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Pazin-Filho A, do Valle Dallora MEL, Velasco TR, Cardoso Dos Santos RDO, Volpe GJ, Moroço DM, de Souza DA, Canabrava CM, Garcia LV, Joviliano EE, Maciel BC. Surgical waiting lists and queue management in a Brazilian tertiary public hospital. BMC Health Serv Res 2024; 24:290. [PMID: 38448876 PMCID: PMC10916210 DOI: 10.1186/s12913-024-10735-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 02/15/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Centralized management of queues helps to reduce the surgical waiting time in the publicly funded healthcare system, but this is not a reality in the Brazilian Unified Healthcare System (BUHS). We describe the implementation of the "Patients with Surgical Indication" (PSI) in a Brazilian public tertiary hospital, the impact on waiting time, and its use in rationing oncological surgeries during the COVID-19 Pandemic. METHODS Retrospective observational study of elective surgical requests (2016-2022) in a Brazilian general, public, tertiary university hospital. We recovered information regarding the inflows (indications), outflows and their reasons, the number of patients, and waiting time in queue. RESULTS We enrolled 82,844 indications in the PSI (2016-2022). The waiting time (median and interquartile range) in days decreased from 98(48;168) in 2016 to 14(3;152) in 2022 (p < 0.01). The same occurred with the backlog that ranged from 6,884 in 2016 to 844 in 2022 (p < 001). During the Pandemic, there was a reduction in the number of non-oncological surgeries per month (95% confidence interval) of -10.9(-18.0;-3.8) during Phase I (January 2019-March 2020), maintenance in Phase II (April 2020-August 2021) 0.1(-10.0;10.4) and increment in Phase III (September 2021-December 2022) of 23.0(15.3;30.8). In the oncological conditions, these numbers were 0.6(-2.1;3.3) for Phase I, an increase of 3.2(0.7;5.6) in Phase II and 3.9(1,4;6,4) in Phase III. CONCLUSION Implementing a centralized list of surgical indications and developing queue management principles proved feasible, with effective rationing. It unprecedentedly demonstrated the decrease in the median waiting time in Brazil.
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Affiliation(s)
- Antonio Pazin-Filho
- Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil.
| | | | - Tonicarlo Rodrigues Velasco
- Clinical Hospital - Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | | | - Gustavo Jardim Volpe
- Clinical Hospital - Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Diego Marques Moroço
- Clinical Hospital - Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Danilo Arruda de Souza
- Clinical Hospital - Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | | | - Luis Vicente Garcia
- Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | | | - Benedito Carlos Maciel
- Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
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Silva RPD, Pazin-Filho A. Rate and direct medical costs of cesarean sections among supplementary health plan holders living in the state of São Paulo, Brazil: 2015-2021. Cien Saude Colet 2024; 29:e00512023. [PMID: 38198318 DOI: 10.1590/1413-81232024291.00512023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/06/2023] [Indexed: 01/12/2024] Open
Abstract
Brazil has the second largest cesarean section rate in the world. Differences in rates exist between the public and private health sectors. This study used data on admissions of supplementary health plan holders aged between 10 and 49 years living in the state of São Paulo admitted between 2015 and 2021 to determine cesarean section rates and costs in the private health sector. We conducted a partial economic analysis in health from a supplementary health perspective focusing on the direct medical costs of admissions. A total of 757,307 admissions were analyzed with total costs amounting to R$7.701 billion. The cesarean section rate over the period was 80%. Rates were lowest in young women (69%) and highest in the oldest age group (86%), exceeding 67% across all groups. The rate was 71% higher than in public services. The proportion of admissions with use of the intensive care unit was higher among cesarian deliveries. The median cost of a cesarean was 15% higher than that of a normal delivery and twice as high in insurance companies than healthcare cooperatives. There is an opportunity to apply policies that are widely used in public services to the private sector with the aim of reducing cesarean rates in private services, direct costs of admission, and the cost of supplementary health plans.
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Affiliation(s)
- Rildo Pinto da Silva
- Programa de Mestrado Profissional em Gestão de Organizações de Saúde, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. R. Pedreira de Freitas, Casa 2, Campus Universitário. 14049-900 Ribeirão Preto SP Brasil.
| | - Antonio Pazin-Filho
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Ribeirão Preto SP Brasil
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Lourençato FM, Miranda CH, de Carvalho Borges M, Pazin-Filho A. Palliative care team in a Brazilian tertiary emergency department. Int J Emerg Med 2022; 15:53. [PMID: 36114470 PMCID: PMC9479313 DOI: 10.1186/s12245-022-00456-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/05/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objectives
To describe the process of implementing a palliative care team (PCT) in a Brazilian public tertiary university hospital and compare this intervention as an active in-hospital search (strategy I) with the Emergency Department (strategy II).
Methods
We described the development of a complex Palliative Care Team (PCT). We evaluated the following primary outcomes: hospital discharge, death (in-hospital and follow-up mortality) or transfer, and performance outcomes-Perception Index (difference in days between hospitalization and the evaluation by the PTC), follow-up index (difference in days between the PTC evaluation and the primary outcome), and the in-hospital stay.
Results
We included 1203 patients—strategy I (587; 48.8%) and strategy II (616; 51.2%). In both strategies, male and elderly patients were prevalent. Most came from internal medicine I (39.3%) and II (57.9%), p < 0.01. General clinical conditions (40%) and Oncology I (27.7%) and II (32.4%) represented the majority of the population. Over 70% of all patients had PPS 10 and ECOG 4 above 85%. There was a reduction of patients identified in ICU from I (20.9%) to II (9.2%), p < 0.01, reduction in the ward from I (60.8%) to II (42.5%), p < 0.01 and a significant increase from I (18.2%) to II (48.2%) in the emergency department, p < 0.01. Regarding in-hospital mortality, 50% of patients remained alive within 35 days of hospitalization (strategy I), while for strategy II, 50% were alive within 20 days of hospitalization (p < 0.01). As for post-discharge mortality, in strategy II, 50% of patients died 10 days after hospital discharge, while in strategy I, this number was 40 days (p < 0.01). In the Cox multivariate regression model, adjusting for possible confounding factors, strategy II increased 30% the chance of death. The perception index decreased from 10.9 days to 9.1 days, there was no change in follow-up (12 days), and the duration of in-hospital stay dropped from 24.3 to 20.7 days, p < 0.01. The primary demand was the definition of prognosis (56.7%).
Conclusion
The present work showed that early intervention by an elaborate and complex PCT in the ED was associated with a faster perception of the need for palliative care and influenced a reduction in the length of hospital stay in a very dependent and compromised old population.
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Pazin-Filho A. Participación de enfermería en la vigilancia y prevención de la resistencia antimicrobiana. Rev Cuid 2022. [DOI: 10.15649/cuidarte.2980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Highlights:
El control de la resistencia antimicrobiana es uno de los mayores problemas que el hospital moderno enfrenta.
Las estimativas de la Organización Mundial de la Salud (OMS) para el año 2020 fueron de 700.000 muertes/año atribuidas a las infecciones por gérmenes resistentes y podrán alcanzar la marca de 10 millones de muertes/año en 2050.
El desarrollo de nuevos antimicrobianos es complejo y una aproximación multidisciplinaria es fundamental para el control de la infección hospitalaria, en la cual la Enfermaría es clave.
La infección nosocomial tiene sus orígenes en el propio nacimiento de los hospitales. Sin embargo, antes del desarrollo de los antibióticos, los hospitales eran instituciones para los pobres necesitados de cuidado, con una elevada tasa de mortalidad, causada no solamente por las enfermedades de base para las cuales no había tratamiento, sino incluso por las condiciones que propiciaban la infección nosocomial.
