The Role of Predictive Models in the Assessment of the Poor Outcomes in Pediatric Acute Liver Failure

Objectives: In children, acute liver failure (ALF) is a severe condition with high mortality. As some patients need liver transplantation (LT), it is essential to predict the fatal evolution and to refer them early for LT if needed. Our study aimed to evaluate the prognostic criteria and scores for assessing the outcome in children with ALF. Methods: Data of 161 children with ALF (54.66% female, mean age 7.66 ± 6.18 years) were analyzed based on final evolution (32.91% with fatal evolution or LT) and etiology. We calculated on the first day of hospitalization the PELD score (109 children), MELD, and MELD-Na score (52 children), and King’s College Criteria (KCC) for all patients. The Nazer prognostic index and Wilson index for predicting mortality were calculated for nine patients with ALF in Wilson’s disease (WD). Results: PELD, MELD, and MELD-Na scores were significantly higher in patients with fatal evolution (21.04 ± 13.28 vs. 13.99 ± 10.07, p = 0.0023; 36.20 ± 19.51 vs. 20.08 ± 8.57, p < 0.0001; and 33.07 ± 8.29 vs. 20.08 ± 8.47, p < 0.0001, respectively). Moreover, age, bilirubin, albumin, INR, and hemoglobin significantly differed in children with fatal evolution. Function to etiology, PELD, MELD, MELD-Na, and KCC accurately predicted fatal evolution in toxic ALF (25.33 vs. 9.90, p = 0.0032; 37.29 vs. 18.79, p < 0.0001; 34.29 vs. 19.24, p = 0.0002, respectively; with positive predicting value 100%, negative predicting value 88.52%, and accuracy 89.23% for King’s College criteria). The Wilson index for predicting mortality had an excellent predictive strength (100% sensibility and specificity), better than the Nazer prognostic index. Conclusions: Prognostic scores may be used to predict the fatal evolution of ALF in children in correlation with other parameters or criteria. Early estimation of the outcome of ALF is essential, mainly in countries where emergency LT is problematic, as the transfer to a specialized center could be delayed, affecting survival chances.

O AVANÇO DA DOENÇA MENTAL DURANTE A PANDEMIA COVID-19

Introdução: Com a descoberta do novo coronavírus, em 2019, e seu rápido impacto na população mundial, tudo mudou. Por meio de uma metodologia bibliográfica exploratória, extraiu-se dados do Google Acadêmico, adotando como parâmetro a legislação brasileira. Objetivo: O objetivo consiste em analisar pesquisas desenvolvidas sobre os serviços de saúde mental diante do atual cenário pandêmico, buscando efetividade na garantia de direitos para o amparo das pessoas afetadas, especialmente neste setor. Material e métodos: Destacam-se estudos da psiquiatra Fernanda Benquerer Costa de 2020, que demonstraram que características particulares são determinantes para maior reação em situações de estresse, como idosos, profissionais da saúde, pessoas que já possuem doenças crônicas ou transtornos mentais. Em um levantamento de dados de 2020, publicado no periódico científico The Lancet, pesquisadores do King’s College London, na Inglaterra, afirmam que se a Covid19 continuar nos mesmos passos da síndrome aguda respiratória grave − Sars (2002/2003), há chances do desenvolvimento de doenças psiquiátricas em massa nos próximos meses − a China foi o país mais atingido à época, registrando 30% de aumento dos casos de doenças psiquiátricas entre aqueles que estiveram em quarentena. Resultados: Segundo relatório da Organização Mundial da Saúde (OMS), a pandemia de COVID-19 interrompeu serviços essenciais à saúde mental em 93% dos países em todo o mundo. Foi uma pesquisa com 130 países que registraram reflexos da pandemia nos serviços de saúde mental e rechaça a urgente necessidade de mais financiamento na área – inclusive no Brasil, um dos países mais afetados. A Constituição brasileira tem como um de seus objetivos a promoção do bem de todos. A saúde é dever do Estado, com políticas sociais e econômicas que reduzam o risco de doença e outros agravos e ao acesso universal e igualitário às ações e serviços para a sua promoção, proteção e recuperação. Conclusão: É preciso remodelar ações assistenciais à saúde mental segundo suas especificidades, prestando, principalmente a pacientes infectados e aos profissionais na linha de frente do controle da COVID-19, uma assistência resiliente. Incumbência esta do Poder Público, de regulamentar, fiscalizar e controlar a saúde pública e, ao SUS, com ações de vigilância sanitária e epidemiológica, além das previsões infraconstitucionais.

Dental Policy Lab 2 - towards paying for health in dentistry

The first Alliance for a Cavity-Free Future (ACFF)/King's College London Dental Policy Lab, held in 2017, identified the need for a review of dental payment systems in order to see progress towards achieving improvements in caries and cavities. The lack of incentivisation for preventive intervention and care has long been a barrier to progress. The second Dental Policy Lab, held in July 2018, focused on this issue with the overarching question: 'How can we create and implement acceptable prevention-based dental payment systems to achieve and maintain health outcomes?' Using a design approach and participatory research, 29 participants from five stakeholder categories developed a blueprint report that aims to serve as a framework to adapt or create remuneration systems that are compatible with evidence-based dentistry with a focus on preventive care. Aimed at policymakers and policy entrepreneurs, this blueprint provides guidance and potential solutions using several international examples. The report and accompanying infographic explored in this paper have been well received and have helped to frame discussions in several country settings, with a direct implementation which is being trialled in France in 2021.

