP) 64%), with families demonstrating high-risk characteristics such as lower maternal education, maternal smoking, and maternal mental health need. Home visitor characteristics explained more of the variation (87%) in the receipt of services for HFA, while family characteristics explained more of the variation (75%) in the receipt of services for NFP. At the family level, NFP may improve the consistency with which they engage families by increasing retention efforts among mothers with lower education and smoking mothers. HFA sites seeking to improve engagement consistency should consider increasing the flexible in home visitor job responsibilities and examining the current expected-visit policies followed by home visitors on difficult-to-engage families.

Diabetes, a large and growing worldwide health concern, affects the functional mass of the pancreatic beta cell, which in turn affects the glucose regulation of the body. Successful transplantation of cadaveric islets and pancreata for patients with uncontrolled type 1 diabetes has provided proof-of-concept for the development of commercial cell therapy approaches to treat diabetes. Three broad issues must be addressed before surrogate insulin-producing cells can become a reality: the development of a surrogate beta-cell source, immunoprotection, and translation. Cell therapy for diabetes is a real possibility, but many questions remain; through the collaborative efforts of multiple stakeholders this may become a reality.

Objective: To examine our experience with methotrexate (MTX) and daily prednisone (PRED) as the initial treatment of Wegener's granulomatosis (WG)., Methods: Between November 1992 and November 1997, we treated 19 patients with non-life threatening WG with the combination of oral weekly MTX (starting at 7.5-10.0 mg/week) and daily PRED (median starting dose 40 mg/day, range 20-60). The MTX dose was increased to 15 mg/week by the end of the first month, and then by 2.5 mg/week until the disease was controlled. We attempted to taper PRED to 20 mg/day by the end of the second month, but did not use alternate day corticosteroids. Before treatment with this regimen, no patient had received previous treatment for WG., Results: At presentation, the average number of organ systems involved was 3.6. Nine of the 19 patients (47%) had glomerulonephritis, but none had a serum creatinine > 1.2 mg/dl at presentation. Only 37% of the patients were hospitalized at presentation. Seventeen of 19 patients (89%) improved with treatment, and 14 (74%) achieved remission. However, half those who achieved remission suffered relapses, and no patient achieved a durable, complete remission (disease-free status free of all medications). Fifteen patients (79%) were able to taper PRED to < 10 mg/day. Seven of 8 disease relapses responded to increases of MTX and/or PRED. Only one patient developed glomerulonephritis while receiving treatment and required a change of therapy to cyclophosphamide. There were no deaths among patients in this series. Treatment with MTX and PRED was well tolerated: only 2 (11%) of the patients stopped treatment because of side effects (major liver function test abnormalities in both cases). No patient suffered permanent morbidity from MTX treatment., Conclusion: In selected patients with WG, the combination of MTX and daily PRED effectively controls the disease. However, chronic disease courses are the rule with this treatment regimen, and the likelihood of disease relapse is high. In our experience, the use of MTX and PRED in WG was safer than previously described, despite the use of daily corticosteroids.

Study Design: Randomized 3-group pretest-posttest with blind assessment of outcome., Objectives: The purpose of this study was to examine the effect of sagittal plane hold-relax exercise applied to the ipsilateral anterior thigh, and prone positioning on passive unilateral straight-leg raise measurements., Background: Straight-leg raising has been viewed as a measurement for hamstring muscle length, but literature suggests that other structures may affect this measurement., Methods and Measures: Sixty subjects (45 men, 15 women) qualified for inclusion into the study based on a straight-leg raise measurement of < or = 65 degrees. Subjects were randomly assigned to one of three groups: control, static stretch, or sagittal plane hold-relax exercise. Pretest and posttest straight-leg raise measurements of the right lower extremity were performed for each subject., Results: A 1-way ANOVA of the change scores showed a significant difference between groups. A Tukey post hoc analysis of the change scores showed that both treatment groups' means differed significantly from the control group and from each other, with the sagittal plane hold-relax group exhibiting the largest change (mean of 7.8 degrees +/- 2.8 degrees)., Conclusions: The results of this study show that sagittal plane hold-relax exercise and passive prone results of this study show that sagittal plane hold-relax and passive prone positioning can significantly increase straight-leg raise range of motion, however the sagittal plane hold-relax stretching of the anterior thigh is more effective than passive prone positioning.

