Flowchart for selecting an appropriate surgical airway in neurologically impaired pediatric intubated patients: a case series

Abstract Objective: Medical advances have resulted in increased survival rates of neurologically impaired children who may require mechanical ventilation and subsequent tracheostomy as a surgical airway. However, at present, there is no definite consensus regarding the timing and methods for placement of a surgical airway in a neurologically impaired intubated child who needs to be cared for over a long-term period. We therefore created a flowchart for the selection of a surgical airway for Neurologically Impaired Pediatric Patients (NIPPs). Methods: The flowchart includes information on the patients' backgrounds, such as intubation period, prognosis related to reversibility, and history of aspiration pneumonia. To evaluate the importance of the flowchart, first we conducted a survey of pediatricians regarding selection of a surgical airway, and we also evaluated the appropriateness of the flowchart among pediatricians and caregivers through questionnaire surveys which include satisfaction with the decision-making process, and postoperative course after discharge. Results: A total of 21 NIPPs with intubation underwent surgery and a total of 24 participants (14 pediatricians and 10 caregivers) completed the survey. The answers regarding the importance of the flowchart showed that eleven pediatricians had experience selecting of surgical airways, nine of whom had had experiences in which they had to make a difficult decision. The answers regarding the appropriateness of the flowchart revealed that all pediatricians and caregivers were satisfied with the decision-making process and postoperative course after discharge using the flowchart. Conclusions: The present study demonstrated the effectiveness of our flowchart for selecting an appropriate surgical airway in NIPP. By referring to our flowchart, pediatricians and caregivers are likely to be able to select an appropriate surgical airway, leading to increased satisfaction with the decision-making process and postoperative course. Level of Evidence: 4.

Rare tumors: a blue ocean of investigation / 医学前沿

Advances in novel drugs, therapies, and genetic techniques have revolutionized the diagnosis and treatment of cancers, substantially improving cancer patients' prognosis. Although rare tumors account for a non-negligible number, the practice of precision medicine and development of novel therapies are largely hampered by many obstacles. Their low incidence and drastic regional disparities result in the difficulty of informative evidence-based diagnosis and subtyping. Sample exhaustion due to difficulty in diagnosis also leads to a lack of recommended therapeutic strategies in clinical guidelines, insufficient biomarkers for prognosis/efficacy, and inability to identify potential novel therapies in clinical trials. Herein, by reviewing the epidemiological data of Chinese solid tumors and publications defining rare tumors in other areas, we proposed a definition of rare tumor in China, including 515 tumor types with incidences of less than 2.5/100 000 per year. We also summarized the current diagnosis process, treatment recommendations, and global developmental progress of targeted drugs and immunotherapy agents on the status quo. Lastly, we pinpointed the current recommendation chance for patients with rare tumors to be involved in a clinical trial by NCCN. With this informative report, we aimed to raise awareness on the importance of rare tumor investigations and guarantee a bright future for rare tumor patients.

Uma proposta metodológica para Análise do Discurso baseada na hermenêutica de Paul Ricoeur / A methodological proposal for discourse analysis based on the hermeneutic of Paul Ricoeur / Una propuesta metodológica para el análisis del discurso basada en la hermenéutica de Paul Ricoeur

Este estudo tem como objetivo apresentar uma proposta metodológica de análise do discurso baseada na fenomenologia hermenêutica de Paul Ricoeur. Discutiu-se seu conceito de interpretação e suas implicações para a análise do discurso. Não obstante Paul Ricoeur tenha enfatizado em sua obra a produção escrita, destacou-se as especificidades das narrativas orais produzidas nos contextos de pesquisa tendo por base as relações interpessoais entre colaboradores e pesquisadores e elaborou-se um instrumento intitulado "Fluxograma para Análise Fenomenológica do Discurso em Paul Ricoeur", composto de quatro etapas, o recorte do texto, as marcas linguísticas, os sentidos vivenciais e a compreensão hermenêutica, com o objetivo de auxiliar o pesquisador na construção de sentidos tendo como base os discursos produzidos na interação com os participantes em pesquisas qualitativas.

