Randomized Controlled Trial of Telementoring During Resource-Limited Patient Care Simulation Improves Caregiver Performance and Patient Survival.

OBJECTIVES: To determine the impact of telementoring on caregiver performance during a high-fidelity medical simulation model (HFMSM) of a critically ill patient in a resource-limited setting. DESIGN: A two-center, randomized, controlled study using a HFMSM of a patient with community-acquired pneumonia complicated by acute respiratory distress syndrome. SETTING: A notional clinic in a remote location staffed by a single clinician and nonmedical assistant. PARTICIPANTS: Clinicians with limited experience managing critically ill patients. INTERVENTIONS: Telemedicine (TM) support. MEASUREMENTS: The primary outcome was clinical performance as measured by accuracy, reliability, and efficiency of care. Secondary outcomes were patient survival, procedural quality, subjective assessment of the HFMSM, and perceived workload. MAIN RESULTS: TM participants (N = 11) performed better than non-TM (NTM, N = 12) in providing expected care (accuracy), delivering care more consistently (reliability), and without consistent differences in efficiency (timeliness of care). Accuracy: TM completed 91% and NTM 42% of expected tasks and procedures. Efficiency: groups did not differ in the mean (± sd) minutes it took to obtain an advanced airway successfully (TM 15.2 ± 10.5 vs. NTM 22.8 ± 8.4, p = 0.10) or decompress a tension pneumothorax with a needle (TM 0.7 ± 0.5 vs. NTM 0.6 ± 0.9, p = 0.65). TM was slower than NTM in completing thoracostomy (22.3 ± 10.2 vs. 12.3 ± 4.8, p = 0.03). Reliability: TM performed 13 of 17 (76%) tasks with more consistent timing than NTM. TM completed 68% and NTM 29% of procedural quality metrics. Eighty-two percent of the TM participants versus 17% of the NTM participants simulated patients survived (p = 0.003). The groups similarly perceived the HFMSM as realistic, managed their patients with personal ownership, and experienced comparable workload and stress. CONCLUSIONS: Remote expertise provided with TM to caregivers in resource-limited settings improves caregiver performance, quality of care, and potentially real patient survival. HFMSM can be used to study interventions in ways not possible with real patients.

Next-generation tourniquet: Recommendations for future capabilities and design requirements.

BACKGROUND: Advances in tourniquet development must meet new military needs for future large-scale combat operations or civilian mass casualty scenarios. This includes the potential use of engineering and automation technologies to provide advanced tourniquet features. A comprehensive set of design capabilities and requirements for an intelligent or smart tourniquet needed to meet the challenges currently does not exist. The goal of this project was to identify key features and capabilities that should be considered for the development of next-generation tourniquets. METHODS: We used a modified Delphi consensus technique to survey a panel of 34 tourniquet subject matter experts to rate various statements and potential design characteristics relevant to tourniquets systems and their use scenarios. Three iterative rounds of surveys were held, followed by virtual working group meetings, to determine importance or agreement with any given statement. We used a tiered consensus system to determine final agreement over key features that were viewed as important or unimportant features or capabilities. This information was used to refine and clarify the necessary tourniquet design features and adjust questions for the following surveys. RESULTS: Key features and capabilities of various were agreed upon by the panelists when consensus was reached. Some tourniquet features that were agreed upon included but are not limited to: Capable of being used longer than 2 hours, applied and monitored by anyone, data displays, semiautomated capabilities with inherent overrides, automated monitoring with notifications and alerts, and provide recommended actions. CONCLUSION: We were able to identify key tourniquet features that will be important for future device development. These consensus results can guide future inventors, researchers, and manufacturers to develop a portfolio of next-generation tourniquets for enhancing the capabilities of a prehospital medical provider. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level V.

Prolonged, High-Fidelity Simulation for Study of Patient Care in Resource-Limited Medical Contexts and for Technology Comparative Effectiveness Testing.