Dental Policy Lab 1 - towards a cavity-free future

Although many dental professionals argue that prevention of oral diseases, including dental caries, will benefit both the patient and public finances, a paradigm shift has yet to happen in most countries. The literature has demonstrated that caries prevention and control is possible, but authorities have yet to implement health systems that allow patients to stay in a good health state. 'Policy Labs' are an innovative policy-making initiative that allow a positive collaboration between the many stakeholders around a given policy issue. In July 2017, 24 international experts, including representatives of both international and European Chief Dental Officers associations, were gathered for the first Alliance for a Cavity-Free Future/King's College London Dental Policy Lab to identify the main barriers for a change, and concrete actions to facilitate a policy shift towards increased resource allocation in prevention. A comprehensive report and well-received infographic summarising the key recommendations (explored in this paper) were produced to explain the situation and highlight the value of a cavity-free world to policymakers, demonstrating where change is needed. The first Dental Policy Lab proved to be an efficient way to generate new ideas and concrete ways to implement them, and has led to several subsequent initiatives worldwide.

Dental Policy Lab 3: towards oral and dental health through partnership

The third and last of the successful Alliance for a Cavity-Free Future (ACFF)/King's College London Dental Policy Lab series, held in 2019, focused on outlining how dental and oral health industries could benefit from enabling positive behaviour change in patients and the public, allowing progress towards caries reduction. During a two-day event, experts from across public health, dentists, global multi-national corporations and dental industry start-ups discussed the issue, collaboratively developing ideas around policy, technology, messaging and engagement for change. An analysis of the current trends in oral health laid out how the implications for industry and corporate social responsibility were identified as crucial. The report and accompanying infographic explored in this paper have been well received and acted as a catalyst for future developments in the area.

THE DIARY OF FREDERIC HARMER

Forgive me writing to you after an interval of what I think must be forty-five years. Let me explain why I am writing. In the process of tidying up my room in the Marshall library, I found a diary of the Bretton Woods Conference. It was a typescript copy on foolscap paper. It was fascinating. It was obviously written by someone very much more alive and intelligent than the ordinary Treasury civil servant. By a process of elimination, I arrived at you as the almost certain author. I sent it to Donald Moggridge, who has edited the Bretton Woods volume in our Collected Writings of John Maynard Keynes. He confirmed that it was not among the Keynes papers in the King's College archive.

HoloMentor: A Novel Mixed Reality Surgical Anatomy Curriculum for Robot-assisted Radical Prostatectomy

ABSTRACT Objectives: The disruption to surgical training and medical education caused by the global COVID-19 pandemic highlighted the need for realistic, reliable, and engaging educational opportunities available outside of the operating theatre and accessible for trainees of all levels. This paper presents the design and development of a virtual reality curriculum which simulates the surgical mentorship experience outside of the operating theatre, with a focus on surgical anatomy and surgical decision making. Method: This was a multi-institutional study between London’s King’s College and Imperial College. The index procedure selected for the module was robotic radical prostatectomy. For each stage of the surgical procedure, subject-matter experts (N=3) at King’s College London, identified: (1) the critical surgical-decision making points, (2) critical anatomical landmarks and (3) tips and techniques for overcoming intraoperative challenges. Content validity was determined by an independent panel of subject-matter experts (N=8) at Imperial College, London using Fleiss’ Kappa statistic. The experts’ teaching points were combined with operative footage and illustrative animations and projected onto a virtual reality headset. The module was piloted to Surgical Science students (N=15). Quantitative analysis compared participants' confidence regarding their anatomical knowledge before and after taking the module. Qualitative data was gathered from students regarding their views on using the virtual reality model. Results: Multi-rater agreement between experts was above the 70.0% threshold for all steps of the procedure. 73% of pilot study participants ‘agreed’ or ‘strongly agreed’ that they achieved a better understanding of surgical anatomy and the rationale behind each procedural step. This was reflected in an increase in the median knowledge score after trialing the curriculum (p<0.001). 100% of subject-matter experts and 93.3% of participants ‘agreed’ or ‘strongly agreed’ that virtual mentorship would be useful for future surgical training. Conclusions: This study demonstrated that virtual surgical mentorship could be a feasible and cost-effective alternative to traditional training methods with the potential to improve technical skills, such as operative proficiency and non-technical skills such as decision-making and situational judgement.

The Bridge is back!

We are honoured to spend some time talking with Dr. Steph Lewis, a Clinical Research Training Fellow at the Institute of Psychiatry, Psychology and Neuroscience, King's College, London, and Editor of The Bridge, about the exciting new relaunch of ACAMH’s magazine, The Bridge.