Relatório de estágio em terapia manual ortopédica

Este estudo visa descrever o caso de um paciente de 63 anos que recorreu aos serviços de Fisioterapia após uma crise de lombalgia com 3 dias de evolução. O doente apresentava dor intensa situada entre a zona lombar e sacro-ilíaca direita (7/10-EVA), irradiando pelas cristas ilíacas, virilha e face anterior da coxa direita. A intervenção dividiu-se em duas fases: aguda e sub-aguda. A primeira exigiu uma abordagem limitada e essencialmente orientada para a mecânica articular, em que foram utilizadas técnicas de terapia manual. A segunda, com um quadro clínico menos doloroso, permitiu avaliar o comprometimento de outras estruturas, nomeadamente miofasciais e neurológicas. Entre as várias etiologias possíveis, foram encontrados sinais e sintomas consistentes com síndroma miofascial do músculo Psoas ilíaco. A intervenção incluiu técnicas de terapia manual, exercício terapêutico e educação do paciente. No final de 9 semanas de tratamento o paciente mantém limitações mínimas relacionadas com a mecânica articular que se traduzem pela sensibilidade em L4-L5 (3/10), e observa-se uma atitude menos sedentária comparativamente ao que se apurou antes desta ocorrência. A abordagem terapêutica foi fundamentada pela anatomia, biomecânica e raciocínio clínico, tendo em conta a evidência científica, experiência clínica e factores psico-sociais.

Efectividade de um programa de fisioterapia na radiculopatia cervical – estudo de caso

Introdução: Não existe um consenso quanto ao melhor tratamento para a radiculopatia cervical pois existe uma grande variedade de manifestações clínicas e opções terapêuticas, mas a sua selecção vai depender do caso particular do utente, sugerindo assim uma correcta avaliação do Fisioterapeuta. Objectivo: Este estudo pretende descrever e avaliar a efectividade de um programa de Fisioterapia num caso de radiculopatia cervical, na dor, funcionalidade e percepção da qualidade de vida. Participantes e Métodos: Estudo observacional descritivo tipo estudo de caso de um utente de 56 anos de idade, com radiculopatia cervical. Para a avaliação foram utilizados testes ortopédicos, a escala visual analógica e os questionários de incapacidade funcional da cervical e do membro superior bem como da percepção da qualidade de vida. Estes questionários foram aplicados em 3 momentos, antes da intervenção, no final e após 6 semanas e os restantes instrumentos foram utilizados em diversos momentos ao longo da intervenção. Esta foi efectuada duas vezes por semana, ao longo de 10 semanas recorrendo a técnicas de terapia manual, exercícios de controlo motor e educação do utente. Resultados: Verificou-se que a dor na cervical passou de 6,5 para 2/10 EVA e no cotovelo direito de 7,3 para 2/10. A resposta ao questionário de incapacidade funcional na cervical variou de 40% no primeiro momento para 11,1% no segundo, o da incapacidade funcional do membro superior variou de 63,6% para 33,5% e o questionário da percepção da qualidade de vida variou de 55,01 para 68,69. Seis semanas após a intervenção, todos estes resultados se mantinham praticamente inalterados. Conclusão: Este caso permitiu demonstrar o processo de raciocínio clínico efectuado ao longo de dez semanas de intervenção em que se utilizou uma abordagem centrada no utente, baseada na evidência científica e na experiência clínica anterior. Os resultados alcançados foram de encontro às expectativas iniciais e parecem evidenciar que, neste caso, o programa de fisioterapia teve efeitos positivos na dor, funcionalidade e percepção da qualidade de vida.

