Professional Practice Guidelines Research Articles

Use and Safety of Per-Oral Endoscopic Myotomy for Achalasia in the US

Several professional practice guidelines recommend per-oral endoscopic myotomy (POEM) as a potential first-line therapy for the management of achalasia, yet payers remain hesitant to reimburse for the procedure owing to unanswered questions regarding safety. To evaluate the use, safety, health care utilization, and costs associated with the use of POEM for treatment of achalasia relative to laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD). This was a retrospective national cohort study of commercially insured patients, aged 18 to 63 years, who underwent index intervention for achalasia with either LHM, PD, or POEM in the US between July 1, 2010, and December 31, 2017. Patient data were obtained from a national commercial claims database. Included in the study were patients with at least 12 months of enrollment after index treatment and a minimum of 6 months of continuous enrollment before their index procedure. Patients 64 years or older were excluded to avoid underestimation of health care claims from enrollment in Medicare supplemental insurance. Data were analyzed from July 1, 2019, to July 1, 2021. Changes in the proportion of annual procedures performed for achalasia were evaluated over time. The frequency of severe procedure-related adverse events, including perforation, pneumothorax, bleeding, and death, were compared. Negative binomial regression was used to compare the incidence rates of subsequent diagnostic testing, reintervention, and unplanned hospitalization. Generalized linear models were used to compare differences in 1-year health-related expenditures across procedures. This cohort study included a total of 1921 patients (median [IQR] age: LHM group, 48 [37-56] years; 737 men [51%]; PD group, 51 [41-58] years; 168 men [52%]; POEM group, 50 [40-57] years; 80 men [56%]). The use of POEM increased 19-fold over the study period, from 1.1% (95% CI, 0.2%-3.2%) of procedures in 2010 to 18.9% in 2017 (95% CI, 13.6%-25.3%; P = .01). Adverse events were rare and did not differ between procedures. Compared with LHM, POEM was associated with more subsequent diagnostic testing (incidence rate ratio [IRR], 2.2; 95% CI, 1.9-2.6) and reinterventions (IRR, 1.9; 95% CI, 1.1-3.3). When compared with PD, POEM was associated with more subsequent diagnostic testing (IRR, 1.5; 95% CI, 1.3-1.8) but fewer reinterventions (IRR, 0.4; 95% CI, 0.2-0.6). The total 1-year health care costs were similar between POEM and LHM, but significantly lower for PD (mean cost difference, $7674; 95% CI, $657-$14 692). Results of this cohort study suggest that POEM was associated with higher health care utilization compared with LHM and lower subsequent health care utilization but higher costs compared with PD. The use of POEM is increasing rapidly; payers should recognize the totality of evidence and current treatment guidelines as they consider reimbursement for POEM. Patients should be informed of the trade-offs between approaches when considering treatment.

Implementation of INHERET, an Online Family History and Cancer Risk Interpretation Program for Primary Care and Specialty Clinics.

Individuals at increased risk for cancer are ascertained at low rates of 1% to 12% in primary care (PC). Underserved populations experience disparities of ascertainment, but data are lacking. INHERET is an online personal and family history tool to facilitate the identification of individuals who are eligible, according to guidelines, to be counseled on germline genetic testing and risk management. INHERET data entry uses cancer genetics clinic questionnaires and algorithms that process patient data through NCCN Clinical Practice Guidelines in Oncology and best practice guidelines. The tool was tested in silico on simulated and retrospective patients and prospectively in a pilot implementation trial. Patients in cancer genetics and in PC clinics were invited to participate via email or a card. Informed consent was completed online. INHERET aimed to integrate patient data by algorithms based on professional and best practice guidelines to elicit succinct, actionable recommendations that providers can use without affecting clinic workflow or encounter length. INHERET requires a 4th-grade reading level, has simple navigation, and produces data lists and pedigree graphs. Prospective implementation testing revealed understandability of 90% to 100%, ease of use of 85%, and completion rates of 85% to 100%. Physicians using INHERET reported no added time to their encounters when patients were identified for counseling. In a specialty genetics clinic, INHERET's data were input, on average, within 72 hours compared with 4 to 6 weeks through standard care, and the queue for scheduling patients decreased from 400 to fewer than 15 in <6 months. INHERET was found to be accessible for all education and age levels, except patients aged >70 years, who encountered more technical difficulties. INHERET aided providers in conveying high-risk status to patients and eliciting appropriate referrals, and, in a specialty clinic, it produced improved workflows and shortened queues.

