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.

Trauma em idosos atendidos pelo serviço pré-hospitalar móvel

O The aim of this study was to characterize the occurrence of trauma in the elderly population served by the mobile pre-hospital service, in Natal, Rio Grande do Norte. This is a descriptive, transversal and quantitative approach and whose population consisted of 2,080 trauma victims. The sample, of systematic random type, consisted of 400 elderly people, aged from 60 years old, assisted by the Office of Mobile Emergency in Natal / RN, between January 2011 and December 2012. Data collection began after consent and assent of the institution of a Research Ethics Committee under No. 309 505. It was proceeded to documentary retrospective analysis of records of this service through a form of self-development, validated by expert judges considered reliable (α> 0.75) and valid (CVI = 0.97) in their clarity and relevance. Data were tabulated by the Statistical Package for Social Sciences, version 20.0. The results show that older victims have an average age of 74.19 years old, with a prevalence of female involvement by chronic diseases, especially hypertension, average usage of 2.2 routine medications with vital signs within normal limits. The trauma prevailed during the daytime, in the residence of the victims, north of the city and on weekends. Among the mechanisms of trauma were falls, traffic accidents and physical aggression, whose most common type was brain-cerebral trauma and the main consequences were suture wounds and closed fractures. Basic Support Units were as more driven to pre-hospital care (87.8%) and the main destination place consisted of a referral hospital for emergency of the state (57.5%). Among the most commonly performed procedures by nursing staff immobilization with rigid board and neck collar and the peripheral venipuncture, and the main component used for volume replacement to saline were highlighted. There was a significant relationship between the deaths and the mechanism of injury, mechanism of injury and procedures, except medication administration procedures carried out, except immobilization and unit for service. It is highlighted the prevalence of trauma in the elderly, poor follow-up Pre-Hospital Trauma Life Support protocol and the paucity of records and nursing procedures performed. There is need for a protocol of care specific to elderly trauma victims and education strategies for the prevention of such events

Terceiro setor em HIV/AIDS: mapeando o ativismo social na contemporaneidade

The struggle against AIDS is a kind of action in favor of life and the organized Brazilian civil society incorporated it in a meaningful dimension. This struggle matured the creation of non-governmental organizations (NGOs) and advanced with the discoveries about the disease. Since the very early 90 s, the consolidation of the partnership involving the movement anti-aids with State came up with a dilemma for the entities of civil society: are they just executors of governmental policies or do they take up the role of effective demands concerning public policies? Since then, activism against aids started to stand for execution of projects and one considers that the institutional way of anti-aids work has problems because it constructs a basic strategy to take off the political aspect of the third sector. The NGOs/aids consolidate the reconfiguration of capital and get far from street activities. This is important to be studied because the relationship between society and aids, contemporarily, can prevent them from accomplishing their agenda referring to political mobilization and collective resistance. This research started to be carried after some visits, previously arranged, to an institutional life support group called Grupo de Apoio à Vida-GAV, in Campina Grande. A semi-structured interview was applied to 31 users and to 6 technicians of the entity mentioned. One aimed at investigating the activist anti-aids practice, identifying the conceptions of activism and knowing how social actors assess those practices. Preliminary results indicate that one of the conceptions on activism among the interviewees refers to the execution of projects through partnership of NGOs and supporting institutions, governmental or non-governmental. Although this new conception on activism consolidates a non-political aspect, there are other ways of executing projects and participating actively, according to some users, such as: meetings, lectures and other sorts of events promoted by the group, which are also legitimate actions representing anti-aids activism at the present context

Ethnic differences in do-not-resuscitate orders after intracerebral hemorrhage.