Most high-fidelity medical simulation is of limited duration, used for education and training, and rarely intended to study medical technology. U.S. caregivers working in prehospital, resource-limited settings may need to manage patients for extended periods (hours to days). This "prolonged casualty care" occurs during military, wilderness, humanitarian, disaster, and space medicine. We sought to develop a standardized simulation model that accurately reflects prolonged casualty care in order to study caregiver decision-making and performance, training requirements, and technology use in prolonged casualty care. DESIGN: Model development. SETTING: High-fidelity simulation laboratory. SUBJECTS: None. INTERVENTIONS: We interviewed subject matter experts to identify relevant prolonged casualty care medical challenges and selected two casualty types to further develop our model: a large thermal burn model and a severe hypoxia model. We met with a multidisciplinary group of experts in prolonged casualty care, nursing, and critical care to describe how these problems could evolve over time and how to contextualize the problems with a background story and clinical environment with expected resource availability. Following initial scenario drafting, we tested the models with expert clinicians. After multiple tests, we selected the hypoxia model for refinement and testing with inexperienced providers. We tested and refined this model until two research teams could proctor the scenario consistently despite subject performance variability. MEASUREMENTS AND MAIN RESULTS: We developed a 6-8-hour simulation model that represented a 14-hour scenario. This model of pneumonia evolved from presentation to severe hypoxia necessitating advanced interventions including airway, breathing, and shock management. The model included: context description, caregiver orientation scripts, hourly progressive physiology tracks corresponding to caregiver interventions, intervention/procedure-specific physiology tracks, intervention checklists, equipment lists, prestudy checklists, photographs of setups, procedure, telementor, and role player scripts, business rules, and data collection methods. CONCLUSIONS: This is the first standardized, high-fidelity simulation model of prolonged casualty care described in the literature. It may be used to assess caregiver performance and patient outcomes resulting from that performance during a complex, 14-hour prolonged casualty care scenario. Because it is standardized, the model may be used to compare differences in the impact of new technologies upon caregiver performance and simulated patient outcomes..

Improving Clinician Decisions and Communication in Critical Care Using Novel Information Technology.

INTRODUCTION: The electronic medical record (EMR) is presumed to support clinician decisions by documenting and retrieving patient information. Research shows that the EMR variably affects patient care and clinical decision making. The way information is presented likely has a significant impact on this variability. Well-designed representations of salient information can make a task easier by integrating information in useful patterns that clinicians use to make improved clinical judgments and decisions. Using Cognitive Systems Engineering methods, our research team developed a novel health information technology (NHIT) that interfaces with the EMR to display salient clinical information and enabled communication with a dedicated text-messaging feature. The software allows clinicians to customize displays according to their role and information needs. Here we present results of usability and validation assessments of the NHIT. MATERIALS AND METHODS: Our subjects were physicians, nurses, respiratory therapists, and physician trainees. Two arms of this study were conducted, a usability assessment and then a validation assessment. The usability assessment was a computer-based simulation using deceased patient data. After a brief five-minute orientation, the usability assessment measured individual clinician performance of typical tasks in two clinical scenarios using the NHIT. The clinical scenarios included patient admission to the unit and patient readiness for surgery. We evaluated clinician perspective about the NHIT after completing tasks using 7-point Likert scale surveys. In the usability assessment, the primary outcome was participant perceptions about the system's ease of use compared to the legacy system.A subsequent cross-over, validation assessment compared performance of two clinical teams during simulated care scenarios: one using only the legacy IT system and one using the NHIT in addition to the legacy IT system. We oriented both teams to the NHIT during a 1-hour session on the night before the first scenario. Scenarios were conducted using high-fidelity simulation in a real burn intensive care unit room. We used observations, task completion times, semi-structured interviews, and surveys to compare user decisions and perceptions about their performance. The primary outcome for the validation assessment was time to reach accurate (correct) decision points. RESULTS: During the usability assessment, clinicians were able to complete all tasks requested. Clinicians reported the NHIT was easier to use and the novel information display allowed for easier data interpretation compared to subject recollection of the legacy EMR.In the validation assessment, a more junior team of clinicians using the NHIT arrived at accurate diagnoses and decision points at similar times as a more experienced team. Both teams noted improved communication between team members when using the NHIT and overall rated the NHIT as easier to use than the legacy EMR, especially with respect to finding information. CONCLUSIONS: The primary findings of these assessments are that clinicians found the NHIT easy to use despite minimal training and experience and that it did not degrade clinician efficiency or decision-making accuracy. These findings are in contrast to common user experiences when introduced to new EMRs in clinical practice.