Use of professional practice guidance resources in pharmacy: a cross-sectional nationwide survey of pharmacists, intern pharmacists, and pharmacy students

BackgroundVariations in practice are commonplace in healthcare where health professionals, such as pharmacists act as autonomous practitioners. This is evident in simulated patient studies, where pharmacists practice does not meet widely accepted standards for medicines supply or treatment of an ailment. To promote best pharmacy practice a myriad of guidance resources including practice guidelines, codes and standards are produced by professional organisations. These resources provide a framework for pharmacy practice and endeavour to facilitate consistency in provision of pharmacy-based services to consumers. Despite their role in specifying essential pharmacist behaviours, there is limited research exploring if and how these resources are used in practice.ObjectiveTo characterise Australian pharmacists’ use of the Pharmaceutical Society of Australia’s Code of Ethics, Professional Practice Guidelines and Professional Practice Standards.MethodsA cross-sectional, self-administered, electronic survey of registered pharmacists, intern pharmacists and pharmacy students living in Australia was conducted in July 2020. Questions considered use of professional practice resources (by resource group) in the preceding 12 months. Data were analysed descriptively.ResultsOf 601 responses included in the analysis 462 (76.9%) of respondents were registered pharmacists, 88 (14.6%) pharmacy students and 51 (8.5%) intern pharmacists. Interns and students accessed overarching practice resources, such as the Professional Practice Standards, Code of Ethics and Dispensing Practice Guidelines more frequently than practising pharmacists. Pharmacists accessed professional practice guidelines, such as Practice Guidelines for the Provision of Immunisation Services Within Pharmacy, more often than students. More pharmacists than interns and students indicated that they would access guidelines to resolve practice and patient care issues. All resources except the Professional Practice Standards for Pharmacists (67.4%) were accessed by less than 50% of respondents in the preceding 12-month period. Reasons for not accessing resources varied between participant and resource groups, and generally were due to a lack of awareness of the resource or not considering them necessary for the individual’s practice.Conclusion(s)Access and use patterns for professional practice guidance resources change with experience. Professional organisations responsible for developing resources should consider these patterns when designing and reviewing resources and related policies. To ensure resources are meeting the needs of the profession, students, interns, and pharmacists should be involved in the review of and design of further resources.

A Review of Predictors of Psychosocial Service Utilization in Youth with Attention-Deficit/Hyperactivity Disorder.

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood disorders. Professional practice guidelines recommend combined treatment, psychopharmacological and psychosocial, for youth with ADHD. There have been multiple reviews of pharmacological prescription practices and utilization, however, less is known about predictors of ADHD psychosocial service utilization. Given the importance of accessing psychosocial treatment in relation to improving functional impairment, this review synthesizes evidence on predictors of ADHD psychosocial intervention utilization in clinic, community, and school settings. Eighteen studies were identified and included in the review. Findings are summarized across informant profile factors, predisposing characteristics, and barriers and facilitators. The most robust findings were for the impact of symptom severity/impairment, the presence of comorbidities, and age on ADHD psychosocial service utilization. Race/ethnicity, sex, parental knowledge of the disorder and insurance coverage were also identified as key factors. Future avenues of research are provided, and clinical and policy implications targeted at reducing psychosocial treatment disparities in youth with ADHD are discussed.

