Language and relationship with the others: contributions from Merleau-Ponty’s phenomenology to child psychotherapy

Our article aims at discussing the notion of language and the relationship with others in Merleau- Ponty’s phenomenology as a possible foundation for humanistic-phenomenological psychotherapy with children. For Merleau-Ponty, language presents itself as a living and intersubjective experience and the recognition of oneself and others by the child would not occur in intellection, but through the experiential dimension. The psychotherapists listen to the child and their participation occurs as recognition and affectation in the face of children’s language. The relationship constitutes a double reversibility: recognition of the other by the child in his own experience of the body and of the manifest feelings about others; affectation of the encounter, experienced by both the psychotherapist and the child. We conclude that this proposal represents a fruitful contribution to humanistic-phenomenological psychotherapy with children by privileging the child’s understanding beyond stereotypes and crystallized notions of childhood.O objetivo deste ensaio teórico é discutir a noção de linguagem e a relação com os outros na fenomenologia de Merleau-Ponty como possível fundamento para a psicoterapia humanista-fenomenológica com crianças. Para Merleau-Ponty, a linguagem se apresenta como experiência viva e intersubjetiva, e o reconhecimento de si e de outrem pela criança não se daria na intelecção, mas pela dimensão experiencial. O psicoterapeuta escuta a criança naquilo que ela tem a dizer e sua participação se dá como reconhecimento e afetação diante da linguagem infantil. A relação se constitui numa dupla reversibilidade: reconhecimento do outro pela criança em sua própria experiência de corpo e dos sentimentos manifestos acerca de outrem; e afetação do encontro vivenciado tanto pelo psicoterapeuta como pela criança. Concluímos que esta proposta representa uma fecunda contribuição para a psicoterapia humanista-fenomenológica com crianças ao privilegiar a compreensão da criança para além dos estereótipos e noções cristalizadas de infância

Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome : Insights from the LUNG SAFE study

Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). Conclusions: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. Trial registration: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073publishersversionPeer reviewe

The Child as Other: An Ethical Review of Child Centered Play Therapy.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel SuperiorA Ludoterapia Centrada na CrianÃa, aqui entendida nÃo somente na proposta original de Axline, mas tambÃm a partir da Ãtica de VanFleet, Sywulak e Sniscak, tem como postulado a noÃÃo de que o brincar à um diÃlogo lÃdico que propicia a expressÃo dos sentimentos e a expansÃo das possibilidades na histÃria de vida da crianÃa. A terapia ajudaria a crianÃa a identificar, reconhecer e expressar melhor seus sentimentos. Cabe ao terapeuta, portanto, apresentar habilidades que possibilitem um espaÃo de seguranÃa para a expressividade da crianÃa. Essa habilidade do terapeuta à compreendida por Amatuzzi como uma predisponibilidade Ãtica. Para que a Ãtica da LCC seja pensada em seu viÃs filosÃfico, toma-se como base para este trabalho a Ãtica da alteridade radical de LÃvinas, que propÃs a responsabilidade como estrutura da subjetividade. A condiÃÃo Ãtica dar-se-ia na abertura e disponibilidade ao Outro, à sua diferenÃa. O Outro levinasiano nÃo conceituÃvel, antecedente e transcendente ao ser, estabelece uma relaÃÃo de assimetria com o Mesmo. Partindo dessas perspectivas, apresenta-se a questÃo norteadora desta pesquisa: qual o lugar destinado ao radicalmente Outro na Ludoterapia Centrada na CrianÃa? Para responder tal questionamento, o seguinte objetivo geral foi traÃado: analisar o lugar destinado ao Outro na Ludoterapia Centrada na CrianÃa. Os objetivos especÃficos sÃo: a investigaÃÃo entre alteridade e subjetividade, a partir da Ãtica levinasiana, na Ludoterapia Centrada na CrianÃa; a realizaÃÃo da releitura da Ludoterapia Centrada na CrianÃa, a partir do radicalmente Outro. A metodologia utilizada à a hermenÃutica filosÃfica de Gadamer, que propÃe a fusÃo de horizontes entre autor e intÃrprete para a criaÃÃo de um novo horizonte de compreensÃo. A partir das aproximaÃÃes entre a Abordagem Centrada na Pessoa e a Ãtica da alteridade radical, realizadas por Vieira e Freire e Schmid, apresenta-se como resultados a existÃncia de espaÃo para o Outro levinasiano na Ludoterapia Centrada na CrianÃa, desde que o terapeuta seja abertura e disponibilidade ao trauma que representa a chegada da crianÃa em sua diferenÃa absoluta. Verifica-se, tambÃm, que a crianÃa que chega para o atendimento se apresenta como Rosto, que remete ao Infinito e à transcendÃncia do Outro. A crianÃa, portanto, seria entendida como o Outro levinasiano, a quem o terapeuta à intimado a responder. Para que a abertura do terapeuta seja possibilitada, este deve vivenciar processos permanentes de inadaptaÃÃo no face a face com a crianÃa. Presta-se agradecimentos pelo apoio da CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior (CAPES) no desenvolvimento deste trabalho.The Child-Centered Play Therapy, understood not only in the Axlineâs original proposal, but also from the VanFleet, Sywulak and Sniscakâs perspective, has as its premise the notion that the play is a ludic dialogue that promotes the expression of feelings and the expansion of possibilities in the childâs life. The therapy would help the child to identify, recognize and express his/her feelings. The therapist should, therefore, have the skills to enable a safe space for the childâs expression. This ability is understood by Amatuzzi as an ethical previous disponibility. For a philosophical perspective of the ethics of the Child-Centered Play Therapy, it is taken as basis the LÃvinasâ ethics of radical alterity, who proposed the responsibility as subjectivityâs structure. The ethical condition would be developed by the openness and availability to the Other, towards the Otherâs difference. The non-conceptuable levinasian Other, human beingâs antecedent and transcendent, establishes an asymmetric relationship with the Same. From these perspectives, it presents the guiding question of this research: what is the place for the radically Other in Child-Centered Play Therapy? To answer this question, the following general objective was traced: analyze the place reserved to the Other in the Child-Centered Play Therapy. The specific objectives are: inquiry the relation between otherness and subjetivity, based on levinasian ethics, in the Child-Centered Play Therapy; to develop a new reading of Child-Centered Play Therapy, based on radically Other. The chosen methodology was the Gadamerâs philosophical hermeneutics, which proposes the fusion of horizons between the author and the interpreter in order to create a new horizon of comprehension. From the similarities between the Person Centered Therapy and the Ethic of radical alterity, developed by Vieira & Freire and Schmid, it is presented as result that there is a place to the levinasian Other in the Child-Centered Play Therapy, as long as the therapist is openness and disponibility to the trauma that represents the arrival of the child in his/her absolute difference. It is also verified that the child who comes to the attendance, therefore, would be understood as the levinasian Other, whom the therapist is called upon to respond. To enable the therapist openness, he/she (the therapist) should experience permanent processes of inadequacy in the face to face relationship with the child. Grateful for the support of the CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior (CAPES) in the development of this research