Factors influencing the adoption of an innovation: an examination of the uptake of the Canadian Heart Health Kit (HHK)

BACKGROUND: There is an emerging knowledge base on the effectiveness of strategies to close the knowledge-practice gap. However, less is known about how attributes of an innovation and other contextual and situational factors facilitate and impede an innovation's adoption. The Healthy Heart Kit (HHK) is a risk management and patient education resource for the prevention of cardiovascular disease (CVD) and promotion of cardiovascular health. Although previous studies have demonstrated the HHK's content validity and practical utility, no published study has examined physicians' uptake of the HHK and factors that shape its adoption. OBJECTIVES: Conceptually informed by Rogers' Diffusion of Innovation theory, and Theory of Planned Behaviour, this study had two objectives: (1) to determine if specific attributes of the HHK as well as contextual and situational factors are associated with physicians' intention and actual usage of the HHK kit; and (2), to determine if any contextual and situational factors are associated with individual or environmental barriers that prevent the uptake of the HHK among those physicians who do not plan to use the kit. METHODS: A sample of 153 physicians who responded to an invitation letter sent to all family physicians in the province of Alberta, Canada were recruited for the study. Participating physicians were sent a HHK, and two months later a study questionnaire assessed primary factors on the physicians' clinical practice, attributes of the HHK (relative advantage, compatibility, complexity, trialability, observability), confidence and control using the HHK, barriers to use, and individual attributes. All measures were used in path analysis, employing a causal model based on Rogers' Diffusion of Innovations Theory and Theory of Planned Behaviour. RESULTS: 115 physicians (follow up rate of 75%) completed the questionnaire. Use of the HHK was associated with intention to use the HHK, relative advantage, and years of experience. Relative advantage and the observability of the HHK benefits were also significantly associated with physicians' intention to use the HHK. Physicians working in solo medical practices reported experiencing more individual and environmental barriers to using the HHK. CONCLUSION: The results of this study suggest that future information innovations must demonstrate an advantage over current resources and the research evidence supporting the innovation must be clearly visible. Findings also suggest that the innovation adoption process has a social element, and collegial interactions and discussions may facilitate that process. These results could be valuable for knowledge translation researchers and health promotion developers in future innovation adoption planning.

Adoption of the Healthy Heart Kit by Alberta family physicians

OBJECTIVE: The Healthy Heart Kit (HHK) is a risk management and patient education kit for the prevention of cardiovascular disease (CVD) and the promotion of CV health. There are currently no published data examining predictors of HHK use by physicians. The main objective of this study was to examine the association between physicians' characteristics (socio-demographic, cognitive, and behavioural) and the use of the HHK. METHODS: All registered family physicians in Alberta (n=3068) were invited to participate in the "Healthy Heart Kit" Study. Consenting physicians (n=153) received the Kit and were requested to use it for two months. At the end of this period, a questionnaire collected data on the frequency of Kit use by physicians, as well as socio-demographic, cognitive, and behavioural variables pertaining to the physicians. RESULTS: The questionnaire was returned by 115 physicians (follow-up rate = 75%). On a scale ranging from 0 to 100, the mean score of Kit use was 61 [SD=26]. A multiple linear regression showed that "agreement with the Kit" and the degree of "confidence in using the Kit" was strongly associated with Kit use, explaining 46% of the variability for Kit use. Time since graduation was inversely associated with Kit use, and a trend was observed for smaller practices to be associated with lower use. CONCLUSION: Given these findings, future research and practice should explore innovative strategies to gain initial agreement among physicians to employ such clinical tools. Participation of older physicians and solo-practitioners in this process should be emphasized.

Kirurgisten potilasohjeiden laatu ja valmius tukea voimavaraistavaa potilasohjausta sekä infektioiden torjuntaan liittyvä sisältö

