ABSTRACT
BACKGROUND: Treatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn't working well-whether to optimize the treatment already begun or to add the other treatment. METHODS: This is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8-17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first ("Main Effect 1"). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment ("Main Effect 2"). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBTâCBT; CBTâmed; medâmed; medâCBT) in non-remitters is significantly better or worse than predicted from main effects alone. DISCUSSION: Findings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders. TRIAL REGISTRATION: This protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275 .
Subject(s)
Cognitive Behavioral Therapy , Adolescent , Animals , Anxiety Disorders/drug therapy , Cats , Child , Fluoxetine , Humans , Psychotherapy , Single-Blind Method , Treatment OutcomeABSTRACT
Las secuencias integradas de cuidado para últimos días de vida proponen estándares de calidad para optimizar la atención de pacientes y familias. Se implementó el Programa Asistencial Multidisciplinario Pallium (PAMPA ©) basado en estándares del International Collaborative for Best Care for the Dying Person en cuatro fases: inducción, implementación, diseminación y sustentabilidad, en cinco centros de salud en Argentina, entre 2008 y 2018. Se incluyeron 1237 pacientes adultos en situación de últimos días de vida, en seguimiento por equipos de cuidados paliativos entrenados en el PAMPA ©. Se efectuó una auditoría antes y después de la ejecución del programa, aún en curso. El rango de medianas de permanencia en los cinco centros desde el inicio de la secuencia hasta el fallecimiento fue de 16 a 178 horas. Se compararon objetivos de cuidado: control de síntomas, comunicación, necesidades multidimensionales, hidratación y nutrición, documentación de intervenciones y cuidados post mortem. El análisis conjunto mostró una mejoría del número de registros (p = 0.001). La comunicación del plan de cuidados con el paciente no mostró diferencias (p = 0.173). Se realizó capacitación y supervisión permanente a los equipos profesionales de quienes se registraron percepciones de la implementación. Los principales emergentes de este análisis cualitativo fueron: actitudes ante el programa, aportes fundamentales, fortalezas, debilidades y definición subjetiva del programa, reconocimiento de las singularidades culturales institucionales y su influencia en el cuidado. El PAMPA © demostró la factibilidad de un modelo de atención para pacientes y familias en final de vida, basado en estándares de calidad internacionales
The integrated care pathways for the last days of life propose quality standards optimizing the care of patients and families. The Pallium Multidisciplinary Assistance Program (PAMPA ©) was implemented based on standards of the International Collaborative for Best Care for the Dying Person in 4 phases: induction, implementation, dissemination and sustainability, in five health centers in Argentina, between 2008 and 2018. A total of 1237 adult patients in the last days of life were included and cared for by palliative care teams trained in PAMPA ©. An audit was conducted before and after the implementation of the Program, which is still going on. The median range of follow up into five centers from the beginning of the pathway until death varied from 16 to 178 hours. Care goals were compared: symptom control, communication, multidimensional needs, hydration and nutrition, documentation of interventions and post-mortem care. The overall analysis showed an improvement in the number of records (p = 0.001). The goal of communication on care plan to the patient showed no difference (p = 0.173). Continuous training, support and permanent teams' supervision were carried out and perceptions and impact of the implementation were registered. The main emerging items of the qualitative analysis were attitudes towards the program, fundamental contributions, strengths, weaknesses and subjective definition of the program, recognition of institutional cultural singularities and its influence on care. PAMPA © demonstrated its feasibility as a model of end of life care for patients and families, based on international quality standards
Dez anos de experiência. Resumo: As sequências integradas de cuidado para últimos dias de vida propõem padrões de qualidade para otimizar a atenção de pacientes e famílias. Implementou-se o Programa Assistencial Multidisciplinar Pallium (PAMPA ©) baseado em parâmetros do International Collaborative for Best Care for the Dying Person em quatro fases: indução, implementação, disseminação e sustentabilidade, em cinco centros de saúde na Argentina, entre 2008 e 2018. Se incluíram 1237 pacientes adultos em situação terminal, assistidos por equipes de cuidados paliativos treinadas no PAMPA ©. Fez-se uma auditoria antes e despois da execução do programa, que ainda está sendo desenvolvido. A média de permanência nos cinco centros desde o início da sequência até a morte deu entre 16 a 178 horas. Conferiram-se objetivos de cuidado: controle de sintomas, comunicação, necessidades multidimensionais, hidratação e nutrição, documentação de intervenções e cuidados post mortem.A análise conjunta tem evidenciado uma melhora do número de registros (p = 0.001). A comunicação do regime de cuidados com o paciente não mostrou diferenças (p = 0.173). Realizou-se capacitação e supervisão permanente às equipes profissionais e se registraram as percepções da implementação.Desta análise qualitativa surgiram notadamente: atitudes em fase do programa, contribuições fundamentais, fortalezas, fraquezas e definição subjetiva do programa, reconhecimento das singularidades culturais institucionais e sua influência no cuidado. O PAMPA © demonstrou a factibilidade de um modelo de atendimento para pacientes e famílias em estado terminal, baseado em padrões de qualidade internacionais
Subject(s)
Humans , Male , Female , Palliative Care , Terminal Care , Hospice Care , Critical IllnessABSTRACT
Resumen El artículo aborda la perspectiva de profesionales de oncología y cuidados paliativos de Argentina sobre la planificación anticipada de los cuidados en el final de la vida de pacientes con enfermedades oncológicas avanzadas. A partir de un diseño de investigación cualitativa, basado en entrevistas semi-estructuradas con profesionales de diferentes disciplinas, se analizaron las dificultades para la participación de los y las pacientes en el proceso de toma de decisiones y en los procesos de consentimiento informado en torno a los cuidados en el final de la vida. Pese a valorar la planificación anticipada del cuidado e instrumentos como las directivas anticipadas, se identifican barreras para la implementación de estas prácticas. La falta de herramientas comunicacionales para abordar este tipo de conversaciones con los pacientes, el ocultamiento de la información sobre el diagnóstico y/o el pronóstico de la enfermedad, la falta de articulación entre equipos que realizan el seguimiento de pacientes con enfermedad avanzada, y la resistencia de familiares y pacientes, limitan los márgenes de decisión y consentimiento por parte de los pacientes.
