Actitudes de los médicos de un hospital pediátrico de tercer nivel ante la muerte / Attitudes of physicians in a tertiary care children's hospital in the face of death

Introducción. La muerte involucra, para los médicos, un análisis complejo que determina su actitud hacia el paciente, principalmente los comportamientos en situaciones de diagnóstico, tratamiento y la relación médico-paciente. Objetivos. 1) Describir las actitudes del personal médico de un hospital pediátrico ante la muerte. 2) Explorar si existen factores asociados a esas actitudes. Población y métodos. Estudio transversal, por encuesta. Se invitó a los médicos de un hospital pediátrico de tercer nivel de la Ciudad Autónoma de Buenos Aires, Argentina, a completar el Cuestionario de actitud ante la muerte (CAM). Se investigaron variables sociodemográficas, categoría profesional y área laboral, haber presenciado la muerte de pacientes, autopercepción de actitud positiva ante la muerte y actitud ante la muerte según CAM. Resultados. Entre el 01 de junio de 2021 y el 01 de junio de 2022 se incluyeron 362 participantes, con edad media de 39,88 (± 11,56) años y experiencia médica asistencial de 14,06 (± 11,97) años. Presentaron actitud positiva 35 (9,67 %). Encontramos significancia estadística para mayor probabilidad de actitud positiva en edad ≥ 40 años (p = 0,02, IC95 % 1,1-3,9), experiencia médica asistencial ≥ 14 años (p = 0,042, IC95 % 1-4,1), creencia religiosa (p = 0,003, IC95 % 1,4-10,5), práctica religiosa activa (p <0,001, IC95 % 1,6-6,9) y autopercepción positiva ante la muerte (p = 0,002, IC95 % 1,7-30,8). Conclusiones. El 9,67 % de los encuestados presentó actitud positiva ante la muerte. Los factores asociados a ella fueron edad ≥ 40 años, experiencia médica asistencial ≥ 14 años, creencia religiosa, práctica religiosa activa y la autopercepción personal de actitud positiva ante la muerte.

Introduction. For physicians, death involves an intricate analysis that determines their attitude towards the patient. Objectives. 1) To describe the attitudes towards death among medical staff working at a children's hospital. 2) To explore factors associated with such attitudes. Population and methods. Cross-sectional, survey study. The physicians working at a tertiary care children's hospital completed the Questionnaire of attitudes towards death (QAD). Sociodemographic variables, professional category, work setting, having witnessed the death of patients, self-perception of a positive attitude towards death, and attitude towards death according to the QAD were studied. Results. Between June 1st, 2021 and June 1st, 2022, 362 participants were included; mean age: 39.88 years (± 11.56), health care experience: 14.06 years (± 11.97). A positive attitude was observed in 35 (9.67%). A statistical significance was observed for a greater probability of a positive attitude among those who were ≥ 40 years old (p = 0.02, 95% CI: 1.1­3.9), had health care experience for ≥ 14 years (p = 0.042, 95% CI: 1­4.1), had a religious belief (p = 0.003, 95% CI: 1.4­10.5), actively practiced their religion (p < 0.001, 95% CI: 1.6­6.9), and had a positive self-perception in the face of death (p = 0.002, 95% CI: 1.7­30.8). Conclusions. A positive attitude towards death was observed in 9.67% of surveyed participants. Associated factors were age ≥ 40 years, health care experience for ≥ 14 years, religious belief, active religious practice, and self-perception of a positive attitude towards death.

Attitudes of physicians in a tertiary care children's hospital in the face of death. / Actitudes de los médicos de un hospital pediátrico de tercer nivel ante la muerte.

