Association between education in EOL care and variability in EOL practice: a survey of ICU physicians

This study investigated the association between physician education in EOL and variability in EOL practice, as well as the differences between beliefs and practices regarding EOL in the ICU. Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, as well physicians' personal, professional and EOL educational characteristics. The response rate was 89%, with 105 questionnaires analyzed. Mean age was 38 +/- A 8 years, with a mean of 14 +/- A 7 years since graduation. Physicians who did not apply do-not-resuscitate (DNR) orders were less likely to have attended EOL classes than those who applied written DNR orders [0/7 vs. 31/47, OR = 0.549 (0.356-0.848), P = 0.001]. Physicians who involved nurses in the decision-making process were more likely to be ICU specialists [17/22 vs. 46/83, OR = 4.1959 (1.271-13.845), P = 0.013] than physicians who made such decisions among themselves or referred to ethical or judicial committees. Physicians who would apply "full code" had less often read about EOL [3/22 vs. 11/20, OR = 0.0939 (0.012-0.710), P = 0.012] and had less interest in discussing EOL [17/22 vs. 20/20, OR = 0.210 (0.122-0.361), P < 0.001], than physicians who would withdraw life-sustaining therapies. Forty-four percent of respondents would not do what they believed was best for their patient, with 98% of them believing a less aggressive attitude preferable. Legal concerns were the leading cause for this dichotomy. Physician education about EOL is associated with variability in EOL decisions in the ICU. Moreover, actual practice may differ from what physicians believe is best for the patient.

Metropolitan and regional health planning: dilemmas of the Pact for Health in the Baixada Santista Metropolitan Area, Sao Paulo State, Brazil

This paper focuses on the relationship between metropolitan and regional health planning based on the processes of regionalization and the Pact for Health in the Baixada Santista Metropolitan Area, Sao Paulo State, Brazil. The method used was a case study in two stages, namely during initial implementation of the Pact for Health (2007) and the Regional Administration Committees (CGR) and in 2010. Municipal and regional health systems managers and the director of the Metropolitan Agency were interviewed, and records were analyzed from ten years of meetings of the Regional Inter-Administration Committee and the Regional Development Council. Four issues emerged: financing and infrastructure; health services utilization; inefficiency of the Regional Health Administration's instruments and decision-making levels; and the relationship between different levels in the Administration. Metropolitan health management remained as an underlying issue, appearing only incidentally or tangentially to regional management. Despite some limitations, the CGR has been legitimized as a space for regional health management.

The efficacy of chemical agents in cleaning and disinfection programs

Abstract Background Due to the growing number of outbreaks of infection in hospital nurseries, it becomes essential to set up a sanitation program that indicates that the appropriate chemical agent was chosen for application in the most effective way. Method For the purpose of evaluating the efficacy of a chemical agent, the minimum inhibitory concentration (MIC) was reached by the classic method of successive broth dilutions. The reference bacteria utilized were Bacillus subtilis var. globigii ATCC 9372, Bacillus stearothermophilus ATCC 7953, Escherichia coli ATCC 25922, Staphylococcus aureus ATCC 25923. The strains of Enterobacter cloacae IAL 1976 (Adolfo Lutz Institute), Serratia marcescens IAL 1478 and Acinetobactev calcoaceticus IAL 124 (ATCC 19606), were isolated from material collected from babies involved in outbreaks of infection in hospital nurseries. Results The MIC intervals, which reduced bacteria populations over 08 log10, were: 59 to 156 mg/L of quaternarium ammonium compounds (QACs); 63 to 10000 mg/L of chlorhexidine digluconate; 1375 to 3250 mg/L of glutaraldehyde; 39 to 246 mg/L of formaldehyde; 43750 to 87500 mg/L of isopropanol or ethanol; 1250 to 6250 mg/L of iodine in polyvinyl-pyrolidone complexes, 150 to 4491 mg/L of chlorine-releasing-agents (CRAs); 469 to 2500 mg/L of hydrogen peroxide; and, 2310 to 18500 mg/L of peracetic acid. Conclusions Chlorhexidine showed non inhibitory activity over germinating spores. A. calcoaceticus, was observed to show resistance to the majority of the agents tested, followed by E. cloacae and S. marcescens.