OBJECTIVE: To explore ethnic differences in do-not-resuscitate orders after intracerebral hemorrhage. DESIGN: Population-based surveillance. SETTING: Corpus Christi, Texas. PATIENTS: All cases of intracerebral hemorrhage in the community of Corpus Christi, TX were ascertained as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed for do-not-resuscitate orders. Unadjusted and multivariable logistic regression were used to test for associations between ethnicity and do-not-resuscitate orders, both overall ("any do-not-resuscitate") and within 24 hrs of presentation ("early do-not-resuscitate"), adjusted for age, gender, Glasgow Coma Scale, intracerebral hemorrhage volume, intraventricular hemorrhage, infratentorial hemorrhage, modified Charlson Index, and admission from a nursing home. A total of 270 cases of intracerebral hemorrhage from 2000-2003 were analyzed. Mexican-Americans were younger and had a higher Glasgow Coma Scale than non-Hispanic whites. Mexican-Americans were half as likely as non-Hispanic whites to have early do-not-resuscitate orders in unadjusted analysis (odds ratio 0.45, 95% confidence interval 0.27, 0.75), although this association was not significant when adjusted for age (odds ratio 0.61, 95% confidence interval 0.35, 1.06) and in the fully adjusted model (odds ratio 0.75, 95% confidence interval 0.39, 1.46). Mexican-Americans were less likely than non-Hispanic whites to have do-not-resuscitate orders written at any time point (odds ratio 0.37, 95% confidence interval 0.23, 0.61). Adjustment for age alone attenuated this relationship although it retained significance (odds ratio 0.49, 95% confidence interval 0.29, 0.82). In the fully adjusted model, Mexican-Americans were less likely than non-Hispanic whites to use do-not-resuscitate orders at any time point, although the 95% confidence interval included one (odds ratio 0.52, 95% confidence interval 0.27, 1.00). CONCLUSIONS: Mexican-Americans were less likely than non-Hispanic whites to have do-not-resuscitate orders after intracerebral hemorrhage although the association was attenuated after adjustment for age and other confounders. The persistent trend toward less frequent use of do-not-resuscitate orders in Mexican-Americans suggests that further study is warranted.

The assessment of standardized training programs in public health preparedness

The Texas Bioterrorism Continuing Education Consortium (BCE) provided National Disaster Life Support (NDLS) training courses throughout the state of Texas in 2005, to help improve knowledge and skills pertaining to bioterrorism and other public health emergencies. The NDLS training courses include curriculum in Basic Disaster Life Support (BDLS) and Core Disaster Life Support (CDLS). A course evaluation which included items assessing ability and willingness of training participants, role of responders, and other variables was mailed to all NDLS participants who provided contact information. An analysis was conducted to determine whether the survey respondents participated in the Hurricanes Katrina and/or Rita relief efforts, as well as to evaluate the impact of the NDLS training courses on the participant's ability and willingness to respond during a disaster. The study population (n = 2150) consisted mostly of nurses (50%) (n=1074). A chi-square test of analysis indicated the following results. Among the survey respondents who took the CDLS course, there was no statically significant difference by occupation pertaining to ability or willingness to respond (x2 [df = 5] = 4.02, p= 0.546); (x2 [df = 5] = 2.45, p = .783). However, there was a statistically significant difference among those respondents who took the BDLS course with respect to ability, and a slightly significant difference with respect to willingness (x2 [df = 5] = 13.35, p = .020 and (x2 = [df = 5] = 10.299, p = .067). These findings are similar to previous studies assessing willingness to respond to a disaster.^ A second analysis was conducted with these survey data to evaluate the implications for disaster response training for the NDLS courses. Results indicated that the majority of disaster responders served in the role for which they were professionally trained (Physicians=68%; Nurses = 50.4%). Nurses, EMT, and Fire professionals served in multiple roles. These results suggest the importance of developing training programs that will prepare professionals to serve in multiple roles. The development of standardized evaluation methods would fill an important gap in assessing impact of national training programs. ^

El nuevo escenario global y un modelo de negocio para la industria naval militar del 2025

