A participação da Equipe de Saúde da Família na vigilância de cuidados ao idoso

Objetivou-se neste trabalho elaborar uma proposta de intervenção para proteção contra os agravos à saúde do idoso provocados pela negligência e abandono. A partir de uma ação de recadastramento de famílias da área de uma Equipe de Saúde, notou-se a informação de que havia idosos em situação de risco nesta área. O questionamento sobre a Saúde do Idoso na EFS foi instigado na coleta de dados para o Diagnóstico Situacional da Área de abrangência da equipe em que se constatou grande número de idosos residentes. Embasado no referencial teórico da Saúde do Idoso o questionamento de pesquisa, "Por que os idosos dependentes de cuidados domiciliares são vítimas de violência, negligencia e abandono?", foi respondido através de uma revisão bibliográfica, de maneira que a partir dos dados e do referencial teórico, elaborou-se um projeto de intervenção. Por conseguinte, observou-se que um planejamento de intervenção que envolva vários atores sociais é a aplicação de uma estrutura vigilante que consegue proteger um grupo etário mais vulnerável aos agravos de saúde.

Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients : does it matter ?

RESUME DE THESEContexte de l'étudeLe but de cette étude est de comparer le drainage percutané (DP) et la chirurgie d'urgence (CU) de la vésicule biliaire (VB) pour le traitement de la cholécystite aiguë lithiasique/alithiasique dans un groupe homogène de patients gravement malades et hospitalisés aux soins intensifs (SI).Patients et méthodeEntre les années 2001 et 2007, tous les patients successivement traités par DP ou CU pour cholécystite aiguë aux SI ont été rétrospectivement analysés. Les cas ont été collectés à partir d'une base de données prospective. Le DP était effectué par voie trans-hépatique et la chirurgie par voie ouverte ou laparoscopique. L'état général des patients et la dysfonction des organes étaient évalués par deux scores validés (SAPS Π et SOFA, respectivement). L'analyse des données s'est portée sur les complications à court terme (morbidité, mortalité hospitalière) et à long terme (récurrence des symptômes) après drainage ou chirurgie en urgence.RésultatsQuarante-deux patients (âge médian 65 ans, 32-94 ans) ont été inclus dans l'étude ; 45% ont eu une CU (10 laparoscopics, 9 voies ouvertes) et 55% un DP (n=23) de la vésicule biliaire. Le DP et la CU ont eu des taux de succès respectifs de 91 et 100% pour la résolution du sepsis lié à la cholécystite aigiie. Après drainage et chirurgie de la VB, la dysfonction des organes secondaire au sepsis s'est résolue dans les 3 jours. Malgré le drainage, deux patients ont nécessité une cholécystectomie en urgence pour cholécystite gangréneuse. Le taux de conversion de la laparoscopic à la voie ouverte était de 20%. La morbidité majeure était de 0% après drainage et 21% après chirurgie en urgence (p=0.034). Finalement, la mortalité hospitalière était similaire (13% après DP vs. 16% après CU, p=1.0) et uniquement liée aux co-morbidités des patients. La récurrence des symptômes liés à la VB n'est apparue que chez des patients initialement drainés pour cholécystite lithiasique.ConclusionsChez les patients gravement malades des soins intensifs, le drainage percutané et la chirurgie en urgence de la VB sont tous deux efficaces pour la résolution d'un sepsis lié à une cholécystite aigiie. Cependant, la chirurgie d'urgence est associée à une morbidité majeure accrue et l'approche par laparoscopic n'est pas toujours réalisable. Le drainage percutané de la VB est donc une modalité de traitement valable, mais nécessite à distance de l'épisode aigu une cholécystectomie par laparoscopic, surtout après une cholécystite lithiasique.

County-Funded Treatment Services for Mentally Ill Offenders Under Community-Based Corrections Supervision, Data Download, Iowa Department of Corrections, June 2008

In a previous Data Download, we reported that about 27% of offenders under CBC field supervision and 42.6% of offenders in residential facilities are in need of mental health treatment services. In addition,more than 35% of offenders needing mental health treatment are not receiving services.

Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?

