Cost and outcomes after cold and mixed adenotonsillectomy in children.

OBJECTIVE/HYPOTHESIS: To compare cold and mixed (electrocautery tonsillectomy with curettage adenoidectomy) adenotonsillectomies in children in terms of hospital medications' and materials' costs, surgical time, aspirated blood volume, and postoperative pain. STUDY DESIGN: Randomized clinical trial in community hospitals. METHODS: Seventy-two patients aged 3 to 12 years, undergoing adenotonsillectomy, were randomized in two groups through sealed envelopes that were opened just prior to the procedure. Surgical time and aspirated blood volume were measured by a staff nurse. Hospital medication and material costs were supplied by the hospital's accounting department. A validated facial pain scale was used from the day of surgery to the 10th postoperative day to quantify pain. RESULTS: Bicaudal t test showed that materials' cost was lower in the mixed technique. Surgical time and aspirated blood volume were also lower with the mixed technique. The postoperative pain was more intense in the cold technique on the day of surgery, but was more intense in the mixed technique from the 4th day to the 6th day. Linear regression showed a weak association between materials' cost and aspirated blood volume. CONCLUSIONS: Mixed technique reduces the costs of materials while offering the patient and the surgeon a safer and faster method to perform adenotonsillectomy, although it is slightly more painful than the cold technique in the latter part of the postoperative period.

Clinical reasoning in the real world is mediated by bounded rationality: implications for diagnostic clinical practice guidelines.

BACKGROUND: Little is known about the reasoning mechanisms used by physicians in decision-making and how this compares to diagnostic clinical practice guidelines. We explored the clinical reasoning process in a real life environment. METHOD: This is a qualitative study evaluating transcriptions of sixteen physicians' reasoning during appointments with patients, clinical discussions between specialists, and personal interviews with physicians affiliated to a hospital in Brazil. RESULTS: FOUR MAIN THEMES WERE IDENTIFIED: simple and robust heuristics, extensive use of social environment rationality, attempts to prove diagnostic and therapeutic hypothesis while refuting potential contradictions using positive test strategy, and reaching the saturation point. Physicians constantly attempted to prove their initial hypothesis while trying to refute any contradictions. While social environment rationality was the main factor in the determination of all steps of the clinical reasoning process, factors such as referral letters and number of contradictions associated with the initial hypothesis had influence on physicians' confidence and determination of the threshold to reach a final decision. DISCUSSION: Physicians rely on simple heuristics associated with environmental factors. This model allows for robustness, simplicity, and cognitive energy saving. Since this model does not fit into current diagnostic clinical practice guidelines, we make some propositions to help its integration.

Carcinoma espinocelular de osso temporal como diagnóstico diferencial de otite externa maligna / Epidermoid carcinoma of temporal bone as a diferential diagnosis of malignant external otitis

Os autores apresentam um caso de carcinoma espinocelular de osso temporal que mimetizou otite externa maligna. Apresentam uma revisäo de otite externa maligna e de carcinoma espinocelular de osso temporal. Sugerem que a biópsia da lesäo faça parte do protocolo de investigaçäo dos casos de otite externa maligna.

Incidência de enteroparasitas em crianças de Joinville (SC) / Incidence of intestinal parasitosis in children from Joinville (SC)

Para determinar a incidência de enteroparasitoses em crianças de Joinville (SC) foram estudadas 156 crianças matriculadas em um colégio de regime aberto e 31 crianças matriculadas em regime de semi-internato. Realizou-se exame parasitológico de fezes pelos métodos de Faust et al. e Hoffman, Pons & Janner para cada criança. Determinou-se que no regime aberto 39 por cento das crianças estavam infectadas, contra 74 por cento do regime de semi-internato; quanto ao sexo 50 por cento dos meninos contra 31 por cento das meninas estavam infectados. No regime aberto a maior incidência foi de Giardia lamblia (41 por cento), já no semi-internato foi de Entamoeba coli. Os resultados demonstram as más condiçoes de saneamento básico que nos atinge, e a relaçao entre o convívio e a disseminaçao dos parasitas.