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.

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

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.

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.

Prevalence of mastitis and characterization of milking management of dairy cows in northwestern Sao Paulo State / Prevalência de mastite e caracterização do manejo de ordenha de bovinos leiteiros da região de Fernandópolis, São Paulo

The lack of application of good practices in milking management can lead to the occurrence of one of the main diseases affecting the Brazilian dairy herd - mastitis. This study was developed to examine the prevalence of clinical and subclinical mastitis as well as to evaluate the contribution of milking management to this prevalence, thereby providing bases for a better control of mastitis in dairy herds at Fernandopolis region, Sao Paulo State, Brazil The study involved nine farms with 223 lactating cows. All cows were evaluated by the strip-cup test and the California Mastitis Test (CMT). In addition, the employees' conduct during milking; the physical structure of the farm; animal handling; and dry cow treatment were observed. Results were tabulated and evaluated for the development of a flowchart of good practices. Subclinical mastitis was detected in 30.5% of the farms; 66.7% perform mechanical milking and 89% have a cooling tank, but 77.7% do not sanitize the equipment after milking. Pre-and post-dipping were not performed by 89%; 66.6% do not adopt a milking line; and none of the farms realized mastitis detection tests. In conclusion, subclinical mastitis is present in the evaluated herds. By observing the management adopted on each farm, the main critical points were found to be related to failures in handling and in milking and equipment hygiene. The implementation of a flowchart of good milking practices is extremely important for the producer, since the main method to avert and control infection is prevention.(AU)

A falta da aplicação de boas práticas no manejo de ordenha pode resultar na ocorrência de uma das principais doenças que acomete o rebanho leiteiro no Brasil, a mastite. O objetivo deste trabalho foi avaliar a prevalência de mastite clínica e subclínica bem como avaliar a contribuição do manejo da ordenha nessa prevalência para que, dessa forma, se tenham subsídios que proporcionem um melhor controle da mastite em rebanhos leiteiros da região de Fernandópolis, São Paulo. Participaram da pesquisa 9 propriedades rurais, com 223 vacas em lactação. Todas as vacas em lactação foram avaliadas por meio da realização do teste da caneca de fundo escuro e CMT (“California Mastitis Test”). Além disso foi realizada observação da conduta do funcionário durante a ordenha, estrutura física da propriedade, manejo com os animais e tratamento das vacas secas. Os resultados obtidos foram tabulados, avaliados para elaboração de um fluxograma de ações de boas práticas. A prevalência de mastite subclínica detectada foi de 30,5%, sendo que, 66,7% possuíam ordenha mecânica e 89% tanque de expansão, mas 77,7% não efetuavam higiene dos equipamentos após ordenha. O pré e o pós-dipping não eram realizados por 89%, sendo que, 66,6% não faziam linha de ordenha e ninguém realizava testes de detecção de mastite. Conclui-se que a mastite subclínica está presente nos rebanhos avaliados. Pode-se observar o manejo adotado em cada propriedade e elencar os principais pontos críticos sendo eles relacionados principalmente a falhas de manejo e higiene de ordenha e equipamentos. A implantação do fluxograma de boas práticas de ordenha é de extrema importância para o produtor, uma vez que, o principal método para evitar e controlar a infecção é a prevenção.(AU)

Prevalence of mastitis and characterization of milking management of dairy cows in northwestern Sao Paulo State / Prevalência de mastite e caracterização do manejo de ordenha de bovinos leiteiros da região de Fernandópolis, São Paulo

The lack of application of good practices in milking management can lead to the occurrence of one of the main diseases affecting the Brazilian dairy herd - mastitis. This study was developed to examine the prevalence of clinical and subclinical mastitis as well as to evaluate the contribution of milking management to this prevalence, thereby providing bases for a better control of mastitis in dairy herds at Fernandopolis region, Sao Paulo State, Brazil The study involved nine farms with 223 lactating cows. All cows were evaluated by the strip-cup test and the California Mastitis Test (CMT). In addition, the employees' conduct during milking; the physical structure of the farm; animal handling; and dry cow treatment were observed. Results were tabulated and evaluated for the development of a flowchart of good practices. Subclinical mastitis was detected in 30.5% of the farms; 66.7% perform mechanical milking and 89% have a cooling tank, but 77.7% do not sanitize the equipment after milking. Pre-and post-dipping were not performed by 89%; 66.6% do not adopt a milking line; and none of the farms realized mastitis detection tests. In conclusion, subclinical mastitis is present in the evaluated herds. By observing the management adopted on each farm, the main critical points were found to be related to failures in handling and in milking and equipment hygiene. The implementation of a flowchart of good milking practices is extremely important for the producer, since the main method to avert and control infection is prevention.