Cacogeusia e ingesta de piñones / Cacogeusia and ingestion of pine nuts

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Photodynamic therapy has antifungal effect and reduces inflammatory signals in Candida albicans-induced murine vaginitis.

BACKGROUND: Vaginal candidiasis (VC) is a disease that affects thousands of women of childbearing age, mainly caused by Candida albicans fungus. Photodynamic therapy (PDT) uses photosensitizing substances that are nontoxic in the dark, but able to produce reactive oxygen species when they are subjected to a light source. In this work our purpose was to investigate PDT effects on fungal burden and inflammatory cells in a murine model of C. albicans-induced vaginal candidiasis. METHODS: Female BALB/c mice 6-10 weeks were estrogenized and maintained in this state during all experiment. After 72h, mices were inoculated intravaginally (IV) with 20µL of 2×10(5)C. albicans cells suspension. Mice were separated into 5 groups after five days: H (healthy), PBS (control), laser, MB (methylene blue) and PDT. PDT and MB groups received IV 20µL solution with 1mM of MB, others received PBS. PDT and laser groups were irradiated with a red laser (100mW, 660nm) in one (36J, 6min) or two sessions (18J, 3min). After the end of treatment, mice were submitted to microbiological and histomorphometric analysis with ImageJ software. Data were plotted by mean values and standard deviations of CFU/mL and percentage of inflammatory cells area. ANOVA and Bonferroni post-test were used and data were considered significant when p<0.05. RESULTS: PDT significantly reduced C. albicans after the two tested protocols, however, percentage area of inflammatory cells was significantly reduced just with two sessions of PDT. CONCLUSIONS: PDT with MB and red laser is a promising therapy for VC. It is able to reduce fungal infection in biofilm and inflammatory signals associated with VC in a murine model of vaginitis.

The removal and degradation of pharmaceutical compounds during membrane bioreactor treatment.

Pharmaceutical compounds such as non-steroidal anti-inflammatory drugs (NSAIDs) and antibiotics have been detected in sewage treatment plant (STP) effluents, surface and ground water and even in drinking water all over the world, and therefore have developed as compounds of concern. Membrane bioreactor (MBR) treatment has gained significant popularity as an advanced wastewater treatment technology and might be effective for an advanced removal of these pollutants. This paper evaluates the treatment of wastewater containing three NSAIDs (acetaminophen, ketoprofen and naproxen) and three antibiotics (roxithromycin, sulfamethoxazole and trimethoprim) performed in two MBRs with sludge retention times (SRTs) of 15 (MBR-15) and 30 (MBR-30) days over a period of four weeks. It was observed that NSAIDs were removed with higher efficiencies than the antibiotics for both MBRs, and the MBR-30 presented higher removal efficiencies for all the compounds than obtained by MBR-15. Removal rates ranged from 55% (sulfamethoxazole) up to 100% (acetaminophen, ketoprofen). Besides mineralisation biological transformation products of ketoprofen and naproxen produced by wastewater biocoenosis were identified in both MBR permeates using liquid chromatography coupled with mass spectrometry (LC-MS). The results indicated the importance of investigating the environmental fate of pharmaceuticals and their transformation products reaching the environment.

Premature discontinuation of interferon plus ribavirin for adverse effects: a multicentre survey in 'real world' patients with chronic hepatitis C.