Introduction. For physicians, death involves an intricate analysis that determines their attitude towards the patient. Objectives. 1) To describe the attitudes towards death among medical staff working at a children's hospital. 2) To explore factors associated with such attitudes. Population and methods. Cross-sectional, survey study. The physicians working at a tertiary care children's hospital completed the Questionnaire of attitudes towards death (QAD). Sociodemographic variables, professional category, work setting, having witnessed the death of patients, self-perception of a positive attitude towards death, and attitude towards death according to the QAD were studied. Results. Between June 1st, 2021 and June 1st, 2022, 362 participants were included; mean age: 39.88 years (± 11.56), health care experience: 14.06 years (± 11.97). A positive attitude was observed in 35 (9.67%). A statistical significance was observed for a greater probability of a positive attitude among those who were ≥ 40 years old (p = 0.02, 95% CI: 1.1-3.9), had health care experience for ≥ 14 years (p = 0.042, 95% CI: 1-4.1), had a religious belief (p = 0.003, 95% CI: 1.4-10.5), actively practiced their religion (p < 0.001, 95% CI: 1.6-6.9), and had a positive self-perception in the face of death (p = 0.002, 95% CI: 1.7-30.8). Conclusions. A positive attitude towards death was observed in 9.67% of surveyed participants.Associated factors were age ≥ 40 years, health care experience for ≥ 14 years, religious belief, active religious practice, and self-perception of a positive attitude towards death.

Introducción. La muerte involucra, para los médicos, un análisis complejo que determina su actitud hacia el paciente, principalmente los comportamientos en situaciones de diagnóstico, tratamiento y la relación médico-paciente. Objetivos. 1) Describir las actitudes del personal médico de un hospital pediátrico ante la muerte. 2) Explorar si existen factores asociados a esas actitudes. Población y métodos. Estudio transversal, por encuesta. Se invitó a los médicos de un hospital pediátrico de tercer nivel de la Ciudad Autónoma de Buenos Aires, Argentina, a completar el Cuestionario de actitud ante la muerte (CAM). Se investigaron variables sociodemográficas, categoría profesional y área laboral, haber presenciado la muerte de pacientes, autopercepción de actitud positiva ante la muerte y actitud ante la muerte según CAM. Resultados. Entre el 01 de junio de 2021 y el 01 de junio de 2022 se incluyeron 362 participantes, con edad media de 39,88 (± 11,56) años y experiencia médica asistencial de 14,06 (± 11,97) años. Presentaron actitud positiva 35 (9,67 %). Encontramos significancia estadística para mayor probabilidad de actitud positiva en edad ≥ 40 años (p = 0,02, IC95 % 1,1-3,9), experiencia médica asistencial ≥ 14 años (p = 0,042, IC95 % 1-4,1), creencia religiosa (p = 0,003, IC95 % 1,4-10,5), práctica religiosa activa (p <0,001, IC95 % 1,6-6,9) y autopercepción positiva ante la muerte (p = 0,002, IC95 % 1,7-30,8). Conclusiones. El 9,67 % de los encuestados presentó actitud positiva ante la muerte. Los factores asociados a ella fueron edad ≥ 40 años, experiencia médica asistencial ≥ 14 años, creencia religiosa, práctica religiosa activa y la autopercepción personal de actitud positiva ante la muerte.

Enhanced recovery after bariatric surgery: Implementation of program and clinical outcomes from a bariatric surgery and metabolic diseases reference center.