Immunocompromised patients with acute respiratory distress syndrome: Secondary analysis of the LUNG SAFE database

Background: The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. Methods: We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Results: Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p &lt; 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p &lt; 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio. Conclusions: Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013

International Nosocomial Infection Control Consortiu (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module

We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care–associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line–associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U.S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN

Outcomes of Patients Presenting with Mild Acute Respiratory Distress Syndrome Insights from the LUNG SAFE Study

BACKGROUND: Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population. METHODS: This study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: "worsening" if moderate or severe acute respiratory distress syndrome criteria were met, "persisting" if mild acute respiratory distress syndrome criteria were the most severe category, and "improving" if patients did not fulfill acute respiratory distress syndrome criteria any more from day 2. RESULTS: Among 580 patients with initial mild acute respiratory distress syndrome, 18% (103 of 580) continuously improved, 36% (210 of 580) had persisting mild acute respiratory distress syndrome, and 46% (267 of 580) worsened in the first week after acute respiratory distress syndrome onset. Global in-hospital mortality was 30% (172 of 576; specifically 10% [10 of 101], 30% [63 of 210], and 37% [99 of 265] for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively), and the median (interquartile range) duration of mechanical ventilation was 7 (4, 14) days (specifically 3 [2, 5], 7 [4, 14], and 11 [6, 18] days for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively). Admissions for trauma or pneumonia, higher nonpulmonary sequential organ failure assessment score, lower partial pressure of alveolar oxygen/fraction of inspired oxygen, and higher peak inspiratory pressure were independently associated with worsening. CONCLUSIONS: Most patients with initial mild acute respiratory distress syndrome continue to fulfill acute respiratory distress syndrome criteria in the first week, and nearly half worsen in severity. Their mortality is high, particularly in patients with worsening acute respiratory distress syndrome, emphasizing the need for close attention to this patient population.status: publishe

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p&lt;0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p&lt;0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status

Mechanical ventilation in patients with cardiogenic pulmonary edema: a sub-analysis of the LUNG SAFE study