La Guerra de la Crimea en 1854 fue la primera cubierta por la prensa, que destacaron las malas condiciones en el cuidado de los soldados heridos en combate, con tasas de mortalidad alrededor del 42%. La presión popular inglesa incentivó a que Florence Nightingale (1820-1910) se desplazase hasta Crimea y las medidas sanitarias implementadas derrumbaron la tasa de mortalidad hasta el 2% rápidamente. Mientras aún no se conocía la Teoría de los Gérmenes, es posible afirmar que el éxito ocurrió a causa del control de la infección en las heridas. Esos esfuerzos garantizaron a Florence Nightingale la notoriedad para que le encargasen el perfeccionamiento de las condiciones sanitarias hospitalarias cuando regresó a Inglaterra, fortaleciendo la asepsia (la limpieza seguida por la esterilización de los equipos para procedimientos) y la antisepsia (el uso de substancias esterilizantes). Uno de sus cambios fue justamente el desarrollo de la Enfermería como profesión, que ya nace asociada al control de las infecciones.
La transformación del hospital se completó con el descubrimiento de los antibióticos en la década de 1940, el nacimiento de la Anestesia y los cambios sociales de las ciudades. Nacía el hospital moderno, capacitado para realizar procedimientos quirúrgicos y tratamientos que lo convirtieron en el centro de la Salud actual, hecho que se incrementó después de los reportes de Flexner acerca de las condiciones de enseñanza en las facultades de medicina en los EEUU.
Los antibióticos impactaron de modo tan exitoso las tasas de infección en los principios de su utilización, que el énfasis en las otras medidas de prevención disminuyó. Además, la incidencia de resistencia a los antibióticos fue detectada tempranamente, casi al mismo tiempo que su introducción. En conjunto, esos dos puntos añadidos al incremento de procedimientos invasivos y al uso indiscriminado en otras áreas fuera de la Salud, como la ganadería, contribuyeron para que la resistencia a los antibióticos se convirtiese en la calamidad que vivimos actualmente.
Mientras se sigan buscando nuevos antibióticos, mucho de la investigación es dedicada a la búsqueda de otras soluciones como las vacunas, inmunoterápicos, nanobios, terapia fágica, células madre y moléculas de adhesión. Sin embargo, aunque mucho se haya descubierto, aún no estamos preparados para aplicarlos a la clínica diaria.
Como citar este artículo: Pazin-Filho Antonio. Participación de enfermería en la vigilancia y prevención de la resistencia antimicrobiana. Revista Cuidarte. 2022;13(3):e2980. http://dx.doi.org/10.15649/cuidarte.2980
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Moreira HT, Volpe GJ, Mesquita GM, Braggion-Santos MF, Pazin-Filho A, Marin-Neto JA, Schmidt A. Association of left ventricular abnormalities with incident cerebrovascular events and sources of thromboembolism in patients with chronic Chagas cardiomyopathy. J Cardiovasc Magn Reson 2022; 24:52. [PMID: 36329520 PMCID: PMC9632087 DOI: 10.1186/s12968-022-00885-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 08/16/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Although Chagas cardiomyopathy is related to thromboembolic stroke, data on risk factors for cerebrovascular events in Chagas disease is limited. Thus, we assessed the relationship between left ventricular (LV) impairment and cerebrovascular events and sources of thromboembolism in patients with Chagas cardiomyopathy. METHODS This retrospective cohort included patients with chronic Chagas cardiomyopathy who underwent cardiovascular magnetic resonance (CMR). CMR was performed with a 1.5 T scanner to provide LV volumes, mass, ejection fraction (LVEF), and myocardial fibrosis. The primary outcome was a composite of incident ischemic cerebrovascular events (stroke or transient ischemic attack-TIA) and potential thromboembolic sources (atrial fibrillation (AF), atrial flutter, or intracavitary thrombus) during the follow-up. RESULTS A total of 113 patients were included. Median age was 56 years (IQR: 45-67), and 58 (51%) were women. The median LVEF was 53% (IQR: 41-62). LV aneurysms and LV fibrosis were present in 38 (34%) and 76 (67%) individuals, respectively. The median follow-up time was 6.9 years, with 29 events: 11 cerebrovascular events, 16 had AF or atrial flutter, and two had LV apical thrombosis. In the multivariable model, only lower LVEF remained significantly associated with the outcomes (HR: 0.96, 95% CI: 0.93-0.99). Patients with reduced LVEF lower than 40% had a much higher risk of cerebrovascular events and thromboembolic sources (HR: 3.16 95% CI: 1.38-7.25) than those with normal LVEF. The combined incidence rate of the combined events in chronic Chagas cardiomyopathy patients with reduced LVEF was 13.9 new cases per 100 persons-year. CONCLUSIONS LV systolic dysfunction is an independent predictor of adverse cerebrovascular events and potential sources of thromboembolism in patients with chronic Chagas cardiomyopathy.
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Affiliation(s)
- Henrique Turin Moreira
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - Gustavo Jardim Volpe
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - Gustavo Marques Mesquita
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - Maria Fernanda Braggion-Santos
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - Antonio Pazin-Filho
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - José Antonio Marin-Neto
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
| | - André Schmidt
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School, Hospital das Clínicas de Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP 14048-900 Brazil
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Mattiello RMA, Pazin-Filho A, Aragon DC, Cupo P, Carlotti APDCP. Impact of children with complex chronic conditions on costs in a tertiary referral hospital. Rev Saude Publica 2022; 56:89. [PMID: 36259914 PMCID: PMC9550162 DOI: 10.11606/s1518-8787.2022056004656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/23/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To investigate the impact of complex chronic conditions on the use of healthcare resources and hospitalization costs in a pediatric ward of a public tertiary referral university hospital in Brazil. METHODS This is a longitudinal study with retrospective data collection. Overall, three one-year periods, separated by five-year intervals (2006, 2011, and 2016), were evaluated. Hospital costs were calculated in three systematic samples of 100 patients each, consisting of patients with and without complex chronic conditions in proportion to their participation in the studied year. RESULTS Over the studied period, the hospital received 2,372 admissions from 2,172 patients. The proportion of hospitalized patients with complex chronic conditions increased from 13.3% in 2006 to 16.9% in 2016 as a result of a greater proportion of neurologically impaired children, which rose from 6.6% to 11.6% of the total number of patients in the same period. Patients’ complexity also progressively increased, which greatly impacted the use of healthcare resources and costs, increasing by 11.6% from 2006 (R$1,300,879.20) to 2011 (R$1,452,359.71) and 9.4% from 2011 to 2016 (R$1,589,457.95). CONCLUSIONS Hospitalizations of pediatric patients with complex chronic conditions increased from 2006 to 2016 in a Brazilian tertiary referral university hospital, associated with an important impact on hospital costs. Policies to reduce these costs in Brazil are greatly needed.
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Affiliation(s)
- Regina Maria Antunes Mattiello
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Puericultura e PediatriaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Puericultura e Pediatria. Ribeirão Preto, SP, Brasil
| | - Antonio Pazin-Filho
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Clínica MédicaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Clínica Médica. Ribeirão Preto, SP, Brasil
| | - Davi Casale Aragon
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Puericultura e PediatriaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Puericultura e Pediatria. Ribeirão Preto, SP, Brasil
| | - Palmira Cupo
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Puericultura e PediatriaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Puericultura e Pediatria. Ribeirão Preto, SP, Brasil
| | - Ana Paula de Carvalho Panzeri Carlotti
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Puericultura e PediatriaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Puericultura e Pediatria. Ribeirão Preto, SP, Brasil
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Moroço DM, Pazin-Filho A. Decreasing boarders in the emergency department by reducing clerical work in the discharge process of in-hospital patients in Brazil - an interrupted time-series analysis. BMC Emerg Med 2022; 22:99. [PMID: 35672683 PMCID: PMC9171467 DOI: 10.1186/s12873-022-00656-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency Department (ED) boarding is related to in-hospital patients' discharge since no beds will be available for receiving ED patients if there is a delay for patients in the yard leaving the hospital. New techniques implemented in hospital institutions, such as digital signatures to facilitate clerical work improve these processes. We evaluated the impact of expediting patients' discharge after medical orders with the number of patients with an unplanned hospital admission from the Hospital Out Clinic directed to ED for waiting for an available bed in a public tertiary hospital in Brazil. METHODS We conducted a quasi-experimental study before and after an intervention. It consisted of an encrypted digital signature to reduce clerical work and expedite the patient's release from the institution after medical discharge. We used an interrupted time-series analysis based on administrative data (number of hospital discharges, bed turnover, the time between medical discharge, and the time the patient effectively left the hospital) from 2011 to 2020. RESULTS We enrolled 210,496 patients admitted to the hospital from January 2011 to December 2020. Of those, 69,897(33%) composed the group after the intervention. There was no difference between the groups' gender, age distribution, the proportion of surgical patients, or in-hospital stay (≤ 7 or > 7 days). The interrupted time series analysis for the time from medical order to effectively hospital discharge showed an immediate change in level (Coefficient β2 -3.6 h-95% confidence interval -3.9;-3.4), but no a difference in the slope of the behavior of the post-intervention curve (β3 0.0005 coefficient-95% confidence interval -0.0040;0.0050). For the number of patients directed to ED, we observed no immediate change in level (Coefficient β2 -0.84 patients-95% confidence interval -0.33;0.16), but a difference in the slope of the behavior of the post-intervention curve (β3 0.0005 coefficient-95% confidence interval -0.0040;0.0050). CONCLUSION Reducing clerical work and expediting patient discharge was associated with decreased potential boarders to ED.
