RESUMEN
BACKGROUND: Children with complex chronic medical conditions benefit from early introduction of palliative care services and advanced care planning for symptom management and to support quality of life and medical decision-making. This study evaluated whether introducing palliative care during primary care appointments (1) was feasible; (2) increased access and improved knowledge of palliative care; and (3) facilitated advanced care planning. METHODS: Pilot study of a multi-modal intervention including targeted education for primary care providers (PCPs), an informational packet for families and presence of a palliative care team member in the outpatient clinic. PCPs completed pre- and post-surveys assessing experience, knowledge and comfort with palliative care. Enrolled families received an information packet; a subset also met a palliative care team member. All families were encouraged to make an appointment with the palliative care team, during which the team assessed palliative care needs and goals of care. Upon study completion, the investigators assessed family and PCP satisfaction and collected feedback on project feasibility. RESULTS: Twenty families were enrolled and received the information packet; 15 met a palliative care team member. Of the 17 participating families who were reached and completed a post-study survey, 11 families had never heard of palliative care and 13 were unaware that the palliative care team existed. Most families perceived palliative care information as 'very helpful' and 'very important'. All would recommend palliative care team services to others. Nine families followed up with the palliative care team, but none was prepared to complete an advanced care plan. PCPs reported lack of training in communicating bad news and conducting goals of care discussions. However, they felt increasingly comfortable introducing palliative care to families and supported program continuation. CONCLUSIONS: Initiating palliative care services in the outpatient primary care setting is logistically challenging but increases access to palliative care for children with complex chronic medical conditions and improves palliative care knowledge and comfort for PCPs.
Asunto(s)
Enfermedad Crónica/terapia , Cuidados Paliativos , Comodidad del Paciente/organización & administración , Atención Primaria de Salud/organización & administración , Cuidado Terminal/organización & administración , Adulto , Niño , Servicios de Salud del Niño/organización & administración , Enfermedad Crónica/psicología , Femenino , Humanos , Masculino , Padres/psicología , Grupo de Atención al Paciente , Proyectos Piloto , Calidad de VidaRESUMEN
BACKGROUND: Risk factors for the development of posttransplant lymphoproliferative disease (PTLD), a major cause of morbidity and mortality after pediatric liver transplantation, are primary Epstein-Barr virus (EBV) infection and intensity of immunosuppression. The authors assessed monitoring of EBV replication and preemptive immunosuppression reduction in pediatric liver transplant recipients. METHODS: The authors prospectively followed monthly EBV-quantitative competitive polymerase chain reaction to measure EBV replication in 23 patients who underwent liver transplant between July 1997 and November 1998. Preemptive immunosuppression reduction was instituted for significant EBV replication. Patients were followed up for at least 1 year and divided in two groups for analysis (group 1, pretransplant seronegative for EBV [13 patients]; group 2, seropositive for EBV [10 patients]). RESULTS: In group 1, 9 of 13 patients had positive polymerase chain reaction results at a mean time of 22.4 weeks after transplantation. All but one of these patients were asymptomatic. In seven of nine patients, preemptive immunosuppression reduction was undertaken without development of PTLD or rejection. In two of nine patients, immunosuppression could not be continuously reduced, and both patients experienced low-grade and medically responsive PTLD. In no patient in group 2 did an EBV-positive viral load or PTLD develop. CONCLUSIONS: Prospective longitudinal measurement of EBV by quantitative competitive polymerase chain reaction permits early detection of asymptomatic viral replication. Subsequent preemptive reduction of immunosuppression may prevent the progression to PTLD.
