End-of-life practices in seven Brazilian pediatric intensive care units

Objective: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). Design. Cross-sectional multicenter retrospective study based on medical chart review. Setting: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in Sao Paulo (southeastern region), and three in Salvador (northeastern region). Patients. Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. Interventions: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (K = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Student`s t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. Measurements and Main Results. Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p =.0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. Conclusions. The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.

The CATH classification revisited-architectures reviewed and new ways to characterize structural divergence in superfamilies

The latest version of CATH (class, architecture, topology, homology) (version 3.2), released in July 2008 (http://www.cathdb.info), contains 1 14215 domains, 2178 Homologous superfamilies and 1110 fold groups. We have assigned 20 330 new domains, 87 new homologous superfamilies and 26 new folds since CATH release version 3.1. A total of 28 064 new domains have been assigned since our NAR 2007 database publication (CATH version 3.0). The CATH website has been completely redesigned and includes more comprehensive documentation. We have revisited the CATH architecture level as part of the development of a `Protein Chart` and present information on the population of each architecture. The CATHEDRAL structure comparison algorithm has been improved and used to characterize structural diversity in CATH superfamilies and structural overlaps between superfamilies. Although the majority of superfamilies in CATH are not structurally diverse and do not overlap significantly with other superfamilies, similar to 4% of superfamilies are very diverse and these are the superfamilies that are most highly populated in both the PDB and in the genomes. Information on the degree of structural diversity in each superfamily and structural overlaps between superfamilies can now be downloaded from the CATH website.