Abstract The article addresses the perspective of oncologist and palliative care professionals of Argentina on the advance end of life care planning for patients with advanced cancer. Based on semi-structured interviews with professionals from different disciplines, the paper explores barriers for the patient participation in the decision-making process in end of life care. Despite the acceptance of advance care planning and instruments such as advance directives, barriers to the implementation of these practices are identified. The lack of communication skills to deal with this type of conversation with patients, the concealment of information on the diagnosis and prognosis of the disease, the lack of coordination between teams that keep track of patients with advanced disease, and the resistance from relatives and patients, limit the margins of decision and consent by patients.
Resumo O artigo aborda a perspectiva dos profissionais de oncologia e cuidados paliativos na Argentina sobre o planejamento antecipado dos cuidados de fim de vida para pacientes com doenças oncológicas avançadas. Partindo de um desenho de pesquisa qualitativa, com base em entrevistas semiestruturadas com profissionais de diferentes disciplinas, o artigo analisa as dificuldades para a participação dos pacientes no processo de tomada de decisão e nos processos de consentimento informado em torno aos cuidados de fim de vida. Apesar de valorizar o planejamento do cuidado antecipado e instrumentos como as diretrizes antecipadas, identificam-se barreiras para a implantação dessas práticas. A falta de instrumentos de comunicação para atender esse tipo de conversa com os pacientes, o encobrimento do diagnóstico e / ou prognóstico da doença, a falta de articulação entre as equipes que acompanham os pacientes com doença avançada e a resistência dos familiares e pacientes, limitam as margens de decisão e consentimento por parte dos pacientes.
Subject(s)
Humans , Terminal Care , Advance Directives , Terminally Ill , Decision Making , Informed Consent , Neoplasms , Patient Care Team , Patients , Argentina , Hospice Care , Critical Illness , Qualitative ResearchABSTRACT
The integrated care pathways for the last days of life propose quality standards optimizing the care of patients and families. The Pallium Multidisciplinary Assistance Program (PAMPA ©) was implemented based on standards of the International Collaborative for Best Care for the Dying Person in 4 phases: induction, implementation, dissemination and sustainability, in five health centres in Argentina, between 2008 and 2018. A total of 1237 adult patients in the last days of life were included and cared for by palliative care teams trained in PAMPA©. An audit was conducted before and after the implementation of the Program, which is still going on. The median range of follow up into five centres from the beginning of the pathway until death varied from 16 to 178 hours. Care goals were compared: symptom control, communication, multidimensional needs, hydration and nutrition, documentation of interventions and post-mortem care. The overall analysis showed an improvement in the number of records (p = 0.001). The goal of communication on care plan to the patient showed no difference (p = 0.173). Continuous training, support and permanent teams supervision were carried out and perceptions and impact of the implementation were registered. The main emerging items of the qualitative analysis were: attitudes towards the program, fundamental contributions, strengths, weaknesses and subjective definition of the program, recognition of institutional cultural singularities and its influence on care. PAMPA© demonstrated its feasibility as a model of end of life care for patients and families, based on international quality standards.