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Affiliation(s)
| | - Antonio Pazin-Filho
- Department Ribeirão Preto Medical School, University of São Paulo, Ribeirão, Brazil.
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da Silva TL, Pazin-Filho A, Romano MMD, Ferriani VPL, Marin-Neto JA, Maciel BC, Schmidt A. Mitral valve thickening in acute rheumatic fever as a predictor of late valvar dysfunction. PLoS One 2021; 16:e0259737. [PMID: 34788321 PMCID: PMC8598055 DOI: 10.1371/journal.pone.0259737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 10/25/2021] [Indexed: 12/04/2022] Open
Abstract
Background Rheumatic heart disease (RHD) complicating acute rheumatic fever (ARF) remains an important health problem in developing countries. No definitive diagnostic test for ARF exists and the role of Doppler echocardiography (DEC) for long-term prognostic evaluation following ARF is not well established. Objective To investigate the prognostic value of DEC in patients with ARF as a predictor of chronic valve dysfunction. Methods Prospectively enrolled patients with clinical ARF had a DEC performed soon after diagnosis and repeated at 1, 3, 6 and 12 months and thereafter at every 1–2 years. We defined chronic valve dysfunction by ≥ 3 of the following: increased valve thickening, commissure fusion, subvalvular thickening, reduced leaflet mobility, non-trivial mitral and/or aortic regurgitation. We performed univariate analysis and developed multivariate logistic regression models to identify variables that may influence evolution to RHD. p <0.05 was considered significant. Results We evaluated 70(57% men) patients, 10.8±5.6 years-old during the ARF episode and followed for 95±26 months. Chronic valve dysfunction was identified in 36(51.4%) which fulfilled criteria for RHD and 10(27.8%) of them died or underwent valve surgery. Univariate analysis showed that mitral valve thickening and presence of mitral regurgitation at baseline DEC, were associated with RHD(p<0.01). Multivariate logistic regression showed that only mitral valve thickness either as a continuous (Odds-Ratio:5.8;95%CI:1.7–19.7) or as a categorical variable (Odds-Ratio:4.04;95%CI:1.06–15.3) was an independent predictor of chronic valve dysfunction. Conclusions Mitral leaflets thickening documented at the time of diagnosis of ARF is a consistent prognostic marker for the subsequent evolution to RHD.
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Affiliation(s)
- Telêmaco Luis da Silva
- Internal Medicine Department, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Antonio Pazin-Filho
- Internal Medicine Department, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Minna M. D. Romano
- Internal Medicine Department, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Virgínia P. L. Ferriani
- Pediatrics Department, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - José A. Marin-Neto
- Internal Medicine Department, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Benedito C. Maciel
- Internal Medicine Department, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - André Schmidt
- Internal Medicine Department, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
- * E-mail:
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Romo-Castillo HF, Pazin-Filho A. Towards implementing an Antibiotic Stewardship Intervention (ASI) in Ecuador - Evaluating antibiotic consumption and the impact of an ASI in a tertiary hospital according to the World Health Organization (WHO) recommendations. J Glob Antimicrob Resist 2021; 29:462-467. [PMID: 34788689 DOI: 10.1016/j.jgar.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/22/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Ecuador is a lower-to-middle income country (LMIC) not yet adherent to World Health Organization Antibiotic Stewardship Strategies (WHO-ASI) and we still lack data regarding basic metrics. METHODS We conducted a retrospective study of an ASI consisting of a restrictive measure to carbapenems dispensation pending on required preauthorization and expert audit. We evaluated antibiotic consumption and its relationship to carbapenems resistance at a 610-bed, tertiary level hospital in Quito, Ecuador. We used prescription data from 2010 to 2017 and converted into Defined Daily Doses (DDD). We them correlated these findings with the nature of service provided and antibiotic resistance from microbiologic lab. We used descriptive statistics and interrupted time-series analysis. RESULTS Throughout the study period, we analyzed 16,984,355 prescriptions of 8,191,418.57 grams of antibiotics (5,760,479.37 DDD). The in-hospital mean (SD) antibiotic prescription was 148.8 (14.8) DDD/100 occupied bed-dayss and 293.5 (65.3) DDD/100 occupied bed-dayss in the ICU. First, second and third line antibiotics consumption were 38%, 52% and 10% respectively. Our hospital data showed a high rate of antibiotic prescription in all hospital areas, mainly broad-spectrum antibiotics. Regarding the ASI introduced in 2016, the interrupted time-series analysis showed a change in the outcome level immediately following the introduction for imipenem (-3.97; 95% CI -5.31 -2.61) but not for meropenem (0.66; 95%CI -0.37 1.71). CONCLUSION Even though our institution's ASI was successful in reducing imipenen consumption, a more embracing plan is required for further interventions to avoid unexpected effects.
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Affiliation(s)
- Hugo Fernando Romo-Castillo
- Department of Pharmacology, Universidad Central del Ecuador, Hospital Carlos Andrade Marín (IESS), Quito Ecuador.
| | - Antonio Pazin-Filho
- Full Professor, Internal Medicine Department, Ribeirao Preto Medical School, University of São Paulo, Brazil.
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Lopes MI, Bonjorno LP, Giannini MC, Amaral NB, Menezes PI, Dib SM, Gigante SL, Benatti MN, Rezek UC, Emrich-Filho LL, Sousa BAA, Almeida SCL, Luppino Assad R, Veras FP, Schneider A, Rodrigues TS, Leiria LOS, Cunha LD, Alves-Filho JC, Cunha TM, Arruda E, Miranda CH, Pazin-Filho A, Auxiliadora-Martins M, Borges MC, Fonseca BAL, Bollela VR, Del-Ben CM, Cunha FQ, Zamboni DS, Santana RC, Vilar FC, Louzada-Junior P, Oliveira RDR. Beneficial effects of colchicine for moderate to severe COVID-19: a randomised, double-blinded, placebo-controlled clinical trial. RMD Open 2021; 7:e001455. [PMID: 33542047 PMCID: PMC7868202 DOI: 10.1136/rmdopen-2020-001455] [Citation(s) in RCA: 140] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To evaluate whether the addition of colchicine to standard treatment for COVID-19 results in better outcomes. DESIGN We present the results of a randomised, double-blinded, placebo-controlled clinical trial of colchicine for the treatment of moderate to severe COVID-19, with 75 patients allocated 1:1 from 11 April to 30 August 2020. Colchicine regimen was 0.5 mg thrice daily for 5 days, then 0.5 mg twice daily for 5 days. The primary endpoints were the need for supplemental oxygen, time of hospitalisation, need for admission and length of stay in intensive care unit and death rate. RESULTS Seventy-two patients (36 for placebo and 36 for colchicine) completed the study. Median (and IQR) time of need for supplemental oxygen was 4.0 (2.0-6.0) days for the colchicine group and 6.5 (4.0-9.0) days for the placebo group (p<0.001). Median (IQR) time of hospitalisation was 7.0 (5.0-9.0) days for the colchicine group and 9.0 (7.0-12.0) days for the placebo group (p=0.003). At day 2, 67% versus 86% of patients maintained the need for supplemental oxygen, while at day 7, the values were 9% versus 42%, in the colchicine and the placebo groups, respectively (log rank; p=0.001). Two patients died, both in placebo group. Diarrhoea was more frequent in the colchicine group (p=0.26). CONCLUSION Colchicine reduced the length of both, supplemental oxygen therapy and hospitalisation. The drug was safe and well tolerated. Once death was an uncommon event, it is not possible to ensure that colchicine reduced mortality of COVID-19. TRIAL REGISTRATION NUMBER RBR-8jyhxh.
