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Revista de Psiquiatria do Rio Grande do Sul

Print version ISSN 0101-8108

Rev. psiquiatr. Rio Gd. Sul vol.27 no.1 Porto Alegre Jan./Apr. 2005

http://dx.doi.org/10.1590/S0101-81082005000100009 

REVIEW ARTICLE

 

Aspects of consultation-liaison psychiatry at trauma hospitals

 

Aspectos de la interconsulta psiquiátrica en hospital de trauma

 

 

Ricardo SchmittI; Roberta Horn GomesII

IPyschiatrist. MSc at Universidade Federal do Rio Grande do Sul (UFRGS). Centro de Ciências da Saúde, UNOCHAPECÓ. Professor at the Instituto de Formação em Teoria Psicanalítica, GEPA, Chapecó, SC, Brazil. Former physician, Hospital Cristo Redentor, Porto Alegre, RS, Brazil
IIPsychiatrist. Former psychiatry resident, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil

Correspondence

 

 


ABSTRACT

The objective of this paper is to describe the main aspects of consultation-liaison psychiatry at a trauma hospital. The characteristics of consultation-liaison psychiatry in general hospitals are discussed. After that, the unique characteristics of consultation-liasion psychiatry at trauma hospitals are presented. The most common psychiatric trauma-related events are violent suicide attempts, substance abuse and psychological reaction to trauma. The main focus is on the specificity of the relationship between trauma and psychiatric disorders: they can be both a consequence and a cause. This is a new field for interdisciplinary action and scientific research in Psychiatry.

Keywords: Consultation-liaison, trauma, hospital, psychiatry.


RESUMEN

Los autores se proponen a abordar aspectos particulares de la interconsulta psiquiátrica en un hospital de trauma. Para eso, revisan los aspectos generales de una interconsulta en hospital general y, posteriormente, destacan las características que diferencian la consultoría psiquiátrica en un hospital de trauma. Los eventos psiquiátricos más relevantes en el trauma son las tentativas de suicidio violentas, el abuso de substancias y las reacciones psíquicas al traumatismo. El destaque se refiere a la especificidad de la relación del trauma y las enfermedades psiquiátricas: ambos pueden ser causa o consecuencia. Ese es un nuevo campo de actuación interdisciplinaria y producción científica para la psiquiatría.

Palabras clave: Interconsulta, trauma, psiquiatría, hospital.


 

 

INTRODUCTION

The introduction of psychiatry in the context of general hospitals is not something new. In fact, there is evidence of that relationship since the 18th century.1,2 In fact, it was in the 20th century, especially after the Second World War, that this phenomenon gained momentum in the Unites Sates and Europe. In Brazil, the inclusion of psychiatry in general hospitals started after the 1950s, but it was after the discussion of the psychiatric reformation3 that such movement started to grow.

With the arrival of psychiatrists in general hospitals, a new professional field developed: the consultation-liaison psychiatry. The literature is plenty of publications about this new area of psychiatry;4,5 there are many studies concerning the concept, diagnostic, techniques, interventions and epidemiology of consultation-liaison psychiatry in general hospitals.1,2,4,5

The demand for psychiatrists has been also increasing in another area of hospital medicine: trauma services. Diseases resulting from trauma have required other medical areas to specialize, such as surgery, orthopedics and neurology. Once psychiatry is in the context of general hospitals as well, it also needs to adapt itself to those areas. However, few studies have been published in the specific area of consultation-liaison psychiatry.6

The goal of the present study was to review the major aspects of the consultation-liaison psychiatry in trauma services. For that end, the article is organized as it follows: a) review of psychiatry in the context of general hospitals and b) psychiatry in trauma hospitals and its singularities.

The references were taken from: a) electronic libraries - MEDLINE (1993-2003) and LILACS (1993-2003); b) abstracts of conferences and congresses annals; c) review of books chapters on consultation-liaison psychiatry and psychiatry in trauma hospitals. The terms used in the search were: consultation-liaison and psychiatry; psychiatry and trauma; hospital and psychiatry; hospital and trauma.

The selected theoretical support for the first part of the article included sources that contained information about the main aspects of consultation-liaison psychiatry in general hospitals, and studies about consultation-liaison psychiatry in trauma hospitals that contained clinical and epidemiologic data of psychiatric disorders resulting from trauma.