This study aimed to present a methodological proposal for discourse analysis based on Paul Ricoeur's hermeneutic phenomenology. This paper discusses the concepts of interpretation and its implications for discourse analysis. Although Paul Ricoeur emphasized the written production in his work, the specificities of the oral narratives produced in the research contexts were highlighted based on the interpersonal relationships between collaborators and researchers. An instrument was elaborated and denominated "Flowchart to Phenomenological Discourse Analysis In Paul Ricoeur", formed by four steps, the extract of the text, the language marks, the senses of experience and the hermeneutic comprehension, in order to assist the researchers in the construction of meanings on the speeches produced during the interaction with the participants in qualitative researches.

Este estudio tuvo como objetivo presentar una propuesta metodológica para un Análisis del Discurso basada en la fenomenología hermenéutica de Paul Ricoeur. Fueron discutidos sus conceptos de interpretación y sus implicaciones para el análisis del discurso. Aunque Paul Ricoeur enfatizó la producción escrita en su trabajo, se resaltaron las especificidades de las narraciones orales producidas en los contextos de investigación, basadas en las relaciones interpersonales entre los colaboradores e investigadores y fue elaborado un instrumento llamado "Diagrama de Flujo para el Análisis Fenomenológico del Discurso en Paul Ricoeur" formado por cuatro etapas, el recorte de texto, las marcas lingüísticas, los sentidos experienciales y la comprensión hermenéutica, para ayudar al investigador en la construcción de sentidos de los discursos producidos en la interacción con los participantes en las investigaciones cualitativas.

Decision flowchart for food classification by the extension and purpose of industrial processing: update and practical application / Fluxograma de decisão para classificação de alimentos conforme a extensão e propósito do processamento industrial: atualização e aplicação prática

ABSTRACT Objective To describe the development and update of an instrument for food categorisation according to the extension and purpose of industrial processing, and to test its practical application. Methods After updating the instrument based on a recent publication on the NOVA classification, it was applied by five researchers to a database of 108 food items. These items are part of a database of foods announced in the health-related sections of supermarket promotional circulars. The Cohen's weighted kappa coefficient was calculated to determine intra-rater agreement; Fleiss' kappa and Kendall's coefficient were applied to determine inter-rater agreement. Results In the updated version, two classes of additives and eight substances considered by the most recent publication as specific to ultra-processed foods were added. The intra-rater agreement was 100% (p<0.001), indicating an "almost perfect" agreement; Fleiss' agreement among all raters ranged from 74% to 97% (p<0.001), which represents an agreement that ranged from "strong" to "almost perfect"; Kendall's W was higher than 0.93 (p<0.001) among all raters. Conclusion The updated instrument showed high agreement and proved to be a methodologically sound and applicable tool for the purpose of classifying foods by the extension and purpose of industrial processing.

RESUMO Objetivo Descrever o desenvolvimento e atualização de um instrumento para categorização dos alimentos de acordo com a extensão e propósito de seu processamento industrial e avaliar sua aplicação prática. Métodos Após a atualização do instrumento com base em publicação recente sobre o tema, ele foi aplicado por cinco pesquisadores em um banco de dados de 108 alimentos. Esses alimentos são parte de um banco de dados de alimentos anunciados em seções relacionadas à saúde de panfletos promocionais de supermercado. Para avaliar a concordância intra-avaliador foi calculado o kappa ponderado de Cohen e para a concordância interavaliadores foram calculados o kappa de Fleiss e o coeficiente de concordância de Kendall. Resultados Na versão atualizada foram adicionadas duas classes de aditivos e oito substâncias, consideradas pela publicação mais recente como específicas de alimentos ultraprocessados. A concordância intra-avaliador foi de 100% (p<0,001), o que indica uma concordância "quase perfeita"; a concordância de Fleiss entre todos os avaliadores variou de 74% a 97% (p<0,001), o que representa uma concordância que variou de "forte" a "quase perfeita"; a concordância de Kendall foi W >0,93 (p<0,001) entre todos os avaliadores. Conclusão O instrumento atualizado apresentou uma elevada concordância e mostrou-se uma ferramenta metodologicamente útil e aplicável quando se tem por objetivo classificar alimentos pela extensão e propósito do processamento industrial.