Las secuencias integradas de cuidado para últimos días de vida proponen estándares de calidad para optimizar la atención de pacientes y familias. Se implementó el Programa Asistencial Multidisciplinario Pallium (PAMPA©) basado en estándares del International Collaborative for Best Care for the Dying Person en cuatro fases: inducción, implementación, diseminación y sustentabilidad, en cinco centros de salud en Argentina, entre 2008 y 2018. Se incluyeron 1237 pacientes adultos en situación de últimos días de vida, en seguimiento por equipos de cuidados paliativos entrenados en el PAMPA©. Se efectuó una auditoría antes y después de la ejecución del programa, aún en curso. El rango de medianas de permanencia en los cinco centros desde el inicio de la secuencia hasta el fallecimiento fue de 16 a 178 horas. Se compararon objetivos de cuidado: control de síntomas, comunicación, necesidades multidimensionales, hidratación y nutrición, documentación de intervenciones y cuidados post mortem. El análisis conjunto mostró una mejoría del número de registros (p = 0.001). La comunicación del plan de cuidados con el paciente no mostró diferencias (p = 0.173). Se realizó capacitación y supervisión permanente a los equipos profesionales de quienes se registraron percepciones de la implementación. Los principales emergentes de este análisis cualitativo fueron: actitudes ante el programa, aportes fundamentales, fortalezas, debilidades y definición subjetiva del programa, reconocimiento de las singularidades culturales institucionales y su influencia en el cuidado. El PAMPA© demostró la factibilidad de un modelo de atención para pacientes y familias en final de vida, basado en estándares de calidad internacionales.
Subject(s)
Palliative Care/standards , Program Evaluation , Quality Assurance, Health Care/standards , Terminal Care/standards , Adult , Aged , Aged, 80 and over , Argentina , Critical Pathways/standards , Female , Health Plan Implementation/methods , Health Plan Implementation/standards , Humans , Male , Middle Aged , Palliative Care/methods , Reproducibility of Results , Terminal Care/methods , Time FactorsABSTRACT
OBJECTIVE: To examine the effectiveness of playing chess as a treatment option for children with ADHD. METHODS: Parents of 44 children ages 6 to 17 with a primary diagnosis of ADHD consented to take part in the study. Parents completed the Spanish version of the Swanson, Nolan and Pelham Scale for parents (SNAP-IV) and the Abbreviated Conner's Rating Scales for parents (CPRS-HI) prior to an 11-week chess-training program. We used a paired t-test to compare pre- and post-intervention outcomes, and Cohen-d calculations to measure the magnitude of the effect. The statistical significance was set at P<.05. RESULTS: Children with ADHD improved in both the SNAP-IV (t=6.23; degrees of freedom (df)=41; P<.001) and the CPRS-HI (t=5.39; df=33; P<.001). Our results suggest a large effect in decreasing the severity of ADHD as measured by the SNAP-IV (d=0.85) and the CPRS-HI (d=0.85). Furthermore, we found a correlation between intelligence quotient and SNAP-IV improvement (P<.05). CONCLUSIONS: The results of our pilot study should be interpreted with caution. This pilot project highlights the importance of carrying out larger studies with a case-control design. If our results are replicated in better designed studies, playing chess could be included within the multimodal treatment of ADHD.
Subject(s)
Attention Deficit Disorder with Hyperactivity/therapy , Games, Recreational , Adolescent , Attention Deficit Disorder with Hyperactivity/diagnosis , Child , Female , Humans , Male , Pilot Projects , Prospective Studies , Psychiatric Status Rating Scales , Severity of Illness Index , Treatment OutcomeABSTRACT
Las percepciones de los profesionales de la salud ante el final de la vida pueden influir en la comunicación con pacientes y familias. Si bien en cuidados paliativos (CP) la muerte es algo esperable y natural, genera emociones de distinta intensidad y pone en evidencia la propia finitud y/o la de seres amados y pérdidas previas no elaboradas. El Liverpool Care Pathway (LCP) propone un programa de calidad de atención para personas en situación de últimos días (SUD). En Argentina y España se está implementando el LCP (en español) desde las ONG Pallium (programa PAMPA) y Cudeca respectivamente. Nuestro objetivo es explorar las condiciones subjetivas (percepciones) que enfrentan los profesionales de la salud en relación con la atención en el final de la vida, en el contexto previo y posterior a la implementación de una secuencia de cuidado integral LCP/PAMPA en un contexto binacional latino (Argentina-España). Proponemos identificar y describir los significados que los profesionales le asignan a: los cuidados del muriente, la comunicación, el trabajo en equipo, la documentación y las actitudes en SUD. METODOLOGÍA: Es un estudio de casos múltiples, conformado por 2 módulos independientes articulados en un análisis integrador. El primer módulo realizó un tipo de etnografía utilizada en instituciones sanitarias (EF) en el equipo hospitalario de CP que iniciaban la capacitación con el LCP/PAMPA en Argentina. El segundo módulo consistió en la aplicación de un cuestionario estructurado y pregunta abierta sobre las percepciones de los profesionales sobre las necesidades y condiciones de implementación del LCP (en ambos países). RESULTADOS: Módulo 1. Ejes de indagación: a) acercamiento a la intervención en SUD; b) expectativas sobre la capacitación con LCP; c) dudas y temores en la aplicabilidad del LCP y d) lugar de la intuición en las INTERVENCIONES: Los datos muestran la variabilidad en los motivos de elección a los CP como formación profesional (personales versus necesidades del sistema sanitario) y las expectativas favorables con respecto a la utilidad del LCP. Módulo 2. Se exploraron las categorías específicas para ambos países (España n: 23, Argentina n: 112), siendo lo más relevante el acuerdo pleno del 73,7% de los encuestados argentinos respecto a los indicadores que reflejan los objetivos de calidad del instrumento. En España el acuerdo pleno alcanza el 91,4% teniendo en cuenta la capacitación específica en CP de los profesionales del Plan Nacional de CP. En Argentina aparece como evidente la falta de formación específica en CP antes de la implementación del LCP/PAMPA (91%) CONCLUSIÓN: Este estudio pretendió explorar por primera vez en un contexto de habla hispana, tanto en España como en América latina, las condiciones subjetivas de profesionales de la salud que pueden implementar una secuencia de cuidado integral sistemática muy utilizada en el contexto cultural anglosajón