Studies concerning specific aspects of the consultation-liaison psychiatry in general hospitals that were not relevant for the purposes of the present work, and texts about trauma that did not evaluate comorbidity and possible psychiatric complications were excluded from our review.

 

DEVELOPMENT

1) Consultation-liaison psychiatry in general hospitals - History

In Brazil, liaison has been gaining space since the 1980s, when the issue started to be approached in scientific congresses, as the symposiums carried out by the Escola Paulista de Medicina, the congresses of Universidade Federal de São Paulo (USP) and forums of the Associação Brasileira de Psiquiatris (ABP), among others. Today, some of the most outstanding psychiatric associations count on departments or centers for consultation-liaison psychiatry, as, for example, the Department of Psychiatry of the ABP General Hospital and the General Hospital of the Sociedade de Psiquiatria do Rio Grande do Sul,1 Brazil.

The consultation-liason psychiatry gained even more importance after the Brazilian Law 10216 of April 6th 2001 was launched,3 which instituted the psychiatric reformation. This law recommends the creation of psychiatric units within general hospitals, enforcing the relation that already existed between psychiatry and other medical specialties.

A context that propitiated the integration of different medical areas was therefore established, meeting the biopsychosocial approach required by ill individuals. On the other hand, this reality requires psychiatrists to recognize they are working within a specialized field of medicine. The consultation-liaison psychiatry has been fundamental in the return of psychiatry to the medical field and in the restoration of the medical identity of psychiatrists.2

2) Concepts and objectives

In general, the consultation-liaison psychiatry consists of the presence of a psychiatrist in a unit or general medical service under the request of a physician from another specialty.1 It is an interprofessional and interdisciplinary activity, so, strictly speaking, we could define the consultation-liaison psychiatry and its objectives as a sub-field of psychiatry that:1,2,4,5

- has an interface with general medicine;
- complements care provided to general hospital patients;
- collaborates with the psychiatric, psychological and social approach to the patient;
- collaborates with the teaching and research task.

Based on these 4 items we may define the following goals for the consultation-liaison psychiatry:

- To help in the diagnose and treatment of patients with comorbid clinical disease and psychiatric disease;
- To help and provide the non-psychiatrist physician with knowledge to handle with situations of psychiatric nature;
- To help the biopsychosocial understanding of patients and their diseases;
- To make psychiatric understanding known among other medical areas.

3) Nature of consultation requests

The nature of psychiatric consultation requests in general hospitals vary enormously, however, their different nature can be classified in three different approaches:1,4

a) clinical and psychiatric assessment;
b) psychological and familial assessment;
c) assessment of bioethical aspects;

The great variety of aspects involved in psychiatric consultations usually requires the engagement of a team of health care professionals, such as psychologists and social assistants. Maybe, in a near future we will be talking about a consultation-liaison psychiatry team.

Clinical psychiatric evaluation

Although there may be some variations, data usually demonstrate that about 30% of clinical or surgical unit's inpatients have some kind of psychiatric diagnose.4 In this group, the prevalence (median) of the following psychiatric diagnoses is found: a) mood disorders (35%); b) anxiety disorders (20%); c) substances-use disorders (20%); organic mental disorders (20%); d) others (5%).

Based on those data, the following considerations can be made:

a) mood disorders include depression and bipolar disorder;
b) the anxiety disorders include adjustment reactions and somatic symptoms;
c) the organic disorders include delirium, dementia, and psychiatric symptoms secondary to an organic disease.

It is worth noticing that epidemiological studies usually show wide variations. Thus, for example, a recent review7 showed that mood disorders (56%) and alcohol-related disorders (29%) were the main diagnoses found in psychiatric consultations in the 1990s in the University Medical Center of the University of Minnesota, USA. According to another study,2 when the age bias is adjusted, the prevalence of organic mental disorders reaches 22%; however substance-use disorders are not mentioned. Such diversity yields some reflections: a) the routine of psychiatric consultation fluctuates from service to service; b) acknowledgement and consequent diagnosis of some disorders have been changing; c) data collection and diagnostic criteria are not systematic. Of note, psychiatric disorders are usually comorbid, for instance, there may be a patient with borderline personality with adjustment reaction to depressive mood.