Physician-directed genetic screening to evaluate personal risk for medically actionable disorders: a large multi-center cohort study

BackgroundThe use of proactive genetic screening for disease prevention and early detection is not yet widespread. Professional practice guidelines from the American College of Medical Genetics and Genomics (ACMG) have encouraged reporting pathogenic variants that confer personal risk for actionable monogenic hereditary disorders, but only as secondary findings from exome or genome sequencing. The Centers for Disease Control and Prevention (CDC) recognizes the potential public health impact of three Tier 1 actionable disorders. Here, we report results of a large multi-center cohort study to determine the yield and potential value of screening healthy individuals for variants associated with a broad range of actionable monogenic disorders, outside the context of secondary findings.MethodsEligible adults were offered a proactive genetic screening test by health care providers in a variety of clinical settings. The screening panel based on next-generation sequencing contained up to 147 genes associated with monogenic disorders within cancer, cardiovascular, and other important clinical areas. Sequence and intragenic copy number variants classified as pathogenic, likely pathogenic, pathogenic (low penetrance), or increased risk allele were considered clinically significant and reported. Results were analyzed by clinical area and severity/burden of disease using chi-square tests without Yates’ correction.ResultsAmong 10,478 unrelated adults screened, 1619 (15.5%) had results indicating personal risk for an actionable monogenic disorder. In contrast, only 3.1 to 5.2% had clinically reportable variants in genes suggested by the ACMG version 2 secondary findings list to be examined during exome or genome sequencing, and 2% had reportable variants related to CDC Tier 1 conditions. Among patients, 649 (6.2%) were positive for a genotype associated with a disease of high severity/burden, including hereditary cancer syndromes, cardiovascular disorders, or malignant hyperthermia susceptibility.ConclusionsThis is one of the first real-world examples of specialists and primary care providers using genetic screening with a multi-gene panel to identify health risks in their patients. Nearly one in six individuals screened for variants associated with actionable monogenic disorders had clinically significant results. These findings provide a foundation for further studies to assess the role of genetic screening as part of regular medical care.

Comparison of clinical pharmacogenetic recommendations across therapeutic areas.

Evaluations from pharmacogenetics implementation programs at major US medical centers have reported variability in the clinical adoption of pharmacogenetics across therapeutic areas. A potential cause for this variability may involve therapeutic area-specific differences in published pharmacogenetics recommendations to clinicians. To date, however, the potential for differences in clinical pharmacogenetics recommendations by therapeutic areas from prominent US guidance sources has not been assessed. Accordingly, our objective was to comprehensively compare essential elements from clinical pharmacogenetics recommendations contained within Clinical Pharmacogenetics Implementation Consortium guidelines, US Food and Drug Administration drug labels and clinical practice guidelines from US professional medical organizations across therapeutic areas. We analyzed clinical pharmacogenetics recommendation elements within Clinical Pharmacogenetics Implementation Consortium guidelines, US Food and Drug Administration drug labels and professional clinical practice guidelines through 05/24/19. We identified 606 unique clinical pharmacogenetics recommendations, with the most recommendations involving oncology (217 recommendations), hematology (79), psychiatry (65), cardiovascular (43) and anesthetic (37) medications. Within our analyses, we observed considerable variability across therapeutic areas within the following essential pharmacogenetics recommendation elements: the recommended clinical management strategy; the relevant genetic biomarkers; the organizations providing pharmacogenetics recommendations; whether routine genetic screening was recommended; and the time since recommendations were published. On the basis of our results, we infer that observed differences in clinical pharmacogenetics recommendations across therapeutic areas may result from specific factors associated with individual disease states, the associated genetic biomarkers, and the characteristics of the organizations providing recommendations.