International audienceBackground: Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) may require mechanical ventilation that can cause further lung damage. Our aim was to determine the impact of ventilatory settings on CPE mortality. Methods: Patients from the LUNG SAFE cohort, a multicenter prospective cohort study of patients undergoing mechanical ventilation, were studied. Relationships between ventilatory parameters and outcomes (ICU discharge/ hospital mortality) were assessed using latent mixture analysis and a marginal structural model. Results: From 4499 patients, 391 meeting CPE criteria (median age 70 [interquartile range 59-78], 40% female) were included. ICU and hospital mortality were 34% and 40%, respectively. ICU survivors were younger (67 [57-77] vs 74 [64-80] years, p < 0.001) and had lower driving (12 [8-16] vs 15 [11-17] cmH 2 O, p < 0.001), plateau (20 [15-23] vs 22 [19-26] cmH 2 O, p < 0.001) and peak (21 [17-27] vs 26 [20-32] cmH 2 O, p < 0.001) pressures. Latent mixture analysis of patients receiving invasive mechanical ventilation on ICU day 1 revealed a subgroup ventilated with high pressures with lower probability of being discharged alive from the ICU (hazard ratio [HR] 0.79 [95% confidence interval 0.60-1.05], p = 0.103) and increased hospital mortality (HR 1.65 [1.16-2.36], p = 0.005). In a marginal structural model, driving pressures in the first week (HR 1.12 [1.06-1.18], p < 0.001) and tidal volume after day 7 (HR 0.69 [0.52-0.93], p = 0.015) were related to survival. Conclusions: Higher airway pressures in invasively ventilated patients with CPE are related to mortality. These patients may be exposed to an increased risk of ventilator-induced lung injury

Mechanical ventilation in patients with cardiogenic pulmonary edema: a sub-analysis of the LUNG SAFE study

Background: Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) may require mechanical ventilation that can cause further lung damage. Our aim was to determine the impact of ventilatory settings on CPE mortality. Methods: Patients from the LUNG SAFE cohort, a multicenter prospective cohort study of patients undergoing mechanical ventilation, were studied. Relationships between ventilatory parameters and outcomes (ICU discharge/hospital mortality) were assessed using latent mixture analysis and a marginal structural model. Results: From 4499 patients, 391 meeting CPE criteria (median age 70 [interquartile range 59-78], 40% female) were included. ICU and hospital mortality were 34% and 40%, respectively. ICU survivors were younger (67 [57-77] vs 74 [64-80] years, p &lt; 0.001) and had lower driving (12 [8-16] vs 15 [11-17] cmH2O, p &lt; 0.001), plateau (20 [15-23] vs 22 [19-26] cmH2O, p &lt; 0.001) and peak (21 [17-27] vs 26 [20-32] cmH2O, p &lt; 0.001) pressures. Latent mixture analysis of patients receiving invasive mechanical ventilation on ICU day 1 revealed a subgroup ventilated with high pressures with lower probability of being discharged alive from the ICU (hazard ratio [HR] 0.79 [95% confidence interval 0.60-1.05], p = 0.103) and increased hospital mortality (HR 1.65 [1.16-2.36], p = 0.005). In a marginal structural model, driving pressures in the first week (HR 1.12 [1.06-1.18], p &lt; 0.001) and tidal volume after day 7 (HR 0.69 [0.52-0.93], p = 0.015) were related to survival. Conclusions: Higher airway pressures in invasively ventilated patients with CPE are related to mortality. These patients may be exposed to an increased risk of ventilator-induced lung injury. Trial registration Clinicaltrials.gov NCT02010073

Outcome of acute hypoxaemic respiratory failure: insights from the LUNG SAFE Study

Background: Current incidence and outcome of patients with acute hypoxaemic respiratory failure requiring mechanical ventilation in the intensive care unit (ICU) are unknown, especially for patients not meeting criteria for acute respiratory distress syndrome (ARDS). Methods: An international, multicentre, prospective cohort study of patients presenting with hypoxaemia early in the course of mechanical ventilation, conducted during four consecutive weeks in the winter of 2014 in 459 ICUs from 50 countries (LUNG SAFE). Patients were enrolled with arterial oxygen tension/inspiratory oxygen fraction ratio ≤300 mmHg, new pulmonary infiltrates and need for mechanical ventilation with a positive end-expiratory pressure of ≥5 cmH2O. ICU prevalence, causes of hypoxaemia, hospital survival and factors associated with hospital mortality were measured. Patients with unilateral versus bilateral opacities were compared. Findings: 12 906 critically ill patients received mechanical ventilation and 34.9% with hypoxaemia and new infiltrates were enrolled, separated into ARDS (69.0%), unilateral infiltrate (22.7%) and congestive heart failure (CHF; 8.2%). The global hospital mortality was 38.6%. CHF patients had a mortality comparable to ARDS (44.1% versus 40.4%). Patients with unilateral-infiltrate had lower unadjusted mortality, but similar adjusted mortality compared to those with ARDS. The number of quadrants on chest imaging was associated with an increased risk of death. There was no difference in mortality comparing patients with unilateral-infiltrate and ARDS with only two quadrants involved. Interpretation: More than one-third of patients receiving mechanical ventilation have hypoxaemia and new infiltrates with a hospital mortality of 38.6%. Survival is dependent on the degree of pulmonary involvement whether or not ARDS criteria are reached