Psychological and familial assessment

One of the goals of the psychiatric consultation is the possibility of approaching biological psychological and social aspects of patients, therefore the evaluation of their psychological and familial aspects is a key process. The definition of a psychodynamic diagnostic is of paramount importance for psychiatrists.4 It is the consultant's role to identify the defense mechanisms the patients use, their usual psychological functioning and personality structure.

The evaluation of the patient's family is as important as his psychological aspects. It allows completing data collected from the patient, team and patient's history. Besides, understanding the family's behavior and the way how they deal with the patient's problems (both sound and pathologic) is important for diagnosis and treatment.

Bioethical evaluation

Sometimes, the psychiatrist is called to help the service team decide complex issues. Not rarely, the request for psychiatric consultation is associated to patients that do not want to follow treatment prescribed or do not collaborate with the team. Help in the approach of terminal patients or who received "difficult" diagnoses, like cancer or HIV, is also frequent. In those situations, we have to face relative questioning, for example, which the patient's autonomy level is, at which critical judgment level, is there a need to hide the diagnosis or not, among others. To be able to deal with those issues, the psychiatrist should be well trained in bioethics and count on the assistance, whenever needed, from the ethical committees of hospitals.

Psychiatric consultation: a comprehensive view4

By reviewing the nature of consultation we could reflect upon its multiple aspects. The three aspects mentioned above should be considered for every patient. The consultant should identify and handle them adequately. For example, if the patient is refusing to follow the team's orientations he may have a psychiatric disease that impose him judgment impairment and low tolerance to frustration, besides having a controlling family. The consultant will determine the patient's autonomy during treatment. It is the psychiatrist's responsibility to identify the prevailing aspect in the diagnosis, treatments priorities and what the care provider's team will need.

4) Liaison psychiatry in trauma hospitals

Similarities and differences in the consultation-liaison psychiatry in trauma and general hospitals

Generally speaking, the psychiatry-liaison in trauma hospitals (TH) follows the same principles of the general hospital consultation-liaison psychiatry. However, some singularities make psychiatry different in TH.

Trauma may be secondary to intentional injury or not. It means since a simple lesion or wound caused by small domestic injuries up to severe transit accidents, resulting from urban and interpersonal violence, as well as suicide attempts.8 Trauma is a disease that has been gaining importance over the last decades and today it is the main cause of death between the first and the 44th year of life.9 The number of years potentially lost because of trauma is higher than the sum of years lost with cardiovascular and neoplasic diseases.9 Therefore, traumatically injured patients have a potentially fatal and acute disease, besides possible previous history morbidity.

The notion of "accident" is no longer accepted in the medical area,9 once most of traumatic events could be prevented if some factors were observed. For example, the trauma history can be linked to previous psychiatric disorders, which may have been identified or not: traffic accidents may be related to drug abuse, burns to suicide attempts, aggressions to moral exposition, etc. Therefore, the way how trauma occurs can provide hints on the presence of a psychiatric disorder.

The association between trauma and psychiatric disorders is twofold: the trauma is a risk factor for psychiatric disorders10 and psychiatric disorders are risk factors for trauma. If trauma-related psychiatric aspects are not identified the trauma may relapse.10 An alcoholic patient can suffer a car accident, get over and later get involved in an inter-personal violent event.

Eventually, the psychiatric consultation in TH is a recent sub-field of psychiatry and even in the consultation-liason area. Its strengthening will depend on the involvement of psychiatrists in the tasks of making the scientific community aware of it, as well as on the interaction with the trauma "frontline" professionals (surgeons and emergency physicians.)

Psychiatric disorders in trauma hospitals

The psychiatric disorders can be considered as risk factors for the trauma occurrence and relapse.10 As described above, data vary widely. The literature points to drug abuse in 20 to 55% of patients with trauma.10 However, cross-sectional studies6 cite a prevalence of 13% for this disorder. The main bias seems to be selection. Some studies samples6 are patients who are under psychiatric consultation, while others10 mention general data, regardless of psychiatric evaluation. Moreover, there may be also a biased record of a disorder as the major one, masking the presence of another. There are no clear specifications of, for example, how many patients who tried to commit suicide were substance-abusers or had mood disorder, just to mention a possible type of interaction. It is possible that the hospital team identifies a patient as drug-abuser but no assessment is made by an expert psychiatrist. This feeling was confirmed by a study showing:11 there is resistance of some professionals to admit drug-addiction as a disease (and so there is consequent resistance to psychiatric consultation), there are not treatment programs in trauma hospitals, and there is lack of drug-screening tests in emergency services (or there is not a routine for these tests.)