Oh Baby! There's a Pregger in My PACU…

<h3>Background Information</h3> With a trending increase in patient volume and acuity in the Post-Anesthesia Care Unit (PACU)s in a large academic medical center, it was noted that one of the demographics fostering this growth is the Obstetric (OB) population. It is important to note that the OB patients presenting to the PACUs required post-anesthesia care for non-OB procedures and interventions with the exception of OB procedures requiring general anesthesia. Hospital leadership and nursing staff noticed that caring for the OB patient in a non-OB PACU setting offered some distinct challenges related to the special considerations unique to the OB population. Instead of viewing OB patients in the PACU as a quagmire, the PACUs viewed this as an opportunity to collaborate with the OB department, promulgating maternal care in the PACU. <h3>Objectives of Project</h3> The objective was to create a program increasing knowledge related to the care of the OB patient in the PACU. <h3>Process of Implementation</h3> Collaborative gap analyses by the PACU and OB educators revealed that fundamental knowledge, skills, and adherences to professional organization recommendations regarding standards of care were opportunities for improvement. "Special Population Considerations: The OB Patient" was created and added to the existing PACU Residency/ Transition to Practice and PACU Preceptor curriculums which offer didactic and simulation activities to facilitate learning. Topics addressed included OB assessment, fetal monitoring (FM) expectations, postpartum hemorrhage care, and OB emergencies and equipment guided by professional practice guidelines and recommendations. Further, the OB department committed to collaborative care for FM and additional resources as needed, easing the anxiety of PACU nurses. Knowledge assessment was performed pre and post offering to measure changes in knowledge and program evaluation. <h3>Statement of Successful Practice</h3> After completion of the program by five cohorts, the average preassessment score of 30.6% increased to 85.6% post assessment showing an increase in knowledge and program success. Further, 100% of participants found the program beneficial. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> In addition to the new OB curriculum being offered, OB learning enrichment opportunities should be added to unit in-services, yearly skills and drills, and/ or unit-based competencies to ensure that PACU nurses are retaining knowledge regarding the care of the OB patient in the PACU.

Twenty-year trends in elementary teachers' beliefs about best practices for students with ADHD.

In an effort to understand teachers' perceptions of best practices for treatment of students with attention-deficit/hyperactivity disorder (ADHD) and how those may have shifted over the past 20 years, general education elementary school teachers completed surveys regarding their opinions of evidence-based interventions in the classroom. Two independent and anonymous samples of general education, elementary school teachers were collected: One in 1999 (n = 598) and a second in 2019 (n = 661). Teachers responded to questions about their interactions with students with ADHD as well as their beliefs about best practices for these students. Across survey samples, teachers generally agreed that behavioral classroom management, medications, and the combination of the two are effective treatments for students with ADHD. Comparisons of the 1999 and 2019 survey samples suggest that teachers in 2019 perceive the use of behavioral classroom management somewhat less favorably than did teachers in 1999. Teacher perceptions of best practices for students with ADHD in 1999 and 2019 were generally consistent with professional practice guidelines. Teacher responses also highlight a critical need for training and support related to evidence-based strategies for students with ADHD in the classroom. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

2020 NICE guideline update: Good news for pregnant women with type 1 diabetes and past or current gestational diabetes.

In December 2020, the National Institute for Health and Care Excellence (NICE) reviewed the evidence and updated their recommendations on intermittently scanned (commonly known as Flash) and Continuous Glucose Monitoring (CGM) during pregnancy for women with type 1 diabetes (1). The NICE guidelines now recommend offering CGM to all pregnant women with type 1 diabetes to help them meet their pregnancy glucose targets and improve neonatal outcomes. Their evidence review, based on the CONCEPTT randomised trial (2) and a Swedish observational study (3) found that, compared to capillary glucose monitoring, CGM resulted in more women achieving their blood glucose targets, fewer caesarean sections and fewer neonatal intensive care admissions.

