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.

Subjective versus objective stress in noncritically ill hospitalized and outpatient adult men

A cross-sectional study of 120 subjects was performed with the purpose of evaluating stress hormones and emotional stress (anxiety) in outpatient and hospitalized subjects. The aims were to determine the degree of objective stress, as well as to correlate this finding with subjective findings, estimated using Beck's Anxiety Inventory.. METHOD: Three populations were investigated, namely outpatient clinical cases (Group I, n = 30), hospitalized clinical individuals (Group II, n = 30), and hospitalized surgical candidates (Group III, n = 30). Controls (Group IV, n = 30) were healthy volunteers who were health-care professionals and students. To avoid hormone interactions, only men were enrolled in all groups. All hospitalized subjects were tested on admission and before therapeutic interventions. Fasting epinephrine, norepinephrine, and cortisol were measured in the morning, and Beck's Anxiety Inventory was adminstered by a trained psychologist. RESULTS: The 3 patient groups displayed higher anxiety levels than the controls. Hormone concentrations did not present remarkable changes and did not correlate with subjective stress (anxiety). CONCLUSIONS: 1) Subjective disorders (as determined with Beck's Anxiety Inventory ) were a common finding in both outpatient and hospitalized populations, without differences between the various groups; 2) Objective stress (as determined by elevated hormone levels) was more difficult to confirm-findings rarely exceeded the reference range; 3) Correlation between the two variables could not be demonstrated; 4) Further studies are necessary to define stress quantification and interpretation in patient populations, especially in relationship with nutritional diagnosis and dietetic prescription.

The effect of the presence of muscle tissue in a bone healing site

PURPOSE: The recovery of a bone fracture is a process that is not yet fully understood. The literature conflicts on the results obtained by the interposition of foreign tissue inside a damaged bone. The objective of the present study was to ascertain the effect of placing muscle tissue between the stumps of a fractured bone. METHOD: The study was carried out on 10 rabbits divided into 2 groups (n = 5): Group 1-partial fracture of the humerus and interposition of muscle tissue; Group 2-complete fracture of the humerus and interposition of muscle tissue. The fractured limb of all animals was immobilized for 8 weeks. At the end of this time, the rabbits were killed and their operated humeri were carefully removed for roentgenological and histological assessment. RESULTS: All humeri of Group 1 recovered their integrity and normal aspect. However, the healing of the humeri of Group 2 was not perfect. Gross angulation of the bone diaphysis occurred in all animals, and immature trabecular bone, osteochondral tissue, and persistence of muscle tissue substituted normal bone. CONCLUSIONS: Interposed muscle does not affect partial bone fracture healing but causes instability in a complete fracture.

Hypophosphatemia in critically ill children

The purpose of this paper is to review clinical studies on hypophosphatemia in pediatric intensive care unit patients with a view to verifying prevalence and risk factors associated with this disorder. We searched the computerized bibliographic databases Medline, Embase, Cochrane Library, and LILACS to identify eligible studies. Search terms included critically ill, pediatric intensive care, trauma, sepsis, infectious diseases, malnutrition, inflammatory response, surgery, starvation, respiratory failure, diuretic, steroid, antiacid therapy, mechanical ventilation. The search period covered those clinical trials published from January 1990 to January 2004. Studies concerning endocrinological disorders, genetic syndromes, rickets, renal diseases, anorexia nervosa, alcohol abuse, and prematurity were not included in this review. Out of 27 studies retrieved, only 8 involved pediatric patients, and most of these were case reports. One clinical trial and one retrospective study were identified. The prevalence of hypophosphatemia exceeded 50%. The commonly associated factors in most patients with hypophosphatemia were refeeding syndrome, malnutrition, sepsis, trauma, and diuretic and steroid therapy. Given the high prevalence, clinical manifestations, and multiple risk factors, the early identification of this disorder in critically ill children is crucial for adequate replacement therapy and also to avoid complications.

Sonae MC: The road model of Kaizen

Sonae MC is considered the first success case of Kaizen in the retail industry. Before becoming a true role model for so many companies, there was a long road to walk. However, it may still be hard to understand the steps taken on the way. How could a training program develop into an integral continuous improvement system, and how did it affect the company – its people, culture, operations and strategy? How was it possible to get everyone on board? How could it be sustained until today, when Kaizen usually fails in the West? What were the critical factors for success?

A Presença islâmica em al-Qasr : uma análise sobre o urbanismo e o sistema defensivo

Alcácer do Sal é uma cidade que esteve desde sempre ligada ao rio Sado, permitindo essa mesma ligação, que nela se fossem fixando ao longo do tempo, distintos povos, provindos das mais diversas partes do mundo. Esta ocupação por parte das populações, só foi possível, porque o território era abundante em recursos naturais e, entre eles, possuía solos bastante férteis para a agricultura. Uma das comunidades que mais marcas deixou da sua presença naquele núcleo urbano, foi, sem dúvida, a muçulmana, tal como se pode verificar no topónimo que dá o nome à cidade, assim como pela presença dos vários vestígios materiais, como a imponente fortificação militar, que se ergue na colina mais alta da povoação, assim como pelas estruturas e espólios encontrados nas diversas intervenções arqueológicas realizadas naquela cidade. Tendo em conta estes aspetos, esta dissertação pretende fazer uma aproximação ao estudo do urbanismo da medina islâmica de al-Qasr, abarcando cronologicamente o século IX, altura em que os Banu Danis se fixam na cidade, até aos inícios do século XIII, correspondente à última fase de ocupação muçulmana da cidade.