Other revealing data come from a cross-sectional study,10 which showed the prevalence of psychiatric disorders in 29% of trauma inpatients. From these, 27% had a diagnosis of drug abuse, and 1.3 % were diagnosed depressive. In that study, the diagnosis was made by the service team and not by psychiatrists. The discrepancy between 29% psychiatric diagnoses made by the service team and 10% consultation requests11 (this is discussed further on) helps understand the differences in the epidemiologic findings.

Cross-sectional studies evidence suggest an association between psychiatric symptoms and trauma. The psychiatric evaluation is requested in about 10% of trauma inpatients.6 The psychiatric referral group had twice the length of stay as compared to non-referral patients. The extended hospital stay does not seem to be associated with trauma severity, which is usually slightly smaller than in patients assessed by the psychiatrist. Possible reasons include the need for diagnostic confirmation, which usually takes longer in psychiatry, as well as the need of transfer to a specialized unit.6 The delay resulting from the evaluation of another expert may be the reason why the service team does not request the psychiatric consultation. Some data regarding patients under psychiatric evaluation should be highlighted: a) the suicide attempt (acknowledged by the service team) is the main reason why consultation is required (45%) (table 1); mood disorders are the main diagnosis (28%) (table 2); and also the major previous diagnosis (28%).

 

 

 

 

The psychiatric history frequently indicates the presence of mental disorders. This finding suggests trauma to be much more the consequence of a psychiatric disorder than its cause.6

1) Suicide attempt

The suicide attempt (SA) is the major cause of consultation requests in trauma hospitals.6,12 The suicide attempt is also responsible for the early request of consultation as compared to other reasons. The SA usually requires more time to assess the patient than other disorders. Suicidal attempts patients represent 19% of violent trauma (gun injuries, burns, falls etc.), even though only 10% of traumas are assessed by an expert.6

In a study12 carried out in general hospitals, 45% of suicide attempters were diagnosed with comorbid psychoactive substance abuse (PSA). Comorbid depression and substance abuse was the most frequent category in suicide attempters, which were mostly men ranging from 30 and 60 years. However, there was a high prevalence of SA and substance abuse regardless of sex and age.12 Besides, comorbidity between depression and PSA was responsible for higher scores of suicidal ideation (high risk of suicide), suggesting that the mood instability in the context of SPA is a risk factor for severe suicide attempt.12

SA is an event that requires diagnostic investigation as for triggering event and risk of relapse. The SA referred to TH is usually violent, which is already a risk of relapse.13

2) Substance abuse

The substance abuse, especially alcohol, is associated with the occurrence of trauma.10 As mentioned earlier in this article, 20 to 55% of trauma inpatients have a current or previous history of alcohol abuse. Those patients usually have an increased risk of relapse and surgical intervention.14

In the trauma unit, the service team usually recognizes alcohol or other substance abuse in 27% of patients.10 Those data were also found in a study that observed acute alcohol intoxication in 29% of traumatically-injured patients.11 Despite the diagnosis, many patients are not assessed by psychiatrists. In another study, about 10% of traumatically-injured patients are assessed by psychiatrists;6 of those, 17% have a diagnosis of substance abuse.

The alcoholic traumatically-injured patient is usually man, 40-years-old or less, drug-abuser; length of hospital stay is smaller as compared to other patients with similar injuries.11 Another study10 shows that length of hospital stay is 10% smaller in patients with alcohol abuse diagnosis, with 12% decrease in costs.

Alcohol or other drugs abuse is present in about 20% of patients with a burn trauma.15

Some considerations about alcohol abuse and trauma may be meaningful. The prevalence of alcohol abuse during the general population's life is of 13.8%.11 Comorbidity between substance abuse and other psychiatric disorder is usually high. Among psychiatric disorders, mood disorders have prevalent comorbidity of 77.2%, having the most frequent association with alcohol abuse.12 Literature shows that mood disorders are the most frequently diagnosed in traumatically-injured patients, therefore, screeening the trauma patient for alcohol abuse is compulsory.

3) Burns

A recent study15 showed that most of burn patients have important predisposing factors. About 59% of women and 38% of men have risk factors for severe burns. Among those factors we find alcohol and drug abuse, dementia, schizophrenia and bipolar disorders. In psychiatric cases, burns are usually secondary to deliberate self-harm, impaired judgment and poor coordination associated with substance intoxications and risk-taking behavior.