Los retos y oportunidades a los que se enfrentan las organizaciones y administraciones de las primeras décadas del siglo XXI se caracterizan por una serie de fuerzas perturbadoras como la globalización, el avance de las tecnologías emergentes y el desequilibrio económico, que están actuando como impulsores de la transformación del mercado. La acción conjunta de estos factores está obligando a todas las empresas industriales a tener que trabajar con mayores y más exigentes niveles de productividad planteándose continuamente como mejorar y lograr satisfacer los requerimientos de los clientes. De esta situación surge la necesidad de volver a plantearse de nuevo ¿quién es el cliente?, ¿qué valora el cliente? y ¿cómo se pueden generan beneficios sostenibles? La aplicación de esta reflexión a la industria naval militar marca los objetivos a los que esta tesis doctoral busca dar respuesta. El primer objetivo, de carácter general, consiste en la definición de un modelo de negocio sostenible para la industria naval militar del 2025 que se adapte a los requisitos del cliente y al nuevo escenario político, económico, social, tecnológico y ambiental que rodea esta industria. El segundo objetivo, consecuencia del modelo general, trata de desarrollar una metodología para ejecutar programas de apoyo al ciclo de vida del “buque militar”. La investigación se estructura en cuatro partes: en la primera se justifica, por un lado, la necesidad del cambio de modelo y por otro se identifican los factores estructurantes para la definición del modelo. La segunda parte revisa la literatura existente sobre uno de los aspectos básicos para el nuevo modelo, el concepto Producto-Servicio. La tercera parte se centra totalmente en la industria naval militar estudiando los aspectos concretos del sector y, en base al trabajo de campo realizado, se identifican los puntos que más valoran las Marinas de Guerra y como estas gestionan al buque militar durante todo su ciclo de vida. Por último se presentan los principios del modelo propuesto y se desarrollan los pilares básicos para la ejecución de proyectos de Apoyo al Ciclo de Vida (ACV). Como resultado de la investigación, el modelo propuesto para la industria naval militar se fundamenta en once principios: 1. El buque militar (producto de alto valor añadido) debe ser diseñado y construido en un astillero del país que desarrolla el programa de defensa. 2. El diseño tiene que estar orientado al valor para el cliente, es decir, se tiene que diseñar el buque militar para que cumpla su misión, eficaz y eficientemente, durante toda su vida operativa, asegurando la seguridad del buque y de las personas y protegiendo el medio ambiente de acuerdo con las regulaciones vigentes. 3. La empresa debe suministrar soluciones integrales de apoyo al ciclo de vida al producto. 4. Desarrollar y mantener las capacidades de integración de sistemas complejos para todo el ciclo de vida del buque militar. 5. Incorporar las tecnologías digitales al producto, a los procesos, a las personas y al propio modelo de negocio. 6. Desarrollar planes de actuación con el cliente domestico a largo plazo. Estos planes tienen que estar basados en tres premisas: (i) deben incluir el ciclo de vida completo, desde la fase de investigación y desarrollo hasta la retirada del buque del servicio; (ii) la demanda debe ser sofisticada, es decir las exigencias del cliente, tanto desde la óptica de producto como de eficiencia, “tiran” del contratista y (iii) permitir el mantenimiento del nivel tecnológico y de las capacidades industriales de la compañía a futuro y posicionarla para que pueda competir en el mercado de exportación. 7. Impulsar el sector militar de exportación mediante una mayor actividad comercial a nivel internacional. 8. Fomentar la multilocalización ya que representa una oportunidad de crecimiento y favorece la exportación posibilitando el suministro de soluciones integrales en el país destino. 9. Reforzar la diplomacia institucional como palanca para la exportación. 10. Potenciar el liderazgo tecnológico tanto en producto como en procesos con políticas activas de I + D+ i. 11. Reforzar la capacidad de financiación con soluciones innovadoras. El segundo objetivo de esta tesis se centra en el desarrollo de soluciones integrales de Apoyo al Ciclo de Vida (ACV). La metodología planteada trata de minimizar la brecha entre capacidades y necesidades a lo largo de la vida operativa del barco. Es decir, el objetivo principal de los programas de ACV es que la unidad conserve durante toda su vida operativa, en términos relativos a las tecnologías existentes, las capacidades equivalentes a las que tendrá cuando entre en servicio. Los ejes de actuación para conseguir que un programa de Apoyo al Ciclo de Vida cumpla su objetivo son: el diseño orientado al valor, la ingeniería de Apoyo al Ciclo de Vida, los proyectos de refresco de tecnología, el mantenimiento Inteligente y los contratos basados en prestaciones. ABSTRACT On the first decades of the 21st century, organizations and administrations face challenges and come across opportunities threatened by a number of disruptive forces such as globalization, the ever-changing emerging technologies and the economic imbalances acting as drivers of the market transformation. This combination of factors is forcing all industrial companies to have more and higher demanding productivity levels, while bearing always in mind how to improve and meet the customer’s requirements. In this situation, we need to question ourselves again: Who is the customer? What does the customer value? And how can we deliver sustainable economic benefits? Considering this matter in a military naval industry framework sets the goals that this thesis intends to achieve. The first general goal is the definition of a new sustainable business model for the 2025 naval industry, adapted to the customer requirements and the new political, economic, social, technological and environmental scenario. And the second goal that arises as a consequence of the general model develops a methodology to implement “warship” through life support programs. The research is divided in four parts: the first one justifies, on the one hand, the need to change the existing model and, on the other, identifies the model structural factors. On the second part, current literature regarding one of the key issues on the new model (the Product-Service concept) is reviewed. Based on field research, the third part focuses entirely on military shipbuilding, analyzing specific key aspects of this field and identifying which of them are valued the most by Navies and how they manage through life cycles of warships. Finally, the foundation of the proposed model is presented and also the basic grounds for implementing a Through Life Support (TLS) program are developed. As a result of this research, the proposed model for the naval industry is based on eleven (11) key principles: 1. The warship (a high added value product) must be designed and built in a shipyard at the country developing the defense program. 2. Design must be customer value oriented, i.e.warship must be designed to effectively fulfill its mission throughout its operational life, ensuring safety at the ship and for the people and protecting the environment in accordance with current regulations. 3. The industry has to provide integrated Through Life Support solutions. 4. Develop and maintain integrated complex systems capabilities for the entire warship life cycle. 5. Introduce the product, processes, people and business model itself to digital technologies. 6. Develop long-term action plans with the domestic customer. These plans must be based on three premises: (i) the complete life cycle must be included, starting from the research and development stage throughout the ship’s disposal; (ii) customer demand has to be sophisticated, i.e. customer requirements, both from the efficiency and product perspective, "attract" the contractor and (iii) technological level and manufacturing capabilities of the company in the future must be maintained and a competitive position on the export market has to be achieved. 7. Promote the military exporting sector through increased international business. 8. Develop contractor multi-location as it entails an opportunity for growth and promote export opportunities providing integrated solutions in the customer's country. 9. Strengthen institutional diplomacy as a lever for export. 10. Promote technological leadership in both product and processes with active R & D & I policies (Research & Development & Innovation) 11. Strengthen financing capacity through innovative solutions. The second goal of this thesis is focused on developing integrated Through Life Support (TLS) solutions. The proposed methodology tries to minimize the gap between needs and capabilities through the ship operational life. It means, the main TLS program objective is to maintain the ship’s performance and capabilities during operational life, in relative terms to current technologies, equivalent to those the ship had when it entered service. The main actions to fulfill the TLS program objectives are: value-oriented design, TLS engineering, technology updating projects, intelligent maintenance and performance based contracts.

