Therapeutic Project at Extra-Hospital Mental Health Services: a critical reflection on the elaboration and management of services' therapeutic projects

Based on a study conducted in Ribeirao Preto, SP, Brazil in extra-hospital mental health services that addressed the organization of these services, therapeutic projects and the inclusion of psychosocial rehabilitation in health actions available, a theoretical-critical reflection concerning the development process of the therapeutic projects by the services' teams is presented. The qualitative study was conducted in an outpatient clinic and a Psychosocial Care Center. Data were collected through semi-structured interviews and focal groups. Data analysis was based on the hermeneutic dialectic philosophy of Jurgen Habermas according to the techniques of reconstruction and interpretation. Data analysis revealed that professionals have difficulty developing and managing therapeutic projects. Health actions are made available without being concretely supported by a proposal guiding the service's practical activities. The therapeutic projects are referred by professionals as the result of guidelines provided by management levels or technical orientations inherent to each profession but not as an activity that represents a philosophy of work of the health team. When the therapeutic project is focused on as a type of consensus that results from a communicative action directed to a mutual and intersubjective understanding among the members of the mental health extra-hospital team, the difficulties of the services' team dialogically organizing themselves to collectively construct the therapeutic project is evidenced.

Assessment and management of oral health in liver transplant candidates

Liver transplantation has become a standard treatment for end-stage liver disease and the number of recipients has grown rapidly in the last few years. Dental care during pre-transplant workup is important to reduce potential sources of infection in the drug-induced immunosuppression phase of liver transplantation. Objectives: The objectives of this study were to document the prevalence of oral abnormalities in patients on a liver transplant waiting list presenting to an urban dental school clinic, discuss the appropriate dental treatment according their systemic conditions and compare their oral manifestations with those of healthy individuals. Material and Methods: A pilot study was conducted involving 16 end-stage liver disease individuals (study group- SG) attending the Special Care Dentistry Center of the University of So Paulo and 16 control individuals (control group- CG) with no liver diseases, receiving dental care at the Dental School of the University of So Paulo. These individuals were assessed for their dental status (presence of oral disease or abnormalities), coagulation status, and dental treatment indications. Results: The patients from SG exhibited a greater incidence of oral manifestations compared with CG (p=0.0327) and were diagnosed with at least one oral disease or condition that required treatment. Coagulation abnormalities reflecting an increased risk of bleeding were found in 93.75% of the patients. However, no bleeding complications occurred after dental treatment. Conclusions: The patients with chronic liver diseases evaluated in this study exhibited a higher incidence of oral manifestations compared with the control group and had at least one oral disease or abnormality which required dental treatment prior to liver transplantation. Careful oral examination and evaluation of the patient, including laboratory tests, will ensure correct oral preparation and control of oral disease prior to liver transplantation.

Association between UCP2 A55V polymorphism and risk of cardiovascular events in patients with multi-vessel coronary arterial disease

Background UCP2 (uncoupling protein 2) plays an important role in cardiovascular diseases and recent studies have suggested that the A55V polymorphism can cause UCP2 dysfunction. The main aim was to investigate the association of A55V polymorphism with cardiovascular events in a group of 611 patients enrolled in the Medical, Angioplasty or Surgery Study II (MASS II), a randomized trial comparing treatments for patients with coronary artery disease and preserved left ventricular function. Methods The participants of the MASS II were genotyped for the A55V polymorphism using allele-specific PCR assay. Survival curves were calculated with the Kaplan–Meier method and evaluated with the log-rank statistic. The relationship between baseline variables and the composite end-point of cardiac death, acute myocardial infarction (AMI), refractory angina requiring revascularization and cerebrovascular accident were assessed using a Cox proportional hazards survival model. Results There were no significant differences for baseline variables according genotypes. After 2 years of follow-up, dysglycemic patients harboring the VV genotype had higher occurrence of AMI (p=0.026), Death+AMI (p=0.033), new revascularization intervention (p=0.009) and combined events (p=0.037) as compared with patients carrying other genotypes. This association was not evident in normoglycemic patients. Conclusions These findings support the hypothesis that A55V polymorphism is associated with UCP2 functional alterations that increase the risk of cardiovascular events in patients with previous coronary artery disease and dysglycemia.