Determination of decimal reduction time (D value) of chemical agents used in hospitals for disinfection purposes

Abstract Background Prior to the selection of disinfectants for low, intermediate and high (sterilizing) levels, the decimal reduction time, D-value, for the most common and persistent bacteria identified at a health care facility should be determined. Methods The D-value was determined by inoculating 100 mL of disinfecting solution with 1 mL of a bacterial suspension (104 ��� 105 CFU/mL for vegetative and spore forms). At regular intervals, 1 mL aliquots of this mixture were transferred to 8 mL of growth media containing a neutralizing agent, and incubated at optimal conditions for the microorganism. Results The highest D-values for various bacteria were determined for the following solutions: (i) 0.1% sodium dichloroisocyanurate (pH 7.0) ��� E. coli and A. calcoaceticus (D = 5.9 min); (ii) sodium hypochlorite (pH 7.0) at 0.025% for B. stearothermophilus (D = 24 min), E. coli and E. cloacae (D = 7.5 min); at 0.05% for B. stearothermophilus (D = 9.4 min) and E. coli (D = 6.1 min) and 0.1% for B. stearothermophilus (D = 3.5 min) and B. subtilis (D = 3.2 min); (iii) 2.0% glutaraldehyde (pH 7.4) ��� B. stearothermophilus, B. subtilis (D = 25 min) and E. coli (D = 7.1 min); (iv) 0.5% formaldehyde (pH 6.5) ��� B. subtilis (D = 11.8 min), B. stearothermophilus (D = 10.9 min) and A. calcoaceticus (D = 5.2 min); (v) 2.0% chlorhexidine (pH 6.2) ��� B. stearothermophilus (D = 9.1 min), and at 0.4% for E. cloacae (D = 8.3 min); (vi) 1.0% Minncare�� (peracetic acid and hydrogen peroxide, pH 2.3) ��� B. stearothermophilus (D = 9.1 min) and E. coli (D = 6.7 min). Conclusions The suspension studies were an indication of the disinfectant efficacy on a surface. The data in this study reflect the formulations used and may vary from product to product. The expected effectiveness from the studied formulations showed that the tested agents can be recommended for surface disinfection as stated in present guidelines and emphasizes the importance and need to develop routine and novel programs to evaluate product utility.

Identification of bacteria in drinking and purified water during the monitoring of a typical water purification system

Abstract Background A typical purification system that provides purified water which meets ionic and organic chemical standards, must be protected from microbial proliferation to minimize cross-contamination for use in cleaning and preparations in pharmaceutical industries and in health environments. Methodology Samples of water were taken directly from the public distribution water tank at twelve different stages of a typical purification system were analyzed for the identification of isolated bacteria. Two miniature kits were used: (i) identification system (api 20 NE, Bio-M��rieux) for non-enteric and non-fermenting gram-negative rods; and (ii) identification system (BBL crystal, Becton and Dickson) for enteric and non-fermenting gram-negative rods. The efficiency of the chemical sanitizers used in the stages of the system, over the isolated and identified bacteria in the sampling water, was evaluated by the minimum inhibitory concentration (MIC) method. Results The 78 isolated colonies were identified as the following bacteria genera: Pseudomonas, Flavobacterium and Acinetobacter. According to the miniature kits used in the identification, there was a prevalence of isolation of P. aeruginosa 32.05%, P. picketti (Ralstonia picketti) 23.08%, P. vesiculares 12.82%,P. diminuta 11.54%, F. aureum 6.42%, P. fluorescens 5.13%, A. lwoffi 2.56%, P. putida 2.56%, P. alcaligenes 1.28%, P. paucimobilis 1.28%, and F. multivorum 1.28%. Conclusions We found that research was required for the identification of gram-negative non-fermenting bacteria, which were isolated from drinking water and water purification systems, since Pseudomonas genera represents opportunistic pathogens which disperse and adhere easily to surfaces, forming a biofilm which interferes with the cleaning and disinfection procedures in hospital and industrial environments.