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Affiliation(s)
- Maria Isabel Lopes
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Leticia P Bonjorno
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Marcela C Giannini
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Natalia B Amaral
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Pamella Indira Menezes
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Saulo Musse Dib
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Samara Libich Gigante
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Maira N Benatti
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Uebe C Rezek
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Laerte L Emrich-Filho
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Betania A A Sousa
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Sergio C L Almeida
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Rodrigo Luppino Assad
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Flavio P Veras
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Ayda Schneider
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Tamara S Rodrigues
- Department of Cell Biology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Luiz O S Leiria
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Larissa D Cunha
- Department of Cell Biology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Jose C Alves-Filho
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Thiago M Cunha
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Eurico Arruda
- Department of Cell Biology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Carlos H Miranda
- Department of Emergency Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Antonio Pazin-Filho
- Department of Emergency Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Maria Auxiliadora-Martins
- Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Marcos C Borges
- Department of Emergency Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Benedito A L Fonseca
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Valdes R Bollela
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Cristina M Del-Ben
- Department of Neuroscience and Behaviour, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Fernando Q Cunha
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Dario S Zamboni
- Department of Cell Biology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Rodrigo C Santana
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Fernando C Vilar
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Paulo Louzada-Junior
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Rene D R Oliveira
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
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Lemos ACB, do Espírito Santo DA, Salvetti MC, Gilio RN, Agra LB, Pazin-Filho A, Miranda CH. Therapeutic versus prophylactic anticoagulation for severe COVID-19: A randomized phase II clinical trial (HESACOVID). Thromb Res 2020; 196:359-366. [PMID: 32977137 PMCID: PMC7503069 DOI: 10.1016/j.thromres.2020.09.026] [Citation(s) in RCA: 175] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Coronavirus disease 2019 (COVID-19) causes a hypercoagulable state. Several autopsy studies have found microthrombi in pulmonary circulation. METHODS In this randomized, open-label, phase II study, we randomized COVID-19 patients requiring mechanical ventilation to receive either therapeutic enoxaparin or the standard anticoagulant thromboprophylaxis. We evaluated the gas exchange over time through the ratio of partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen (FiO2) at baseline, 7, and 14 days after randomization, the time until successful liberation from mechanical ventilation, and the ventilator-free days. RESULTS Ten patients were assigned to the therapeutic enoxaparin and ten patients to prophylactic anticoagulation. There was a statistically significant increase in the PaO2/FiO2 ratio over time in the therapeutic group (163 [95% confidence interval - CI 133-193] at baseline, 209 [95% CI 171-247] after 7 days, and 261 [95% CI 230-293] after 14 days), p = 0.0004. In contrast, we did not observe this improvement over time in the prophylactic group (184 [95% CI 146-222] at baseline, 168 [95% CI 142-195] after 7 days, and 195 [95% CI 128-262] after 14 days), p = 0.487. Patients of the therapeutic group had a higher ratio of successful liberation from mechanical ventilation (hazard ratio: 4.0 [95% CI 1.035-15.053]), p = 0.031 and more ventilator-free days (15 days [interquartile range IQR 6-16] versus 0 days [IQR 0-11]), p = 0.028 when compared to the prophylactic group. CONCLUSION Therapeutic enoxaparin improves gas exchange and decreases the need for mechanical ventilation in severe COVID-19. TRIAL REGISTRATION REBEC RBR-949z6v.
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Affiliation(s)
- Anna Cristina Bertoldi Lemos
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Douglas Alexandre do Espírito Santo
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Maísa Cabetti Salvetti
- Hospital Estadual de Américo Brasiliense, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Renato Noffs Gilio
- Hospital Estadual de Américo Brasiliense, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Lucas Barbosa Agra
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Antonio Pazin-Filho
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Carlos Henrique Miranda
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil.
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Ferreira AH, Pazin-Filho A. Lung Ultrasound in a Patient With ARDS Secondary to Pancreatitis. Chest 2020; 158:e85-e87. [DOI: 10.1016/j.chest.2019.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/19/2019] [Accepted: 09/01/2019] [Indexed: 10/23/2022] Open
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Ribeiro Cury Pavão ML, Arfelli E, Scorzoni-Filho A, Pavão RB, Pazin-Filho A, Marin-Neto JA, Schmidt A. Electrical Storm in Chagas Cardiomyopathy: Clinical Predictors, Outcome, and Arrhythmic Characteristics in a Prospective Registry. JACC Clin Electrophysiol 2020; 6:1238-1245. [PMID: 33092749 DOI: 10.1016/j.jacep.2020.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study of patients with Chagas heart disease (CHD) with an implantable cardioverter-defibrillator (ICD) for secondary prevention of sudden cardiac death sought to compare the characteristics of those with or without electrical storm (ES) during long-term follow-up. BACKGROUND ES is a common problem in patients with CHD harboring an ICD, but data on clinical predictors and outcomes are limited. METHODS The authors retrospectively evaluated 110 patients with CHD with a mean follow-up of 1,949 ± 1,271 days. Demographic, clinical, arrhythmia characteristics, ICD treatment, and death data were collected. Descriptive statistics included mean ± SD and Fisher exact tests used for comparisons. A p value <0.05 was considered significant. RESULTS The ES group (n = 57; 43 men; age 62 ± 10 years) and the non-ES group (n = 53; 43 men; age 57 ± 14 years) had similar baseline demographic and clinical parameters, but left ventricular ejection fraction was higher in the ES group (44 ± 14% vs. 37 ± 14%; p = 0.02) and QRS duration was shorter (109 ± 35 ms vs. 134 ± 36 ms; p = 0.0027). Mortality rates were comparable in the 2 groups (odds ratio: 1.2; 95% confidence interval: 0.79 to 1.85; p = 0.44). The ES group presented 116 ES (2.03 ±1.47, 1 to 6). A total of 2,953 (61%) arrhythmic events required ICD therapy. No deaths occurred directly caused by ES, but clinical triggers were reported in 20 patients. CONCLUSIONS ES is frequent in CHD but in itself does not carry a worse prognosis in this study population and was not associated with a more depressed left ventricular systolic function or a longer QRS.
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Affiliation(s)
- Maria Lícia Ribeiro Cury Pavão
- Cardiology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Elerson Arfelli
- Cardiology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Adilson Scorzoni-Filho
- Surgical Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Rafael Brolio Pavão
- Cardiology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Antonio Pazin-Filho
- Cardiology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - José Antonio Marin-Neto
- Cardiology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - André Schmidt
- Cardiology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
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Abstract
Background Sepsis is a major public health problem, with a growing incidence and mortality rates still close to 30% in severe cases. The speed and adequacy of the treatment administered in the first hours of sepsis, particularly access to intensive care, are important to reduce mortality. This study compared the triage strategies and intensive care rationing between septic patients and patients with other indications of intensive care. This study included all patients with signs for intensive care, enrolled in the intensive care management system of a Brazilian tertiary public emergency hospital, from January 1, 2010, to December 31, 2016. The intensivist periodically evaluated the requests, prioritizing them according to a semi-quantitative scale. Demographic data, Charlson Comorbidity Index (CCI), Sequential Organ Failure Assessment (SOFA), and quick SOFA (qSOFA), as well as surgical interventions, were used as possible confounding factors in the construction of incremental logistic regression models for prioritization and admission to intensive care outcomes. Results The study analyzed 9195 ICU requests; septic patients accounted for 1076 cases (11.7%), 293 (27.2%) of which were regarded as priority 1. Priority 1 septic patients were more frequently hospitalized in the ICU than nonseptic patients (52.2% vs. 34.9%, p < 0.01). Septic patients waited longer for the vacancy, with a median delay time of 43.9 h (interquartile range 18.2–108.0), whereas nonseptic patients waited 32.5 h (interquartile range 11.5–75.8)—p < 0.01. Overall mortality was significantly higher in the septic group than in the group of patients with other indications for intensive care (72.3% vs. 39.8%, p < 0.01). This trend became more evident after the multivariate analysis, and the mortality odds ratio was almost three times higher in septic patients (2.7, 2.3–3.1). Conclusion Septic patients had a lower priority for ICU admission and longer waiting times for an ICU vacancy than patients with other critical conditions. Overall, this implied a 2.7-fold increased risk of mortality in septic patients.
