Ethical aspects in the management of the terminally ill patient in the pediatric intensive care unit

OBJECTIVE: To identify the prevalence of management plans and decision-making processes for terminal care patients in pediatric intensive care units. METHODOLOGY: Evidence-based medicine was done by a systematic review using an electronic data base (LILACS, 1982 through 2000) and (MEDLINE, 1966 through 2000). The key words used are listed and age limits (0 to 18 years) were used. RESULTS: One hundred and eighty two articles were found and after selection according to the exclusion/inclusion criteria and objectives 17 relevant papers were identified. The most common decisions found were do-not-resuscitation orders and withdrawal or withholding life support care. The justifications for these were "imminent death" and "unsatisfatory quality of life". CONCLUSION: Care management was based on ethical principles aiming at improving benefits, avoiding harm, and when possible, respecting the autonomy of the terminally ill patient.

Nutritional status and specific leaf area of mahogany and tonka bean under two light environments

Studies on nutritional status and leaf traits were carried out in two tropical tree species Swietenia macrophylla King (mahogany) and Dipetryx odorata Aubl. Willd. (tonka bean) planted under contrasting light environments in Presidente Figueiredo-AM, Brazil. Leaves of S. macrophylla and D. odorata were collected in three year-old trees grown under full sunlight (about 2000 µmol m-2 s-1) and natural shade under a closed canopy of Balsa-wood plantation (Ochroma pyramidale Cav. Ex. Lam.Urb) about 260 µmol m-2 s-1. The parameters analysed were leaf area (LA), leaf dry mass (LDM), specific leaf area (SLA) and leaf nutrient contents. It was observed that, S. macrophylla leaves grown under full sunlight showed LA 35% lower than those grown under shade. In D. odorata leaves these differences in LA were not observed. In addition, it was observed that S. macrophylla shade leaves, for LDM, were 50% smaller than sun leaves, while in D. odorata, there differences were not observed. SLA in S. macrophylla presented that sun leaves were three times smaller than those grown under shade. In D. odorata, no differences were observed. Nutrient contents in S. macrophylla, regardless of their light environments, showed higher contents for P and Ca than those found in D. odorata. The N, K, Fe and Mn contents in S. macrophylla leaves decreased under shade. Finally, we suggest that the decreasing in leaf nutrient contents may have a negative influence on leaf growth. The results demonstrated that the tested hypothesis is true for leaf traits, which D. odorata, late-successional species, showed lower plasticity for leaf traits than Swietenia macrophylla, mid-successional species.

Effects of light and temperature on isoprene emission at different leaf developmental stages of eschweilera coriacea in central Amazon

Isoprene emission from plants accounts for about one third of annual global volatile organic compound emissions. The largest source of isoprene for the global atmosphere is the Amazon Basin. This study aimed to identify and quantify the isoprene emission and photosynthesis at different levels of light intensity and leaf temperature, in three phenological phases (young mature leaf, old mature leaf and senescent leaf) of Eschweilera coriacea (Matamatá verdadeira), the species with the widest distribution in the central Amazon. In situ photosynthesis and isoprene emission measurements showed that young mature leaf had the highest rates at all light intensities and leaf temperatures. Additionally, it was observed that isoprene emission capacity (Es) changed considerably over different leaf ages. This suggests that aging leads to a reduction of both leaf photosynthetic activity and isoprene production and emission. The algorithm of Guenther et al. (1999) provided good fits to the data when incident light was varied, however differences among E S of all leaf ages influenced on quantic yield predicted by model. When leaf temperature was varied, algorithm prediction was not satisfactory for temperature higher than ~40 °C; this could be because our data did not show isoprene temperature optimum up to 45 °C. Our results are consistent with the hypothesis of the isoprene functional role in protecting plants from high temperatures and highlight the need to include leaf phenology effects in isoprene emission models.