Background The aim if this study was to compare percutaneous drainage (PD) of the gallbladder to emergency cholecystectomy (EC) in a well-defined patient group with sepsis related to acute calculous/acalculous cholecystitis (ACC/AAC).Methods Between 2001 and 2007, all consecutive patients of our ICU treated by either PD or EC were retrospectively analyzed. Cases were collected from a prospective database. Percutaneous drainage was performed by a transhepatic route and EC by open or laparoscopic approach. Patients' general condition and organ dysfunction were assessed by two validated scoring systems (SAPS II and SOFA, respectively). Morbidity, mortality, and long-term outcome were systematically reviewed and analyzed in both groups.Results Forty-two patients [median age = 65.5 years (range = 32-94)] were included; 45% underwent EC (ten laparoscopic, nine open) and 55% PD (n = 23). Both patient groups had similar preoperative characteristics. Percutaneous drainage and EC were successful in 91 and 100% of patients, respectively. Organ dysfunctions were similarly improved by the third postoperative/postdrainage days. Despite undergoing PD, two patients required EC due to gangrenous cholecystitis. The conversion rate after laparoscopy was 20%. Overall morbidity was 8.7% after PD and 47% after EC (P = 0.011). Major morbidity was 0% after PD and 21% after EC (P = 0.034). The mortality rate was not different (13% after PD and 16% after EC, P = 1.0) and the deaths were all related to the patients' preexisting disease. Hospital and ICU stays were not different. Recurrent symptoms (17%) occurred only after ACC in the PD group.Conclusions In high-risk patients, PD and EC are both efficient in the resolution of acute cholecystitis sepsis. However, EC is associated with a higher procedure-related morbidity and the laparoscopic approach is not always possible. Percutaneous drainage represents a valuable intervention, but secondary cholecystectomy is mandatory in cases of acute calculous cholecystitis.

Excellent outcome after surgical treatment of massive pulmonary embolism in critically ill patients

OBJECTIVE: Treatment of central and paracentral pulmonary embolism in patients with hemodynamic compromise remains a subject of debate, and no consensus exists regarding the best method: thrombolytic agents, catheter-based thrombus aspiration or fragmentation, or surgical embolectomy. We reviewed our experience with emergency surgical pulmonary embolectomy. METHODS: Between January of 2000 and March of 2007, 25 patients (17 male, mean age 60 years) underwent emergency open embolectomy for central and paracentral pulmonary embolism. Eighteen patients presented in cardiogenic shock, 8 of whom had cardiac arrest and required cardiopulmonary resuscitation. All patients underwent operation with mild hypothermic cardiopulmonary bypass. Concomitant procedures were performed in 8 patients (3 coronary artery bypass grafts, 2 patent foramen ovale closures, 4 ligations of the left atrial appendage, 3 removals of a right atrial thrombus). Follow-up is 96% complete with a median of 2 years (range, 2 months to 6 years). RESULTS: All patients survived the procedure, but 2 patients died in the hospital on postoperative days 1 (intracerebral bleeding) and 11 (multiorgan failure), accounting for a 30-day mortality of 8% (95% confidence interval: 0.98-0.26). Four patients died later because of their underlying disease. Pre- and postoperative echocardiographic pressure measurements demonstrated the reduction of the pulmonary hypertension to half of the systemic pressure values or less. CONCLUSION: Surgical pulmonary embolectomy is an excellent option for patients with major pulmonary embolism and can be performed with minimal mortality and morbidity. Even patients who present with cardiac arrest and require preoperative cardiopulmonary resuscitation show satisfying results. Immediate surgical desobstruction favorably influences the pulmonary pressure and the recovery of right ventricular function, and remains the treatment of choice for patients with massive central and paracentral embolism with hemodynamic and respiratory compromise.

A study of nurses' perceptions of and participation in the resolution of treatment dilemmas for critically ill newborns

This study was an exploratory investigation of variables which are associated with neonatal intensive care nurses' perceptions of and participation in life-sustaining treatment decisions for critically ill newborns. The primary purpose of the research was to examine the extent to which assessment of infants' physical and mental prognoses, parents' preferences regarding treatment, and legal consequences of non-treatment influence nurses' recommendations about life-saving treatment decisions for handicapped newborns. Secondly, the research explored the extent and nature of nurses' reported participation in the resolution of treatment dilemmas for these critically ill newborns. The framework of the study draws upon the work of Crane (1977), Blum (1980), and Pearlman (1982) who have explored the sociological context of decision-making with critical care patients.^ Participants in the study were a volunteer sample of eighty-three registered nurses who were currently working in neonatal intensive care units in five large urban hospitals in Texas. Data were collected through the use of intensive interviews and case study questionnaires. Results from the study indicate that physical and mental prognoses as well as parent preferences and concerns about legal liability are related to nurses' treatment recommendations, but their levels of significance vary according to the type of handicapping condition and whether the treatment questions are posed in terms of initiating aggressive therapy or withdrawing aggressive therapy.^ The majority of nurses reported that the extent of their participation in formal decision-making regarding handicapped newborns was fairly minimal although they provide much of the definitive data used to make decisions by physicians and parents. There was substantial evidence that nurse respondents perceive their primary role as advocates for critically ill newborns, and believe that their involvement in the resolution of treatment dilemmas should be increased. ^

Parents of the handicapped; self-organized parents' and relatives' groups for treatment of ill and handicapped children.