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Affiliation(s)
- Hudson Henrique Gomes Pires
- Department of Internal Medicine, Urgency and Emergency Discipline, Triangulo Mineiro Medical School, Federal University of Triangulo Mineiro, Avenida Getúlio Guaritá, 159, Bairro, Nossa Senhora da Abadia, Uberaba, Minas Gerais, 38025-440, Brazil.
| | - Fábio Fernandes Neves
- Department of Internal Medicine, São Carlos Medical School, Federal University of São Carlos, São Carlos, Brazil
| | - Antonio Pazin-Filho
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, São Paulo, Brazil
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Schmidt A, Pazin-Filho A. Rational Use of Evidence-Based Medicine: Why We Resist So Much? Arq Bras Cardiol 2019; 112:727-728. [PMID: 31314825 PMCID: PMC6636369 DOI: 10.5935/abc.20190100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- André Schmidt
- Faculdade de Medicina de Ribeirão Preto - USP - Disciplina
de Cardiologia - Departamento de Clínica Médica, Ribeirão
Preto, SP - Brazil
| | - Antonio Pazin-Filho
- Faculdade de Medicina de Ribeirão Preto - USP - Disciplina
de Emergências Clínicas - Departamento de Clínica
Médica, Ribeirão Preto, SP - Brazil
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Soriano LDA, Castro TT, Vilalva K, Borges MDC, Pazin-Filho A, Miranda CH. Validation of the Pulmonary Embolism Severity Index for risk stratification after acute pulmonary embolism in a cohort of patients in Brazil. J Bras Pneumol 2019; 45:e20170251. [PMID: 30810642 PMCID: PMC6534413 DOI: 10.1590/1806-3713/e20170251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/12/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To validate the Pulmonary Embolism Severity Index (PESI), which was developed for risk stratification after acute pulmonary embolism (PE), for use in Brazil. METHODS This was a single-center retrospective study involving patients admitted to the emergency department with acute PE. The original and simplified versions of the PESI were calculated using hospital admission data from medical records. The outcome measure was the overall 30-day mortality rate. RESULTS We included 123 patients. The mean age was 57 ± 17 years, and there was a predominance of females, who accounted for 60% of the cohort. There were 28 deaths, translating to an overall 30-day mortality rate of 23%. In the cluster analysis by risk class, overall 30-day mortality was 2.40% for classes I-II, compared with 20.00% for classes III-IV-V (relative risk [RR] = 5.9; 95% CI: 1.88-18.51; p = 0.0002). When we calculated overall 30-day mortality using the simplified version (0 points vs. ≥ 1 point), we found it to be 3.25% for 0 points and 19.51% for ≥ 1 point (RR = 2.38; 95% CI: 0.89-6.38; p = 0.06). Using the original version, a survival analysis showed that risk classes I and II presented similar Kaplan-Meier curves (p = 0.59), as did risk classes III, IV, and V (p = 0.25). However, the curve of the clusters based on the original version, showed significantly higher mortality in the III-IV-V classes than in the I-II classes (RR = 7.63; 95% CI: 2.29-25.21; p = 0.0001). The cluster analysis based on the original version showed a greater area under the ROC curve than did the analysis based on the simplified version (0.70; 95% CI: 0.62-0.77 vs. 0.60; 95% CI: 0.51-0.67; p = 0.05). CONCLUSIONS The PESI adequately predicted the prognosis after acute PE in this sample of the population of Brazil. The cluster analysis based on the original version is the most appropriate analysis in this setting.
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Affiliation(s)
- Leonardo de Araujo Soriano
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Talita Tavares Castro
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Kelvin Vilalva
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Marcos de Carvalho Borges
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Antonio Pazin-Filho
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Carlos Henrique Miranda
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
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Volpe GJ, Moreira HT, Trad HS, Wu KC, Braggion-Santos MF, Santos MK, Maciel BC, Pazin-Filho A, Marin-Neto JA, Lima JA, Schmidt A. Left Ventricular Scar and Prognosis in Chronic Chagas Cardiomyopathy. J Am Coll Cardiol 2018; 72:2567-2576. [DOI: 10.1016/j.jacc.2018.09.035] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 09/12/2018] [Accepted: 09/18/2018] [Indexed: 01/16/2023]
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Alvarenga CW, Fernandes LH, Pazin-Filho A, Dos Santos LL. Questionnaire to avoid transfers to healthcare: a Brazilian experience. Int J Prison Health 2018; 14:142-150. [PMID: 29869585 DOI: 10.1108/ijph-04-2017-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this paper is to test whether training correctional facility (CF) officers in the admission process would identify risk factors for inmates' unscheduled transfers to healthcare units in the first 24 hours. Design/methodology/approach Correctional officers (COs) were trained to use a questionnaire with ten closed questions, which seeks to identify occupational or nosocomial risk, applied upon the admission of inmates to a CF. Findings There were 1,288 admissions in six CFs in Ribeirão Preto and Serra Azul/Brazil from March 2010 to May 2011. Of those admissions, 21.2 percent were in penitentiaries and 78.9 percent in provisional detention centers. Of the questionnaires applied, 580 answered affirmatively (45 percent) for one or more of the questions, with nearly 60 percent related to drug use in the last 12 hours, 37.7 percent use of medications while the most frequently mentioned diseases were respiratory diseases (37 percent) and mental disorders (19 percent).The number of positive responses per evaluation presented an odds ratio of 3.6 (CI 95% - 1.6, 10.5) for unscheduled transfers for external clinical evaluation. Research limitations/implications The lack of a control group and the fact that morbidities described by prisoners could not be confirmed are study limitations. The research does, however, still contribute to the goal of achieving appropriate medical care within CFs. Originality/value The training of COs to identify risk factors that predict the need for unplanned transfers to healthcare units was feasible. These findings have important implications for CFs that do not provide ongoing medical service, a universal reality in Brazil.