Pregnant crack addicts in a psychiatric unit

OBJECTIVE: In this study we aim to characterize a sample of 85 pregnant crack addicts admitted for detoxification in a psychiatric inpatient unit. METHOD: Cross-sectional study. Sociodemographic, clinical, obstetric and lifestyle information were evaluated. RESULTS: Age of onset for crack use varied from 11 to 35 years (median = 21). Approximately 25% of the patients smoked more than 20 crack rocks in a typical day of use (median = 10; min-max = 1-100). Tobacco (89.4%), alcohol (63.5%) and marijuana (51.8%) were the drugs other than crack most currently used. Robbery was reported by 32 patients (41.2%), imprisonment experience by 21 (24.7%), trade of sex for money/drugs by 38 (44.7%), home desertion by 33 (38.8%); 15.3% were positive for HIV, 5.9% for HCV, 1.2% for HBV and 8.2% for syphilis. After discharge from the psychiatric unit, only 25% of the sample followed the proposed treatment in the chemical dependency outpatient service. CONCLUSION: Greater risky behaviors for STD, as well as high rates of maternal HIV and Syphilis were found. Moreover, the high rates of concurrent use of other drugs and involvement in illegal activities contribute to show their chaotic lifestyles. Prevention and intervention programs need to be developed to address the multifactorial nature of this problem.

Desenvolvimento e avaliação das propriedades psicométricas da versão brasileira do Addiction Severity Index 6 (ASI-6) Light

Objetivo Desenvolver e avaliar as propriedades psicométricas de uma versão brasileira reduzida do Addiction Severity Index 6 Light (ASI-6 Light) previamente proposta com base em um estudo de validação dos construtos do instrumento e desenvolver os novos escores de cada área do instrumento baseados na Teoria de Resposta ao Item (TRI). Métodos Foram entrevistados 200 sujeitos, 100 com uso problemático de álcool e outras drogas e 100 sem uso problemático. Foram calculados os escores dos indivíduos com base na TRI. As propriedades psicométricas foram avaliadas pela correlação entre os escores do ASI-6 Light e do Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), padrão-ouro do estudo. Foram avaliados os índices de sensibilidade e especificidade. Resultados Foi encontrada alta correlação entre os escores da área “álcool” do ASI-6 Light e os escores do ASSIST em relação ao álcool (r = 0,79), correlações moderadas em relação ao tabaco (r = 0,47) e cocaína/crack (r = 0,44) e baixa (r = 0,39) em relação à maconha. Ao correlacionarem-se os escores do ASSIST e os escores da área “drogas” do ASI-6 Light, obteve-se alta correlação em relação à cocaína/crack (r = 0,85), correlações moderadas em relação ao tabaco (r = 0,57) e maconha (r = 0,68) e baixa (r = 0,29) em relação ao álcool. A área sob a curva ROC da área “álcool” foi de 0,93 e a da área “drogas” foi de 0,88. Conclusão Boas evidências de validade das áreas “álcool” e “drogas” foram apresentadas. Essa nova versão tornou-se um instrumento de fácil manejo e de rápida aplicação, contendo os itens que melhor avaliam a gravidade de problemas.

Evaluation of the Medical Care of Patients with Hypertension in an Emergency Department and in Ambulatory Hypertension Unit

OBJECTIVE: To evaluate the characteristics of the patients receiving medical care in the Ambulatory of Hypertension of the Emergency Department, Division of Cardiology, and in the Emergency Unit of the Clinical Hospital of the Ribeirão Preto Medical School. METHODS: Using a protocol, we compared the care of the same hypertensive patients in on different occasions in the 2 different places. The characteristics of 62 patients, 29 men with a mean age of 57 years, were analyzed between January 1996 and December 1997. RESULTS: The care of these patients resulted in different medical treatment regardless of their clinical features and blood pressure levels. Thus, in the Emergency Unit, 97% presented with symptoms, and 64.5% received medication to rapidly reduce blood pressure. In 50% of the cases, nifedipine SL was the elected medication. Patients who applied to the Ambulatory of Hypertension presenting with similar features, or, in some cases, presenting with similar clinically higher levels of blood pressure, were not prescribed medication for a rapid reduction of blood pressure at any of the appointments. CONCLUSION: The therapeutic approach to patients with high blood pressure levels, symptomatic or asymptomatic, was dependent on the place of treatment. In the Emergency Unit, the conduct was, in the majority of cases, to decrease blood pressure immediately, whereas in the Ambulatory of Hypertension, the same levels of blood pressure, in the same individuals, resulted in therapeutic adjustment with nonpharmacological management. These results show the need to reconsider the concept of hypertensive crises and their therapeutical implications.