Variations in Management of Mild Prenatal Hydronephrosis Among Maternal-Fetal Medicine Obstetricians, and Pediatric Urologists and Radiologists

Purpose: There are no current guidelines for diagnosing and managing mild prenatal hydronephrosis. Variations in physician approach make it difficult to analyze outcomes and establish optimal management. We determined the variability of diagnostic approach and management regarding prenatal hydronephrosis among maternal-fetal medicine obstetricians, pediatric urologists and pediatric radiologists. Materials and Methods: Online surveys were sent to mailing lists for national societies for each specialty. Participants were surveyed regarding criteria for diagnosing mild prenatal hydronephrosis and recommendations for postnatal management, including use of antibiotic prophylaxis, followup scheduling and type of followup imaging. Results: A total of 308 maternal-fetal medicine obstetricians, 126 pediatric urologists and 112 pediatric radiologists responded. Pediatric urologists and radiologists were divided between Society for Fetal Urology criteria and use of anteroposterior pelvic diameter for diagnosis, while maternal-fetal medicine obstetricians preferred using the latter. For postnatal evaluation radiologists preferred using personal criteria, while urologists preferred using anteroposterior pelvic diameter or Society for Fetal Urology grading system. There was wide variation in the use of antibiotic prophylaxis among pediatric urologists. Regarding the use of voiding cystourethrography/radionuclide cystography in patients with prenatal hydronephrosis, neither urologists nor radiologists were consistent in their recommendations. Finally, there was no agreement on length of followup for mild prenatal hydronephrosis. Conclusions: We observed a lack of uniformity regarding grading criteria in diagnosing hydronephrosis prenatally and postnatally among maternal-fetal medicine obstetricians, pediatric urologists and pediatric radiologists. There was also a lack of agreement on the management of mild intermittent prenatal hydronephrosis, resulting in these cases being managed inconsistently. A unified set of guidelines for diagnosis, evaluation and management of mild intermittent prenatal hydronephrosis would allow more effective evaluation of outcomes.

Alternative management of diabetic ketoacidosis in a Brazilian pediatric emergency department

DKA is a severe metabolic derangement characterized by dehydration, loss of electrolytes, hyperglycemia, hyperketonemia, acidosis and progressive loss of consciousness that results from severe insulin deficiency combined with the effects of increased levels of counterregulatory hormones (catecholamines, glucagon, cortisol, growth hormone). The biochemical criteria for diagnosis are: blood glucose > 200 mg/dl, venous pH <7.3 or bicarbonate <15 mEq/L, ketonemia >3 mmol/L and presence of ketonuria. A patient with DKA must be managed in an emergency ward by an experienced staff or in an intensive care unit (ICU), in order to provide an intensive monitoring of the vital and neurological signs, and of the patient's clinical and biochemical response to treatment. DKA treatment guidelines include: restoration of circulating volume and electrolyte replacement; correction of insulin deficiency aiming at the resolution of metabolic acidosis and ketosis; reduction of risk of cerebral edema; avoidance of other complications of therapy (hypoglycemia, hypokalemia, hyperkalemia, hyperchloremic acidosis); identification and treatment of precipitating events. In Brazil, there are few pediatric ICU beds in public hospitals, so an alternative protocol was designed to abbreviate the time on intravenous infusion lines in order to facilitate DKA management in general emergency wards. The main differences between this protocol and the international guidelines are: intravenous fluid will be stopped when oral fluids are well tolerated and total deficit will be replaced orally; if potassium analysis still indicate need for replacement, it will be given orally; subcutaneous rapid-acting insulin analog is administered at 0.15 U/kg dose every 2-3 hours until resolution of metabolic acidosis; approximately 12 hours after treatment initiation, intermediate-acting (NPH) insulin is initiated at the dose of 0.6-1 U/kg/day, and it will be lowered to 0.4-0.7 U/kg/day at discharge from hospital.