Objective: To assess the efficacy of a new fluid-based, automated, thin-layer system for cervical screening, in routine use in our clinical laboratory., Study Design: Data from 39,408 conventional cervical cytologic smears and 10,694 ThinPrep slides collected concurrently were analyzed to compare diagnostic detection rates, specimen adequacy, sensitivity and specificity., Results: The ThinPrep slides yielded a significantly higher proportion of low grade squamous intraepithelial lesions (LSILs) and high grade squamous intraepithelial lesion (HSIL) diagnoses when compared to the conventional smear. This increase was greater than twofold. The ASCUS:LSIL ratio was reduced by 55% in the ThinPrep group. Specimen adequacy was also improved: the ThinPrep method reduced the "satisfactory but limited by" (SBLB) rate by 35% and the "unsatisfactory" category by 73%. Limited biopsy results confirmed the increased sensitivity of ThinPrep., Conclusion: In routine use in our laboratory, the ThinPrep method demonstrated a significant increase in the detection of LSIL and HSIL diagnoses. Specimen adequacy was also dramatically improved. The ThinPrep method significantly reduced the number of SBLB and unsatisfactory specimens.

Objective: We sought to determine the prevalence and severity of dyspnea, and to correlate dyspnea with clinical features and exercise limitation in ambulatory patients with systemic lupus erythematosus (SLE)., Methods: Twenty-five consecutive patients were evaluated with a validated pulmonary questionnaire, chest radiograph, 2-dimensional echocardiography, resting pulmonary function tests, and incremental exercise testing., Results: Dyspnea was reported by 60% (95% CI 39-79) of patients; 20% (95% CI 7-40) had severe dyspnea (inability to dress without dyspnea) and 12% (95% CI 3-31) had moderate dyspnea (dyspnea after walking 100 yards). Compared to patients without dyspnea, patients with dyspnea were more likely to have had a history of clinical lupus involving the lung (80 vs 40%, p = 0.05), a lower total lung capacity (77.5 vs 94.8%, p = 0.002), and a reduced maximum oxygen consumption (VO2max of 53.4 vs 67.7%, p = 0.01). Patients with severe dyspnea and patients without dyspnea did not differ in duration of prednisone use, activity of disease, weight, or in frequency of Raynaud's phenomenon (p > 0.05). Only 4% of all patients had abnormal left ventricular motion on 2-dimensional echo; patients with moderate or severe dyspnea had normal left ventricular motion. Of the 5 patients with severe dyspnea, 4 (80%) had restrictive lung disease and 1 (20%) had an isolated diffusion defect. All patients with dyspnea had an abnormal exercise test, but so did 9/10 without dyspnea (p > 0.05). Severity of dyspnea correlated highly with maximum exercise tolerance measured by VO2max (R2 = 0.51, p = 0.0001)., Conclusion: In ambulatory patients with SLE, dyspnea is common, frequently disabling, associated with a history of lupus involvement of the lung, and correlates highly with objective measures of exercise limitation.

Collagenous colitis is a clinicopathologic syndrome characterized by chronic watery diarrhea and a mucosal inflammatory process with increased subepithelial collagen band on colonic biopsy. This disorder occurs primarily in females, and the etiology is unknown. We report the atypical presentation of collagenous colitis in two older-aged men following prolonged use of nonsteroidal antiinflammatory agents and short-term use of antibiotics. Although one patient had colonic pseudomembranes, neither patient had microbiological evidence of C. difficile toxin or infection. A variety of medications were initially given to these patients without resolution of diarrhea. Only after the diagnosis of collagenous colitis was made and antiinflammatory drugs directed at the colitis given did the diarrhea abate. These cases illustrate an unusual presentation of collagenous colitis with possible implications for pathogenesis.

