Assistance to parents who have lost their child with cancer

AIMS AND BACKGROUND: To assess the psychological needs of parents after the death of their child from cancer. METHODS: The study comprises a preliminary retrospective phase to identify parents who spontaneously contacted the medical staff, followed by a prospective phase in which families were contacted by telephone and were invited to a meeting. RESULTS: The retrospective study demonstrated that more than 50% of the families spontaneously sought contact with the department. In the prospective study, 17 families were contacted and the majority of them subsequently decided to come to the department for a talk. CONCLUSIONS: Our experience shows that parents have a strong need to have further contact with the team that took care of their children for months. In the process of coping with bereavement, anxiety and depression are common and not necessarily pathological, though there may be psychopathological reactions that can interfere with the parents' quality of life.     

Liver function and encephalopathy after partial vs direct side-to-side portacaval shunt: a prospective randomized clinical trial

BACKGROUND: The aim of this study was to determine, in a prospective randomized clinical trial, whether the partial portacaval shunt offers any advantage in terms of liver function and encephalopathy rate when compared with direct side-to-side direct portacaval shunt. METHODS: Forty-six "good risk" patients with cirrhosis and with documented variceal hemorrhage were randomly assigned to either a partial shunt procedure (achieved by 10-mm diameter interposition portacaval H-graft) or direct small-diameter side-to-side portacaval anastomosis. RESULTS: Operative mortality was zero in both groups. During the follow-up period, encephalopathy developed in 3 patients in the partial shunt group and 9 in the direct shunt group (P =.04). Kaplan-Meier analysis demonstrated that encephalopathy-free survival was significantly longer in the partial shunt group (P =.025). Direct shunt patients had significant hepatic functional deterioration postoperatively compared with the partial shunt group. CONCLUSIONS: The partial portacaval shunt effectively controls variceal hemorrhage. Compared with direct side-to-side portacaval shunt, partial shunt preserves long-term hepatic function and minimizes postoperative encephalopathy. We conclude that the partial portacaval shunt is the preferred approach over direct shunts for patients with cirrhosis and with variceal bleeding.     

Liver resection for HCC with cirrhosis: Surgical perspectives out of EASL/AASLD guidelines

EASL/AASLD guidelines clearly define indications for liver surgery for HCC: patients with single HCC and completely preserved liver function without portal hypertension. These guidelines exclude from operation many patients that could benefit from radical resection and that are daily scheduled for hepatectomy in surgical centers. Patients with large tumors or with portal vein thrombosis cannot be transplanted or treated by interstitial treatments. In selected cases liver resection may obtain good long-term outcomes, significantly better than non-curative therapies. In cases of multinodular HCC, liver transplantation is the treatment of choice within Milan criteria; patients beyond these limits can benefit from liver resection, especially if only two nodules are diagnosed: even if they have a worse prognosis, survival results after liver surgery are better than those reported after TACE or conservative treatments. EASL/AASLD guidelines excluded from operating patients with portal hypertension but data about this topic are not conclusive and further studies are necessary. Selected patients with mild portal hypertension could probably be scheduled for liver resection and, considering the shortage of donors, listing for transplantation could be avoided.     

Posicionamento para Ressuscitação Cardiopulmonar de Pacientes com Diagnóstico ou Suspeita de COVID-19 – 2020

Care for patients with cardiac arrest in the context of the coronavirus disease 2019 (COVID-19) pandemic has several unique aspects that warrant particular attention. This joint position statement by the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Society of Cardiology (SBC), Brazilian Association of Intensive Care Medicine (AMIB), and Brazilian Society of Anesthesiology (SBA), all official societies representing the corresponding medical specialties affiliated with the Brazilian Medical Association (AMB), provides recommendations to guide health care workers in the current context of limited robust evidence, aiming to maximize the protection of staff and patients alike.It is essential that full aerosol precautions, which include wearing appropriate personal protective equipment, be followed during resuscitation. It is also imperative that potential causes of cardiac arrest of particular interest in this patient population, especially hypoxia, cardiac arrhythmias associated with QT prolongation, and myocarditis, be considered and addressed. An advanced invasive airway device should be placed early. Use of HEPA filters at the bag-valve interface is mandatory. Management of cardiac arrest occurring during mechanical ventilation or during prone positioning demands particular ventilator settings and rescuer positioning for chest compressions which deviate from standard cardiopulmonary resuscitation techniques. Apart from these logistical issues, care should otherwise follow national and international protocols and guidelines, namely the 2015 International Liaison Committee on Resuscitation (ILCOR) and 2019 American Heart Association (AHA) guidelines and the 2019 Update to the Brazilian Society of Cardiology Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guideline.

Postoperative physiotherapy for cardiac patients: two different organizational models

Physiotherapists are involved in the postoperative recovery of cardiac patients. Physiotherapy is a discipline that is characterized by a one-on-one relationship between patient and professional, as well as by many relationships between each physiotherapist and other professionals. Ideally, this relational synergy contributes to the pursuit and attainment of valuable therapeutic goals. However, this becomes complicated when dealing with complex and challenging physical conditions, which often happens in critical cardiac settings. Given such a frame, public health institutions must choose the organizational model that can best facilitate the provision of optimal care. Models can be divided into a care setting model, in which a physiotherapist’s intervention is provided within a ward, or a pathway-centered model, in which professionals follow a patient’s care along its clear progression from hospital admission to discharge. One of the main determinants of the decision to choose a care setting or a pathway-centered model involves the volume of therapeutic services to be provided. Responding to the demand for health care is a difficult task that requires more than just effort: it requires in-depth knowledge of the patient, a broad perspective on and understanding of professional standards. The best patient care should be pursued by means of the coordination of the managerial decisions with the therapeutic actions, together with a continuous monitoring of the system.     

The therapeutic strategy in calculosis of the main biliary tract

With the advent of laparoscopic techniques and other nonoperative techniques, the management of patients with common bile duct (CBD) stones became more complex. With low, medium or high preoperative suspicion of CBD stones, three factors influence the correct management: the degree of endoscopic, radiologic and laparoscopic expertise; the severity of symptoms; the presence or absence of the gallbladder. In patients with a low probability of having CBD stones routine ERCP pre-LC appears inappropriate. The management of patients with medium probability of CBD stones depends on the ability of the laparoscopist to remove CBD stones. A single laparoscopic procedure for cholelithiasis and CBD stones would be the best approach in the majority of patients. ERCP should be considered the procedure of choice in patients with severe gallstones pancreatitis, acute cholangitis and in those with a high probability of having CBS stones.