BACKGROUND: Enhanced recovery after bariatric surgery (ERABS) protocols involve a series of multimodal perioperative procedures based on evidence designed to reduce physiological stress, improve recovery, and reduce costs on medical attention by decreasing length of hospital stay (length of stay [LOS]). OBJECTIVE: The objective of the study was to report the viability and results of the ERABS application in a reference bariatric center. MATERIALS AND METHODS: A prospective, observational, and descriptive study on bariatric procedures conducted over 12 months in the ERABS context which includes pre-procedure, intraprocedure, and post-procedure measures. The collected data include demographic data, comorbidity, morbimortality, LOS, and readmission to hospital. RESULTS: Sixty-four patients within a median of 38.8 ± 9.5 years and 44.1 ± 6.20 kg/m2 BMI underwent surgery. Fifty-five (85.93%) were Roux-en-Y gastric bypass (RYGB) cases and 9 (14.06%) were sleeve gastrectomy (SG). Related comorbidities were hypertension 37%, diabetes 34%, dyslipidemia 23%, and obstructive sleep apnea 21%. Two (3.12%) patients developed post-operative morbidity (respiratory and thromboembolic complications). LOS for RYGB was 1.16 ± 0.97 and 1 ± 0 days for SG. The successful discharge rate on the 1st day after procedure was 96% and 100%, respectively. Readmission to hospital within a 30-day period presented itself on 4 patients (6.25%). CONCLUSION: Applying ERABS protocols is feasible, safe, morbidity low, LOS acceptable, and a low readmission rate within 30 days.

ANTECEDENTES: Los protocolos de recuperación mejorada tras cirugía bariátrica (ERABS, Enhanced Recovery After Bariatric Surgery) implican intervenciones perioperatorias multimodales basadas en la evidencia diseñadas para reducir el estrés fisiológico, facilitar el retorno temprano de la función corporal y reducir los costos de atención médica al disminuir la duración de la estancia intrahospitalaria. OBJETIVO: Reportar la viabilidad y los resultados de la utilización de ERABS en un centro bariátrico de referencia. MÉTODO: Estudio prospectivo, observacional y descriptivo de procedimientos bariátricos realizados durante 12 meses en contexto ERABS, que incluyó medidas preoperatorias, intraoperatorias y posoperatorias. Los datos recopilados fueron demografía, comorbilidad, morbimortalidad, estancia intrahospitalaria y reingresos. RESULTADOS: 64 pacientes, edad 38.8 ± 9.5 años, índice de masa corporal 44.1 ± 6.20 kg/m2, 55 (85.93%) bypass gástricos en Y de Roux (BGYR) y 9 (14.06%) mangas gástricas. Comorbilidad: hipertensión 37%, diabetes 34%, dislipidemia 23% y apnea obstructiva 21%. Dos (3.12%) pacientes desarrollaron morbilidad posoperatoria (complicaciones respiratorias y tromboembólicas). La estancia intrahospitalaria para el BGYR fue de 1.16 ± 0.97 días y para la manga 1 ± 0 días. El alta exitosa al primer día posoperatorio fue del 96% para el BGYR y del 100% para la manga. El reingreso hospitalario a 30 días se produjo en cuatro (6.25%) pacientes. CONCLUSIÓN: La aplicación de protocolos ERABS es factible, segura, de baja morbilidad, con una estancia intrahospitalaria aceptable y una baja tasa de reingresos a 30 días.

Smartphone-Based Platform for Secure Multi-Hop Message Dissemination in VANETs.

Vehicular ad-hoc Networks (VANETs) are recognized as a cornerstone of Intelligent Transportation Systems (ITS) to enable the exchange of information among vehicles, which is crucial for the provision of safety-related and entertainment applications. However, practical useful realizations of VANETs are still missing, mainly because of the elevated costs and the lack of a final standardization. In this regard, the feasibility of using smartphones as nodes in VANETs has been explored focusing on small-scale deployments to mainly validate single-hop communication capabilities. Moreover, existing smartphone-based platforms do not consider two crucial requirements in VANETs, namely, multi-hop communication and the provision of security services in the message dissemination process. Furthermore, the problem of securing message dissemination in VANETs is generally analyzed through simulation tools, while performance evaluations on smart devices have not been reported so far. In this paper, we aim to fill this void by designing a fully on-device platform for secure multi-hop message dissemination. We address the multi-hop nature of message dissemination in VANETs by integrating a location-based protocol that enables the selection of relay nodes and retransmissions criteria. As a main distinction, the platform incorporates a novel certificateless cryptographic scheme for ensuring data integrity and nodes' authentication, suitable for VANETs lacking of infrastructure.