Selective Permeation and Organic Extraction of Recombinant Green Fluorescent Protein (gfpuv) from Escherichia coli

Background Transformed cells of Escherichia coli DH5-�� with pGFPuv, induced by IPTG (isopropyl-��-d-thiogalactopyranoside), express the green fluorescent protein (gfpuv) during growth phases. E. coli subjected to the combination of selective permeation by freezing/thawing/sonication cycles followed by the three-phase partitioning extraction (TPP) method were compared to the direct application of TPP to the same culture of E. coli on releasing gfpuv from the over-expressing cells. Material and Methods Cultures (37��C/100 rpm/ 24 h; �� = 0.99 h-1 - 1.10 h-1) of transformed (pGFP) Escherichia coli DH5-��, expressing the green fluorescent protein (gfpuv, absorbance at 394 nm and emission at 509 nm) were sonicated in successive intervals of sonication (25 vibrations/pulse) to determine the maximum amount of gfpuv released from the cells. For selective permeation, the transformed previously frozen (-75��C) cells were subjected to three freeze/thaw (-20��C/ 0.83��C/min) cycles interlaid by sonication (3 pulses/ 6 seconds/ 25 vibrations). The intracellular permeate with gfpuv in extraction buffer (TE) solution (25 mM Tris-HCl, pH 8.0, 1 mM ��-mercaptoethanol ��-ME, 0.1 mM PMSF) was subjected to the three-phase partitioning (TPP) method with t-butanol and 1.6 M ammonium sulfate. Sonication efficiency was verified on the application to the cells previously treated by the TPP method. The intra-cell releases were mixed and eluted through methyl HIC column with a buffer solution (10 mM Tris-HCl, 10 mM EDTA, pH 8.0). Results The sonication maximum released amount obtained from the cells was 327.67 ��g gfpuv/mL (20.73 ��g gfpuv/mg total proteins ��� BSA), after 9 min of treatment. Through the selective permeation by three repeated freezing/thawing/sonication cycles applied to the cells, a close content of 241.19 ��g gfpuv/mL (29.74 ��g gfpuv/mg BSA) was obtained. The specific mass range of gfpuv released from the same cultures, by the three-phase partitioning (TPP) method, in relation to total proteins, was higher, between 107.28 ��g/mg and 135.10 ��g/mg. Conclusions The selective permeation of gfpuv by freezing/thawing/sonication followed by TPP separation method was equivalent to the amount of gfpuv extracted from the cells directly by TPP; although selective permeation extracts showed better elution through the HIC column.

Oral cleft prevention program (OCPP)

Background Oral clefts are one of the most common birth defects with significant medical, psychosocial, and economic ramifications. Oral clefts have a complex etiology with genetic and environmental risk factors. There are suggestive results for decreased risks of cleft occurrence and recurrence with folic acid supplements taken at preconception and during pregnancy with a stronger evidence for higher than lower doses in preventing recurrence. Yet previous studies have suffered from considerable design limitations particularly non-randomization into treatment. There is also well-documented effectiveness for folic acid in preventing neural tube defect occurrence at 0.4 mg and recurrence with 4 mg. Given the substantial burden of clefting on the individual and the family and the supportive data for the effectiveness of folic acid supplementation as well as its low cost, a randomized clinical trial of the effectiveness of high versus low dose folic acid for prevention of cleft recurrence is warranted. Methods/design This study will assess the effect of 4 mg and 0.4 mg doses of folic acid, taken on a daily basis during preconception and up to 3 months of pregnancy by women who are at risk of having a child with nonsyndromic cleft lip with/without palate (NSCL/P), on the recurrence of NSCL/P. The total sample will include about 6,000 women (that either have NSCL/P or that have at least one child with NSCL/P) randomly assigned to the 4 mg and the 0.4 mg folic acid study groups. The study will also compare the recurrence rates of NSCL/P in the total sample of subjects, as well as the two study groups (4mg, 0.4 mg) to that of a historical control group. The study has been approved by IRBs (ethics committees) of all involved sites. Results will be disseminated through publications and presentations at scientific meetings. Discussion The costs related to oral clefts are high, including long term psychological and socio-economic effects. This study provides an opportunity for huge savings in not only money but the overall quality of life. This may help establish more specific clinical guidelines for oral cleft prevention so that the intervention can be better tailored for at-risk women. ClinicalTrials.gov Identifier NCT00397917