Asunto(s)
Infecciones por Virus de Epstein-Barr/complicaciones , Trastornos Linfoproliferativos/etiología , Trastornos Linfoproliferativos/prevención & control , Trasplante de Órganos/efectos adversos , Complicaciones Posoperatorias/etiología , Adolescente , Adulto , Niño , Preescolar , Estudios de Cohortes , Infecciones por Virus de Epstein-Barr/transmisión , Resultado Fatal , Femenino , Rechazo de Injerto/prevención & control , Herpesvirus Humano 4/genética , Herpesvirus Humano 4/aislamiento & purificación , Humanos , Terapia de Inmunosupresión/efectos adversos , Inmunosupresores/administración & dosificación , Lactante , Recién Nacido , Trastornos Linfoproliferativos/virología , Masculino , Reacción en Cadena de la Polimerasa , Complicaciones Posoperatorias/virología , Estudios Prospectivos , Factores de Riesgo , Tacrolimus/administración & dosificación , Carga ViralRESUMEN
This modified replication of Jurich and Holt's (1987) test-retest study investigated the stability of scores on the Washington University Sentence Completion Test (SCT; Loevinger, 1985; Loevinger & Wessler, 1970; Loevinger, Wessler & Redmore, 1970) across alternate instructional formats. Initially, 90 adult participants completed the SCT using standardized instructions. After a 1-week interval participants were readministered the SCT based on random assignment to either a standardized instruction (control) group, a role-play instructional set, or a best-effort instructional set. A repeated measures multivariate analysis of variance yielded statistically significant differences in ego level scores across the 3 instructional sets. The differences in ego level scores were approximately one-half level higher for the role-play and best-effort instructional sets. Effect sizes for the experimental instructional sets ranged from .23 using item sum scores to .45 using total protocol ratings. Results are supportive of Jurich and Holt's (1987) findings, indicating that the standardized instruction SCT may be susceptible to the motivational set of the test-taker.
Asunto(s)
Ego , Pruebas Psicológicas , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Desempeño de PapelRESUMEN
The present study revealed an association between the family configurations of cohesion and adaptability and juvenile offenders' level of ego development. This association was explained by four post hoc comparisons which revealed that functional perspectives of family cohesion and adaptability by the juvenile offender and one or both parents were associated with higher levels of ego development. Lower levels of ego development were associated with (a) shared dysfunctional perspectives of the family dimensions by the juvenile offender and both parents, and (b) a functional perspective of the family dimensions by the juvenile offender which was not shared by either parent. These results were based on 61 nonchronic juvenile offenders and their parents who were assessed by the Family Adaptability and Cohesion Evaluation Scales II. The offenders' level of ego development was assessed by the Washington University Sentence Completion Test.
Asunto(s)
Ego , Familia/psicología , Delincuencia Juvenil/psicología , Psicología del Adolescente , Adolescente , Etnicidad , Femenino , Humanos , Masculino , Desarrollo de la Personalidad , Pruebas de PersonalidadRESUMEN
We evaluated the response of 15 male patients with severe chronic obstructive pulmonary disease (COPD) to sequential inhalations of an anticholinergic agent, ipratropium bromide 0.25 mg (IB) and a B2 adrenergic agonist, terbutalin 2.5 mg (TER), in a double-blind crossover study. We found no statistically significant difference in the bronchodilatory response between the two agents when comparing the change in forced vital capacity and forced expiratory volume in 1 sec. The subsequent effect of the sequential inhalation demonstrated some additional bronchodilatory response when IB was given after TER, but not when TER was given after IB. However, the end result after the two protocols was not statistically different. The results indicate that in COPD patients the two agents are equipotent. However, in order to prescribe the best treatment schedule for each patient, it is still necessary to evaluate how each individual patient responds to each of the agents. Sequential inhalation may be beneficial in some patients.
Asunto(s)
Agonistas Adrenérgicos beta/uso terapéutico , Enfermedades Pulmonares Obstructivas/tratamiento farmacológico , Parasimpatolíticos/uso terapéutico , Agonistas Adrenérgicos beta/administración & dosificación , Anciano , Método Doble Ciego , Volumen Espiratorio Forzado , Humanos , Ipratropio/administración & dosificación , Ipratropio/uso terapéutico , Enfermedades Pulmonares Obstructivas/fisiopatología , Masculino , Persona de Mediana Edad , Parasimpatolíticos/administración & dosificación , Terbutalina/administración & dosificación , Terbutalina/uso terapéutico , Capacidad VitalRESUMEN
The handling of hazardous organisms or chemical substances in any research and development activity must be performed in such a manner as to minimize worker exposure to these materials. The term containment is used to describe the assemblage of primary and secondary preventive measures that provide personal, experimental, and environmental protection.