Retrospective Study of the Survival of Patients who Underwent Cardiopulmonary Resuscitation in an Intensive Care Unit

OBJECTIVE: To evaluate clinical and evolutive characteristics of patients admitted in an intensive care unit after cardiopulmonary resuscitation, identifying prognostic survival factors.METHODS: A retrospective study of 136 patients admitted between 1995 and 1999 to an intensive care unit, evaluating clinical conditions, mechanisms and causes of cardiopulmonary arrest, and their relation to hospital mortality.RESULTS: A 76% mortality rate independent of age and sex was observed. Asystole was the most frequent mechanism of death, and seen in isolation pulmonary arrest was the least frequent. Cardiac failure, need for mechanical ventilation, cirrhosis and previous stroke were clinically significant (p<0.01) death factors.CONCLUSION: Prognostic factors supplement the doctor's decision as to whether or not a patient will benefit from cardiopulmonary resuscitation.

Impact of Light Salt Substitution for Regular Salt on Blood Pressure of Hypertensive Patients

Background: Studies have shown sodium restriction to have a beneficial effect on blood pressure (BP) of hypertensive patients. Objective: To evaluate the impact of light salt substitution for regular salt on BP of hypertensive patients. Methods: Uncontrolled hypertensive patients of both sexes, 20 to 65 years-old, on stable doses of antihypertensive drugs were randomized into Intervention Group (IG - receiving light salt) and Control Group (CG - receiving regular salt). Systolic BP (SBP) and diastolic BP (DBP) were analyzed by using casual BP measurements and Home Blood Pressure Monitoring (HBPM), and sodium and potassium excretion was assessed on 24-hour urine samples. The patients received 3 g of salt for daily consumption for 4 weeks. Results: The study evaluated 35 patients (65.7% women), 19 allocated to the IG and 16 to the CG. The mean age was 55.5 ± 7.4 years. Most participants had completed the Brazilian middle school (up to the 8th grade; n = 28; 80.0%), had a family income of up to US$ 600 (n = 17; 48.6%) and practiced regular physical activity (n = 19; 54.3%). Two patients (5.7%) were smokers and 40.0% consumed alcohol regularly (n = 14). The IG showed a significant reduction in both SBP and DBP on the casual measurements and HBPM (p < 0.05) and in sodium excretion (p = 0.016). The CG showed a significant reduction only in casual SBP (p = 0.032). Conclusions: The light salt substitution for regular salt significantly reduced BP of hypertensive patients.

BNP was Associated with Ischemic Myocardial Scintigraphy and Death in Patients at Chest Pain Unit

Background:Recent studies have suggested that B-type Natriuretic Peptide (BNP) is an important predictor of ischemia and death in patients with suspected acute coronary syndrome. Increased levels of BNP are seen after episodes of myocardial ischemia and may be related to future adverse events.Objectives:To determine the prognostic value of BNP for major cardiac events and to evaluate its association with ischemic myocardial perfusion scintigraphy (MPS).Methods:This study included retrospectively 125 patients admitted to the chest pain unit between 2002 and 2006, who had their BNP levels measured on admission and underwent CPM for risk stratification. BNP values were compared with the results of the MPS. The chi-square test was used for qualitative variables and the Student t test, for quantitative variables. Survival curves were adjusted using the Kaplan-Meier method and analyzed by using Cox regression. The significance level was 5%.Results:The mean age was 63.9 ± 13.8 years, and the male sex represented 51.2% of the sample. Ischemia was found in 44% of the MPS. The mean BNP level was higher in patients with ischemia compared to patients with non-ischemic MPS (188.3 ± 208.7 versus 131.8 ± 88.6; p = 0.003). A BNP level greater than 80 pg/mL was the strongest predictor of ischemia on MPS (sensitivity = 60%, specificity = 70%, accuracy = 66%, PPV = 61%, NPV = 70%), and could predict medium-term mortality (RR = 7.29, 95% CI: 0.90-58.6; p = 0.045) independently of the presence of ischemia.Conclusions:BNP levels are associated with ischemic MPS findings and adverse prognosis in patients presenting with acute chest pain to the emergency room, thus, providing important prognostic information for an unfavorable clinical outcome.