Progress in animal experimentation ethics: a case study from a Brazilian medical school and from the international medical literature

PURPOSE: This study describes in Brazil and in the global biomedical community the time course of the development of animal research welfare guidelines. METHODS: The database of the Ethics Committee of the Faculty of Medicine of Ribeirao Preto (EC/FMRP-USP), Brazil, was surveyed since its inception in 2002 as the regulations became more stringent to provide better protection of animal research welfare at this institution. Medline database was evaluated to identify the number of publications in the period between 1968 and 2008 that used research animals and were in compliance with established ethics guidelines. RESULTS: The EC/FMRP-USP evaluated 979 projects up until 2009. Most of the applications came from Department of Physiology and the most frequently requested species was the rat. In 2004, national research funding agencies started to request prior approval from institutional review ethics committees prior to application review and this requirement became federal law in Brazil in 2008. The analysis of international publications revealed a relative reduction in studies involving research animals (18% in 1968 to 7.5% in 2008). CONCLUSIONS: The present work showed that in the last four decades major changes occurred in the guidelines dictating use of research animals occurred and they are being adopted by developing countries. Moreover, animal welfare concern in the scientific community preceded the introduction of journal guidelines for this purpose. Furthermore, in Brazil it was anticipated that laws were needed to protect animal research welfare from being not upheld.

��tica da pesquisa em modelos animais

A utiliza����o de animais em experimentos cient��ficos �� descrita desde o s��culo V a.C. Avan��os cient��ficos na ��rea da sa��de s��o atribu��dos a modelos animais. O status moral dos animais sempre foi debatido. OBJETIVOS: Este artigo visa �� revis��o hist��rica e resumo da legisla����o atual, para orientar pesquisadores ao utilizar modelos animais na pesquisa em otorrinolaringologia. MATERIAL E M��TODOS: Pesquisa na base de dados Medline. RESULTADOS: no Brasil, por muitos anos n��o havia regulamenta����o para o uso de animais em experimenta����o. Eram seguidas normas de organiza����es nacionais e internacionais. Recentemente, foi sancionada a lei n�� 11.794/08, que estabelece procedimentos para o uso cient��fico de animais. Na otorrinolaringologia, os estudos com laringe utilizaram coelho, porco, cachorro, cobaias (Cavia porcellus) e camundongo; estudos para face coelho, rato e cachorro; rinoplastia com coelho; e orelha interna com ratos e cobaias (albinas). CONCLUS��ES: Os pesquisadores envolvidos em trabalhos cient��ficos com animais devem conhecer os princ��pios da lei n�� 11.794/08 e pesquisar quais animais s��o apropriados para cada sub��rea estudada seus modelos com maior aplicabilidade. Os otorrinolaringologistas, especialmente aqueles que se dedicam �� pesquisa, necessitam estar sempre atentos para o respeito ��s regras ��ticas de utiliza����o de animais em seus estudos.

La nutrizione-idratazione artificiale �� terapia? All'interfaccia tra scienza, diritto e bioetica, il fine vita in Italia, secondo una prospettiva di comunicazione della scienza post-accademica e Science&Technologies Studies (STS)