Hoitotyössä infektioiden torjunnan painopistealueena on ollut lisätä potilaiden osallistuvuutta voimavaraistavalla potilasohjauksella. Potilasohjauksen apuna käytetään usein kirjallisia potilasohjeita, joiden rakenne ja laatu tulee olla hyvä. Lisäksi potilasohjeiden tulee omata valmiuksia tukea voimavaraistavaa potilasohjausta. Kirjalliset potilasohjeet ovat hyvä potilasohjauksen keino, mutta systemaattinen tieto potilasohjeiden laadusta, valmiuksista tukea voimavaraistavaa potilasohjausta sekä infektioiden torjunnan sisällöstä puuttuu. Tutkimuksen tarkoituksena oli analysoida Suomen yliopistosairaaloiden kirurgisten potilasohjeiden infektioiden torjuntaan liittyvää sisältöä. Lisäksi oltiin kiinnostuneita potilasohjeiden laadusta hyvien kirjallisten potilasohjeiden ominaispiirteiden toteutumisessa sekä potilasohjeiden valmiuksista tukea voimavaraistavaa potilasohjausta. Tutkimuksen aineistona oli viiden yliopistosairaalan kirurgisille aikuispotilaille tarkoitetut potilasohjeet (N = 237). Organisaatioittain joka viides potilasohje (n = 50) analysoitiin potilasohjeiden laadun osalta sisällönerittelyllä ja aikaisemmin kehitetyn mittarin avulla (Salanterä ym. 2004). Deduktiivisella sisällönanalyysillä analysoitiin potilasohjeiden valmiuksia tukea voimavaraistavaa potilasohjausta, jonka ulottuvuuksien esiintyvyyden arviointiasteikko oli kehitetty tätä tutkimusta varten. Induktiivisella sisällönerittelyllä analysoitiin infektioiden torjuntaan liittyvä sisältö. Potilasohjeiden laadussa oli paljon vaihtelua, ja vain 36 % (n = 18) potilasohjeista oli julkaistu viimeisen kolmen vuoden (2010–2012) aikana. Potilasohjeet olivat ulkoasultaan selkeitä ja johdonmukaisia, jolloin kirjallisten potilasohjeiden ominaisuuksista parhaiten toteutuivat ulkoasun sekä kielen ja rakenteen ominaisuudet. Potilasohjeet kuvasivat toimenpidettä ja siitä selviytymistä, antaen parhaiten valmiuksia tukea toiminnallista ja bio-fysiologista selviytymistä potilasohjauksella. Infektioiden torjuntaan liittyvä sisältö oli pääasiassa esitetty epäsuorasti toisen asian kautta. Infektioiden syntyyn tai torjuntaan ei viitattu, vaan asiaa tarkasteltiin muusta näkökulmasta esimerkiksi ylipainon ja ihon kunnon osalta. Yleisin infektioiden torjuntaan liittyvä sisältö koski käsihygieniaa, vaikka sen toteuttamista ei opastettu tai ohjeistettu. Tutkimus tarjoaa lähtökohdan kehittää potilasohjeiden infektioiden torjuntaan liittyvää sisältöä sekä potilaan osallistuvuuden lisäämistä. Erityisesti tulisi kehittää potilaan osallistuvuuden tukemista voimavaraistavalla potilasohjauksella. Jatkotutkimuksena tulisi kartoittaa potilaiden tarpeet infektioiden torjunnan sisällöstä sekä kehittää kansallinen ohjeistus potilasohjeiden infektioon torjuntaan liittyvästä sisällöstä ja rakenteesta.

Analysis of procedures used in tooth avulsion by 100 dental surgeons

Accurate diagnosis and adequate treatment plan may constitute very complex tasks, particularly in tooth avulsion, because several variables are involved. In addition to the technical knowledge and clinical experience directed toward the quality of treatment, patient education may favorably influence the survival of replanted teeth. The aim of this study was to analyze the procedures used in the management of tooth avulsion by 100 dental surgeons (DSs). Thus, by means of a descriptive questionnaire, information was obtained about the profile of the professionals interviewed, procedures used in cases of tooth avulsion, and patient orientation and education. One hundred properly filled questionnaires were obtained. Descriptive statistics was used for the data, and the chi-squared statistics was employed (EPI-INFO 3.2 software). According to the results, this type of trauma is part of the routine of 15 DSs, although 71 have reported some experience with avulsed,teeth. Great deficiencies were found regarding root surface treatment and occlusal adjustment. Positive findings were related to socket treatment, adjunctive therapy, and patient education and orientation (extra-alveolar period, storage medium, manipulation of the avulsed tooth, replantation by the own patient). It was possible to conclude that 47.5% of the procedures reported by, 100 professionals interviewed are adequate, and patient education is favorable in 87.7% of cases, a fact that can positively interfere with the prognosis of tooth replantation.