Pediatric pain: prevalence, assessment, and management in a teaching hospital

The goal of this study was to examine the prevalence, assessment and management of pediatric pain in a public teaching hospital. The study sample consisted of 121 inpatients (70 infants, 36 children, and 15 adolescents), their families, 40 physicians, and 43 nurses. All participants were interviewed except infants and children who could not communicate due to their clinical status. The interview included open-ended questions concerning the inpatients’ pain symptoms during the 24 h preceding data collection, as well as pain assessment and pharmacological/non-pharmacological management of pain. The data were obtained from 100% of the eligible inpatients. Thirty-four children/adolescents (28%) answered the questionnaire and for the other 72% (unable to communicate), the family/health professional caregivers reported pain. Among these 34 persons, 20 children/adolescents reported pain, 68% of whom reported that they received pharmacological intervention for pain relief. Eighty-two family caregivers were available on the day of data collection. Of these, 40 family caregivers (49%) had observed their child’s pain response. In addition, 74% reported that the inpatients received pharmacological management. Physicians reported that only 38% of the inpatients exhibited pain signs, which were predominantly acute pain detected during clinical procedures. They reported that 66% of patients received pharmacological intervention. The nurses reported pain signs in 50% of the inpatients, which were detected during clinical procedures. The nurses reported that pain was managed in 78% of inpatients by using pharmacological and/or non-pharmacological interventions. The findings provide evidence of the high prevalence of pain in pediatric inpatients and the under-recognition of pain by health professionals.

Incidence and Predictors of Adverse Drug Reactions Caused by Drug-Drug Interactions in Elderly Outpatients: A Prospective Cohort Study

Purpose. The primary objective of this study was to investigate the incidence of drug-drug interactions (DDIs) related to adverse drug reactions (ADRs) in elderly outpatients who attended public primary healthcare units in a southeastern region of Brazil. The secondary objective was to investigate the possible predictors of DDI-related ADRs. Methods. A prospective cohort study was conducted between November 1, 2010, and November 31, 2011, in the primary public healthcare system in the Ourinhos micro-region in Brazil. Patients who were at least 60 years old, with at least one potential DDI, were eligible for inclusion in the study. Eligible patients were assessed by clinical pharmacists for DDI-related ADRs for 4 months. The causality of DDI-related ADRs was assessed independently by four clinicians using three decisional algorithms. The incidence of DDI-related ADRs during the study period was calculated. Logistic regression analysis was used to study DDI-related ADR predictors. Results. A total of 433 patients completed the study. The incidence of DDI-related ADRs was 6.5%. A multivariate analysis indicated that the adjusted odds ratios (ORs) rose from 0.91 (95% confidence interval [CI] = 0.75-1.12, p = 0.06) in patients aged 65-69 years to 4.40 (95% CI = 3.00-6.12, p < 0.01) in patients aged 80 years or older. Patients who presented two to three diagnosed diseases presented lower adjusted ORs (OR = 0.93 [95% CI = 0.68-1.18, p = 0.08]) than patients who presented six or more diseases (OR = 1.12 [95% CI = 1.02-2.01, p < 0.01]). Elderly patients who took five or more drugs had a significantly higher risk of DDI-related ADRs (OR = 2.72 [95% CI = 1.92-3.12, p < 0.01]) than patients who took three to four drugs (OR = 0.93 [95% CI = 0.74-1.11, p = 0.06]). No significant difference was found with regard to sex (OR = 1.08 [95% CI 0.48-2.02, p = 0.44]). Conclusion. The incidence of DDI-related ADRs in elderly outpatients was significant, and most of the events presented important clinical consequences. Because clinicians still have difficulty managing this problem, highlighting the factors that increase the risk of DDI-related ADRs is essential. Polypharmacy was found to be a significant predictor of DDI-related ADRs in our sample.

Spatial and temporal patterns in size and maturation of Loligo plei and Loligo sanpaulensis (Cephalopoda: Loliginidae) in southeastern Brazilian waters, between 23 degrees S and 27 degrees S

Patterns of population dynamics of Loligo plei and Loligo sanpaidensis in Southeastern Brazil were investigated with samples obtained from commercial catches and research cruises from 1999 to 2000 and from 2002 to 2003. Size and maturity Structure of the two species varied according to depth and season. Body size decreased with depth for L plei, whereas for L. sanpaidensis size increased with depth LIP to 100 m and decreased again in deeper areas. GSI and incidence of mature animals decreased with depth in both species. L. plei females matured at a larger size in summer, while size at maturity in L. sanpaulensis was greater in autumn. For L. plei, reproductive events Occurred in the late winter and spring, in depths up to 40 m, and during summer in inshore waters. L. sanpaidensis increased reproductive activity ill Summer, winter and spring between depths of 30 and 80 Ill. The presence of high proportions of immature Squid offshore Suggests that juveniles might develop in these areas and, upon maturation, migrate back to inshore waters to spawn, particularly in spring and Summer. However, differences found in aggregation patterns in different depth strata, as well as the seasonal differences found in the size structure of L. plei and L. sanpaidensis, Could ultimately be due to Changes in the water Column related to food availability. Considering that L. plei and L. sanpaidensis are both caught as by-catch by shrimp trawlers throughout file year, we also discuss hypotheses on the life cycle of the species and its implications for fishery management. We recommend measures to protect squid spawning grounds by creating spring and summer protected areas where trawling would be prohibited until 60 m depth, i.e. in the area and time of year when mature individuals concentrate.