The Rights of Persons With Dementia and Their Meanings

Concern about the lack of human rights afforded to persons living with dementia has emerged in recent years. Although the literature addresses certain rights, it does not include a holistic framework of rights in terms of the lived experience of older persons with cognitive impairment. Inspired by the 20 rights advocated for children by physician-educator Janusz Korczak, this article analyzes his formulation of rights in the context of persons with dementia, linking them to the ethical principles of Beneficence, Autonomy, and Justice. The analysis thus provides a holistic framework for addressing the human rights of persons with dementia, and their meanings for the lived experiences of persons with dementia and their caregivers. It offers new insights into the philosophy and practice of care, with implications for dementia care research, public health policy, practice guidelines for health care professionals, and the instruction of family and other caregivers of persons with dementia.

EFPA Perspective

IntroductionPsychologically, the question of profession-specific instruments and tools is not trivial. A profession is characterized by specific knowledge. Knowledge is regarded as part of professional competencies: What is done? How is something done? Why is something done? Knowledge and skills are acquired through specific training and continuing education.ObjectivesProfessional knowledge is represented in a specific language. In addition, standards and regulations apply to differentiate it from other professions. Different languages and special professional regulations make cooperation more difficult. These obstacles must be overcome.MethodsInstruments stand for professional identity. Competence-based tools are subject to professional legal regulations (e.g. following standards defined by EuroPsy Certificate of EFPA), ethical guidelines of the profession (professional ethics according to EFPA Meta-Code of Ethics) and external guidelines for professional practice (e.g. national and EU regulations). This ensures patient safety through Europe-wide standards. The investigation of profession-specific profiles and their modification, also under the conditions of the pandemic, becomes important.ResultsProfessional instruments are protected by professional political boundaries. Profession-specific profiles are also an invitation to “coopetition”. While differentiation tends to lead to complementary mission fulfillment in practice, openness leads to a “spill-over of skills” in interdisciplinary practice. Alignment of competence profiles and cooperation are encouraged.ConclusionThe future certainly lies in closer cooperation between the professions. The search for fundamental common ground (consilience), for effective and sustainable interventions (efficiency) and the demand for evidence-based practice (according to common ethical standards) place the well-founded benefit of an instrument for clients above any other interests.DisclosureNo significant relationships.

The place of non-invasive brain stimulation in the RANZCP clinical practice guidelines for mood disorders.

Clinical practice guidelines are important documents as they have the capacity to significantly influence and shape clinical practice in important areas of therapeutics. As such, they need to be developed informed by comprehensive and quality-based systematic reviews, involve consensus deliberations representative of the appropriate experts in the field and be subject to thorough critical review. A revised clinical practice guideline for the management of patients with mood disorders was recently published under the auspices of the Royal Australian and New Zealand College of Psychiatrists. However, this clinical practice guideline was not developed in a manner that reflects the appropriate standards that should apply to clinical practice guideline development and it has critical flaws, especially as it pertains to the use of repetitive transcranial magnetic stimulation treatment for patients with depression. The revision of the college clinical practice guideline has explicitly removed clear and unequivocal evidence-based recommendations that were found in a previous version of the clinical practice guideline and replaced these with consensus-based recommendations. However, the consensus-based recommendations were developed without consultation of the appropriate expert body within the college and contradict the scientific literature. There is substantive and unequivocal evidence supporting the antidepressant use of repetitive transcranial magnetic stimulation in the treatment of patients with depression and its use after a patient with depression has failed a limited number (typically around two) of antidepressant medication trials. Readers should refer to the college Professional Practice Guidelines for repetitive transcranial magnetic stimulation published in 2018 for thorough information about the use of this important new treatment.

Tilt testing remains a valuable asset.

Head-up tilt test (TT) has been used for >50 years to study heart rate/blood pressure adaptation to positional changes, to model responses to haemorrhage, to assess orthostatic hypotension, and to evaluate haemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction, and hypertension. During these studies, some subjects experienced syncope due to vasovagal reflex. As a result, tilt testing was incorporated into clinical assessment of syncope when the origin was unknown. Subsequently, clinical experience supports the diagnostic value of TT. This is highlighted in evidence-based professional practice guidelines, which provide advice for TT methodology and interpretation, while concurrently identifying its limitations. Thus, TT remains a valuable clinical asset, one that has added importantly to the appreciation of pathophysiology of syncope/collapse and, thereby, has improved care of syncopal patients.