Mode of access: Internet.

Prophylactic ranitidine treatment in critically ill children - a population pharmacokinetic study

Aims - To characterize the population pharmacokinetics of ranitidine in critically ill children and to determine the influence of various clinical and demographic factors on its disposition. Methods - Data were collected prospectively from 78 paediatric patients (n = 248 plasma samples) who received oral or intravenous ranitidine for prophylaxis against stress ulcers, gastrointestinal bleeding or the treatment of gastro-oesophageal reflux. Plasma samples were analysed using high-performance liquid chromatography, and the data were subjected to population pharmacokinetic analysis using nonlinear mixed-effects modelling. Results - A one-compartment model best described the plasma concentration profile, with an exponential structure for interindividual errors and a proportional structure for intra-individual error. After backward stepwise elimination, the final model showed a significant decrease in objective function value (−12.618; P < 0.001) compared with the weight-corrected base model. Final parameter estimates for the population were 32.1 l h−1 for total clearance and 285 l for volume of distribution, both allometrically modelled for a 70 kg adult. Final estimates for absorption rate constant and bioavailability were 1.31 h−1 and 27.5%, respectively. No significant relationship was found between age and weight-corrected ranitidine pharmacokinetic parameters in the final model, with the covariate for cardiac failure or surgery being shown to reduce clearance significantly by a factor of 0.46. Conclusions - Currently, ranitidine dose recommendations are based on children's weights. However, our findings suggest that a dosing scheme that takes into consideration both weight and cardiac failure/surgery would be more appropriate in order to avoid administration of higher or more frequent doses than necessary.

A demonstration of mobile phone deployment to support the treatment of acutely ill children under five in Bushenyi district, Uganda.

Background: Benefits of mobile phone deployment for children <5 in low-resource settings remain unproven. The target population of the current demonstration study in Bushenyi District, Uganda, presented with acute fever, pneumonia, or diarrhoea and were treated by community health workers (CHWs) providing integrated community case management (iCCM). Methods: An observational study was conducted in five parishes (47 villages) served by CHWs well versed in iCCM with supplemental training in mobile phone use. Impact was assessed by quantitative measures and qualitative evaluation through household surveys, focus group discussions, and key informant interviews. Results: CHWs in targeted sites improved child healthcare through mobile phone use coupled with iCCM. Of acutely ill children, 92.6% were correctly managed. Significant improvements in clinical outcomes compared to those obtained by CHWs with enhanced iCCM training alone were unproven in this limited demonstration. Nonetheless, qualitative evaluation showed gains in treatment planning, supply management, and logistical efficiency. Provider confidence and communications were enhanced as was ease and accuracy of record keeping. Conclusion: Mobile phones appear synergistic with iCCM to bolster basic supportive care for acutely ill children provided by CHWs. The full impact of expanded mobile phone deployment warrants further evaluation prior to scaling up in low-resource settings.

Combination of an anaerobic process with O(3), UV and O(3)/UV for cellulose pulp bleaching effluent treatment

Recent studies have shown that partial oxidation by advanced oxidation processes (AOP) is able to transform hard-to-degrade compounds and increase their biodegradability. In this work, anaerobic treatment was followed by ozonation, UV radiation and ozonation in the presence of UV radiation, to treat bleaching effluents from a cellulose kraft Pulp plant. The anaerobic reactor (horizontal anaerobic immobilized Sludge bed, HAISB) was Used as a pretreatment to reduce the efficient organic load before applying ACIP. The ozone treatments were applied in three different pH environments (3, 8 and 10) with retention times of 10, 30, 45 and 60 min. COD and adsorbable organic halogens (AOX) removal efficiencies at the HAISB were approximately 50%, while the BOD removal efficiency reached 80%. Ozonation promoted further removal of AOX and COD so that the combined efficiency reached 96% for AOX and 70% for COD. In the oxidation process, BOD was either removed in small quantities or actually increased, as intended, so that a second biological treatment would be able to complete the treatment. The maximum increase in the BOD(5)/COD ratio (biodegradability indicator) Occurred at pH 8, reaching 104% for ozonation at a dosage of 1540 mg(O3).L(-1). Applying UV radiation alone resulted in lower values: a 34% increase ill the BOD(5)/COD ratio and a 76% AOX removal efficiency. These results indicate that the combination of anaerobic treatment with ozonation or ozonation/UV radiation improves the treatability of cellulose pulp bleaching efficients and that the resulting wastewater is suitable for further biological treatment under aerobic conditions with a low level of toxic compounds from the halogenated family.