Análise dos procedimentos empregados por 100 cirurgiões-dentistas nos casos de avulsão dentária

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Einfluss einer pharmazeutischen Betreuung auf den klinischen Verlauf und die Behandlungsergebnisse von Diabetikern mit Diabetischem Fußsyndrom (DFS)

Einfluss einer Pharmazeutischen Betreuung auf den klinischen Verlauf und die Behandlungsergebnisse von Diabetikern mit Diabetischem Fußsyndrom (DFS) Hintergrund/Rationale: In Deutschland gibt es etwa 6 Millionen Diabetiker und die Tendenz ist steigend. Das Diabetische Fußsyndrom (DFS) stellt eine häufige und besonders gravierende Folgeerkrankung des Diabetes mellitus dar. Jährlich werden in Deutschland ca. 45.000 Amputationen aufgrund des DFS bei Diabetikern durchgeführt. Es verursacht bei den Patienten physische und psychische Beeinträchtigungen und produziert hohe Krankheitskosten. Der Prävention, der Behandlung und der Rezidivprophylaxe des DFS kommt daher ein hoher Stellenwert zu. Ziel dieser Arbeit war es, ein klinisch-pharmazeutisches Betreuungsprogramm für Patienten mit DFS zu erarbeiten und den Einfluss der Pharmazeutischen Betreuung, speziell einer intensivierten Patientenschulung, auf klinische und soziale Behandlungsergebnisse hin zu untersuchen. Es sollte geklärt werden, ob eine zusätzliche pharmazeutische Betreuung Einfluss auf den Wundheilungsverlauf und die Abheilungsrate der Fußläsionen von Diabetikern mit DFS nehmen kann. Methoden: 52 Patienten mit DFS wurden in eine randomisierte, kontrollierte Studie eingeschlossen und im Verhältnis 1:1 einer Interventions- oder Kontrollgruppe zugeteilt. Die Interventionsgruppe wurde kontinuierlich durch einen Apotheker zusätzlich individuell betreut (Anleitung zum sachgerechten Umgang mit Arzneimitteln, Medizinprodukten und Therapiemaßnahmen), die Kontrollgruppe erhielt die übliche medizinische Betreuung. Die Auswirkungen der Intervention auf den klinischen Verlauf der beobachteten Fußläsionen, die Rezidivfreiheit und Rehospitalisierungsrate, aber auch auf die Patientenzufriedenheit, das Patientenwissen und die Lebensqualität wurden untersucht. Jeder Patient wurde über einen Zeitraum von 12 Monaten beobachtet. Ergebnisse: Die Studienergebnisse belegen einen positiven Einfluss der Pharmazeutischen Betreuung auf die klinischen Endpunkte der Diabetiker mit DFS. Die Wundheilung der Läsionen in der Interventionsgruppe, bezogen auf Abheilungsdauer und -rate, konnte klinisch positiv beeinflusst werden. Des weiteren konnte in der Interventionsgruppe die Anzahl an neu aufgetretenen Läsionen, sowie weiterer Krankenhausaufenthalte um jeweils fast 50% verringert werden. Durch die Pharmazeutische Betreuung konnte die Patientenzufriedenheit mit der Behandlung deutlich gesteigert werden. Entsprechendes fand sich für das Patientenwissen und die Lebensqualität.

Evaluation of the Western Australian Department of Health telehealth project

In 1999, the Department of Health in Western Australia began a telehealth project, which finished in 2004. The 75 videoconferencing sites funded by the project were part of a total state-wide videoconference network of 104 sites. During the period from January 2002 to December 2003, a total of 3266 consultations, case reviews and patient education sessions took place. Clinical use grew to 30% of all telehealth activity. Educational use was approximately 40% (1416 sessions) and management use was about 30% (1031 sessions). The average overhead cost per telehealth session across all regions and usage types was $A192. Meaningful comparisons of the results of the present study with other public health providers were difficult, because many of the available Websites on telehealth were out of date. Despite the successful use of telehealth to deliver clinical services in Western Australia, sustaining the effort in the post-project phase will present significant challenges.