The question ���artificial nutrition and hydration (ANH) is therapy or not?��� is one of the key point of end-of-life issues in Italy, since it was (and it is also nowadays) a strategic and crucial point of the Italian Bioethics discussion about the last phases of human life: determining if ANH is therapy implies the possibility of being included in the list of treatments that could be mentioned for refusal within the living will document. But who is entitled to decide and judge if ANH is a therapy or not? Scientists? The Legislator? Judges? Patients? This issue at first sight seems just a matter of science, but at stake there is more than a scientific definition. According to several scholars, we are in the era of post-academic Science, in which Science broaden discussion, production, negotation and decision to other social groups that are not just the scientific communities. In this process, called co-production, on one hand scientific knowledge derives from the interaction between scientists and society at large. On the other hand, science is functional to co-production of social order. The continuous negotation on which science has to be used in social decisions is just the evidence of the mirroring negotation for different way to structure and interpret society. Thus, in the interaction between Science and Law, deciding what kind of Science could be suitable for a specific kind of Law, envisages a well defined idea of society behind this choice. I have analysed both the legislative path (still in progress) in the living will act production in Italy and Eluana Englaro���s judicial case (that somehow collapsed in the living will act negotiation), using official documents (hearings, texts of the official conference, committees comments and ruling texts) and interviewing key actors in the two processes from the science communication point of view (who talks in the name of science? Who defines what is a therapy? And how do they do?), finding support on the theoretical framework of the Science&Technologies Studies (S&TS).

���This is TZ power! Kenkey can���t do this!��� : Die performative Aushandlung nationaler Kultur ; das National Festival of Arts and Culture in Ghana /// Arbeitspapiere / Institut f��r Ethnologie und Afrikastudien ; 92

Der vorliegende Artikel besch��ftigt sich mit der performativen Aushandlung nationaler Kultur auf dem National Festival of Arts and Culture, das 2006 in Wa, Nordwestghana, stattfand. Die Autorin nahm an der Vorbereitung und Planung des Festivals in lokalen staatlichen Kulturinstitutionen teil, und beobachtete die Diskussionen um die Repr��sentation einer (imaginierten) spezifischen Kultur des Nordens in scharfer Abgrenzung zu der des als dominant und diskriminierend empfundenen S��dens. In diesem Zusammenhang werden Fragen der Authentizit��t und Authentifizierung, wie sie in der Planung und Rezeption diskutiert wurden, aufgegriffen und mit der Konzeption des Festivals als gleichzeitig einheitsstiftendes Vehikel f��r nationale Identit��t und als Austragungsort eines Wettbewerbs der Regionen um Anerkennung und Ressourcen in Verbindung gesetzt. Das Festival, so die Argumentation, ist eine cultural performance, die das Wesen einer ���Kultur��� nicht nur abbildet, sondern auch die M��glichkeit des Wandels und der Subversion birgt. Performance meint hier also gleichzeitig die Auff��hrung und das Skript der Diskurse, die der Auff��hrung Bedeutung zuschreiben. Diesen doppelten Ansatz verfolgt der Artikel durch die Verkn��pfung von Festivalbeobachtungen und Komiteesitzungsmitschriften im Rahmen der Vorbereitung.

Procedimento legislativo e qualita' della legislazione. Criticita' e prospettive

La tesi riprende un tema che �� stato oggetto in passato di studi anche molto approfonditi; oggi sembra essere tornato alla ribalta grazie ad alcuni contributi che hanno nuovamente stimolato la dottrina a confrontarsi su aspetti cos�� delicati anche alla luce della crisi economica. E'stato da sempre rilevato che la buona scrittura delle norme �� un fattore fondamentale per il rilancio dell���economia del paese, per la semplificazione e per garantire ordine, coerenza e chiarezza all���ordinamento giuridico. La prima parte �� incentrata su una ricostruzione storica e giuridica delle fonti che hanno disciplinato le ���regole per la qualit�� delle regole���, oltre ad una panoramica della dottrina che si �� occupata in passato del tema. Segue l���individuazione specifica di quali sono le regole formali e sostanziali di drafting. In particolare, una parte �� dedicata alla giurisprudenza costituzionale per comprendere se esiste o meno un aggancio per la Corte Costituzionale da permetterle il sindacato sulle ���regole oscure��� e dichiararle illegittime. La seconda parte analizza le pressai, in particolare si �� scelto di analizzare il rapporto tra Governo e Parlamento nelle problematiche principali che attengono al procedimento legislativo e alla cornice entro la quale viene esplicato in relazione alla decretazione d���urgenza, maxiemendamenti, questione di fiducia, istruttoria in commissione, gruppi di pressione. Ci�� che �� stato rilevato, �� una scarsa aderenza ai principi e ai criteri di better regulation, peraltro difficilmente giustiziabili da parte della Corte costituzionale e sottratti al controllo di chi, al contrario, ha competenza in questo settore, ossia il Comitato per la legislazione e il DAGL. Le conclusioni, pertanto, prendono le mosse da una serie di criticit�� rilevate e tentano di tracciare una strada da percorrere che sia rispettosa dei canoni della ���better regulation��� anche alla luce delle riforme costituzionali e dei regolamenti parlamentari in corso di approvazione.