Atividade de formação interprofissional em urgência pré-hospitalar

To acting in emergencies it is important that health professionals develop specific and differentiated skills, which shows us the importance of training in emergency planning. So undergraduate courses in medicine and nursing should encourage the development of these skills and evaluate them through various instruments targeted to the different fields. The aim of this study was to implement an optional and interprofessional curricular component, focusing on interprofessional education in pre-hospital emergency for medical and nursing courses Federal University of Rio Grande do Norte (UFRN). This is an exploratory descriptive study, with 24 medical and nursing graduates of last year undergraduate of supervised training, who underwent theoretical and practical training in the care of pre-hospital emergency services. There were theoretical and practical lessons per week for one school semester, taught by doctors and nurses of the Emergency Medical Service (EMS), where the topics discussed were: basic and advanced life support, safe transport in clinical emergencies, trauma, gynecological, obstetric, pediatric and psychiatric diseases, and have been carried out practical activities in ambulances. The students were evaluated by pre-test, post-test and practical stations made through the Objective Structured Clinical Evaluation (OSCE), in the skills laboratory of the Health Sciences Center. During the activities the students were encouraged to critical and reflective thinking, highlighting the importance of integration between the various health care professionals. It was observed that 88% of the students had a score increase over the pre-test. In the evaluation process carried out by medical students and nursing UFRN have similar expectations regarding the essential skills acquired during the training activity. The results of this study will form the basis for the organization of interprofessional education activity in pre-hospital emergency medical students and nursing, as well as helped to organize practices stations, identifying basic clinical skills, and implementing student assessment tools UFRN.