Health professionals' perceptions on the end of life (EoL) can influence communication with patients and families. Although death is expected in palliative care (PC), emotions of varying intensity are generated. The fears and difficulties encountered in facing this subject will be different according to previous personal experiences. The Liverpool Care Pathway (LCP) proposes a quality programme of care for people at the EoL. Both in Argentina, Pallium and in Spain, Cudeca, are implementing a Spanish version of LCP. Our goal is to explore the subjective conditions (perceptions) faced by health professionals concerning EoL, and the influence before and after the implementation of the LCPin a Latin-American cultural context (Argentina-Spain). We propose to: identify and describe the meanings that professionals assigned to the care of the dying, communication, teamwork, documentation, and attitudes to EoL. METHODOLOGY: A multiple case study, consisting of 2 independent modules articulated in integrative analysis. The first module performed a type of ethnography used in health institutions (focused ethnography) in a PC hospital team who started training with the LCP/PAMPA in Argentina. The second module was the implementation of a structured questionnaire and open questions about the professional's perceptions and conditions of the implementation of the LCP (in both countries). RESULTS: Module 1. Axes of inquiry: a) approach to intervention in EoL, b) expectations about training with LCP, c) doubts and fears in the applicability of LCP, and d) place of intuition in INTERVENTIONS: The data show the variability for choosing the PC as training and the favorable expectations regarding the use of the LCP. Module 2. Specific categories were explored for both countries (Spain n: 23, Argentina n: 112) the most relevant of the full agreement of 73.7% of Argentines respondents on indicators that reflect the quality goals of the instrument. In Spain the full agreement reached 91.4%, keeping in mind the specific training of professionals of the PC National Plan. Argentina showed evidence of the lack of specific training in PC before the implementation of the LCP/PAMPA (91%). CONCLUSIONS: This study aimed to explore, for the first time in a Spanish-speaking context, both in Spain and in Latin America, the subjective conditions of health professionals who can implement a systematic pathway widely used in the Anglo-Saxon cultural context
Subject(s)
Female , Humans , Male , Palliative Care/methods , Palliative Care/standards , Palliative Care , Hospice Care/methods , Research/trends , Palliative Care/organization & administration , Hospice Care/organization & administration , Hospice Care/standards , Hospice Care , Perception , Anthropology, Cultural/statistics & numerical data , Surveys and QuestionnairesABSTRACT
PURPOSE OF REVIEW: To review the definition of advanced directive, understand the implications for the patient, family and healthcare team, and address the obstacles involved in the implementation. RECENT FINDINGS: Advanced directives propose a model of healthcare based on patient preferences. Although there is sufficient evidence related to their usefulness, various factors are known to affect the use of advanced directives. Therefore, rules need to be established in order to optimize the implementation process. SUMMARY: An advanced directive is a legal document based on the principle of autonomy that expresses the desire of the patient in relation to different medical treatments when the patient is unable to make those decisions. The advanced directives are represented in three formats: Living Will, Appointment of a Healthcare Proxy and Legal Status of Preferences. The uses of advanced directives have an impact not only on the patients and their families, but also on the healthcare team. Despite their utility being well known, there are several general barriers that affect implementation, as well as factors related to characteristics of each study population.
Subject(s)
Advance Directive Adherence , Advance Directives/legislation & jurisprudence , Palliative Care/standards , Patient Preference , Terminally Ill/psychology , Advance Directives/economics , Advance Directives/psychology , Humans , Palliative Care/economics , Palliative Care/psychology , United StatesABSTRACT
Ocular and adnexal congenital disorders are those that manifest at birth and could involve single or multiple tissues. Several abnormalities have been reported in literature affecting reptilian ocular and/or adnexal tissues. The objectives of this review are: (i) review those disorders previously reported in reptile literature; (ii) present new cases; (iii) provide a basic classification of them according to the moment of occurrence and (iv) indirectly, encourage the clinician dealing with these cases to go further in their diagnosis. The authors consider that categorizing ocular and adnexal congenital disorders could help the clinician to deal with them. The categorization of these disorders required an intense review of cases previously reported in literature and allows the authors suspect that some of them could not have been accurately diagnosed according to the definitions of the anomalies and/or not accurately described. The authors consider that ocular and adnexal congenital disorders could have been underestimated in reptiles and further studies could be helpful to promote the description of new disorders and to expand the knowledge about those previously reported. The review will first describe abnormalities reported during organogenesis (describing possible etiopathogenesis, cases reported, an approach to their diagnosis and recommended therapeutic options).Then a mention of the ocular disorders occurring after organogenesis is made. These disorders are divided when possible in those affecting all or most part of the globe and those affecting only specific tissues (surface ectoderm, neurocrest and mesenchyma and neuroectoderm).
