miércoles, 26 de enero de 2011

Uso de catéteres epidurales y bloqueos de nervios periféricos al final de la vida en niños y adultos jóvenes con cáncer: la colaboración entre el servicio de dolor y de cuidados paliativos


Uso de catéteres epidurales y bloqueos de nervios periféricos al final de la vida en niños y adultos jóvenes con cáncer: la colaboración entre el servicio de dolor y de cuidados paliativos
Use of epidural and peripheral nerve blocks at the end of life in children and young adults with cancer: the collaboration between a pain service and a palliative care service
DORALINA L. ANGHELESCU MD, LANE G. FAUGHNAN BS, JUSTIN N. BAKER MD, J IE YANG PhD AND JAVIER R.KANE MD
Division of Anesthesiology, Division of Palliative and End-of-Life Care and Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
Pediatric Anesthesia 2010 20: 1070-1077 doi:10.1111/j.1460-9592.2010.03449.x 

Summary
Background: Clinicians may avoid continuous pain blocks in pediatric  cancer patients at the end of life for fear of complications or of interfering with the desired location of death. Objectives: To examine the impact of epidural or peripheral nerve catheters on pain control in children and young adults with cancer within the last 3 months of life. Methods: We retrospectively reviewed the medical records to assess pain scores, systemic opioid requirements, and impact on death at the preferred location. Results: Ten patients (4.4-21.3 years of age), nine with solid tumors, one with lymphoma, had 14 devices (11 epidural, 3 peripheral nerve catheters) for a range of 3-81 days. Twelve of 13 catheters provided improvement by at least one of three criteria: improved mean pain scores at 24 h (8 of 13) and decreased opioid requirement at 24 h in nine cases and at day 5 in nine cases. Eight patients died in their preferred setting. Six patients had catheters (five epidural, one peripheral) until death, including two who died at home. In some cases, typical contraindications for indwelling catheters (spinal metastasis, vertebral fracture, thrombocytopenia, fever) were superseded by palliative care needs. We found no bleeding, infectious, or neurological complications. Conclusions: Our findings suggest that continuous catheter-delivered pain blockade at the end of life contributes to analgesia, moderates opioid requirements, and usually does not preclude death at the preferred location.
Keywords: pain; cancer; end of life; epidural; peripheral nerve block.

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Atentamente
Dr. Enrique Hernández-Cortes
Anestesiología y Medicina del Dolor

En este día...


On This Day in HistoryWednesday, January 26th
The 026th day of 2011.
There are 339 days left in the year.
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Today's Highlights in History
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On Jan. 26, 1950, India proclaimed itself a republic. (Go to article.)On Jan. 26 , 1880DouglasMacArthur , the American general who achieved acclaim as a grand strategist in World War II and in Korea , was born. Following hisdeath on April 5 , 1964, his obituary appeared in The Times. (Go to obit. |Other Birthdays)
Editorial Cartoon of the Day

On January 26, 1884Harper's Weekly featured a cartoon about civil service reform. (See the cartoon and read an explanation.)

On this date in:
1788The first European settlers in Australia landed in present-day Sydney.
1802Congress passed an act calling for a library to be established within the U.S. Capitol.
1837Michigan became the 26th state.
1861Louisiana seceded from the Union.
1870Virginia rejoined the Union.
1925Actor Paul Newman was born in Cleveland, Ohio.
1979Former Vice President Nelson A. Rockefeller died at age 70.
1988The Andrew Lloyd Webber musical "Phantom of the Opera," the longest-running show in Broadway history, opened at the Majestic Theater in New York.
1993Former Czechoslovak President Vaclav Havel was elected president of the new Czech Republic.
1996First lady Hillary Rodham Clinton testified before a grand jury connected to the Whitewater probe.
1998President Bill Clinton denied having an affair with former White House intern Monica Lewinsky, telling reporters, "I did not have sexual relations with that woman."
2001An earthquake hit the Indian subcontinent, killing more than 13,000 people.
2005Condoleezza Rice was sworn in as secretary of state.
2006Confronted by Oprah Winfrey on her syndicated talk show, author James Frey acknowledged lies in his addiction memoir "A Million Little Pieces."
2009"Octomom" Nadya Suleman of Whittier, Calif., gave birth to octuplets conceived by in vitro fertilization. Suleman was already a mother of six.

Current Birthdays
Emily Hughes turns 22 years old today.

AP Photo/Charles Sykes Figure skater Emily Hughes turns 22 years old today.

76Bob Uecker
Sportscaster-actor
72Scott Glenn
Actor
62David Strathairn
Actor ("Good Night, and Good Luck")
61Jack Youngblood
Football Hall of Famer
58Lucinda Williams
Country singer
56Eddie Van Halen
Rock musician (Van Halen)
53Ellen DeGeneres
Talk show host, comedian
50Wayne Gretzky
Hockey Hall of Famer
48Andrew Ridgeley
Rock musician (Wham!)
34Vince Carter
Basketball player
33Sara Rue
Actress

Historic Birthdays
Douglas MacArthur
 
1/26/1880 - 4/5/1964
American general 

(Go to obit.)