Among patients that try to suicide by deliberate self-harm, about 70% have previous psychiatric history and 55% have already tried to commit suicide.16

The psychiatric history is also a risk factor for burn mortality. Personality disorder, SA, schizophrenia and alcohol abuse increase mortality of burn patients.15

Different psychiatric disorders are found in burn patients, according to the treatment phase (table 3). In the acute phase, we may find drug-abstinence delirium, burn delirium and acute stress disorder. The presence of delirium is an indication of worse prognosis. Some adjustment reactions, like denial, rebelliousness and hostility are also common in this phase.

 

 

In the reconstruction phase, feelings of sadness and grief with the body image are usual; in this phase post-traumatic stress syndrome, and adjustment and mood disorders are also frequent.

4) Traumatic brain injury (TBI)

TBI is a common event in traumatically-injured patients. The brain lesion resulting from the TBI causes a wide variety of neuropsychiatric symptoms. A recent review on the topic17 proposes the term "sequelae of TBC." Such definition would avoid the normally confusing terms as post-concussion syndrome and TBI-resulting mental disorder, for example. In our review, we use the term neuropsychiatric syndrome associated to TBI (NPS-TBI), once the term sequelae may be mistakenly understood as something irreversible. TBI-associated syndromes are cognitive deficits, mood disorders, anxiety, psychosis, apathy and behavior alterations17 (table 4).

 

 

The main risk factors for NPS-TBI are elder age, arteriosclerosis and alcoholism.18 In general, those factors delay the regenerative process of the central nervous system (CNS).18 Aspects of the patient's personality before trauma are fundamental for recovery. Symonds says that the reaction to the "TBI depends on the type of traumatically-injured head,19 therefore personality disorders are also risk factors of NPS-TBI. Other factors that are common in psychiatric diseases and may trigger the syndrome are unstable marital relationship, absent socio-familial network, unemployment and financial problems.20

4.1) NPS-TBI: cognitive deficit

The TBI usually causes a plethora of cognitive symptoms. These symptoms include deficits of attention, vigilance, concentration, memory, language and executive function. The memory deficit may be verbal or not. Disturbances in the executive functioning include: difficulty making plans and setting goals, problems with organization and actions changes associated with judgment and impulse control impairment.17

The deficit is usually related to a phase of TBI.21 The first phase is the loss of consciousness that happens soon after TBI. The second is characterized by a mix of cognitive and behavioral alterations as motor agitation, lack of orientation and attention. The two first phases last up to one month and are usually named post-traumatic delirium.22 The third phase lasts 6 to 12 months and is characterized by a fast recovery of damage cognitive capacities reaching a maximum of recovery that is kept up to 24 months after TBI. The fourth phase is characterized by permanent cognitive sequelae and includes thinking delay, attention, memory, language and executive functions deficit, as well as concrete thinking impairment. Such phase is usually referred to as post-TBI dementia.17

4.2) PNS-TBI: mood disorders

The major depressive syndrome occurs in about 25% of patients with TBI.23 Feelings of loss, demoralization and depressive mood are usually early detected and followed by symptoms of dysphoria. Fatigue, irritability, suicidal ideation, absence of pleasure and insomnia prevail between the sixth and the 24th months after TBI.24 Studies have shown that the poor psychosocial functioning and history of psychiatric diseases are the major risk factors for post-TBI depression.23 The presence of frontal-lateral injury and basal ganglia are associated with an increased probability of developing depression.17

The development of post-TBI mania is less common than the development of depression, but much more frequent than in the general population. In TBI, the prevalence for mania is 9%.25 Major risk factors are family history of mood disorder and previous sub-cortical atrophy.17 Mania is more common in patients with lesions in the limbic structures of the right hemisphere.25

4.3) Anxiety disorders

The post-TBI patient may present a mix of all anxiety disorders. The most common status is persistent and fluctuating anxiety associated to an excessive and uncontrollable worry, which is typical of generalized anxiety. In this case, the anxiety disorders are more associated with right-hemisphere lesions.17

4.4) Psychosis

Up to 10% of post-TBI patients may develop a psychotic schizophreniform disorder.17 The majority of patients does not have familial history of schizophrenia. In patients with previous diagnosis of schizophrenia, the exacerbation of symptoms occurs in about 15% of cases. The presentation of symptoms can be acute or chronic, transient or persistent, and can be associated to mood changes or not. There is not an evident association between the development of psychotic symptoms and the damaged brain region.