BACKGROUND: Interferon-alpha plus ribavirin therapy for chronic hepatitis C is associated with adverse effects that lead to therapy discontinuation in up to 27% of patients in randomized controlled trials. AIM: To examine the causes and predictive factors for therapy discontinuation in patients treated in current clinical practice. METHODS: We retrospectively enrolled 441 consecutive patients, scheduled to receive interferon-alpha + ribavirin for chronic hepatitis C, in five centres. Patients had been treated with 3 or 6 MU interferon-alpha three times a week plus ribavirin, 800-1200 mg daily, for 6 or 12 months. RESULTS: One hundred and eight [24.5%; confidence interval (CI), 20.5-28.8%] patients failed to finish combination therapy because of adverse events. The discontinuation rate was higher during the first 6 months of treatment; anaemia was an important cause (36.1% of discontinuations); unexplained lipothymia resulted in discontinuation in 11 patients. Female gender [hazard ratio (HR) = 1.85; CI, 1.17-2.92], an interferon-alpha dose > 15 MU/week (HR = 1.79; CI, 1.12-2.86) and no previous interferon-alpha treatment (HR = 1.63; CI, 1.04-2.57) were independent factors associated with discontinuation. The simultaneous presence of these factors identified patients at high risk for discontinuation [odds ratio (OR) = 10; CI, 3.98-25.13]. CONCLUSIONS: The study identified some predictive factors for adverse event-related discontinuation, which may improve the safety profile and effectiveness of interferon-alpha + ribavirin combination therapy in chronic hepatitis C.

[Psychiatric reform in Brazil: contextualization and thoughts about the care for the mentally ill in the family]. / A reforma psiquiátrica no Brasil: contextualização e reflexos sobre o cuidado com o doente mental na família.

This work analyzes the consequences of the Brazilian psychiatric reform to the care provided to the mentally ill in their family environment. It is a descriptive and exploratory study based on a qualitative approach, using the historical-dialectic materialism as its theoretical and methodological framework. The subjects of the research were 11 women that provided care to mentally ill persons. The analysis of their discourses revealed unique aspects related to caring for the mentally ill in their family environment and the difficulties resulting from the process of institutionalization of the mentally ill. The conclusion is that women who provide care for the mentally ill have an important social role that is indispensable to the consolidation of the psychiatric reform in the country.

Effects of multiple injections of ethane 1,2-dimethane sulphonate (EDS) on the frog, Rana esculenta, testicular activity.

Ethane 1,2-dimethane sulphonate (EDS) is an alkylating agent, which has a selective cytotoxic effect on Leydig cells in some mammalian species. Similarly, in the frog, Rana esculenta, Leydig cells are destroyed after a single EDS injection and regenerate after 28 days. Regeneration of Leydig cells in frogs appears to be independent of the pituitary. The present experiments in R. esculenta were carried out: a) to investigate Leydig cell responsiveness to gonadotropin stimulation during 58 days after a single EDS injection; and b) to assess whether four consecutive EDS injections induce additional effects on the testicular cell population. Our results show that androgen stimulation after gonadotropin injections is restored after 44 days from a single EDS injection. Since the interstitial compartment appears to be normal at least 28 days after EDS treatment, it is likely that new Leydig cells lack gonadotropin receptors. With respect to multiple-EDS injections, Leydig cells completely disappear in several areas and the adjacent germinal compartment is disorganised. In some cases damaged germinal compartment is still surrounded by intact Leydig cells. Surprisingly, testicular and plasma androgens strongly increase in EDS-treated animals. Therefore, Sertoli cells may produce substances inhibiting androgen production in Leydig cells. J. Exp. Zool. 287:384-393, 2000.

[The home caregiver in Betim/MG]. / O ser cuidador na Internação Domiciliar em Betim/MG.