Estratégia de capacitação pedagógica do residente: uma perspectiva para melhoria do ensino na Universidade Federal do Rio Grande do Norte

Studies have shown that resident informally plays the role of teacher. It is estimated that up to 25% of the residents of the time is devoted to teaching, mainly contributing as a facilitator, however, almost the entire medical residency programs in Brazil did not offer teacher training during residency education. This paper aims to introduce educational content initiation to teaching as part of the training of resident physician inserted in residency program of the University Hospital Onofre Lopes (HUOL). It is an exploratory, descriptive and prospective study in HUOL the Federal University of Rio Grande do Norte. Three steps were developed: preparation and planning of a pedagogic course, associated with a motivating technical content (basic and advanced life support); second stage, testing of pedagogical model for medical students; and finally, replication to residents. The interventions were made two practice stations life support with performance evaluation in practical activity through OSPE (Objective Structured Practical Examination). The techniques presented teachings were one-minute preceptor and feedback. Data collection was conducted through a structured evaluation form during the life support stations and at the end of the course, and analyzed using descriptive statistics. The results showed that the feedback and one minute preceptor were considered important for teaching and learning for more than 85% of participants. The feedback from evaluators practices stations added information about the performance and were held appreciatively way, according to 100% of the participants. Positive aspects highlighted by the participants were related to educational content, especially the participants of the first intervention. The time of the lectures of motivating technical content was the most repeated negative. Based on the good acceptance of pedagogical contents, this pioneer teacher training strategy was included in the formal residency program in Cardiology of our institution. It is considered therefore that the educational training model with motivating technical content was feasible and had a good evaluation and acceptance by most participants in both interventions. Thus, we believe that the educational content can be inserted in the formal curriculum of medical residency of other programs at HUOL through the training model developed in this study.

Estratégia de capacitação pedagógica do residente: uma perspectiva para melhoria do ensino na Universidade Federal do Rio Grande do Norte

Studies have shown that resident informally plays the role of teacher. It is estimated that up to 25% of the residents of the time is devoted to teaching, mainly contributing as a facilitator, however, almost the entire medical residency programs in Brazil did not offer teacher training during residency education. This paper aims to introduce educational content initiation to teaching as part of the training of resident physician inserted in residency program of the University Hospital Onofre Lopes (HUOL). It is an exploratory, descriptive and prospective study in HUOL the Federal University of Rio Grande do Norte. Three steps were developed: preparation and planning of a pedagogic course, associated with a motivating technical content (basic and advanced life support); second stage, testing of pedagogical model for medical students; and finally, replication to residents. The interventions were made two practice stations life support with performance evaluation in practical activity through OSPE (Objective Structured Practical Examination). The techniques presented teachings were one-minute preceptor and feedback. Data collection was conducted through a structured evaluation form during the life support stations and at the end of the course, and analyzed using descriptive statistics. The results showed that the feedback and one minute preceptor were considered important for teaching and learning for more than 85% of participants. The feedback from evaluators practices stations added information about the performance and were held appreciatively way, according to 100% of the participants. Positive aspects highlighted by the participants were related to educational content, especially the participants of the first intervention. The time of the lectures of motivating technical content was the most repeated negative. Based on the good acceptance of pedagogical contents, this pioneer teacher training strategy was included in the formal residency program in Cardiology of our institution. It is considered therefore that the educational training model with motivating technical content was feasible and had a good evaluation and acceptance by most participants in both interventions. Thus, we believe that the educational content can be inserted in the formal curriculum of medical residency of other programs at HUOL through the training model developed in this study.

Interventions for nurses caring for a child who has an unexpected acute life threatening event (ALTE) in hospital