71Jean-Baptiste Pigalle
1/26/1714 - 8/21/1785
French sculptor

56Claude-Adrien Helvatius
1/26/1715 - 12/26/1771
French philosopher

81Charles XIV John
1/26/1763 - 3/8/1844
French general and later king of Sweden and Norway

68Benjamin Franklin Keith
1/26/1846 - 3/26/1914
American impresario

87Samuel Hopkins Adams
1/26/1871 - 11/15/1958
American journalist and author

85Julia Morgan
1/26/1872 - 2/2/1957
American architect

82Frank Costello
1/26/1891 - 2/18/1973
American syndicate gangster

33Bessie Coleman
1/26/1892 - 4/30/1926
American aviator

83Sean MacBride
1/26/1904 - 1/15/1988
Irish statesman and winner of 1974 Nobel Peace Prize

77Jimmy Van Heusen
1/26/1913 - 2/7/1990
American songwriter

71Nicolae Ceausescu
1/26/1918 - 12/25/1989
Romanian dictator


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F.D.A and Dairy Industry Spar Over Testing of Milk


F.D.A and Dairy Industry Spar Over Testing of Milk

Dennis Curran for The New York Times
The Food and Drug Administration is concerned that antibiotics might be contaminating the milk of American dairy cows.
Each year, federal inspectors find illegal levels ofantibiotics in hundreds of older dairy cows bound for the slaughterhouse. Concerned that those antibiotics might also be contaminating the milk Americans drink, the Food and Drug Administration intended to begin tests this month on the milk from farms that had repeatedly sold cows tainted by drug residue.
But the testing plan met with fierce protest from the dairy industry, which said that it could force farmers to needlessly dump millions of gallons of milk while they waited for test results. Industry officials and state regulators said the testing program was poorly conceived and could lead to costly recalls that could be avoided with a better plan for testing.
In response, the F.D.A. postponed the testing, and now the two sides are sparring over how much danger the antibiotics pose and the best way to ensure that the drugs do not end up in the milk supply.
“What has been served up, up to this point, by Food and Drug has been potentially very damaging to innocent dairy farmers,” said John J. Wilson, a senior vice president for Dairy Farmers of America, the nation’s largest dairy cooperative. He said that that the nation’s milk was safe and that there was little reason to think that the slaughterhouse findings would be replicated in tests of the milk supply.
But food safety advocates said that the F.D.A.’s preliminary findings raised issues about the possible overuse of antibiotics in livestock, which many fear could undermine the effectiveness of drugs to combat human illnesses.
“Consumers certainly don’t want to be taking small amounts of drugs every time they drink milk,” said Caroline Smith DeWaal, food safety director of the Center for Science in the Public Interest, an advocacy group. “They want products that are appropriately managed to ensure those drug residues aren’t there, and the dairy farmer is the one who can control that.”
The F.D.A. said that it would confer with the industry before deciding how to proceed. “The agency remains committed to gathering the information necessary to address its concern with respect to this important potential public health issue,” it said in a statement.
The concerns of federal regulators stem from tests done by the Department of Agriculture on dairy cows sent to be slaughtered at meat plants. For years, those tests have found a small but persistent number of animals with drug residues, mostly antibiotics, that violate legal limits.
The tests found 788 dairy cows with residue violations in 2008, the most recent year for which data was available. That was a tiny fraction of the 2.6 million dairy cows slaughtered that year, but regulators say the violations are warning signs because the problem persists from year to year and some of the drugs detected are not approved for use in dairy cows.
The question for the F.D.A. is whether cows that are producing milk also have improper levels of such drugs in their bodies and whether traces of those drugs are getting into the milk.
Regulators and veterinarians say that high levels of drugs can persist in an animal’s system because of misuse of medicines on the farm.
That can include exceeding the prescribed dose or injecting a drug into muscle instead of a vein. Problems can also occur if farmers do not follow rules that require them to wait for a specified number of days after administering medication before sending an animal to slaughter or putting it into milk production.
“F.D.A. is concerned that the same poor management practices which led to the meat residues may also result in drug residues in milk,” the agency said in a document explaining its plan to the industry. In the same document, the F.D.A. said it believed that the nation’s milk supply was safe.
Today, every truckload of milk is tested for four to six antibiotics that are commonly used on dairy farms. The list includes drugs like penicillin and ampicillin, which are also prescribed for people. Each year, only a small number of truckloads are found to be “hot milk,” containing trace amounts of antibiotics. In those cases, the milk is destroyed.
But dairy farmers use many more drugs that are not regularly tested for in milk. Regulators are concerned because some of those other drugs have been showing up in the slaughterhouse testing.
Federal officials have discussed expanded testing for years. But industry executives said that it was not until last month that the F.D.A. told them it was finally going to begin.
The agency said that it planned to test milk from about 900 dairy farms that had repeatedly been caught sending cows to slaughter with illegal levels of drugs in their systems.
It said it would test for about two dozen antibiotics beyond the six that are typically tested for. The testing would also look for a painkiller and anti-inflammatory drug popular on dairy farms, called flunixin, which often shows up in the slaughterhouse testing.
The problem, from the industry’s point of view, is the lengthy time it takes for test results.
The tests currently done for antibiotics in milk take just minutes to complete. But the new tests could take a week or more to determine if the drugs were present in the milk.
Milk moves quickly onto store shelves or to factories where it is made into cheese or other products. The industry worried that, under the F.D.A. plan, by the time a load of milk was found to be contaminated, it could already be in consumers’ refrigerators, and that could lead to recalls.
One Northeast cooperative, Agri-Mark, sent a letter to its members last month instructing them to dump milk if it had been tested by the F.D.A. “Agri-Mark must ensure that all of our milk sales, cheese, butter and other products are in no danger of recall,” the letter said.
Other industry executives said that processing plants would refuse to take any milk from a farm that had been tested until the results showed it was drug-free, meaning farmers could end up dumping milk for a week or more while waiting.
The F.D.A. plan was also criticized by state officials that regulate the dairy industry.
In a sharply worded Dec. 29 letter, the top agriculture officials of 10 Northeastern states, including New York and Pennsylvania, which are both leading dairy producers, told the F.D.A. that its plan was badly flawed. Among other problems, the letter said, forcing farmers to dump large quantities of milk could create environmental problems.
The F.D.A. said it would consider the regulators’ comments as it reviewed its testing plan.