Safety classification using GIS in decision-making process to define priority road interventions

Given the current economic situation of the Portuguese municipalities, it is necessary to identify the priority investments in order to achieve a more efficient financial management. The classification of the road network of the municipality according to the occurrence of traffic accidents is fundamental to set priorities for road interventions. This paper presents a model for road network classification based on traffic accidents integrated in a geographic information system. Its practical application was developed through a case study in the municipality of Barcelos. An equation was defined to obtain a road safety index through the combination of the following indicators: severity, property damage only and accident costs. In addition to the road network classification, the application of the model allows to analyze the spatial coverage of accidents in order to determine the centrality and dispersion of the locations with the highest incidence of road accidents. This analysis can be further refined according to the nature of the accidents namely in collision, runoff and pedestrian crashes.

An evolutionary multi-objective optimization system for earthworks

Earthworks involve the levelling or shaping of a target area through the moving or processing of the ground surface. Most construction projects require earthworks, which are heavily dependent on mechanical equipment (e.g., excavators, trucks and compactors). Often, earthworks are the most costly and time-consuming component of infrastructure constructions (e.g., road, railway and airports) and current pressure for higher productivity and safety highlights the need to optimize earthworks, which is a nontrivial task. Most previous attempts at tackling this problem focus on single-objective optimization of partial processes or aspects of earthworks, overlooking the advantages of a multi-objective and global optimization. This work describes a novel optimization system based on an evolutionary multi-objective approach, capable of globally optimizing several objectives simultaneously and dynamically. The proposed system views an earthwork construction as a production line, where the goal is to optimize resources under two crucial criteria (costs and duration) and focus the evolutionary search (non-dominated sorting genetic algorithm-II) on compaction allocation, using linear programming to distribute the remaining equipment (e.g., excavators). Several experiments were held using real-world data from a Portuguese construction site, showing that the proposed system is quite competitive when compared with current manual earthwork equipment allocation.

Recycled asphalt mixtures with foamed bitumen: an alternative to build ecofriendly road pavements

Nowadays, recycling has become a very important objective for the society in the scope of a closed loop product life cycle. In recent years, new recycling techniques have been developed in the area of road pavements that allow the incorporation of high percentages of reclaimed asphalt (RA) materials in recycled asphalt mixtures. The use of foamed bitumen for production of recycled asphalt mixtures is one of those techniques, which also allows the reduction of the mixing temperatures (warm mix technology). However, it is important to evaluate if this solution can maintain or improve the performance of the resulting mixtures. Thus, the main aim of the present study is to assess the performance of warm recycled asphalt mixtures incorporating foamed bitumen as the new binder and 50% RA, in comparison with a control mixture using conventional bitumen. Four mixtures have been produced with 50% RA, one of them at typical high mixing temperatures with a conventional bitumen (control mixture) and the other three with foamed bitumen at different production temperatures. These four mixtures were tested to evaluate their compactability and water sensitivity. The laboratory test results showed that the production of recycled mixtures with foamed bitumen can be reduced by 40ºC without changing the performance of the resulting mixtures.

Combining data mining and evolutionary computation for multi-criteria optimization of earthworks

Earthworks tasks aim at levelling the ground surface at a target construction area and precede any kind of structural construction (e.g., road and railway construction). It is comprised of sequential tasks, such as excavation, transportation, spreading and compaction, and it is strongly based on heavy mechanical equipment and repetitive processes. Under this context, it is essential to optimize the usage of all available resources under two key criteria: the costs and duration of earthwork projects. In this paper, we present an integrated system that uses two artificial intelligence based techniques: data mining and evolutionary multi-objective optimization. The former is used to build data-driven models capable of providing realistic estimates of resource productivity, while the latter is used to optimize resource allocation considering the two main earthwork objectives (duration and cost). Experiments held using real-world data, from a construction site, have shown that the proposed system is competitive when compared with current manual earthwork design.

Tree species diversity in a seasonally-dry forest: the case of the Pinkaití site, in the Kayapó Indigenous Area, Southeastern limits of the Amazon

This study investigates patterns of forest structure and tree species diversity in an anthropogenic palm grove and undisturbed areas at the seasonally-dry Pinkaití research station, in the Kayapó Indigenous Area. This site, managed by the Conservation International do Brasil, is the most southeastern site floristically surveyed in the Amazon until now. The secondary and a nearby undisturbed forest were sampled in a group of 52 floristic plots of 0.0625-ha (25x25-m) where all trees with DBH > 10 cm were measured and identified. The analyses were complemented with other two floristic plots of 1-ha (10x1000-m). The present study has shown that the Pinkaití, like other seasonally-dry forests, have great heterogeneity in forest structure and composition, associated with biotic characteristics of the most important tree species, natural disturbance and history of land-use. The palm grove, moderately dominated by the arborescent palm Attalea maripa (Aubl.) Mart., presented high tree species diversity and was floristically similar to undisturbed forests at the study site. It is discussed the importance of large arborescent palms for the seasonally-dry Amazon forests regeneration.