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Affiliation(s)
- Carlos Willie Alvarenga
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Luiz Henrique Fernandes
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Antonio Pazin-Filho
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Luciane Loures Dos Santos
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
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Serrano-Gomez S, Burgos-Angulo G, Niño-Vargas DC, Niño ME, Cárdenas ME, Chacón-Valenzuela E, McCosham DM, Peinado-Acevedo JS, Lopez MM, Cunha F, Pazin-Filho A, Ilarraza R, Schulz R, Torres-Dueñas D. Predictive Value of Matrix Metalloproteinases and Their Inhibitors for Mortality in Septic Patients: A Cohort Study. J Intensive Care Med 2017; 35:95-103. [DOI: 10.1177/0885066617732284] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: Over 170 biomarkers are being investigated regarding their prognostic and diagnostic accuracy in sepsis in order to find new tools to reduce morbidity and mortality. Matrix metalloproteinases (MMPs) and their inhibitors have been recently studied as promising new prognostic biomarkers in patients with sepsis. This study is aimed at determining the utility of several cutoff points of these biomarkers to predict mortality in patients with sepsis. Materials and Methods: A multicenter, prospective, analytic cohort study was performed in the metropolitan area of Bucaramanga, Colombia. A total of 289 patients with sepsis and septic shock were included. MMP-9, MMP-2, tissue inhibitor of metalloproteinase 1 (TIMP-1), TIMP-2, TIMP-1/MMP-9 ratio, and TIMP-2/MMP-2 ratio were determined in blood samples. Value ranges were correlated with mortality to estimate sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiving operating characteristic curve. Results: Sensitivity ranged from 33.3% (MMP-9/TIMP-1 ratio) to 60.6% (TIMP-1) and specificity varied from 38.8% (MMP-2/TIMP-2 ratio) to 58.5% (TIMP-1). As for predictive values, positive predictive value range was from 17.5% (MMP-9/TIMP-1 ratio) to 70.4% (MMP-2/TIMP-2 ratio), whereas negative predictive values were between 23.2% (MMP-2/TIMP-2 ratio) and 80.9% (TIMP-1). Finally, area under the curve scores ranged from 0.31 (MMP-9/TIMP-1 ratio) to 0.623 (TIMP-1). Conclusion: Although TIMP-1 showed higher sensitivity, specificity, and negative predictive value, with a representative population sample, we conclude that none of the evaluated biomarkers had significant predictive value for mortality.
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Affiliation(s)
- Sergio Serrano-Gomez
- Department of Public Health, Medicine Program, Hospital Universitario de Santander, Bucaramanga, Santander, Colombia
| | - Gabriel Burgos-Angulo
- Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | | | | | - María Eugenia Cárdenas
- Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Estephania Chacón-Valenzuela
- Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Diana Margarita McCosham
- Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | | | - M. Marcos Lopez
- Department of Biotechnology, Enterprise Technology Center, Fundación Cardiovascular de Colombia, Bucaramanga, Santander, Colombia
| | - Fernando Cunha
- Department of Pharmacology, Faculty of Medicine, Universidade de Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Antonio Pazin-Filho
- Department of Medical Clinics, Emergency Unit, Faculty of Medicine, Universidade de Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Ramses Ilarraza
- Departments of Pediatrics and Pharmacology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Richard Schulz
- Departments of Pediatrics and Pharmacology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Diego Torres-Dueñas
- Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
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Schmidt A, Braggion-Santos M, Branco M, Moreira H, Volpe G, Simoes M, Romano M, Pazin-Filho A, Maciel B, Marin-Neto J. P3982EKG abnormalities in chronic chagas heart disease correlate with scar mass and left ventricular dysfunction as assessed by cardiac magnetic resonance imaging. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p3982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Moreira HT, Volpe GJ, Marin-Neto JA, Ambale-Venkatesh B, Nwabuo CC, Trad HS, Romano MMD, Pazin-Filho A, Maciel BC, Lima JAC, Schmidt A. Evaluation of Right Ventricular Systolic Function in Chagas Disease Using Cardiac Magnetic Resonance Imaging. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005571. [PMID: 28289020 DOI: 10.1161/circimaging.116.005571] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 01/20/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Right ventricular (RV) impairment is postulated to be responsible for prominent systemic congestion in Chagas disease. However, occurrence of primary RV dysfunction in Chagas disease remains controversial. We aimed to study RV systolic function in patients with Chagas disease using cardiac magnetic resonance. METHODS AND RESULTS This cross-sectional study included 158 individuals with chronic Chagas disease who underwent cardiac magnetic resonance. RV systolic dysfunction was defined as reduced RV ejection fraction based on predefined cutoffs accounting for age and sex. Multivariable logistic regression was used to verify the relationship of RV systolic dysfunction with age, sex, functional class, use of medications for heart failure, atrial fibrillation, and left ventricular systolic dysfunction. Mean age was 54±13 years, 51.2% men. RV systolic dysfunction was identified in 58 (37%) individuals. Although usually associated with reduced left ventricular ejection fraction, isolated RV systolic dysfunction was found in 7 (4.4%) patients, 2 of them in early stages of Chagas disease. Presence of RV dysfunction was not significantly different in patients with indeterminate/digestive form of Chagas disease (35.7%) compared with those with Chagas cardiomyopathy (36.8%) (P=1.000). CONCLUSIONS In chronic Chagas disease, RV systolic dysfunction is more commonly associated with left ventricular systolic dysfunction, although isolated and early RV dysfunction can also be identified.
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Affiliation(s)
- Henrique T Moreira
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.)
| | - Gustavo J Volpe
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.)
| | - José A Marin-Neto
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.)
| | - Bharath Ambale-Venkatesh
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.)
| | - Chike C Nwabuo
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.)
| | - Henrique S Trad
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.)
| | - Minna M D Romano
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.)
| | - Antonio Pazin-Filho
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.)
| | - Benedito C Maciel
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.)
| | - João A C Lima
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.)
| | - André Schmidt
- From the Department of Internal Medicine, Divisions of Cardiology and Radiology, Medical School of Ribeirão Preto, University of São Paulo, Brazil (H.T.M., G.J.V., J.A.M.-N., H.S.T., M.M.D.R., A.P.-F., B.C.M., A.S.); and Department of Cardiovascular Imaging, Johns Hopkins University, Baltimore, MD (B.A.-V., C.C.N., J.A.C.L.).
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Moreira HT, Volpe GJ, Marin-Neto JA, Nwabuo CC, Ambale-Venkatesh B, Gali LG, Almeida-Filho OC, Romano MM, Pazin-Filho A, Maciel BC, Lima JA, Schmidt A. Right Ventricular Systolic Dysfunction in Chagas Disease Defined by Speckle-Tracking Echocardiography: A Comparative Study with Cardiac Magnetic Resonance Imaging. J Am Soc Echocardiogr 2017; 30:493-502. [DOI: 10.1016/j.echo.2017.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Indexed: 01/13/2023]
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Niño ME, Serrano SE, Niño DC, McCosham DM, Cardenas ME, Villareal VP, Lopez M, Pazin-Filho A, Jaimes FA, Cunha F, Schulz R, Torres-Dueñas D. TIMP1 and MMP9 are predictors of mortality in septic patients in the emergency department and intensive care unit unlike MMP9/TIMP1 ratio: Multivariate model. PLoS One 2017; 12:e0171191. [PMID: 28192449 PMCID: PMC5305237 DOI: 10.1371/journal.pone.0171191] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 01/18/2017] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Matrix metalloproteinases and tissue inhibitors of metalloproteinases could be promising biomarkers for establishing prognosis during the development of sepsis. It is necessary to clarify the relationship between matrix metalloproteinases and their tissue inhibitors. We conducted a cohort study with 563 septic patients, in order to elucidate the biological role and significance of these inflammatory biomarkers and their relationship to the severity and mortality of patients with sepsis. MATERIALS AND METHODS A multicentric prospective cohort was performed. The sample was composed of patients who had sepsis as defined by the International Conference 2001. Serum procalcitonin, creatinine, urea nitrogen, C-Reactive protein, TIMP1, TIMP2, MMP2 and MMP9 were quantified; each patient was followed until death or up to 30 days. A descriptive analysis was performed by calculating the mean and the 95% confidence interval for continuous variables and proportions for categorical variables. A multivariate logistic regression model was constructed by the method of intentional selection of covariates with mortality at 30 days as dependent variable and all the other variables as predictors. RESULTS Of the 563 patients, 68 patients (12.1%) died within the first 30 days of hospitalization in the ICU. The mean values for TIMP1, TIMP2 and MMP2 were lower in survivors, MMP9 was higher in survivors. Multivariate logistic regression showed that age, SOFA and Charlson scores, along with TIMP1 concentration, were statistically associated with mortality at 30 days of septic patients; serum MMP9 was not statistically associated with mortality of patients, but was a confounder of the TIMP1 variable. CONCLUSION It could be argued that plasma levels of TIMP1 should be considered as a promising prognostic biomarker in the setting of sepsis. Additionally, this study, like other studies with large numbers of septic patients does not support the predictive value of TIMP1 / MMP9.