The role of the health care organization in supporting nurses in the delivery of culturally competent care

This study was designed to explore ways in which health care organizations (HCOs) can support nurses in their delivery of culturally competent care. While cultural competence has become a priority for the federal government as well as the major health professional organizations, its integration into care delivery has not yet been realized. Health professionals cite a lack of educational preparation, time, and organizational resources as barriers. Most experts in the field agree that the cultural and linguistic needs of ethnic minorities pose challenges that individual care providers are unable to manage without the support of the health care organizations within which they practice. While several studies have identified implications for HCOs, there is a paucity of research on their role in this aspect of care delivery. Using a qualitative design with a case study approach, data collection included face-to-face interviews with 23 registered nurses, document analysis, and reports of critical incidents. The site chosen was a large health care system in South Florida that serves a culturally diverse population. Major findings from the study included language barriers, lack of training, difficulty with cultural differences, lack of organizational support, and reliance on culturally diverse staff members. Most nurses thought the ethnic mix was adequate, but rated other supports such as language services, training, and patient education materials as inadequate. Some of the recommendations for organizational performance were to provide the expectations and support for culturally competent care. Implications and recommendations for practice include nurses using trained interpreters instead of relying on coworkers or trying to "wing it", pursuing training, and advocating for organizational supports for culturally competent care. Implications and recommendations for theory included a blended model that combines both models in the conceptual framework. Recommendations for future research were for studies on the impact of language bathers on care delivery, develop and test a quantitative instrument, and to incorporate Gilbert's model into nursing research.

Medication competence of nursing students in Finland

Lääkehoidon turvallinen toteuttaminen edellyttää sairaanhoitajalta hyvää lääkehoidon osaamisperustaa. Sairaanhoitajakoulutuksen tehtävänä on mahdollistaa tämän osaamisen kehittyminen. Kansainvälisissä tutkimuksissa on kuitenkin osoitettu, että lääkehoidon opetuksen laajuudessa, sisällössä ja toteutuksessa on vaihtelevuutta. Aikaisemmissa tutkimuksissa on raportoitu myös puutteita lääkehoidon osaamisessa sekä sairaanhoitajilla että sairaanhoitajaopiskelijoilla. Koulutuksen ja lääkehoidon osaamisen kehittämiseksi lääkehoidon opetuksen ja sairaanhoitajaopiskelijoiden lääkehoidon osaamisen monipuolinen arviointi ja osaamista selittävien tekijöiden tarkastelu on tarpeen. Tämän tutkimuksen tarkoituksena oli i) arvioida lääkehoidon opetusta suomalaisessa sairaanhoitajakoulutuksessa, ii) arvioida sairaanhoitajaopiskelijoiden lääkehoidon osaamista sekä iii) tunnistaa sairaanhoitajaopiskelijan lääkehoidon osaamiseen yhteydessä olevat tekijät. Tutkimus toteutettiin kolmessa vaiheessa. Ensimmäisessä vaiheessa kahden integroidun kirjallisuuskatsauksen kautta määriteltiin tutkimuksen kohteena oleva sairaanhoitajan lääkehoidon osaaminen ja aiemmin tunnistetut sairaanhoitajaopiskelijan lääkehoidon osaamiseen yhteydessä olevat tekijät. Toisessa vaiheessa toteutettiin valtakunnallinen lääkehoidon opetukseen liittyvä kysely hoitotyön koulutusohjelmasta vastaaville koulutuspäälliköille (n=22) ja opettajille (n=136). Tutkimuksen kolmannessa vaiheessa opintojensa alku‐ (n=328) ja loppuvaiheessa olevien sairaanhoitajaopiskelijoiden (n=338) lääkehoidon osaaminen arvioitiin ja osaamiseen yhteydessä olevat tekijät tunnistettiin. Aineistojen analyysissä käytettiin pääosin tilastollisia menetelmiä. Tulosten perusteella lääkehoidon opetuksen laajuus vaihteli eri ammattikorkeakouluissa, mutta opetuksen sisältö oli kuitenkin monipuolista. Lisää huomiota tulisi kiinnittää lääkehoidon teoreettiseen perustaan ja itsehoitoon sekä lääkehoidon ohjaukseen liittyviin sisältöalueisiin. Opiskelijoiden lääkehoidon osaamista arvioitiin säännöllisesti kaikissa ammattikorkeakouluissa. Sairaanhoitajaopiskelijan lääkehoidon osaamista arvioitiin tutkimuksessa tietotestillä, lääkelaskentatehtävillä ja lyhyiden potilastapausten ratkaisemisen avulla. Lääkehoidon osaamiseen yhteydessä olevia tekijöitä tarkasteltiin kolmesta näkökulmasta: 1) yksilölliset tekijät, 2) kliiniseen oppimisympäristöön ja 3) ammattikorkeakouluun liittyvät tekijät. Lääkehoidon teoreettista osaamista arvioivassa tietotestissä opiskelijat vastasivat keskimäärin 72 prosenttiin kysymyksistä täysin oikein; lääkelaskuista täysin oikein oli 74 % ja potilastapauksissa 57 % valitsi parhaan mahdollisen toimintatavan. Tulosten perusteella sairaanhoitajaopiskelijan osaamista selittivät eniten yksilölliset tekijät. Lääkehoidon osaamiseen yhteydessä olevien tekijöiden välillä oli eroa opintojen alussa ja lopussa. Opintojen alkuvaiheessa opiskelijan aikaisempi opintomenestys oli yhteydessä lääkehoidon osaamiseen, kun taas opintojen loppuvaiheessa siihen olivat yhteydessä opiskelijan kyky itseohjautuvaan oppimiseen sekä opiskelumotivaatio. Johtopäätöksenä voidaan todeta tutkimuksen tulosten olevan samansuuntaisia kuin aikaisemmissa tutkimuksissa. Lääkehoidon opetuksen laajuus vaihtelee opetussuunnitelmatasolla, mutta täsmällinen arviointi on vaikeaa opetuksen sisältöjen integroimisen takia. Sairaanhoitajaopiskelijoiden lääkehoidon osaaminen oli hieman parempaa kuin aikaisemmissa tutkimuksissa, mutta osaamisessa on edelleen puutteita. Lääkehoidon opetuksen ja osaamisen kehittäminen edellyttää kansallista ja kansainvälistä tutkimus‐ ja kehittämisyhteistyötä. Tutkimuksen tulokset tukevat lääkehoidon opetuksen sekä osaamisen tutkimusta ja kehittämistä.