Do new biologics meet the unmet medical need in rheumatoid arthritis? Safety and efficacy of abatacept following B-cell depletion

Sir, anti TNF-�� agents (aTNFs) are the most commonly prescribed biological agents in RA. More recently abatacept (ABA), a T-cell costimulation modulator, and rituximab (RTX), a monoclonal antibody directed against CD20, have become available. Observational studies suggest that switching to a new drug class may be more effective in uncontrolled RA than switching to a class of biologics to which the patient had unsuccessfully been exposed [1]. Information about the efficacy and safety of cycling strategies through third-line biologics is lacking. This study aimed to analyse the effectiveness and safety of switching patients to ABA as the third biological class after failure of aTNF plus RTX. The Swiss Clinical Quality Management (SCQM) programme for RA is a longitudinal population-based cohort, which has been approved by the local ethics committees of all participating centres [2]. For this analysis, we collected all the ���

Effect of fibroblast growth factor NV1FGF on amputation and death: a randomised placebo-controlled trial of gene therapy in critical limb ischaemia

Patients with critical limb ischaemia have a high rate of amputation and mortality. We tested the hypothesis that non-viral 1 fibroblast growth factor (NV1FGF) would improve amputation-free survival.

The Blue Dog Coalition: Impact of a Single-Issue Caucus from the 104th to the 110th Congress

The Blue Dog Coalition is an informal organization of legislators within the House of Representatives that strives to influence policy on fiscal responsibility, attract the attention of the electorate, They are a group that elicits wide range of reactions covering the length of the political spectrum, but despite this, their claims of special defense of fiscal conservatism within the Democratic Party have gone relatively undocumented by the academic community.This project has integrated a party literature with a caucus literature, in the attempt of building a novel framework for research. Work on polarization, the significance of parties, the purpose and history of caucuses all have been fused in such away that the Blue Dogs have created an opportunity to test broad congressional questions on a caucus-microcosm scale. Three important questions have emerged from the many possible avenues of exploration on the topic: How does admission into the Blue Dog Coalition effect voting behavior - measured by interest, ideology, and party unityscores? How does party leadership delegate prestigious committee assignments, a traditional indicator of partisan favor and influence, towards Blue Dogs? Can we use the Blue Dog Coalition as an indicator of fiscal conservatism? To each of these questions, a number of interesting results emerged. Blue Dogs, in the 104th scored higher in conservative interest group scores, more towards the center in ideological methods, and lower in party unity Dogs began to behave closer to their Democratic counterparts. In addition, membership on these select committees rose from a very small number to greater proportional parity within the Democratic Party. Perhaps most interesting, the Blue Dog Coalition does behave as a significant, independent predictor effect on NTU scores, a variable used to demonstrate fiscal conservatism. This research has shown, first and foremost, that it is useful and practical to applyold arguments within the party literature to a smaller, caucus level of analysis that is relatively untouched by the political science field. For the Blue Dogs, specifically, we have tested the validity of their claims in an attempt to reach broader questions ofdemocratic responsibility and electoral clarity. This work, and other work I have drawn upon, has barely scratched the surface on Blue Dog Democrats and other caucuses of comparable influence and popularity, and there remains a wealth of research material onthis caucus alone to be explored by scholars in the field of congressional politics.