Subject(s)
Eye Abnormalities/veterinary , Reptiles/abnormalities , Animals , Anophthalmos/diagnosis , Anophthalmos/veterinary , Aphakia/diagnosis , Aphakia/veterinary , Coloboma/diagnosis , Coloboma/veterinary , Eye Abnormalities/diagnosis , Holoprosencephaly/diagnosis , Holoprosencephaly/veterinary , Microphthalmos/diagnosis , Microphthalmos/veterinary , Snakes/abnormalities , Turtles/abnormalitiesABSTRACT
BACKGROUND AND AIMS: It has traditionally been considered that the flowers of Scrophularia are mainly pollinated by wasps. We studied the pollination system of four species which stand out for their large and showy flowers: S. sambucifolia and S. grandiflora (endemics of the western Mediterranean region), S. trifoliata (an endemic of the Tyrrhenian islands) and S. calliantha (an endemic of the Canary Islands). Our principal aim was to test whether these species were pollinated by birds or showed a mixed pollination system between insects and birds. METHODS: Censuses and captures of insects and birds were performed to obtain pollen load transported and deposited on the stigmas. Also, a qualitative and quantitative analysis of the flowers and inflorescences was carried out. KEY RESULTS: Flowers were visited by Hymenoptera and by passerine birds. The Canarian species was the most visited by birds, especially by Phylloscopus canariensis, and its flowers were also accessed by juveniles of the lizard Gallotia stehlini. The most important birds in the other three species were Sylvia melanocephala and S. atricapilla. The most important insect-functional groups in the mixed pollination system were: honey-bees and wasps in S. sambucifolia; bumble-bees and wasps in S. grandiflora; wasps in S. trifoliata; and a small bee in S. calliantha. CONCLUSIONS: The species studied show a mixed pollination system between insects and passerine birds. In S. calliantha there is, in addition, a third agent (juveniles of Gallotia stehlini). The participation of birds in this mixed pollination system presents varying degrees of importance because, while in S. calliantha they are the main pollinators, in the other species they interact to complement the insects which are the main pollinators. A review of different florae showed that the large showy floral morphotypes of Scrophularia are concentrated in the western and central Mediterranean region, Macaronesia and USA (New Mexico).
Subject(s)
Flowers/anatomy & histology , Flowers/growth & development , Scrophularia/anatomy & histology , Scrophularia/growth & development , Animals , Birds , Insecta , Lizards , Pollination/physiology , WaspsABSTRACT
BACKGROUND: Primary retinal telangiectasia is characterized by abnormalities in the retinal vasculature. Any alteration of the normal retinal vasculature may result in variable degrees of retinal leakage, hemorrhages, and exudates. The retinal telangiectatic conditions of Coats' disease, Leber's miliary aneurysms, and idiopathic macular telangiectasia (IMT), although historically considered separate entities, may in fact be variants of the same pathophysiologic vascular process. This is based on observations noting that they share similarities in pathogenesis, histology, and clinical presentation. These observations are controversial and are contested in the literature. Conversely, others have documented Coats' disease, Leber's miliary aneurysms, and IMT as unique and separate retinal conditions, each with specific features. METHODS: Three cases are presented spanning the spectrum of primary retinal telangiectasia. Clinical evaluation, dilated fundus examination, and auxiliary testing document both the similar characteristics that the entities share as well as the distinct features, which define each disease's nomenclature and categorization. CONCLUSION: Coats' disease, Leber's miliary aneurysms, and IMT may be part of a singular clinical spectrum sharing pathophysiologic and histopathologic features and similarities in clinical presentation.