Ampicillin/sulbactam compared with polymyxins for the treatment of infections caused by carbapenem-resistant Acinetobacter spp.

Background: There has been an increase in worldwide infections caused by carbapenem-resistant Acinetobacter. This poses a therapeutic challenge as few treatment options are available. Objectives: The aim of this study was to evaluate the efficacy and safety of polymyxins and ampicillin/sulbactam for treating infections caused by carbapenem-resistant Acinetobacter spp. and to evaluate prognostic factors. Methods: This was a retrospective review of patients from two teaching hospitals who had nosocomial infections caused by carbapenem-resistant Acinetobacter spp. from 1996 to 2004. Diagnosis of infection was based on CDC criteria plus the isolation of Acinetobacter from a usually sterile site or from bronchoalveolar lavage. Urinary tract infections were not included. Data on demographic and clinical features and treatment were collected from medical records. Prognostic factors associated with two outcomes (mortality during treatment and in-hospital mortality) were evaluated. Results: Eighty-two patients received polymyxins and 85 were treated with ampicillin/sulbactam. Multiple logistic regression analysis revealed that independent predictors of mortality during treatment were treatment with polymyxins, higher Acute Physiological and Chronic Health Evaluation II (APACHE II) score, septic shock, delay in starting treatment and renal failure. On multivariate analysis, prognostic factors for in-hospital mortality were older age, septic shock and higher APACHE II score. Conclusions: This is the first study comparing current therapeutic options for infections due to carbapenem-resistant Acinetobacter. The most important finding of the present study is that ampicillin/sulbactam appears to be more efficacious than polymyxins, which was an independent factor associated with mortality during treatment.

A randomized controlled trial comparing a computer-assisted insulin infusion protocol with a strict and a conventional protocol for glucose control in critically ill patients

Purpose: The objective of this study is to evaluate blood glucose (BG) control efficacy and safety of 3 insulin protocols in medical intensive care unit (MICU) patients. Methods: This was a multicenter randomized controlled trial involving 167 MICU patients with at least one BG measurement +/- 150 mg/dL and one or more of the following: mechanical ventilation, systemic inflammatory response syndrome, trauma, or burns. The interventions were computer-assisted insulin protocol (CAIP), with insulin infusion maintaining BG between 100 and 130 mg/dL; Leuven protocol, with insulin maintaining BG between 80 and 110 mg/dL; or conventional treatment-subcutaneous insulin if glucose > 150 mg/dL. The main efficacy outcome was the mean of patients` median BG, and the safety outcome was the incidence of hypoglycemia (<= 40 mg/dL). Results: The mean of patients` median BG was 125.0, 127.1, and 158.5 mg/dL for CAIP, Leuven, and conventional treatment, respectively (P = .34, CAIP vs Leuven; P < .001, CAIP vs conventional). In CAIP, 12 patients (21.4%) had at least one episode of hypoglycemia vs 24 (41.4%) in Leuven and 2 (3.8%) in conventional treatment (P = .02, CAIP vs Leuven; P = .006, CAIP vs conventional). Conclusions: The CAIP is safer than and as effective as the standard strict protocol for controlling glucose in MICU patients. Hypoglycemia was rare under conventional treatment. However, BG levels were higher than with IV insulin protocols. (C) 2009 Elsevier Inc. All rights reserved.

Prognostic heterogeneity among patients with chronic stable coronary disease: determinants of long-term mortality after treatment with percutaneous intervention

Aims: To evaluate the risk and predictors of death in a large population of patients with stable coronary disease treated with percutaneous intervention. Methods and results: The study population comprised 1,276 patients with chronic angina or silent ischaemia who underwent elective coronary angioplasty. Baseline and in-hospital mortality data were prospectively collected for all patients during the index hospitalisation. Post-discharge outcome was assessed at out-patient clinic, by review of the patients` records, or direct phone contact. Deaths were classified as cardiac and non-cardiac. Age, peripheral arterial disease, congestive heart failure with NYHA class Ill, triple-vessel disease, and procedural success (i.e. angiographic success for all lesions in the absence of pen-procedural infarction) remained as multivariate independent predictors of death. For the entire population 4-year cumulative all-cause and cardiac mortality were respectively 5.4% and 4.1%. Four-year mortality for patients without any multivariate predictor was 2.4%, while for patients with two or more predictors the death rate was 16.3% after four years. Conclusions: Patients with stable coronary disease undergoing percutaneous treatment have an overall low mortality rate after four years. Nevertheless, stable patients comprise a heterogeneous population in terms of risk profile, ranging from patients at very low risk of late death to individuals with a poor long-term prognosis.