Procedimentos cirúrgicos e não cirúrgicos para elevação das sobrancelhas: revisão sistemática e fluxograma de abordagem / Surgical and non-surgical procedures for eyebrow lift: systematic review and decision flowchart

Introdução: Realizar levantamento na literatura médica sobre os tratamentos cirúrgicos e não cirúrgicos da ptose de sobrancelha e apresentar um fluxograma de decisão para elevação da sobrancelha. Métodos: Revisão sistemática da literatura disponível no banco de dados da PUBMED seguindo critérios de inclusão e exclusão. Elaboração de um fluxograma para abordagem da queda de sobrancelha baseado na experiência dos autores. Resultados: Foi encontrada uma abundância de artigos descrevendo diversas táticas cirúrgicas e não cirúrgicas para correção da ptose de supercílio. As táticas cirúrgicas mais comuns foram a elevação interna do supercílio, elevação direta, elevação via temporal e ritidoplastia coronal / pré-triquial / endoscópica. Para a abordagem não cirúrgica foram encontradas o uso de toxina botulínica, preenchimento e fios de sustentação. Conclusão: Há diversas táticas cirúrgicas e não cirúrgicas descritas na literatura para elevação da sobrancelha, demonstrando que não há uma tática ideal para todos os pacientes. O uso de fluxograma pode ajudar a realizar uma abordagem sistemática e personalizada e considerando característica de cada paciente.

Introduction: To review the medical literature regarding the surgical and non-surgical treatments of eyebrow ptosis and to present a decision flowchart for eyebrow lift. Methods: A systematic review of the literature available was held in PUBMED following inclusion and exclusion criteria. A flowchart was elaborated to systematize the approach to eyebrow ptosis based on the experience of the authors. Results: Several articles were included describing a variety of surgical and non-surgical correction techniques for eyebrow ptosis. The most common surgical approaches were internal eyebrow elevation, direct elevation, temporal elevation, and coronal/pretrichial/endoscopic rhytidoplasty. The non-surgical approaches found were botulinum toxin injections, fillers, and fixation threads. Conclusion: There are several surgical and non-surgical procedures described in the literature for lifting of the eyebrow, demonstrating that there is no ideal method for all patients. The use of a flowchart can help carry out a systematic and personalized approach according to the characteristics of each patient.

Presurgical assessment of splenic tumors in dogs: a retrospective study of 57 cases (2012–2017)

The purpose of this study was to evaluate the clinical and imaging characteristics of canine splenic tumors and to establish guidelines for the presurgical assessment of splenic tumors in dogs. Fifty-seven dogs that underwent total splenectomy for the treatment of splenic tumors were evaluated by examining medical records, hematologic results, diagnostic imaging results, and histopathologic results. The maximum lesion size from ultrasonography was significantly different between malignant and benign tumors (p = 0.002). There was a correlation between tumor margination and type of splenic tumors (p = 0.045). Precontrast lesion attenuation on computed tomography was significantly different between splenic malignant and benign tumors (p = 0.001). The mean ± SD precontrast lesion attenuation of malignant tumors was 40.3 ± 5.9 Hounsfield units (HU), and for benign tumors, it was 52.8 ± 6.8 HU. In conclusion, some variables of the imaging examination could be used to distinguish the type of splenic tumor. Based on the study results, using a diagnostic flowchart would be effective in increasing the survival rate of patients with splenic malignant tumors. In addition, fine needle aspiration or magnetic resonance imaging prior to surgical exploration and histopathologic examination may be useful in achieving a more accurate diagnosis.

Design and application of flowchart for putting normal saline column by gravity drip via Groshong PICCs to guide intracavitary ECG / 现代临床护理

Objective To work out a flowchart for putting normal saline column by gravity drip via Groshong PICCs to guide intracavitary ECG and investigate the effect. Methods We developed the flowchart and trained the nurses to use it. Then the flowchart was used in catheteration of Groshong PICC to guide intracavitary ECG for 30 patients. Results The normal target rate was 93.3%(28/30) and the optimal tip target rate was 90.0%(27/30). The score on the flowchart by the nurses was (4.8 ± 0.4), indicating they were satisfied with it. Conclusion The flowchart for pushing normal saline column with gravity drip method via Groshong PICCs to guide intracavitary ECG provides an operational standard, enhancing the operational quality.