This is a qualitative study about the care provided by "caregivers" enrolled in the Home Care Program in Betim, Minas Gerais. Interviews were held during home visits in order to identify characteristics of home care providers, analyze their perception about health care, verify factors which interfere in home care and relationships which are established between caregiver/person cared for/other family members. Discourse analysis (Fiorin, 1993) was used to build the empirical categories which revealed that most of the caregivers are family members, women, average age of 42 years, limited schooling, mostly housewives. The subjects sampled reported that the act of caring involves technique, duty and dedication. They referred to financial difficulties, physical and emotional stress. The relationships established during care involved feelings of pleasure, satisfaction and helplessness in the face of the needs and sufferings of the person cared for. The authors concluded that home care fosters more humane care, but requires technical guidance and emotional training for the caregivers and support from the health institution.

[Reception: possibility of reorganizing nursing care]. / Acolhimento: perspectiva de reorganização da assistência de enfermagem.

The study analyzes reception as a strategy for reorganizing nursing care, identifying its presuppotions and mechanisms which make it possible to implement and qualifying potentialities of care. It uses the qualitive approach, giving priority to primary sources: questionnaires answered by managers, degree nurses, nursing auxilliares and doctors from the Municipal Health Office of Belo Horizonte. It was found that the nursing auxiliary is the main person carrying out this activity, followed by the degree nurse. The main activities are listening, screening and forwarding, with little focus on guidance. The actors emphasize team integration and the understanding of the work process as facilitating factors. The training and qualification of professionals was considered as one of the mechanisms to overcome difficulties. It reveals the failures of the structure of service for reception. The conclusion is that this practice suggests the need for the reorganization of the nursing work process in order to improve the quality of health care.

[Innovative initiative in nursing teaching in Latin America]. / Iniciativa de inovação do ensino de enfermagem na América Latina.

The study describes a set of nine projects which are initiatives in the innovation of the teaching twelve country of Nursing in Latin America. It discusses the purpose of these projects so as to incorporate pedagogical concepts which are critical and provoke reflection, and active methods of teaching and analysis of conceptual aspects, the management, strategies and models which are adopted. It describes the common features of the courses in the semi-present and distance forms and analyzes the teaching methods which focus on the teacher-student relation, as strengthening group and independent learning, as well as the use of adequate teaching materials. It also analyzes the communication system established by the projects, which seeks to strengthen horizontal relations, incorporating technology and distance education. It concludes by suggesting that this initiative is a suitable strategy to contribute to build new models for training nursing personnel.

Fear, anxiety and perceived control in children of agoraphobic parents.

Sixteen children (M = 11 years) of agoraphobic parents were compared with 16 children of parents with no history of psychopathology, matched on age, gender and socioeconomic status. The majority (68%) of children of agoraphobic parents met DSM-III-R diagnostic criteria, anxiety disorders being most common. They reported more fear and anxiety and less control over various risks than did comparison children. Group's perceptions of the prevalence and their vulnerability to these risks did not differ. Agoraphobic mothers reported more separation anxiety than did comparison mothers, and maternal separation anxiety was negatively correlated with children's perceived control. Results are related to models of anxiety transmission.

Typhoid fever in the Neapolitan area: a case-control study.

Typhoid fever is endemic in the Neapolitan area, where its yearly incidence rate largely exceeds the corresponding national figure. During the period from January to June, 1990, a matched case-control study was carried out in order to identify risk factors of the disease in this area; 51 subjects (mean age 27.2 years) with typhoid fever were compared with 102 controls matched with respect to age, sex and educational level. Consumption of raw shellfish was reported by 76.5% of the cases, as opposed to 19.6% of the controls (P < 0.01). Subjects who had eaten this food item had a 13.3-fold risk (C.I. 95% = 5.5 - 32.8) of contracting typhoid fever. In contrast, no risk was found to be associated with consumption of cooked shellfish, raw vegetables, ice-cream, non-potable water, or unpasteurized milk. The risk factor identified in this study shows that hazardous dietary habits and inadequate sewage treatment facilities, combined with lack of sanitation in the harvesting and marketing of shellfish, play a major role in the endemicity of typhoid fever in the Neapolitan area.