Subject(s)
Retinal Vessels , Telangiectasis/pathology , Aneurysm/pathology , Child , Diabetic Retinopathy/diagnosis , Diagnosis, Differential , Exudates and Transudates/metabolism , Female , Fundus Oculi , Humans , Macula Lutea/blood supply , Male , Middle Aged , Retina/metabolism , Retinal Detachment/pathology , Retinal Vessels/pathology , Telangiectasis/classification , Telangiectasis/metabolismABSTRACT
Introducción. La seguridad es una condición dinámica y debe ser la filosofía que sustente la mejora de la calidad en el ámbito sanitario. Las estrategias para reducir incidentes pasan por abordarlos desde un enfoque general para soluciones generales a largo plazo, admitir que los errores se producen (cultura), se notifican (sacan a la luz), y se analizan los factores causales, todo ello desde una actitud proactiva, preventiva y sistemática. Material y método. El Laboratorio Clínico del Hospital de Antequera propuso en el año 2006 realizar un análisis descriptivo modal de su fase preanalítica, proceso de alto riesgo para la seguridad del paciente, en el que se genera el mayor porcentaje de errores y dónde intervienen un importante número de profesionales, la mayoría ajenos al laboratorio cuya contribución al resultado final es decisivo; aplicando el análisis modal de fallos y sus efectos (AMFE). Resultados. En función del número de prioridad de riesgo, se propusieron acciones de mejora, rediseñaron procesos, se realizaron procedimientos e instrucciones y se implementaron indicadores para medir resultados en el tiempo y evaluar las actuaciones para una mejora continua. Conclusiones. Lo importante, al hablar de seguridad en los laboratorios, es la fiabilidad en cuanto a ausencia de errores, y la utilidad de la información que generamos. En este sentido, el AMFE resulta ser una fuente de información importante para detectar fallos activos y los latentes del sistema. Además, la participación y difusión de este tipo de trabajos fomenta el compromiso y la responsabilidad de los profesionales en la seguridad (AU)
Introduction. Safety dynamics should be the philosophy that supports improved quality in the healthcare environment. Strategies to reduce incidents have been undertaken for long-term solutions, to identify that errors occur (culture) are highlighted and the causal factors are pro-actively, preventively and systematically analysed. Material and methods. In 2006 the Clinical Laboratory of Antequera Hospital proposed to carry out a descriptive analytical model to address the risk assessment for the safety of the high-risk patient, as this is the group in which the majority of errors is generated and study how this affects the professionals working in the laboratory, whose contribution to the final results is decisive, by applying the failure mode and effect analysis (FMEA). Results. Considering the number of risk priorities, improvement actions were proposed, processes re-designed and indicators, procedures and instructions were implemented to measure the results in order to evaluate and establish methods for continuous improvement within the laboratory. Conclusions. When looking at safety in the laboratory, the most important factors are the absence of adverse events (errors), reliability of the methods and the use of the information generated. As a result, the FMAE's findings are an important source of information in detecting active and latent failures of the system. In addition, the participation and dissemination of this type of knowledge promotes the commitment and responsibility of the professionals in safety issues (AU)
Subject(s)
Humans , Male , Female , Laboratories/ethics , Laboratories/standards , Clinical Laboratory Information Systems/ethics , Clinical Laboratory Information Systems/organization & administration , Clinical Laboratory Techniques/standards , Clinical Laboratory Techniques/trends , Clinical Laboratory TechniquesABSTRACT
BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a life-threatening condition that may present with symptoms and signs identical to idiopathic intracranial hypertension (IIH). Both conditions consist of increased intracranial pressure (ICP); however, IIH shows no evidence of contributory intracranial pathology. Oral hormonally based contraceptive usage has been associated with both conditions as well. Because disc edema often occurs in CVST, and IIH and is evident in other sight- and life-threatening conditions such as intracranial mass lesions, neuroimaging and other ancillary testing must be conducted for definitive diagnosis. CASE: An 18-year-old white woman with IIH previously diagnosed presented with headaches and severe visual loss in the left eye. Bilateral disc edema with macular edema in the left eye (O.S.) was present. Threshold perimetry found bilaterally enlarged blind spots as well as a central scotoma O.S. Her medical history was significant for a right transverse, sigmoid and jugular siphon thrombosis secondary to a hypercoagulable state and associated with her use of oral birth control medication. Subsequent magnetic resonance venography (MRV) found the presence of CVST. Despite anticoagulation therapy and acetazolamide, she had severe, nonresolving papilledema. Treatment with oral prednisone was initiated. She recovered full visual fields and excellent visual acuity. CONCLUSION: Because of the similarity in clinical presentation of CVST and IIH, it is important to differentiate distinguishing characteristics of these diseases for correct diagnosis and prompt treatment.
Subject(s)
Contraception Behavior , Intracranial Hypertension/etiology , Sinus Thrombosis, Intracranial/complications , Adolescent , Diagnosis, Differential , Female , Glucocorticoids/therapeutic use , Humans , Intracranial Hypertension/diagnosis , Intracranial Hypertension/drug therapy , Jugular Veins , Magnetic Resonance Imaging , Papilledema/drug therapy , Papilledema/etiology , Prednisone/therapeutic use , Scotoma/etiology , Sinus Thrombosis, Intracranial/diagnosis , Sinus Thrombosis, Intracranial/drug therapy , Thrombophilia/chemically induced , Thrombophilia/complications , Treatment Outcome , Venous Thrombosis/etiologyABSTRACT
Este trabajo revisa la perspectiva histórica en la descripción de los 12 nervios craneanos hecha por los anatomistas clásicos, utilizando textos tradicionales y traducciones modernas. La historia de la enumeración de los nervios se remonta a Galeno con su clasificación en 7 pares, pasando por los 9 pares de Willis (1664) y los 12 pares de Soemmerring (1778). Hubo contribuciones de anatomistas medievales como Achillini, Berengario de Carpi y Massa, a pesar de las prohibiciones que pesaron sobre los estudios anatómicos hasta el siglo XVI. La clasificación de los nervios craneanos en 9 pares se siguió utilizando hasta fines del siglo XIX, a pesar de que ya había sido aceptada su clasificación en 12 pares hacia 1778. Se recuerda también a aquellos autores que describieron estructuras individuales y las nombraron por primera vez.(AU)
Subject(s)
Cranial Nerves , Cranial Nerves/anatomy & histologyABSTRACT
Este trabajo revisa la perspectiva histórica en la descripción de los 12 nervios craneanos hecha por los anatomistas clásicos, utilizando textos tradicionales y traducciones modernas. La historia de la enumeración de los nervios se remonta a Galeno con su clasificación en 7 pares, pasando por los 9 pares de Willis (1664) y los 12 pares de Soemmerring (1778). Hubo contribuciones de anatomistas medievales como Achillini, Berengario de Carpi y Massa, a pesar de las prohibiciones que pesaron sobre los estudios anatómicos hasta el siglo XVI. La clasificación de los nervios craneanos en 9 pares se siguió utilizando hasta fines del siglo XIX, a pesar de que ya había sido aceptada su clasificación en 12 pares hacia 1778. Se recuerda también a aquellos autores que describieron estructuras individuales y las nombraron por primera vez.