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Affiliation(s)
- Maria Eugenia Niño
- Department of Public Health, Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Sergio Eduardo Serrano
- Department of Public Health, Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Daniela Camila Niño
- Department of Pharmacology, Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Diana Margarita McCosham
- Department of Pharmacology, Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Maria Eugenia Cardenas
- Microbiology and Inmunology Department, Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Vivian Poleth Villareal
- Department of Pharmacology, Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Marcos Lopez
- Biotechnology Department, Enterprise Technology Center, Fundación Cardiovascular de Colombia, Bucaramanga, Santander, Colombia
| | - Antonio Pazin-Filho
- Department of Medical Clinics, Emergency unit, Faculty of Medicine, Universidade de Sao Paulo, Ribeirao preto, Sao Paulo, Brazil
| | - Fabian Alberto Jaimes
- Department of Internal Medicine, School Of Medicine, Universidad de Antioquia, Medellin, Antioquia, Colombia
| | - Fernando Cunha
- Department of Pharmacology, Faculty of Medicine, Universidade de Sao Paulo, Ribeirao preto, Sao Paulo, Brazil
| | - Richard Schulz
- Departments of Pediatrics and Pharmacology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Diego Torres-Dueñas
- Department of Pharmacology, Medicine Program, Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
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Pazin-Filho A, de Almeida E, Cirilo LP, Lourençato FM, Baptista LM, Pintyá JP, Capeli RD, Silva SMPFD, Wolf CM, Dinardi MM, Scarpelini S, Damasceno MC. Impact of long-stay beds on the performance of a tertiary hospital in emergencies. Rev Saude Publica 2016; 49:S0034-89102015000100266. [PMID: 26603353 PMCID: PMC4650935 DOI: 10.1590/s0034-8910.2015049006078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 06/28/2015] [Indexed: 09/26/2023] Open
Abstract
OBJECTIVE To assess the impact of implementing long-stay beds for patients of low complexity and high dependency in small hospitals on the performance of an emergency referral tertiary hospital. METHODS For this longitudinal study, we identified hospitals in three municipalities of a regional department of health covered by tertiary care that supplied 10 long-stay beds each. Patients were transferred to hospitals in those municipalities based on a specific protocol. The outcome of transferred patients was obtained by daily monitoring. Confounding factors were adjusted by Cox logistic and semiparametric regression. RESULTS Between September 1, 2013 and September 30, 2014, 97 patients were transferred, 72.1% male, with a mean age of 60.5 years (SD = 1.9), for which 108 transfers were performed. Of these patients, 41.7% died, 33.3% were discharged, 15.7% returned to tertiary care, and only 9.3% tertiary remained hospitalized until the end of the analysis period. We estimated the Charlson comorbidity index – 0 (n = 28 [25.9%]), 1 (n = 31 [56.5%]) and ≥ 2 (n = 19 [17.5%]) – the only variable that increased the chance of death or return to the tertiary hospital (Odds Ratio = 2.4; 95%CI 1.3;4.4). The length of stay in long-stay beds was 4,253 patient days, which would represent 607 patients at the tertiary hospital, considering the average hospital stay of seven days. The tertiary hospital increased the number of patients treated in 50.0% for Intensive Care, 66.0% for Neurology and 9.3% in total. Patients stayed in long-stay beds mainly in the first 30 (50.0%) and 60 (75.0%) days. CONCLUSIONS Implementing long-stay beds increased the number of patients treated in tertiary care, both in general and in system bottleneck areas such as Neurology and Intensive Care. The Charlson index of comorbidity is associated with the chance of patient death or return to tertiary care, even when adjusted for possible confounding factors.
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Affiliation(s)
- Antonio Pazin-Filho
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Edna de Almeida
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Leni Peres Cirilo
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | | | - Lisandra Maria Baptista
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - José Paulo Pintyá
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Ronaldo Dias Capeli
- Departamento Regional de Saúde XIII, Secretaria de Saúde do Estado de São Paulo, Ribeirão Preto, SP, Brasil
| | | | - Claudia Maria Wolf
- Departamento Regional de Saúde XIII, Secretaria de Saúde do Estado de São Paulo, Ribeirão Preto, SP, Brasil
| | - Marcelo Marcos Dinardi
- Departamento Regional de Saúde XIII, Secretaria de Saúde do Estado de São Paulo, Ribeirão Preto, SP, Brasil
| | - Sandro Scarpelini
- Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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Czaikoski PG, Mota JMSC, Nascimento DC, Sônego F, Castanheira FVES, Melo PH, Scortegagna GT, Silva RL, Barroso-Sousa R, Souto FO, Pazin-Filho A, Figueiredo F, Alves-Filho JC, Cunha FQ. Neutrophil Extracellular Traps Induce Organ Damage during Experimental and Clinical Sepsis. PLoS One 2016; 11:e0148142. [PMID: 26849138 PMCID: PMC4743982 DOI: 10.1371/journal.pone.0148142] [Citation(s) in RCA: 239] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/13/2016] [Indexed: 02/06/2023] Open
Abstract
Organ dysfunction is a major concern in sepsis pathophysiology and contributes to its high mortality rate. Neutrophil extracellular traps (NETs) have been implicated in endothelial damage and take part in the pathogenesis of organ dysfunction in several conditions. NETs also have an important role in counteracting invading microorganisms during infection. The aim of this study was to evaluate systemic NETs formation, their participation in host bacterial clearance and their contribution to organ dysfunction in sepsis. C57Bl/6 mice were subjected to endotoxic shock or a polymicrobial sepsis model induced by cecal ligation and puncture (CLP). The involvement of cf-DNA/NETs in the physiopathology of sepsis was evaluated through NETs degradation by rhDNase. This treatment was also associated with a broad-spectrum antibiotic treatment (ertapenem) in mice after CLP. CLP or endotoxin administration induced a significant increase in the serum concentrations of NETs. The increase in CLP-induced NETs was sustained over a period of 3 to 24 h after surgery in mice and was not inhibited by the antibiotic treatment. Systemic rhDNase treatment reduced serum NETs and increased the bacterial load in non-antibiotic-treated septic mice. rhDNase plus antibiotics attenuated sepsis-induced organ damage and improved the survival rate. The correlation between the presence of NETs in peripheral blood and organ dysfunction was evaluated in 31 septic patients. Higher cf-DNA concentrations were detected in septic patients in comparison with healthy controls, and levels were correlated with sepsis severity and organ dysfunction. In conclusion, cf-DNA/NETs are formed during sepsis and are associated with sepsis severity. In the experimental setting, the degradation of NETs by rhDNase attenuates organ damage only when combined with antibiotics, confirming that NETs take part in sepsis pathogenesis. Altogether, our results suggest that NETs are important for host bacterial control and are relevant actors in the pathogenesis of sepsis.