Disorders of the thyroid gland are frequently unrecognized and untreated by the attending physician and present the anesthesiologist with a diagnostic and therapeutic challenge. Very large goiters distort and compress the larynx and require an experienced anesthesiologist for safe intubation. If surgery is elective and can be postponed in patients suspected of being hypo- or hyperthyroid, there is sufficient time to permit the anesthesiologist and the attending physician to obtain appropriate tests of thyroid function and institute appropriate therapeutic measures to restore the metabolic rate to normal. When there is insufficient time to confirm a clinical diagnosis of thyroid disease, the anesthesiologist is faced with important therapeutic decisions. It is the author's opinion that therapeutic intervention is, in most instances, preferable to therapeutic nihilism. In the case of a patient suspected of hypothyroidism, it is usually safe to administer a physiologic replacement dose of thyroxine to support the patient intraoperatively or postoperatively. If hypothyroidism is associated with cardiovascular disease, other debilitating illness, or advanced age, thyroxine must be given with extreme caution in order to avoid dangerous tachyarrhythmias or too rapid acceleration of the metabolic rate. The hyperthyroid patient facing nonelective surgery represents a very serious challenge to the anesthesiologist, since marked accentuation of clinical hyperthyroidism (thyroid storm) is a major risk of such surgery. In such a situation, intravenous propranolol and intravenous iodine are the optimal drugs for a safe and uncomplicated clinical course during and following surgery. In both instances, the anesthesiologist must use skillful clinical judgment in making the appropriate diagnosis and selecting appropriate therapy. Careful and continuous supervision of the patient is necessary during and following surgery and appropriate treatment and support of the patient should be provided until it is safe to discontinue therapy, if necessary, to confirm the diagnosis of thyroid disease. Careful clinical judgment and judicious use of appropriate medication should provide the patient with a smooth and safe intraoperative course and a rapid and uncomplicated postoperative recovery.

Exogenous triiodothyronine (T3) was substituted for levothyroxin or desiccated thyroid in 13 athyrotic patients previously treated for papillary, follicular, or mixed papillary-follicular carcinoma of the thyroid. After 4 weeks T3 therapy was discontinued and serial determinations of plasma thyroid stimulating hormone (TSH) concentrations were made. A roughly exponential rise in TSH values, corresponding to a doubling time of 2 days, was observed until a level of 40 microIU/ml was reached, after which the curve passed through a maximum at 20 days. The mean time required for a level of 50 microIU/ml was 11 days, and this time is suggested for TSH determination before I-131 imaging of patients with thyroid cancer. Plasma TSH values in eight patients following "total" thyroidectomy showed a much slower and more variable rise, with a mean doubling time of 7.6 days. Weekly TSH levels beginning at 15 days will provide a rational basis for I-131 imaging in this group, in whom a longer period of hypothyroidism will be required before imaging and therapy. Adherence to these protocols should minimize the duration of hypothyroidism in patients undergoing I-131 treatment of thyroid carcinoma.

To study the difference in myocardial damage produced by the same defibrillation energy delivered at frequent, low-energy discharges vs infrequent, high-energy discharges, experiments were performed on 48 dogs. In Part I, a total of 3000 Wsec energy was delivered; in Part II, a total of 600 Wsec was delivered; and in Parts III and IV, a total of 1800 Wsec was delivered. In half the dogs, the energy was delivered in three shocks within 135 sec. In the other half, the shocks were delivered by 10 smaller shocks at 15-sec intervals. The degree of myocardial damage assessed by ST-segment elevation on precordial mapping or necrotic index from gross and microscopic examination 4 days after the shocks showed no significant difference. However, the three high-energy shocks (600 to 100 Wsec) resulted in ventricular fibrillation or complete heart block in 33% (6 of 18) of the dogs. These arrhythmias were not observed in the animals receiving low-energy (60-, 200-, or 300-Wsec) discharges.