4.5) Apathy

About 10% of post-TBI patients can develop apathy, with no criteria for depression.17 Apathy is characterized by a syndrome of lack of interest, inertia, lack of motivation and affective dullness, with no cognitive changes. This syndrome seems to be associated to lesions in the frontal lobe.26

4.6) Behavioral disorder

A great number of post-TBI patients present a type of syndrome with mixed changes in cognition, mood and behavior.27 A recent review proposes the term behavioral disorder to describe this manifestations.17 Such syndrome is divided into major and minor variants.

The major variant (table 5) can be associated to a focal or diffuse lesion. Injuries in the frontal-orbital area cause disinhibition, while lesions in the dorsal convex of the frontal lobe may cause executive dysfunction (dysexecutive).26 Lesions in the temporal lobe cause emotional liability and memory deficit.

 

 

The minor variant (table 6), usually called post-concussion syndrome is the most diagnosed neuropsychiatry entity in the post-TBI.17 It is a set of signs and symptoms frequently seen in mild to moderate trauma, even though it can happen in any case. It is the most common syndrome in TBI cases with no loss of consciousness. Most patients recover within the six post-TBI months, but some symptoms can persist for more than one year. About 15% present symptoms for an indefinite period. An axonal diffuse lesion, secondary to acceleration-decceleration trauma, is supposed to be responsible for the problem onset. Neurological and imaging examinations are usually carried out. Positron emission tomography studies (PET) and the single photon emission computed tomography (SPECT) demonstrate focal and unspecific alterations in the metabolism of glycolysis and brain blood flow.17

 

 

CONCLUSION

The importance of consultation-liaison psychiatry in the general hospital seems to be consolidated. A movement of more than one century has been creating a hospital-associated and medical identity for psychiatry. Following those changes, psychiatry started to take part in another medical area: the trauma. This disease, modern, costly and with great impact in the public health, has been requiring more attention from psychiatry. Just to mention some examples, in Porto Alegre, two large trauma hospitals count on psychiatry consultant teams, they are the Hospital de Pronto-Socorro (HPS) and Hospital Cristo Redentor (HCR).

The psychiatrist of trauma must have solid knowledge on general principles of consultation-liaison psychiatry. Besides, he must be well supplied of information and specific knowledge on the trauma-psychiatry interface. The proposal of the present article was to approach general aspects of that topic. The idea is to try to begin discussing what exactly the consultation-liaison psychiatry in a trauma hospital is. For that end, we tried to set intersections and differences of this modality as compared to the general consultation-liason: the major difference concerns the singularity of trauma. We observed also that presentation, prevalence and clinical reasoning of psychiatric cases of trauma present some unique characteristics. The psychiatry consultant must have in mind the relations among the different types of trauma and their relation with possible previous psychiatric disorders, as well as the likely-to-develop psychiatric complications resulting from trauma. Eventually, the neuropsychiatric consequences of the traumatic brain injury were focused, which is a specific category of trauma psychiatry, even more than the others.

The present study tried to make a general approach of consultation-liaison psychiatry in a general hospital through a non-systematic literature review. This fact constrains the possibility of generalizing findings. Nevertheless, as discussed all over the text, the wide methodological variations of studies published make it difficult to sytematise data and point to the need of homogeneous research in the field of consultation-liaison psychiatry in TH.

Therefore, current evidence indicates that we should work in the development (or adaptation) of diagnostic scales, systematization of data collection and definition of controlled trials. Psychiatrists that work in this area have to face the challenge of generating new knowledge on epidemiology, clinic and treatment of trauma associated psychiatric disorders.

 

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Correspondence to
Ricardo Schmitt
Rua Guaporé, 33-D/401
CEP 89802-300 - Chapecó - SC - Brazil
Fone: +55-49-328-4961
E-mail: schmitt@superip.com.br

Received on December 30, 2004.
Revised on January 03, 2005.
Accepted on February 18, 2005.

 

 

The present study was carried out at the Centro de Ciências da Saúde, Universidade Comunitária Regional de Chapecó (UNOCHAPECÓ), Santa Catarina, Brazil.

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