School-Based Speech-Language Pathologists' Adherence to Practice Guidelines for Assessment of English Learners.

Purpose The purpose of this study was to ascertain the extent to which school-based speech-language pathologists' (SLPs) assessment practices with individual English learners (ELs) align with federal legislation and professional practice guidelines. Specifically, we were interested in examining SLPs' use of multiple tools during individual EL assessments, as well as relationships between practices and number of types of training experiences. Method School-based SLPs in a Midwestern state were recruited in person or via e-mail to complete an online survey pertaining to assessment. Of the 562 respondents who completed the survey, 222 (39.5%) indicated past or present experience with ELs, and thus, their data were included in the analyses. The questionnaire solicited information about respondent's demographics, caseload composition, perceived knowledge and skills and training experiences pertaining to working with ELs (e.g., graduate school, self-teaching, professional conferences), and assessment practices used in schools. Results The majority of respondents reported using multiple tools rather than a single tool with each EL they assess. Case history and observation were tools used often or always by the largest number of participants. SLPs who used multiple tools reported using both direct (e.g., standardized tests, dynamic assessment) and indirect tools (e.g., case history, interviews). Analyses revealed low to moderate positive associations between tools, as well as the use of speech-language samples and number of types of training experiences. Conclusions School-based SLPs in the current study reported using EL assessment practices that comply with federal legislation and professional practice guidelines for EL assessment. These results enhance our understanding of school-based SLPs' assessment practices with ELs and may be indicative of a positive shift toward evidence-based practice.

A Survey of Hospice and Palliative Care Nurses' and Holistic Nurses' Perceptions of Spirituality and Spiritual Care.

The provision of spiritual care is referred to in professional practice guidelines and mandated in nurses' ethical codes. Still, a gap exists regarding essential training in spiritual conversation and assessment, leaving some health care providers feeling uncomfortable when assessing spiritual support needs. The purpose of this study was to assess hospice and palliative nurses' and holistic nurses' perceptions of spirituality and spiritual care. It was assumed that the standards of care for hospice and palliative nurses and holistic nurses stipulate that spiritualty is addressed within the framework of their specialties and provide education for spiritual care, thus making these nurses proficient in providing spiritual care. This exploratory, descriptive study utilized a web-based survey to measure perception of spirituality and spiritual care giving using a modified Spirituality and Spiritual Care Rating Scale. A convenience sample was recruited from members of the Hospice and Palliative Nurses Association and the American Holistic Nurses Association (n = 250). Descriptive statistics summarized data as well as qualitative analysis of written narratives. Content analysis of open-ended survey questions was used to identify themes until saturation. This study found that given adequate resources and education, nurses can be positioned to address the spiritual needs of patients and provide appropriate care. This study adds to an emerging body of evidence suggesting that training in spiritual care should be an important component of the foundational nursing curriculum.

Norms in AVT

The main objective of this article is to review the concept of norm in Audiovisual Translation (AVT), a concept which has been subject to a dual approach when using it, both a descriptive one and a prescriptive one. The review proposed in this article is intended to be twofold: descriptive and critical. A descriptive approach will be the focus in the first two sections of the paper, where the history and evolution of the concept is analysed. A more critical stance is then adopted in the following two sections of the paper. The dual orientation of the concept of norm is highlighted in Section 3. The hypothetical application of norm theory to professional practices for the main modes within AVT has in most cases taken the form of guidelines, the result of a pure prescriptive approach. This discussion is covered in Section 4. The final fifth section summarizes the review, while pointing out the great significance of this fundamental notion within the field of AVT. All in all, the concept has proven to be successful and long-lasting, and it is mainly accepted that norms obtained from empirical research should give rise to guidelines for professional practice in translation.