Asunto(s)
Biotecnología , Contención de Riesgos Biológicos/normas , Sustancias Peligrosas , Salud Laboral , Seguridad de Equipos , Humanos , Infección de Laboratorio/prevención & control , Factores de RiesgoRESUMEN
Almost 15 years have elapsed since the discussions of the risk of biotechnology began. The tentative principles proposed years ago, that microorganisms were to be contained through the application of proper procedures and practices, and the use of proper facilities and equipment, and that the level of containment was to be matched to the estimated risk, remain applicable and of value today.
Asunto(s)
Biotecnología , Contención de Riesgos Biológicos , Ingeniería Genética , Humanos , RiesgoRESUMEN
Aflatoxins (AFs) produce singlet oxygen upon their exposure to UV (365-nm) light. Singlet oxygen in turn activates them to mutagens and DNA-binding species. DNA binding and mutagenesis by AFs were enhanced in D2O as compared to reactions in H2O, and a singlet oxygen scavenger inhibited mutagenesis. DNA photobinding of 3H-AFB1 increased in the presence of unlabeled AFB2, and the addition of AFB2 enhanced mutagenesis by AFB1 in a synergistic manner. These results are compatible with the notion that singlet oxygen, formed by one aflatoxin molecule, can readily activate another aflatoxin molecule. This may bear an environmental implication in that the weakly carcinogenic AFB2, which is often produced in nature together with AFB1, may be important in enhancing the activation of AFB1 by sunlight.
Asunto(s)
Aflatoxinas/metabolismo , ADN/metabolismo , Mutagénesis , Aflatoxina B1 , Aflatoxinas/toxicidad , Anaerobiosis , Biotransformación , Pruebas de Mutagenicidad , Mutágenos , Oxígeno/metabolismo , Fotoquímica , Oxígeno Singlete , Rayos UltravioletaRESUMEN
The effect of 2 weeks oral digoxin administration on respiratory muscle performance (RMP) in 14 patients with chronic obstructive lung disease (COPD) was investigated in a randomized double-blind placebo-controlled cross-over study. All patients were ambulatory with severe air flow obstruction. FEV1/FVC was 0.44 +/- (SD) 0.11, FEV1 was 0.88 +/- (SD) 0.35 liter/s RMP was assessed by measuring maximal inspiratory pressure (PImax), maximal expiratory pressure (PEmax), and maximal voluntary ventilation. Although these parameters were significantly reduced in the COPD patients, 2 weeks of digoxin administration (with serum levels in the therapeutic range) did not alter any parameter of RMP or spirometry. We conclude that digoxin has no effect on RMP or spirometry in ambulatory patients with severe COPD.
Asunto(s)
Digoxina/farmacología , Enfermedades Pulmonares Obstructivas/fisiopatología , Músculos Respiratorios/fisiopatología , Adulto , Anciano , Digoxina/uso terapéutico , Método Doble Ciego , Humanos , Enfermedades Pulmonares Obstructivas/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Mecánica Respiratoria/efectos de los fármacos , Músculos Respiratorios/efectos de los fármacosRESUMEN
Fifty patients with chronic obstructive pulmonary disease (COPD) who survived their first artificial ventilation were followed for 15 years. Five-year survival was 30%, median survival 23.5 months, and average survival 44.9 months. Sudden death occurred in 47% of the patients (40% at home and 7% in the hospital). Using multivariate analysis, survival correlated positively and significantly with partial pressure of arterial oxygen (PaO2) on discharge (P less than 0.02), presence of wheezes or rhonchi (P less than 0.02), absence of right heart failure on admission (P less than 0.02), and male sex (P less than 0.05), and negatively with age (P less than 0.03). Sixty percent of the patients were artificially ventilated at least twice. Prognosis was better as the number of ventilations increased after the first ventilation. Our finding that discharge PaO2 was the factor that correlated best with survival suggests that treatment for these patients consist of continuous long-term use of domiciliary oxygen.