Subject(s)
Cranial Nerves , Cranial Nerves/anatomy & histologyABSTRACT
Although measuring outcomes is essential to ensuring palliative care effectiveness, there is an absence of properly validated measures in many countries. We undertook a cross-cultural adaptation and validation of the Palliative Outcome Scale (POS) into a Spanish (Argentina) language and cultural context. The methodology used a sequence of phases: 1) verification of conceptual equivalence (literature review, professional interviews, and patient focus groups); 2) multiple translations; 3) committee review; and 4) field testing. Psychometric analysis entailed evaluation of quantitative content validity, construct validity, staff and patients' ratings comparison, internal consistency, test-retest reliability, and responsiveness to change. Conceptual equivalence was achieved. Multiple changes were introduced after the translations and field testing in 65 patients and 20 professionals. Content validity was high for all but one item. Construct validity against a validated quality-of-life measure (European Organization for Research and Treatment of Cancer Quality of Life C-30) was confirmed (rho=0.74, P<0.0005). There was acceptable agreement between staff and patients (Cohen's weighted kappa >0.3) for 5/10, 8/10, and 6/9 items at each of three time-point evaluations and good correlation for all but one item (Spearman coefficient >0.7). Internal consistency was acceptable (Cronbach's alpha=0.68-0.69 and 0.66-0.73) for patient and staff ratings, respectively, and test-retest reliability showed very high agreement for every item (>0.80). The Argentine POS showed adequate responsiveness to change, although significant difference was reached for only 3 out of 10 items for patients and staff, respectively. Completion of the POS did not take more than 12 and 6 minutes for patients and staff, respectively. This study indicates that the Argentine POS is a valid and reliable measure of palliative care outcomes with advanced cancer patients.
Subject(s)
Culture , Medical Audit/methods , Outcome Assessment, Health Care/methods , Palliative Care/standards , Quality of Life , Adult , Aged , Aged, 80 and over , Argentina , Female , Humans , Male , Middle Aged , Reproducibility of ResultsABSTRACT
Objetivos: Describir la anatomía endoscópica del acueducto mesencefálico. Detallar la técnica para el abordaje con éxito de la reción. Enumerar los reparos anatómicos endoscópicos que el cirujano debe conocer para llevar a cabo con éxito el abordaje endoscópico. Método: Se utilizaron diez cadáverez adultos, obteniendose imágenes de 14 cirugías. Utilizamos endoscopios rígidos de cero grados para la inspección del acueducto mesencefálico. En aquellos casos en los que se observó una estenosis del acueducto llevamos a cabo una acueductoplastia con balón. Con la ayuda de un endoscopio flexible se exploró el acueducto y el cuarto ventrículo y se preforaron las obstrucciones membranosas. en un caso fue necesario insertar un stent en el acueducto. Resultados: El acueducto mesencefálico, también llamado acueducto de Silvio, comunica el tercer ventrículo con el cuarto. La entrada al mismo se encuentra en la pared posterior del tercer ventrículo. Esta pared es muy estrecha y se pueden identificar en ella varias estructuras, que en sentido cráneo-caudal son: el receso suprapineal, la comisura habenular, el receso pineal, la comisura posterior, y la entrada al acueducto. En condiciones normales, la entrada al acueducto en el piso del tercer ventrículo es de un ancho aproximado de 1 mm, por lo tanto, el escaso diámetro impide su canulación segura con elementos endoscópicos. En los casos en que el acueducto se encuentra dilatado se constituye en el camino ideal para llegar al cuarto ventrículo y navegar a través del mismo sin dificultad. Conclusión: La región del acueducto es de difícil abordaje, por lo tanto es imprescindible conocer la anatomía endoscópica para poder llevar a cabo con éxito los diversos procedimientos quirúrgicos. (AU)
Subject(s)
Adult , Humans , Cerebral Aqueduct , Endoscopy , Cerebral Aqueduct/anatomy & histology , Cerebral Aqueduct/surgery , General Surgery/methodsABSTRACT