Ambulatory Blood Pressure Monitoring: Five Decades of More Light and Less Shadows

Abstract Casual blood pressure measurements have been extensively questioned over the last five decades. A significant percentage of patients have different blood pressure readings when examined in the office or outside it. For this reason, a change in the paradigm of the best manner to assess blood pressure has been observed. The method that has been most widely used is the Ambulatory Blood Pressure Monitoring - ABPM. The method allows recording blood pressure measures in 24 hours and evaluating various parameters such as mean BP, pressure loads, areas under the curve, variations between daytime and nighttime, pulse pressure variability etc. Blood pressure measurements obtained by ABPM are better correlated, for example, with the risks of hypertension. The main indications for ABPM are: suspected white coat hypertension and masked hypertension, evaluation of the efficacy of the antihypertensive therapy in 24 hours, and evaluation of symptoms. There is increasing evidence that the use of ABPM has contributed to the assessment of blood pressure behaviors, establishment of diagnoses, prognosis and the efficacy of antihypertensive therapy. There is no doubt that the study of 24-hour blood pressure behavior and its variations by ABPM has brought more light and less darkness to the field, which justifies the title of this review.

Análise do tamanho e da forma do ôvo em galinhas das raças Rhode Island Red e Light Sussex e do híbrido entre essas duas raças

Size and shape in eggs of Rhode Island Red and Light Sussex breeds and in the hibrid Rhode x Sussex were studied. These characters are influenced by quantitative genes. Major and minor diameter were used for estimating size of the eggs and the ratio minor/major diameter for shape indice. It was found, in the material analyzed, that: a) the eggs laid by the sa- me chick are pratically uniform; b) the correlation coeficient between major and minor diameter is weak; c) Rhode Island Red has short eggs than Light Sussex; d) short eggs is dominant on long eggs; e) egg shape is the same in Rhode Island Red and Light Sussex breeds and different in the hibrid, which has rounder eggs than the breeds.

Comportamento da raça Light Sussex em Piracicaba

Na Seção Técnica de Avicultura e Cunicultura desta Escola foram feitas durante três anos observações sobre o comportamento da raça Light Sussex, em contraste sobretudo com a Rhode I. Red. Verificou-se ser mais precoce no desenvolvimento, mais pesada, de carne mais tenra, de maior intensidade e menor persistência de postura, de menor fertilidade, do maior precocídade de postura, de maior predisposição ao choco e de maiores ovos. Apresenta boas qualidades de adaptação e criação que a tomam muito recomendável para as pequenas criações caseiras ou dos sitios, no mesmo sistema em que é geralmente criada na Inglaterra. Só excepcionalmente convirá a uma granja industrial preocupar-se com sua criação em larga escala.

Comparação das raças Rhode Island Red, Light Sussex e seu mestiço: ovos, pintos e frangos

The breeds Light Sussex, Rhode Island Red and the hibrid Light Sussex x Rhode Island Red, from the Poultry Department of "Luiz de Queiroz" School of Agriculture, at Piracicaba, S. Paulo, were studied in this paper, Tre authors, analysing eggs, pullets and chick growing arrived to the following conclusion: a) eggs of the Light Sussex breed were haevier; b) the Light Sussex breed was early maturing; c) the cross studied did not show hibrid vigor.

Growth, molt and survival of Palaemonetes argentinus (Decapoda, Caridea) under different light-dark conditions

Growth, survival and molting rate in Palaemonetes argentinus Nobili, 1901 were compared under different light-dark conditions. During 80 days, 150 immatures of both sexes (initial mean weight 0.09±0.002g), from Los Padres lagoon, Mar del Plata, Argentina, were maintained in aquaria at 19±0.4°C under three light conditions: 0:24, 10:14 and 13:11 (L-D). They were fed daily on an artificial diet (45% proteins, 17.2% lipids, 7% water, 7% ash). Good weight increment was obtained with the three treatments, finding a positive linear correlation between mean weight and time (0:24, r=0.97; 10:14, r=0.99; 13:11, r=0.98). There were no significant differences in the percentage increment in mean weight among the treatments (0:24, 19.3%; 10:14, 29.3% and 13:11, 26.5%) (p<0.05). Molting rate was significantly higher at a long-day photoperiod (MR=1.7) than at a short-day (MR=0.6) or continuous dark condition (MR=0.3) (p<0.05). The lowest survival was found in animals maintained under 13:11 L-D conditions (77%), being statistically different of the other two treatments (92% and 89% at 10:14 and 0:24, respectively) (p<0.05). These results suggest that the best growth and survival in P. argentinus result with a 10:14 L-D cycle, and that the growth is less affected by photoperiod than molting rate and survival.