Behavioural changes and occlusal splints are effective in the management of masticatory myofascial pain: a short-term evaluation

The aim of this research was to test the hypothesis that treatment with intra-oral appliances with different occlusal designs was beneficial in the management of pain of masticatory muscles compared with a control group. A total of 51 patients were analysed according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) to obtain the diagnosis of masticatory myofascial pain (MMP). The sample was then randomly divided into three groups: group I (n = 21) wore a full coverage acrylic stabilisation occlusal splint; group II (n = 16) wore an anterior device nociceptive trigeminal inhibitory (NTI) system; and group III (n = 14) only received counselling for behavioural changes and self-care (the control group). The first two groups also received counselling. Follow-ups were performed after 2 and 6 weeks and 3 months. In these sessions, patients were evaluated by means of a visual analogue scale (VAS) and pressure pain threshold (PPT) of the masticatory muscles. Possible adverse effects were also recorded, such as discomfort while using the appliance and occlusal changes. The results were analysed with KruskalWallis, anova, Tukeys and Friedman tests, with a significance level of 5%. Group I showed improvement in the reported pain at the first follow-up (2 weeks), whereas for groups II and III, this progress was detected only after 6 weeks and 3 months, respectively. The PPT values did not change significantly. It was concluded that behavioural changes are effective in the management of pain in MMP patients. However, the simultaneous use of occlusal devices appears to produce an earlier improvement.

Effect of a video on developing skills in undergraduate nursing students for the management of totally implantable central venous access ports

Background: Handling Totally Implantable Access Ports (TIAP) is a nursing procedure that requires skill and knowledge to avoid adverse events. No studies addressing this procedure with undergraduate students were identified prior to this study. Communication technologies, such as videos, have been increasingly adopted in the teaching of nursing and have contributed to the acquisition of competencies for clinical performance. Objective: To evaluate the effect of a video on the puncture and heparinization of TIAP in the development of cognitive and technical competencies of undergraduate nursing students. Method: Quasi-experimental study with a pretest-posttest design. Results: 24 individuals participated in the study. Anxiety scores were kept at levels 1 and 2 in the pretest and posttest. In relation to cognitive knowledge concerning the procedure, the proportion of correct answers in the pretest was 0.14 (SD=0.12) and 0.90 in the posttest (SD=0.05). After watching the video, the average score obtained by the participants in the mock session was 27.20. Conclusion: The use of an educational video with a simulation of puncture and heparinization of TIAP proved to be a strategy that increased both cognitive and technical knowledge. This strategy is viable in the teaching-learning process and is useful as a support tool for professors and for the development of undergraduate nursing students. (C) 2011 Elsevier Ltd. All rights reserved.

ESMO Consensus Guidelines for management of patients with colon and rectal cancer. A personalized approach to clinical decision making

Colorectal cancer (CRC) is the most common tumour type in both sexes combined in Western countries. Although screening programmes including the implementation of faecal occult blood test and colonoscopy might be able to reduce mortality by removing precursor lesions and by making diagnosis at an earlier stage, the burden of disease and mortality is still high. Improvement of diagnostic and treatment options increased staging accuracy, functional outcome for early stages as well as survival. Although high quality surgery is still the mainstay of curative treatment, the management of CRC must be a multi-modal approach performed by an experienced multi-disciplinary expert team. Optimal choice of the individual treatment modality according to disease localization and extent, tumour biology and patient factors is able to maintain quality of life, enables long-term survival and even cure in selected patients by a combination of chemotherapy and surgery. Treatment decisions must be based on the available evidence, which has been the basis for this consensus conference-based guideline delivering a clear proposal for diagnostic and treatment measures in each stage of rectal and colon cancer and the individual clinical situations. This ESMO guideline is recommended to be used as the basis for treatment and management decisions.