Objetivos: Describir la anatomía endoscópica del acueducto mesencefálico. Detallar la técnica para el abordaje con éxito de la reción. Enumerar los reparos anatómicos endoscópicos que el cirujano debe conocer para llevar a cabo con éxito el abordaje endoscópico. Método: Se utilizaron diez cadáverez adultos, obteniendose imágenes de 14 cirugías. Utilizamos endoscopios rígidos de cero grados para la inspección del acueducto mesencefálico. En aquellos casos en los que se observó una estenosis del acueducto llevamos a cabo una acueductoplastia con balón. Con la ayuda de un endoscopio flexible se exploró el acueducto y el cuarto ventrículo y se preforaron las obstrucciones membranosas. en un caso fue necesario insertar un stent en el acueducto. Resultados: El acueducto mesencefálico, también llamado acueducto de Silvio, comunica el tercer ventrículo con el cuarto. La entrada al mismo se encuentra en la pared posterior del tercer ventrículo. Esta pared es muy estrecha y se pueden identificar en ella varias estructuras, que en sentido cráneo-caudal son: el receso suprapineal, la comisura habenular, el receso pineal, la comisura posterior, y la entrada al acueducto. En condiciones normales, la entrada al acueducto en el piso del tercer ventrículo es de un ancho aproximado de 1 mm, por lo tanto, el escaso diámetro impide su canulación segura con elementos endoscópicos. En los casos en que el acueducto se encuentra dilatado se constituye en el camino ideal para llegar al cuarto ventrículo y navegar a través del mismo sin dificultad. Conclusión: La región del acueducto es de difícil abordaje, por lo tanto es imprescindible conocer la anatomía endoscópica para poder llevar a cabo con éxito los diversos procedimientos quirúrgicos.
Subject(s)
Adult , Humans , Cerebral Aqueduct , Endoscopy , Cerebral Aqueduct , General Surgery/methodsABSTRACT
Objetivos: Estudiar la anatomía endoscópica de los componentes diencefálicos de las paredes del tercer ventrículo y de las estructuras adyacentes a éste. Establecer las bases anatómicas para la intervención quirúrgica con éxito de las lesiones que involucran al tercer ventrículo. Método: Se estudiaron 10 cadáveres adultos, obteniendose imágenes de 9 cirugías mediante técnica endoscópica. Se emplearon endoscopios rígidos de cero grados de angulación y de díametros de 1, 8 milímetros. En algunos casos fue necesario utilizar un endoscopio flexible. En todos los casos el abordaje fue precoronal y se utilizó instrumental específico para neuroendoscopía. Resultados: El Tercer ventrículo es una cavidad medial, estrecha, localizada por debajo de los ventrículos laterales, entre las masas diencefálicas. Se describen un techo y un piso, una pared anterior y otra posterior, y dos paredes laterales...(AU)
Subject(s)
Adult , Third Ventricle , Thalamus , Hypothalamus , EndoscopyABSTRACT
Objetivos: Estudiar la anatomía endoscópica de los componentes diencefálicos de las paredes del tercer ventrículo y de las estructuras adyacentes a éste. Establecer las bases anatómicas para la intervención quirúrgica con éxito de las lesiones que involucran al tercer ventrículo. Método: Se estudiaron 10 cadáveres adultos, obteniendose imágenes de 9 cirugías mediante técnica endoscópica. Se emplearon endoscopios rígidos de cero grados de angulación y de díametros de 1, 8 milímetros. En algunos casos fue necesario utilizar un endoscopio flexible. En todos los casos el abordaje fue precoronal y se utilizó instrumental específico para neuroendoscopía. Resultados: El Tercer ventrículo es una cavidad medial, estrecha, localizada por debajo de los ventrículos laterales, entre las masas diencefálicas. Se describen un techo y un piso, una pared anterior y otra posterior, y dos paredes laterales...(AU)
Subject(s)
Adult , Third Ventricle , Thalamus , Hypothalamus , EndoscopyABSTRACT
Objetivos: Estudiar la anatomía endoscópica de los componentes diencefálicos de las paredes del tercer ventrículo y de las estructuras adyacentes a éste. Establecer las bases anatómicas para la intervención quirúrgica con éxito de las lesiones que involucran al tercer ventrículo. Método: Se estudiaron 10 cadáveres adultos, obteniendose imágenes de 9 cirugías mediante técnica endoscópica. Se emplearon endoscopios rígidos de cero grados de angulación y de díametros de 1, 8 milímetros. En algunos casos fue necesario utilizar un endoscopio flexible. En todos los casos el abordaje fue precoronal y se utilizó instrumental específico para neuroendoscopía. Resultados: El Tercer ventrículo es una cavidad medial, estrecha, localizada por debajo de los ventrículos laterales, entre las masas diencefálicas. Se describen un techo y un piso, una pared anterior y otra posterior, y dos paredes laterales...