Application of modified flowchart of items supply in preoperational articles in the operating room / 现代临床护理

Objective To discussed application effect of modified flowchart of preoperational articles in the operating room. Methods A group for the reconstructed flowchart was set up to look into the problems of traditional flowchart for articles preparation and then have the flowchart modified upon the found problems. The duration for article preparation and the flaw rate were compared between pre-and post-modification. Result The duration for preparation after modification was significantly shorter than that before modification and the flaw rate was significantly lower as well (P<0.001). Conclusion The modified flowchart for article preparation in the operation room can reduce the flaw rate and shorten the duration for article preparation, thus ensuring smooth operation.

Aplicación del modelo de gestión por procesos: el caso de la distribución y dispensación de medicamentos en dosis unitaria diaria. Hospital Italiano Monte Buey. Año 201-2013

La distribución y dispensación de medicamentos de uso hospitalarioconstituyen una oportunidad de mejora.Un buen manejo de medicamentos hospitalarios representa unanecesidad para un adecuado y oportuno acceso al paciente que lorequiera.Este trabajo busca realizar un estudio que pueda promover unaadecuada administración en la distribución y dispensación demedicamentos en el ámbito de la farmacia intrahospitalaria delHospital Italiano Monte Buey que permita garantizar la seguridaddel paciente mediante el uso racional y eficiente de los mismosfavoreciendo así la calidad de la atención.El presente estudio se enmarca dentro de la investigación científica,explorativa, descriptiva de corte transversal de naturaleza aplicada.La identificación de los distintos procesos – de gestión - clave y deapoyo, que se integran en la logística de distribución y dispensacióninterna de la Farmacia intrahospitalaria, luego de revisar los distintossistemas de distribución interna con sus ventajas y desventajas, permitenla elaboración del mapa de procesos de la misma con sus correspondientesfichas de proceso y diagrama de flujo.De los resultados obtenidos al analizar el movimiento deampicilina – sulbactam dispensados en el trimestre luego de lapuesta en marcha del sistema de distribución de medicamentos endosis unitaria diaria, se demuestra que se consumieron 91,28% deltotal distribuidos recuperando un 8,71% no utilizados que retornana farmacia, quedando expresado el beneficio del modelos de gestiónpor procesos propuesto con intervención del farmacéutico en lainterpretación del pedido médico, recupero de medicación condisminución del stock y del gasto al no solicitar nuevas compras,todo lo cual impactan en eficiencia y seguridad con eficacia en ladispensación de los medicamentos.

The distribution and dispensation of the medicinal products forhospital use constitute an opportunity for improvement.Good management of hospital drugs represents a need for proper andtimely access to the patient who requires it.This work intends to conduct a study which to promote a properadministration in the distribution and dispensation of medicinalproducts in the hospital pharmacy of Hospital Italiano Monte Buey,that would ensure the safety of the patient through the rational andefficient use of them, favouring the quality of care.This study falls within the scientific, exploratory, descriptive researchof cross section of applied nature.The identification of the various processes – management – keyand support, integrated in the logistic distribution and internalhospital pharmacy dispensation, after reviewing the different systems ofinternal distribution with its advantages, allow the development ofthe process map with its corresponding data sheets of process andflowchart.The results obtained from analyzing the movement of ampicilin –sulbactam dispensed in the quarter after the implementation of thesystem of distribution of drugs in unit dose dayli, is shown that theywere consumed 91,28% of the total distributed recovering 8,71%unused returning to pharmacy, being expressed to the benefit ofthe process management models propored with intervention of thepharmacist in the interpretation of the ordering physician, recoveryof medication with stock and costs decrease by not requesting newpurchases, all which have an impact on efficiency and securityeffectively in the dispensation of drugs.

Application of nursing flowchart in the post-anesthesia care unit / 现代临床护理

Objective To investigate effect of applying nursing flowchart in the post-anesthesia care unit(PACU).Method The nursing flowchart in PACU are as follous,including a ventilator connection,monitoring instrument connection,handover of pipeline and skin and training for PACU nurses.Results After application of the nursing flowchart,the nursing time for postoperative patients was reduced from 7.0 min to 4.0 min.No nursing risks and adverse events occurred.Conclusion Application of nursing flowchart in PACU can improve the quality of nursing and enhance patients safety.