A falta da aplicação de boas práticas no manejo de ordenha pode resultar na ocorrência de uma das principais doenças que acomete o rebanho leiteiro no Brasil, a mastite. O objetivo deste trabalho foi avaliar a prevalência de mastite clínica e subclínica bem como avaliar a contribuição do manejo da ordenha nessa prevalência para que, dessa forma, se tenham subsídios que proporcionem um melhor controle da mastite em rebanhos leiteiros da região de Fernandópolis, São Paulo. Participaram da pesquisa 9 propriedades rurais, com 223 vacas em lactação. Todas as vacas em lactação foram avaliadas por meio da realização do teste da caneca de fundo escuro e CMT (“California Mastitis Test”). Além disso foi realizada observação da conduta do funcionário durante a ordenha, estrutura física da propriedade, manejo com os animais e tratamento das vacas secas. Os resultados obtidos foram tabulados, avaliados para elaboração de um fluxograma de ações de boas práticas. A prevalência de mastite subclínica detectada foi de 30,5%, sendo que, 66,7% possuíam ordenha mecânica e 89% tanque de expansão, mas 77,7% não efetuavam higiene dos equipamentos após ordenha. O pré e o pós-dipping não eram realizados por 89%, sendo que, 66,6% não faziam linha de ordenha e ninguém realizava testes de detecção de mastite. Conclui-se que a mastite subclínica está presente nos rebanhos avaliados. Pode-se observar o manejo adotado em cada propriedade e elencar os principais pontos críticos sendo eles relacionados principalmente a falhas de manejo e higiene de ordenha e equipamentos. A implantação do fluxograma de boas práticas de ordenha é de extrema importância para o produtor, uma vez que, o principal método para evitar e controlar a infecção é a prevenção.

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.

Using Cell Cultures for the Investigation of Treatments for Attention Deficit Hyperactivity Disorder: A Systematic Review.

BACKGROUND: Advances in basic and molecular biology have promoted the use of cell cultures in a wide range of areas, including the evaluation of drug efficacy, safety and toxicity. OBJECTIVE: This article aims to provide a general overview of the methodological parameters of cell cultures used to investigate therapeutic options for Attention Deficit Hyperactivity Disorder. METHOD: A systematic search was performed in the electronic databases PubMed, Scopus, and DOAJ. In vitro experimental studies using cell cultures were included. RESULTS: A total of 328 studies were initially identified, with 16 included for qualitative synthesis. Seven studies used neuronal cells (SH-SY5Y neuroblastoma and PC12 cell line) and nine used nonneuronal cells. All the studies described the culture conditions, but most studies were inconsistent with regard to reporting results and raw data. Only one-third of the studies performed cell viability assays, while a further 30% conducted gene expression analysis. Other additional tests included electrophysiological evaluation and transporter activity. More than 50% of the studies evaluated the effects of drugs such as methylphenidate and atomoxetine, while plant extracts were assessed in four studies and polyunsaturated fatty acids in one. CONCLUSION: We suggested a flowchart to guide the planning and execution of studies, and a checklist to be completed by authors to allow the standardized reporting of results. This may guide the elaboration of laboratory protocols and further in vitro studies.

Use of Flowchart for Automation of Clinical Protocols in mHealth.

For healthcare professionals to use mobile applications we need someone who knows software development, provide them. In healthcare institutions, health professionals use clinical protocols to govern care, and sometimes these documents are computerized through mobile applications to assist them. This work aims to present a proposal of an application of flow as a way of describing clinical protocols for automatic generation of mobile applications to assist health professionals. The purpose of this research is to enable health professionals to develop applications from the description of their own clinical protocols. As a result, we developed a web system that automates clinical protocols for an Android platform, and we validated with two clinical protocols used in a Brazilian hospital. Preliminary results of the developed architecture demonstrate the feasibility of this study.

Avaliação das etapas de recebimento, armazenamento e pré-preparo de produtos cárneos em unidade de alimentação e nutrição hospitalar / Evaluation of the steps of receiving, storing and preparation of meat products in the food and hospital nursing unit

A cadeia da carne envolve etapas que devem ser controladas, garantindo condições higiênicos sanitárias adequadas, principalmente nos hospitais, por lidar com a população enferma. Este artigo analisou o recebimento, armazenamento e pré-preparo, envolvendo a manipulação e descongelamento de produtos cárneos de uma unidade de alimentação e nutrição hospitalar, originando- se um estudo de caso de caráter qualitativo e quantitativo. A qualidade final destes produtos foi avaliada a partir dos procedimentos recomendados, referente aos fornecedores capacitados, ideal área de recebimento, acondicionamento adequado, descongelamento e manipulação em conformidade com as legislações vigentes confrontados com a RDC n° 216 (BRASIL, 2004) e Associação Brasileira de Refeições Coletivas (ABERC, 2009). Observou-se que o local cumpria várias normas propostas, entretanto devem-se rever alguns pontos como problemas com fornecedores (uniforme, veículo e acesso), adequação da área de recebimento, identificação do produto e da validade durante o armazenamento, método de descongelamento, e manipulação (temperatura e conduta do manipulador). É indispensável a garantia da qualidade da matéria-prima, visando a manutenção e/ou promoção da saúde de quem utilizará os serviços da Unidade de Alimentação e Nutrição. (AU)

The meat chain involves steps that must be controlled by ensuring adequate sanitary conditions, especially in hospitals, dealing with ill people. This article analysed the receiving, storage and pre-preparation, involving the handling and thawing of meat products from a unit of hospital food and nutrition, leading to a case study of qualitative and quantitative. The final quality of these products where evaluated from the recommended procedures, relating to suppliers adequated, ideally receiving area, correct preservation, thawing and handling in accordance with existing laws challenged by the RDC No. 216 (BRAZ1L, 2004) and Brazilian Association of Collective Meals (Abere, 2009). It was noted that the site met several proposed standards, but they need to revise some issues related to suppliers (uniform, and vehicle access), adequacy of the receiving area, product identification and validity during storage, thawing method, and manipulation (temperature and handling conduction). It is essential to guarantee the quality of raw materials for the maintenance and/or promotion of health of those who use the services of the Unit of Nutrition. (AU)

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.