The influence of the phase of ventilation on the transthoracic impedance and defibrillation success was studied in 6 mongrel dogs. Ventricular fibrillation was induced by a transvenous bipolar catheter electrode. Defibrillation was attempted after 1 min of ventricular fibrillation. The initial stored energy levels were 20 watt-sec for the 1st two shocks, one delivered in inspiration and one in expiration. If the shock at the initial energy level was not successful, the energy level was increased by 10 watt-sec before the next energy level shock. Initial discharge was given at inspiration in half of the animals and at expiration in the other half. The transthoracic impedance to defibrillator discharge was measured with each shock. The study revealed a significantly higher transthoracic impedance with inspiration (76.3 +/- 13 ohms versus 68.4 +/- 12 ohms expiration, p less than 0.01), and a significant decrease in defibrillation success rate when shocks were delivered in inspiration (10%) compared to expiration (50%). The phase of ventilation is an important determinant of transthoracic impedance to defibrillator discharge and has a significant influence on defibrillation effectiveness.

Eleven patients with high-risk thyroid carcinoma of anaplastic or mixed anaplastic-differentiated histology were treated using an early multimodality approach. Patients were classified using the prognostic index for thyroid carcinoma developed by the EORTC. Therapy consisted of a four-drug chemotherapy combination, radioiodine (131I), and Bacille-Calmette-Guerin (BCG) immunotherapy. Treatment was designed to maximize effects against both anaplastic and differentiated tumor components. There has been prolonged disease-free survival (14+ to 73+ months) in patients with clear cell, small cell, and mixed anaplastic histologies. Currently five patients have been in complete remission for over 4 years. Treatment has been well tolerated. The long-term participation in care by a multispecialty team has produced promising results which we hope can be valuable as a basis for multicenter trials.

Medullary carcinoma (MC) of the thyroid, in contrast to papillary-follicular carcinoma, fails to concentrate iodine and thus has not been treated with radioactive iodine. We have successfully treated a 16-yr-old Mexican-American girl with residual MC after maximal thyroidectomy (Tx), utilizing radioiodine (131I) to deliver radiation to residual follicular cells in the tumor bed. Immediately after Tx, plasma thyrocalcitonin levels before and during calcium infusion were all elevated (640--1200 pg/ml). 131I (150 mCi) was administered 12 days after Tx after four daily im injections of bovine TSH. Three months after 131I therapy, thyrocalcitonin levels before and during calcium infusion were all normal (less than 50 pg/ml). Ten months after 131I therapy, thyrocalcitonin levels before and after iv pentagastrin were all normal (less than 60 pg/ml). These results suggest that parafollicular cells are radiosensitive, and that therapeutic levels of radiation can be delivered to these cells after Tx if iodine trapping by the remaining follicular cells is enhanced by high levels of circulating TSH. 131I may be the therapy of choice for MC after Tx, if disease has not spread beyond the area proximate to the thyroid gland.

In order to assess the effect of hyperthyroidism on systolic and diastolic function of the left ventricle, M-mode echocardiograms and systolic time intervals were obtained in 13 patients while they were clinically hyperthyroid and again when they were euthyroid following radioactive iodine therapy. Echocardiographic tracings of the septum and left ventricular posterior wall were digitized and analyzed to provide the maximum velocity of shortening and maximum velocity of lengthening. These velocities were normalized for left ventricular diastolic dimension. The left ventricular minor axis fractional shortening and the normalized maximum velocity of shortening were both increased during the hyperthyroid state. The normalized maximum velocity of lengthening, a measure of diastolic left ventricular function, was also increased during the hyperthyroid state when compared to the euthyroid state. The preejection period index and the preejection period/left ventricular ejection time ratio were lower when the patients were hyperthyroid than when they were euthyroid. These data confirm the increased inotropic state and demonstrated increased diastolic relaxation velocities of the hyperthyroid left ventricle.