Video Gallery: The Minimalist's Greatest Hits - Interactive Feature - NYTimes.com

Video Gallery: The Minimalist's Greatest Hits - Interactive Feature - NYTimes.com

Obama Calls for Bipartisan Effort to Fight for U.S. Jobs


Obama Calls for Bipartisan Effort to Fight for U.S. Jobs

Doug Mills/The New York Times
President Obama focused attention on preparing the United States to thrive against global competition.
WASHINGTON — President Obama challenged Americans on Tuesday night to unleash their creative spirit, set aside their partisan differences and come together around a common goal of outcompeting other nations in a rapidly shifting global economy.

    Stephen Crowley/The New York Times
    Michelle Obama with Dallas Green, brother of Christina-Taylor Green, the 9-year-old girl killed in Tucson. He was accompanied by his parents, John and Roxanna.
    In a State of the Union address to a newly divided Congress, Mr. Obama outlined what he called a plan to “win the future” — a blueprint for spending in critical areas like education, high-speed rail, clean-energy technology and high-speed Internet to help the United States weather the unsettling impact of globalization and the challenge from emerging powers like China and India.
    “The rules have changed,” he said.
    But at the same time he proposed budget-cutting measures, including a five-year freeze in spending on some domestic programs that he said would reduce the deficit by $400 billion over 10 years.
    Drawing a stark contrast between himself and Republicans, who are advocating immediate and deep cuts in spending, Mr. Obama laid out a philosophy of a government that could be more efficient but would still be necessary if the nation was to address fundamental challenges at home and abroad.
    “We need to out-innovate, outeducate and outbuild the rest of the world,” he said. “We have to make America the best place on earth to do business. We need to take responsibility for our deficit and reform our government. That’s how our people will prosper.”
    Just weeks after the shooting in Tucson that claimed six lives and left Representative Gabrielle Giffords, Democrat of Arizona, gravely injured, Mr. Obama received a reception that was muted and civil.
    There were no boos or a shout of “You lie!” as in speeches past. Many Republicans and Democrats sat side by side — the first time anyone here can remember such mixing — and nearly all wore black-and-white lapel ribbons in honor of the dead and injured. Ms. Giffords’s colleagues held a seat open for her.
    The president’s speech, lasting slightly more than an hour, lacked the loft of the inspirational address he delivered in Tucson days after the shooting. But it seemed intended to elevate his presidency above the bare-knuckled legislative gamesmanship that has defined the first two years of his term.
    Reaching out to Republicans who have vowed to end the pet projects known as “earmarks,” Mr. Obama pledged to veto any bill that contained them. He tried to defuse partisan anger over his health care measure with humor, saying he had “heard rumors” of concerns over the bill, and he reiterated his pledge to fix a tax provision in the measure that both parties regard as burdensome to businesses.
    He drew sustained applause when he declared that colleges should open their doors to military recruiters and R.O.T.C. programs now that “Don’t Ask, Don’t Tell,” the policy barring gay men and lesbians from serving openly, has been repealed.
    And he tried to charm Republicans by weaving the new House speaker, Representative John A. Boehner of Ohio, into his narrative about American greatness, citing Mr. Boehner’s rise from “someone who began by sweeping the floors of his father’s Cincinnati bar” as an example of “a country where anything is possible.”
    Still, the good will lasted only so long. Moments after Mr. Obama finished speaking, Representative Paul D. Ryan of Wisconsin, the chairman of the House Budget Committee, delivered the official Republican response, in which he criticized Mr. Obama as doing too little to attack the deficit.
    And Representative Michele Bachmann of Minnesota, who delivered her own Republican critique with the backing of the Tea Party wing, complained that instead of creating “a leaner, smarter government,” Mr. Obama had created “a bureaucracy that tells us which light bulbs to buy.”
    The president sought to use Tuesday night’s address to shed the tag of big-government liberal that Republicans have placed on him, and to reclaim the mantle of a pragmatic, postpartisan leader that he used to ride to the presidency in 2008.