Asunto(s)
Enfermedades Pulmonares Obstructivas/mortalidad , Respiración Artificial , Causas de Muerte , Muerte Súbita/etiología , Femenino , Humanos , Enfermedades Pulmonares Obstructivas/sangre , Enfermedades Pulmonares Obstructivas/terapia , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oxígeno/sangre , Pronóstico , Estudios RetrospectivosRESUMEN
At the beginning of the school year, 80 first graders, half receiving phonics instruction and half receiving whole word instruction, were asked to spell, read aloud, and recognize 60 regular and exception words. A standardized reading test and phoneme segmentation test were also administered. Those above grade level in reading excelled in phonological recording and application of grapheme-phoneme correspondence rules and were weaker in utilization of visual-orthographic knowledge. Those below grade level applied visual more than phonological coding and benefited from the visual-orthographic knowledge available in a clue word. Results support a continuum of visual and phonological analysis skills in first-grade reading consistent with Frith's (1985) logographic, alphabetic, and orthographic skill levels.
Asunto(s)
Dislexia/psicología , Fonética , Lectura , Percepción Visual , Concienciación , Niño , Humanos , Aprendizaje VerbalRESUMEN
Covalent binding of photoactivated aflatoxins to DNA in vitro under close-to-physiological conditions resulted in the formation of apurinic sites and in strand scission. Linearized pBR322 DNA was randomly fragmented, and supercoiled DNA was relaxed during the binding reaction. A primary amine facilitated fragmentation and relaxation. Quantitative measurements of relaxation revealed that the probability of a binding event to be converted into a DNA chain break was approximately 3-5% in the absence of a primary amine. The presence of the latter increased the probability approximately 2- to 3-fold. The results are compatible with the model that photoactivated aflatoxins bind to guanines on DNA; some of these guanine adducts are released, creating apurinic sites. The latter are converted into DNa chain breaks at physiological pH and temperature. Thus, apurinic sites and DNA chain breaks must be considered as quantitatively important (genotoxic) DNA damage induced by aflatoxins.
Asunto(s)
Aflatoxinas/farmacología , Ácido Apurínico/efectos de la radiación , ADN/efectos de la radiación , Polinucleótidos/efectos de la radiación , Rayos Ultravioleta , Aflatoxina B1 , Aflatoxinas/metabolismo , Aflatoxinas/efectos de la radiación , ADN/metabolismo , Daño del ADN , Cinética , PlásmidosRESUMEN
Bacillus subtilis var. niger spores were used to determine the exposure time for formaldehyde decontamination of biological safety cabinets. Formaldehyde contact times less than 3 hr were insufficient for sterilization. A contact time of 4 hr or more resulted in a reproducible killing of the spore strips placed inside the cabinets. At 6 hr sufficient formaldehyde had diffused through the high efficiency particulate air (HEPA) filter to sterilize the strips with lower spore counts. A minimum of 5 to 6 logs of killing were observed after 4 to 6 hr of treatment.
Asunto(s)
Bacillus subtilis/efectos de los fármacos , Descontaminación/métodos , Contaminación de Equipos , Formaldehído/farmacología , Esterilización/métodos , Esporas Bacterianas/efectos de los fármacosRESUMEN
We report three cases of combined anemia, neutropenia and thrombocytopenia in patients with visceral leishmaniasis (kala-azar). Using immunofluorescence techniques and the common antiglobulin (Coombs') test, we showed membrane-associated antiplatelet, antineutrophil and antierythrocytic IgG antibodies in all three cases. Treatment with sodium stibogluconate raised the patients' platelet, neutrophil and erythrocyte count. At that time no antibodies were detected on peripheral blood cells. Immunological studies performed on these patients did not show marked abnormalities except for reduced T-helper cells and elevated OKM1-positive cells, which normalized after recovery. As bone marrow suppression was not found, it is suggested that pancytopenia resulted from rapid destruction of antibody-coated blood cells. Whether these antibodies are specific is not clear.