Late-medieval construction site management at the Monastery of Jerónimos in Lisbon

Through the analysis of the exceptional accounting documents of 1517 related to the construction of the Monastery of Jerónimos (Lisbon), this paper discusses the main characteristics of a new model of construction site organization. In the later Middle Ages we can find, among others, two main models of constructing site organization. One, older and more widespread, consisted in a centralized and pyramidal management model. The other, apparently more recent, was based in the existence of several autonomous teams working simultaneously, each one responsible for building a specific part or section of the building. This paper describes and discusses this new organizational model as it was adopted and implemented by João de Castilho (1470–1552) for the construction of the Monastery of Jerónimos in 1517, probably for the first time in Portugal, but with some parallels in other places in Europe.

Toxicidade de manipueira de mandioca (Manihot esculenta Crantz) e erva-de-rato (Palicourea marcgravii St. Hill) a adultos de Toxoptera citricida Kirkaldy (Homoptera: Aphididae)

A utilização de extratos de plantas pode ser uma alternativa para o controle de pragas. Dentre as plantas com atividade inseticida, destacam-se a erva-de-rato (Palicourea marcgravii) e o subproduto (manipueira) da produção de farinha de mandioca (Manihot esculenta), plantas comuns na região Amazônica. Esse trabalho teve, como principal objetivo, investigar o potencial inseticida da manipueira e do extrato de erva-de-rato sobre Toxoptera citricida (pulgão-preto do citros). Os extratos liofilizados de manipueira e de erva-de-rato foram pulverizados sobre plantas de citros contendo pulgões em cinco concentrações (10mg/ml, 20mg/ml, 30mg/ml, 40mg/ml e 50mg/ml). Todas as concentrações analisadas causaram mortalidade dos pulgões superior a 50%, sendo que a maior concentração causou a mortalidade de todos os insetos. O potencial destes extratos demonstrado no experimento coloca os mesmos como uma alternativa ao uso de inseticidas sintéticos no controle do pulgão-preto dos citros.

On the Hill estimator: a comparison of methods

Extreme value theory (EVT) deals with the occurrence of extreme phenomena. The tail index is a very important parameter appearing in the estimation of the probability of rare events. Under a semiparametric framework, inference requires the choice of a number k of upper order statistics to be considered. This is the crux of the matter and there is no definite formula to do it, since a small k leads to high variance and large values of k tend to increase the bias. Several methodologies have emerged in literature, specially concerning the most popular Hill estimator (Hill, 1975). In this work we compare through simulation well-known procedures presented in Drees and Kaufmann (1998), Matthys and Beirlant (2000), Beirlant et al. (2002) and de Sousa and Michailidis (2004), with a heuristic scheme considered in Frahm et al. (2005) within the estimation of a different tail measure but with a similar context. We will see that the new method may be an interesting alternative.

Durabilidade de madeira de eucalipto citriodora (Corymbia citriodora (Hook.) K.D. Hill & L.A.S. Johnson) tratada com CCA em ambiente amazônico

A intensa exploração econômica tem causado diminuição do estoque original das espécies madeireiras amazônicas, incluindo aquelas de alta durabilidade natural destinadas a usos em contato com o solo. A escassez dessas madeiras resulta na elevação do preço, inviabilizando economicamente seu uso, sendo uma alternativa a substituição por espécies plantadas de rápido crescimento tratadas com preservativos. Outra vantagem, além da econômica, de utilizar espécies plantadas em substituição às tradicionais é ambiental, pois reduzirá a pressão exploratória sobre aquelas. Este estudo teve por objetivo avaliar o grau de degradação biológica de madeira de eucalipto citriodora (Corymbia citriodora (Hook.) K.D. Hill & L.A.S. Johnson) tratado por processo a vácuo e pressão com arseniato de cobre cromatado (CCA) e exposta em ensaio de campo em Rio Branco-AC. O ensaio foi implantado em maio de 2005 com estacas tratadas ou não com CCA. As variáveis avaliadas foram: 1) degradação por fungos, 2) degradação por cupins, e 3) região ou parte da peça afetada. A partir da terceira avaliação (47 meses de ensaio), 100% dos corpos de prova não tratados foram classificados com o grau de degradação máximo e, ao contrário, 100% dos tratados com CCA, decorridos 60 meses de ensaio, foram classificados com o grau mínimo. As partes não tratadas com maior e menor grau de degradação foram, respectivamente, o topo inferior e a parte aérea acima de 10 cm do solo. A degradação provocada por fungos foi levemente inferior à dos cupins. O ensaio aponta para a viabilidade técnica do uso de madeira tratada de eucalipto em substituição às espécies tradicionais da Amazônia.