A qualitative analysis of disclosure of parental incarceration to children in Singapore – Implications for best practice

Children are often the unintended victims of incarceration, and are frequently subjected to extreme hardship following the arrest of a parent, but their right to information is always compromised in the name of protection. Disclosure of incarceration can be equally challenging for both the family caregivers and the children. This paper presents the data from interviews about disclosure of incarceration, looking at how 10 caregiver–child dyadic pairs interacted and handled disclosure in the process. Disclosure is taken as a continuous process requiring the caregivers and the children to negotiate and make sense of it, rather than a static, one-off decision. Three dimensions of protection have been identified (i.e., protection from future blame, protection of the child, and protection of the inmate), together with the intent to use the disclosure for educational purposes. Although there was not a case where the children protested having limited or no information, they varied in their responses. A lack of interest in asking for essential information and intentional avoidance of the topic of parent’s incarceration have been observed in some children. Self-regulated submission by the child is a result of many factors, including a tacit demand to acknowledge parental authority and a caring intent not to add to the caregiver’s burdens. This article also highlights implications and recommendations for changing professional practice and policy guidelines to promote children’s rights and their healthy growth amidst the challenges of life.

A PRAXIS DA FISIOTERAPIA NO PROGRAMA HIPERDIA: CONCEITOS E DIRETRIZES

Introdução: Atualmente, a hipertensão arterial e a diabetes mellitus constituem a principal causa de morbimortalidade na população brasileira. Dessa forma, é necessária a elaboração de ações direcionadas a contornar essa grave situação de saúde pública, criando estratégias para promoção e prevenção. O programa Hiperdia é destinado ao cadastramento e acompanhamento dos portadores de doenças crônicas não transmissíveis, promovendo orientações e promoção de saúde. Objetivo: identificar as possíveis atuações do fisioterapeuta dentro do programa de saúde pública Hiperdia, criar propostas mais específicas, com diretrizes de atuação profissional. Método: O estudo trata- se de uma revisão interativa que aconteceu a partir de uma busca detalhada, realizada nas bases de dados: Scientific Electronic Library Online (Scielo), Medical Literature Analysis and Retrieval System Online (MedLine /PubMed) e sites do Ministério da Saúde. Resultados: Inegável é a necessidade de se investir na prevenção destas doenças crônicas e a participação do fisioterapeuta pode ser benéfica neste contexto. Conclusão: Portanto, em virtude do tamanho modesto de materiais encontrados abordando a atuação do fisioterapeuta no programa Hiperdia, é importante enfatizar a necessidade de mais estudos abordando o tema, visando esclarecer o papel do profissional em cada nível de atenção à saúde.

Temporal Trends in the Rates of Singletons, Twins and Higher-order Multiple Births Over Five Decades Across Racial Groups in the United States.

We analysed Natality data obtained from the National Vital Statistics System from 1971 through 2018. Overall, the rates of singletons declined among all racial groups over the five decades of the study. However, the rates of twins and higher-order multiples increased over the same period although for the past two decades, the rates of higher-order multiples had substantially plummeted. The global health implication of these findings is that policy changes in the US in the form of professional practice guidelines have succeeded in reducing the birth of vulnerable populations (i.e., higher-order multiples) who are predominantly created using assisted reproductive technology.

Does God make a difference for student affairs? Emerging student affairs in the Christian story

Despite a focus on the holistic formation of students, nonreligious narratives shape student affairs theories and professional practice guidelines. Recognizing this problem, Christian scholar-practitioners have authored a growing body of literature about what might be distinct about Christian student affairs. This article provides an analysis of the theological foundations used in this literature. Our aim was to locate the unique theological building blocks for a more comprehensive Christian theology of student affairs. Our analysis found that placing and practicing the profession of student affairs within the Christian narrative produced noteworthy distinctives in every aspect of student affairs.