    With one eye toward his 2012 re-election campaign, Mr. Obama offered a rosy economic vision. The president who once emphasized the problems he had inherited from his predecessor was instead looking forward and making the case that the nation had at long last emerged from economic crisis.
    “Two years after the worst recession most of us have ever known, the stock market has come roaring back,” Mr. Obama said. “Corporate profits are up. The economy is growing again.”
    The speech was light on new policy proposals, reflecting both political and fiscal restraints on the administration after two years in which it achieved substantial legislative victories but lost the midterm elections, failed to bring the unemployment rate below 9 percent and watched the budget deficit rise sharply.
    Multimedia
    Mr. Obama did not address gun control, a hotly debated topic after the shooting in Tucson.
    He did not lay out any specific plans for addressing the long-term costs ofSocial Security and Medicare, the biggest fiscal challenges ahead. He backed an overhaul of corporate taxes but spoke only in passing about the need to simplify the tax code for individuals. He called for legislation to address illegalimmigration but provided no details.
    He called for an end to subsidies for oil companies and set a goal of reducing dependence on polluting fuels over the next quarter-century, but without any mechanism to enforce it. And in a speech largely devoted to economic issues, he talked only generally about the conflicts in Iraq and Afghanistan.
    As he drew a contrast between the United States and other nations, Mr. Obama gave a nod to the nation’s high unemployment rate, arguing that “the world has changed” and that it was no longer as easy as it once was for Americans to find a good and secure job.
    Government itself, he said, needs to be updated for the information age. “We can’t win the future with a government of the past,” he said.
    He packaged his message in optimistic, almost nationalistic phrasing, saying the country had always risen to challenges.
    “So yes, the world has changed,” Mr. Obama said. “The competition for jobs is real. But this shouldn’t discourage us. It should challenge us. Remember, for all the hits we’ve taken these last few years, for all the naysayers predicting our decline, America still has the largest, most prosperous economy in the world.”
    He continued: “No workers are more productive than ours. No country has more successful companies, or grants more patents to inventers and entrepreneurs. We are home to the world’s best colleges and universities, where more students come to study than any other place on earth.”
    Mr. Obama outlined initiatives in five areas: innovation; education; infrastructure; deficit reduction; and a more efficient federal bureaucracy. He pledged to increase the nation’s spending on research and development, as a share of the total economy, to the highest levels since John F. Kennedy was president, and vowed to prepare an additional 100,000 science and math teachers over the next 10 years.
    He proposed new efforts on high-speed rail, road and airport construction and a “national wireless initiative” that, administration officials said, would extend the next generation of wireless coverage to 98 percent of the population.
    “Our infrastructure used to be the best, but our lead has slipped,” Mr. Obama said. “South Korean homes now have greater Internet access than we do. Countries in Europe and Russia invest more in their roads and railways than we do. China is building faster trains and newer airports.”
    Saying it was imperative for the nation to tackle its deficit, Mr. Obama reiterated his support for $78 billion in cuts to the Pentagon’s budget over five years, in addition to the five-year partial freeze on domestic spending. But he did not adopt any of the recommendations of the bipartisan fiscal commission he appointed to figure out ways to bring the deficit under control.
    Mr. Obama headed into the speech in surprisingly good political shape, given the drubbing Democrats took in the November elections. His job approval ratings are up — in some polls, higher than 50 percent. The public is feeling more optimistic about the economy, voters are giving Mr. Obama credit for reaching out to Republicans in a bipartisan way, and the president won high marks for his speech in Tucson after the shooting.
    “There’s a reason the tragedy in Tucson gave us pause,” Mr. Obama said Tuesday night. “Amid all the noise and passions and rancor of our public debate, Tucson reminded us that no matter who we are or where we come from, each of us is a part of something greater — something more consequential than party or political preference.”