Estágio realizado no Programa Comunitário PLE²NO

A OA é a doença reumática mais comum no ser humano e uma doença crónica com impacto elevado na sociedade. Tem repercussões na saúde, ao nível da funcionalidade, comprometendo a realização das atividades da vida diária e a qualidade de vida dos indivíduos. Uma das articulações mais afetada pela OA é a articulação do joelho. O tratamento eficaz requer a combinação de tratamentos farmacológicos e não farmacológicos. Os tratamentos não farmacológicos, principalmente o exercício e a educação do doente têm vindo a ganhar importância, no que se refere ao controlo dos sintomas. A realização do estágio curricular surge no programa comunitário PLE²NO. O programa é considerado uma opção não farmacológica no tratamento e controlo dos sintomas da Osteoartrose (OA) no joelho. Os principais objetivos do estágio no PLE²NO consistiram: aquisição de conhecimentos teóricos relacionados com OA e práticos com vista ao aperfeiçoamento da prescrição do exercício; aquisição de competências essenciais à ótima liderança e comunicação com as pessoas e instituições envolvidas; prescrição de exercício a indivíduos com OA no joelho; cativar e motivar as pessoas para a prática de exercício; e determinar a eficácia de um programa de 3 meses de educação e exercício nos sintomas, aptidão física e qualidade de vida dos idosos com OA no joelho. Na aptidão física verificaram-se diferenças significativas na capacidade aeróbia, flexibilidade e velocidade da marcha. Nos indicadores de saúde houve melhoria em praticamente todos os parâmetros avaliados: mobilidade, cuidados pessoais, dor/mal-estar e sintomas de ansiedade/depressão. Assim, esta intervenção revelou-se ser uma mais-valia para o tratamento não farmacológico da osteoartrose do joelho a médio prazo.