Introduction: Caring for a child who has an unexpected ALTE in hospital can be stressful. An ALTE may include a cardiac arrest, respiratory arrest or call for immediate assistance. An international survey of practice was conducted to identify any existing interventions to inform a PhD program of work aimed at reducing the stress from these events through preparation and support. Purpose: The purpose of the survey was threefold: (1) Describe ‘normal’ practice when it comes to preparing staff or providing psychological support after caring for a child who has had an ALTE. (2) Determine if there are any interventions to prepare clinical staff for potential psychological effects of caring for a child who has an ALTE. (3) Determine if there are any interventions to provide support for clinical staff after caring for a child who has an ALTE. Material - Methods: An 18 item semi structured questionnaire was designed for the study to allow respondent to describe practices within their institution and outline their opinions and professional experiences. Clinicians from selected children’s and adult hospitals in Australia, Canada, New Zealand, United Kingdom and the United States of America were contacted by telephone. Following consent they were given the option to complete the survey via the telephone, by post or online. Results: Of the 61 hospitals approached 44 (72%) clinicians responded. Eighteen (41%) respondents identified interventions in place to prepare nurses for an ALTE ranging from (but not limited to) ad hoc discussions during life support training through to structured simulation training. Thirty-six (82%) respondents identified that they had interventions in place to support nurses after an ALTE ranging from (but not limited to) debriefing through to structured case reviews. Conclusions: Interventions varied across institutions, with no outcome or evaluation data for the interventions published to date.

Multi-organ support device for combined extracorporeal carbon dioxide removal and hemofiltration treatments with pump-free solution for ultrafiltration

The use of extracorporeal organ support (ECOS) devices is increasingly widespread, to temporarily sustain or replace the functions of impaired organs in critically ill patients. Among ECOS, respiratory functions are supplied by extracorporeal life support (ECLS) therapies like extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R), and renal replacement therapies (RRT) are used to support kidney functions. However, the leading cause of mortality in critically ill patients is multi-organ dysfunction syndrome (MODS), which requires a complex therapeutic strategy where extracorporeal treatments are often integrated to pharmacological approach. Recently, the concept of multi-organ support therapy (MOST) has been introduced, and several forms of isolated ECOS devices are sequentially connected to provide simultaneous support to different organ systems. The future of critical illness goes towards the development of extracorporeal devices offering multiple organ support therapies on demand by a single hardware platform, where treatment lines can be used alternately or in conjunction. The aim of this industrial PhD project is to design and validate a device for multi-organ support, developing an auxiliary line for renal replacement therapy (hemofiltration) to be integrated on a platform for ECCO2R. The intended purpose of the ancillary line, which can be connected on demand, is to remove excess fluids by ultrafiltration and achieve volume control by the infusion of a replacement solution, as patients undergoing respiratory support are particularly prone to develop fluid overload. Furthermore, an ultrafiltration regulation system shall be developed using a powered and software-modulated pinch-valve on the effluent line of the hemofilter, proposed as an alternative to the state-of-the-art solution with peristaltic pump.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

Background: The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge. Method: A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process. Treatment recommendations: This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no special Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.

Neutrophils recruitment during sepsis: Critical points and crossroads

The mechanisms that initiate an inflammatory systemic response to a bacterial infection lead to a high mortality and constitute the first cause of death in Critical Care Units (ICU`s). Sepsis is a poorly understood disease and despite life support techniques and the administration of antibiotics, not much more can be done to improve its diagnosis and treatment. The present article has as main objective to discuss the role of neutrophils recruitment in sepsis, dissecting the molecular mechanisms implicated in this complex process and its importance to the pathogenesis of this outstanding cause of death.

EARLY GOAL-DIRECTED THERAPY IN TREATMENT OF PEDIATRIC SEPTIC SHOCK

In the whole world, around 29,000 children younger than 5 years die every day, and sepsis is the most common cause of death. Whereas in adult patients vasomotor paralysis represents the predominant cause of mortality, death in pediatric sepsis is associated with severe hypovolemia and low cardiac output. The purpose of this article was to review the recent evidence on early treatment of pediatric severe sepsis and septic shock. Although current American College of Critical Care Medicine-Pediatric Advanced Life Support guidelines represent best practice, stronger evidences are lacking to confirm the components of these recommendations. Retrospective studies showed, at the same time, the positive effects arising from the utilization of American College of Critical Care Medicine-Pediatric Advanced Life Support guidelines and the existing barriers to its implementation. And one randomized control trial paralleled the results observed in adult patients and revealed that early goal-directed therapy in children is one of the few therapeutic interventions that proved to be beneficial in septic shock treatment. Early goal-directed therapy in pediatric septic shock is a successful method to optimize and parameterize treatment, but there is still a long way to turn septic shock resuscitation simpler and more widely spread.

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.