Drug resistance mutations during structured interruptions of HAART in two HIV-1-infected children.

Information concerning structured treatment interruptions (STI) of the Highly Active Antiretroviral Therapy (HAART) and their risk for selecting antiretroviral drug resistance in children is scarce. In this study, we searched for antiretroviral drug resistance mutations at the end of five viral rebounds of two children with HIV and a chronically undetectable viral load (VL) who underwent an STI program. The HAART was interrupted for 4 weeks and then restarted and continued for 12 weeks for three cycles. VL, CD4+/CD8+ lymphocytes, and clinical status were evaluated at the end of each STI and at 6 and 12 weeks after HAART was resumed. Treatment of both the patients based on zidovudine+lamivudine+ritonavir remained identical during the study. The reverse transcriptase (RT)- and protease (PR)-coding regions were sequenced at the end of each viral rebound. One patient experienced progressively lower viral rebounds (269000-31300 at the first and third rebounds, respectively), while the other patient did not experience such a reduction, and the VL of both the patients fell to undetectable levels during therapy. In the five viral rebounds examined, no mutations for resistance to protease inhibitors (PIs) were found and the analysis indicated susceptibility to all PIs currently in clinical use. Although the mutation K103R associated with non-nucleoside reverse transcriptase inhibitor resistance was found in two viral rebounds of one patient, the analysis indicated the absence of resistance to RT inhibitors. As no mutation related to antiretroviral drug resistance was found, our results suggest that the STI program evaluated may have a low risk of selecting antiretroviral drug resistance. Nevertheless, further studies evaluating larger cohorts over longer periods are required before definitive conclusions about the safety of STI of HAART in children may be drawn.

Structured interruptions of highly active antiretroviral therapy in cycles of 4 weeks off/12 weeks on therapy in children having a chronically undetectable viral load cause progressively smaller viral rebounds.

OBJECTIVES: To evaluate the viral, immune and clinical impact of a structured treatment interruption (STI) program of highly active antiretroviral therapy (HAART) in three cycles of 4 weeks off/12 weeks on therapy in a cohort of children with HIV infection under chronic viral control. METHODS: Using a single-group time series experimentation design and following informed consent, the HAART of children with HIV and a chronically undetectable viral load (VL) was discontinued for 4 weeks and then restarted and continued for 12 weeks for a total of three cycles. The VL, CD4+/CD8+ lymphocytes, and clinical status were evaluated at the end of each STI and at 6 and 12 weeks after HAART was resumed. RESULTS: Four children with a median age of 10.3 years (range 6.5-11.2 years) were included in the study. Their clinical immune categories were: A1 (n=2), A2 (n=1), and B3 (n=1). Treatment of all four patients was with zidovudine (AZT)+lamivudine (3TC)+ritonavir (RTV). At the end of the first STI, VL was a median 214000 copies/ml (range 27400-616000), corresponding to 5.3 log(10) (range 4.4-5.8). At the end of the second STI, VL was a median 72400 copies/ml (range 17800-126000) or 4.7 log(10) (range 4.2-5.1), which corresponds to a rebound 0.6 log(10) lower than the first. At the end of the third STI, VL was a median 28200 copies/ml (range 5370-140000) or 4.45 log(10) (range 3.7-5.1), a rebound 0.85 log(10) lower than the first. All rebounds were followed by a decrease in the VL to undetectable levels during the treatment periods. CD8+ T lymphocyte counts increased during viral rebounds and an initial decrease in CD4+ T lymphocyte counts was followed by a tendency to increase even exceeding CD8+ T cell counts. Only one event of transitory severe immunosuppression occurred. There were no symptoms related to the HIV infection. CONCLUSIONS: The STI of HAART in cycles of 4 weeks off/12 weeks on therapy in children with chronically undetectable VL can cause progressively lower viral rebounds followed by a decrease to undetectable levels, with a low risk of severe immunosuppression and without the occurrence of symptoms related to HIV.