The improvement of care for paediatric and congenital cardiac disease across the World: a challenge for the World Society for Pediatric and Congenital Heart Surgery

The diagnosis and treatment for paediatric and congenital cardiac disease has undergone remarkable progress over the last 60 years. Unfortunately, this progress has been largely limited to the developed world. Yet every year approximately 90% of the more than 1,000,000 children who are born with congenital cardiac disease across the world receive either suboptimal care or are totally denied care. While in the developed world the focus has changed from an effort to decrease post-operative mortality to now improving quality of life and decreasing morbidity, which the focus of this Supplement, the rest of the world still needs to develop basic access to congenital cardiac care. The World Society for Pediatric and Congenital Heart Surgery [http://www.wspchs.org/] was established in 2006. The Vision of the World Society is that every child born anywhere in the world with a congenital heart defect should have access to appropriate medical and surgical care. The Mission of the World Society is to promote the highest quality comprehensive care to all patients with pediatric and/or congenital heart disease, from the fetus to the adult, regardless of the patient`s economic means, with emphasis on excellence in education, research and community service. We present in this article an overview of the epidemiology of congenital cardiac disease, the current and future challenges to improve care in the developed and developing world, the impact of the globalization of cardiac surgery, and the role that the World Society should play. The World Society for Pediatric and Congenital Heart Surgery is in a unique position to influence and truly improve the global care of children and adults with congenital cardiac disease throughout the world [http://www.wspchs.org/].

Perioperative nutrition in abdominal surgery: recommendations and reality.

Introduction. Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Definition and diagnosis of malnutrition and its treatment is still subject for controversy. Furthermore, practical implementation of nutrition-related guidelines is unknown. Methods. A review of the available literature and of current guidelines on perioperative nutrition was conducted. We focused on nutritional screening and perioperative nutrition in patients undergoing digestive surgery, and we assessed translation of recent guidelines in clinical practice. Results and Conclusions. Malnutrition is a well-recognized risk factor for poor postoperative outcome. The prevalence of malnutrition depends largely on its definition; about 40% of patients undergoing major surgery fulfil current diagnostic criteria of being at nutritional risk. The Nutritional Risk Score is a pragmatic and validated tool to identify patients who should benefit from nutritional support. Adequate nutritional intervention entails reduced (infectious) complications, hospital stay, and costs. Preoperative oral supplementation of a minimum of five days is preferable; depending on the patient and the type of surgery, immune-enhancing formulas are recommended. However, surgeons' compliance with evidence-based guidelines remains poor and efforts are necessary to implement routine nutritional screening and nutritional support.

Colorectal cancer survival in the USA and Europe: a CONCORD high-resolution study.

OBJECTIVES: To assess the extent to which stage at diagnosis and adherence to treatment guidelines may explain the persistent differences in colorectal cancer survival between the USA and Europe. DESIGN: A high-resolution study using detailed clinical data on Dukes' stage, diagnostic procedures, treatment and follow-up, collected directly from medical records by trained abstractors under a single protocol, with standardised quality control and central statistical analysis. SETTING AND PARTICIPANTS: 21 population-based registries in seven US states and nine European countries provided data for random samples comprising 12 523 adults (15-99 years) diagnosed with colorectal cancer during 1996-1998. OUTCOME MEASURES: Logistic regression models were used to compare adherence to 'standard care' in the USA and Europe. Net survival and excess risk of death were estimated with flexible parametric models. RESULTS: The proportion of Dukes' A and B tumours was similar in the USA and Europe, while that of Dukes' C was more frequent in the USA (38% vs 21%) and of Dukes' D more frequent in Europe (22% vs 10%). Resection with curative intent was more frequent in the USA (85% vs 75%). Elderly patients (75-99 years) were 70-90% less likely to receive radiotherapy and chemotherapy. Age-standardised 5-year net survival was similar in the USA (58%) and Northern and Western Europe (54-56%) and lowest in Eastern Europe (42%). The mean excess hazard up to 5 years after diagnosis was highest in Eastern Europe, especially among elderly patients and those with Dukes' D tumours. CONCLUSIONS: The wide differences in colorectal cancer survival between Europe and the USA in the late 1990s are probably attributable to earlier stage and more extensive use of surgery and adjuvant treatment in the USA. Elderly patients with colorectal cancer received surgery, chemotherapy or radiotherapy less often than younger patients, despite evidence that they could also have benefited.