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Affiliation(s)
- Paula Giselle Czaikoski
- Department of Pharmacology, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | | | - Daniele Carvalho Nascimento
- Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Fabiane Sônego
- Department of Pharmacology, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | | | - Paulo Henrique Melo
- Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Gabriela Trentin Scortegagna
- Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Rangel Leal Silva
- Department of Pharmacology, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Romualdo Barroso-Sousa
- Department of Clinics, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Fabrício Oliveira Souto
- Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Antonio Pazin-Filho
- Department of Clinics, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Florencio Figueiredo
- Department of Pathology, School of Medicine, University of Brasilia, Brasilia, Brazil
| | - José Carlos Alves-Filho
- Department of Pharmacology, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Fernando Queiróz Cunha
- Department of Pharmacology, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
- * E-mail:
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Santos SV, Margarido MRRA, Caires IS, Santos RAN, Souza SG, Souza JMA, Martimiano RR, Dutra CSK, Palha P, Zanetti ACG, Pazin-Filho A. Basic life support knowledge of first-year university students from Brazil. ACTA ACUST UNITED AC 2015; 48:1151-5. [PMID: 26397971 PMCID: PMC4661033 DOI: 10.1590/1414-431x20154667] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 06/22/2015] [Indexed: 11/22/2022]
Abstract
We aimed to evaluate knowledge of first aid among new undergraduates and whether it
is affected by their chosen course. A questionnaire was developed to assess knowledge
of how to activate the Mobile Emergency Attendance Service - MEAS (Serviço de
Atendimento Móvel de Urgência; SAMU), recognize a pre-hospital emergency situation
and the first aid required for cardiac arrest. The students were also asked about
enrolling in a first aid course. Responses were received from 1038 of 1365 (76.04%)
new undergraduates. The questionnaires were completed in a 2-week period 1 month
after the beginning of classes. Of the 1038 respondents (59.5% studying biological
sciences, 11.6% physical sciences, and 28.6% humanities), 58.5% knew how to activate
the MEAS/SAMU (54.3% non-biological vs 61.4% biological, P=0.02),
with an odds ratio (OR)=1.39 (95%CI=1.07-1.81) regardless of age, sex, origin, having
a previous degree or having a relative with cardiac disease. The majority could
distinguish emergency from non-emergency situations. When faced with a possible
cardiac arrest, 17.7% of the students would perform chest compressions (15.5%
non-biological vs 19.1% biological first-year university students,
P=0.16) and 65.2% would enroll in a first aid course (51.1% non-biological
vs 74.7% biological, P<0.01), with an OR=2.61
(95%CI=1.98-3.44) adjusted for the same confounders. Even though a high percentage of
the students recognized emergency situations, a significant proportion did not know
the MEAS/SAMU number and only a minority had sufficient basic life support skills to
help with cardiac arrest. A significant proportion would not enroll in a first aid
course. Biological first-year university students were more prone to enroll in a
basic life support course.
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Affiliation(s)
- S V Santos
- Programa de Educação Tutorial, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - M R R A Margarido
- Programa de Educação Tutorial, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - I S Caires
- Programa de Educação Tutorial, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - R A N Santos
- Programa de Educação Tutorial, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - S G Souza
- Programa de Educação Tutorial, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - J M A Souza
- Programa de Educação Tutorial, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - R R Martimiano
- Programa de Educação Tutorial, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - C S K Dutra
- Programa de Educação Tutorial, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - P Palha
- Programa de Educação Tutorial, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - A C G Zanetti
- Programa de Educação Tutorial, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - A Pazin-Filho
- Programa de Educação Tutorial, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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Abstract
No mundo todo atualmente busca-se, dentro da moderna ciência educacional médica, tecnologias e métodos de ensino aprendizagem realmente eficazes ao ensino de competências, que envolvam adequadamente as esferas cognitivas, comportamentais e psico-motoras.1 Mais ainda, é desejável a esse fim que se utilize de meios que, ativamente, promovam o desenvolvimento reflexivo do estudante em medicina espelhando o mais próximo possível a prática médica real. É fundamental que se assegure que o processo educacional respeite e garanta de forma inalienável e primordial a segurança física e emocional dos pacientes, no ensino e na assistência. Também é reconhecido largamente que comportamentos não podem ser adequadamente desenvolvidos através somente de memorização e reprodução da teoria médica e ou ética isoladamente. Este artigo pretende em nível introdutório apresentar e descrever o uso da Simulação como metodologia ativa de ensino, demonstrando seu potencial e suas limitações, contextualizando-a para o ensino e avaliação em áreas de saúde.
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Braggion-Santos MF, Volpe GJ, Pazin-Filho A, Maciel BC, Marin-Neto JA, Schmidt A. Sudden cardiac death in Brazil: a community-based autopsy series (2006-2010). Arq Bras Cardiol 2014; 104:120-7. [PMID: 25424162 PMCID: PMC4375655 DOI: 10.5935/abc.20140178] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 06/27/2014] [Indexed: 11/20/2022] Open
Abstract
Background Sudden cardiac death (SCD) is a sudden unexpected event, from a cardiac cause,
that occurs in less than one hour after the symptoms onset, in a person without
any previous condition that would seem fatal or who was seen without any symptoms
24 hours before found dead. Although it is a relatively frequent event, there are
only few reliable data in underdeveloped countries. Objective We aimed to describe the features of SCD in Ribeirão Preto, Brazil (600,000
residents) according to Coroners’ Office autopsy reports. Methods We retrospectively reviewed 4501 autopsy reports between 2006 and 2010, to
identify cases of SCD. Specific cause of death as well as demographic information,
date, location and time of the event, comorbidities and whether cardiopulmonary
resuscitation (CPR) was attempted were collected. Results We identified 899 cases of SCD (20%); the rate was 30/100000 residents per year.
The vast majority of cases of SCD involved a coronary artery disease (CAD) (64%)
and occurred in men (67%), between the 6th and the 7th
decades of life. Most events occurred during the morning in the home setting
(53.3%) and CPR was attempted in almost half of victims (49.7%). The most
prevalent comorbidity was systemic hypertension (57.3%). Chagas’ disease was
present in 49 cases (5.5%). Conclusion The majority of victims of SCD were men, in their sixties and seventies and the
main cause of death was CAD. Chagas’ disease, an important public health problem
in Latin America, was found in about 5.5% of the cases.
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Affiliation(s)
| | - Gustavo Jardim Volpe
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Antonio Pazin-Filho
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Benedito Carlos Maciel
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - José Antonio Marin-Neto
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - André Schmidt
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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Gonzalez MM, Timerman S, Gianotto-Oliveira R, Polastri TF, Canesin MF, Schimidt A, Siqueira AW, Pispico A, Longo A, Pieri A, Reis A, Tanaka ACS, Santos AM, Quilici AP, Ribeiro ACL, Barreto ACP, Pazin-Filho A, Timerman A, Machado CA, Franchin Neto C, Miranda CH, Medeiros CR, Malaque CMS, Bernoche C, Gonçalves DM, Sant'Ana DG, Osawa EA, Peixoto E, Arfelli E, Evaristo EF, Azeka E, Gomes EP, Wen FH, Ferreira FG, Lima FG, Mattos FR, Galas FG, Marques FRB, Tarasoutchi F, Mancuso FJN, Freitas GR, Feitosa-Filho GS, Barbosa GC, Giovanini GR, Miotto HC, Guimarães HP, Andrade JP, Oliveira-Filho J, Fernandes JG, Moraes Junior JBMX, Carvalho JJF, Ramires JAF, Cavalini JF, Teles JMM, Lopes JL, Lopes LNGD, Piegas LS, Hajjar LA, Brunório L, Dallan LAP, Cardoso LF, Rabelo MMN, Almeida MFB, Souza MFS, Favarato MH, Pavão MLRC, Shimoda MS, Oliveira Junior MT, Miura N, Filgueiras Filho NM, Pontes-Neto OM, Pinheiro PAPC, Farsky OS, Lopes RD, Silva RCG, Kalil Filho R, Gonçalves RM, Gagliardi RJ, Guinsburg R, Lisak S, Araújo S, Martins SCO, Lage SG, Franchi SM, Shimoda T, Accorsi TD, Barral TCN, Machado TAO, Scudeler TL, Lima VC, Guimarães VA, Sallai VS, Xavier WS, Nazima W, Sako YK. [First guidelines of the Brazilian Society of Cardiology on Cardiopulmonary Resuscitation and Cardiovascular Emergency Care]. Arq Bras Cardiol 2014; 101:1-221. [PMID: 24030145 DOI: 10.5935/abc.2013s006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Facchin LT, Gir E, Pazin-Filho A, Hayashida M, da Silva Canini SRM. Under-reporting of accidents involving biological material by nursing professionals at a Brazilian emergency hospital. Int J Occup Saf Ergon 2014; 19:623-9. [PMID: 24321641 DOI: 10.1080/10803548.2013.11077011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pathogens can be transmitted to health professionals after contact with biological material. The exact number of infections deriving from these events is still unknown, due to the lack of systematic surveillance data and under-reporting. METHODS A cross-sectional study was carried out, involving 451 nursing professionals from a Brazilian tertiary emergency hospital between April and July 2009. Through an active search, cases of under-reporting of occupational accidents with biological material by the nursing team were identified by means of individual interviews. The Institutional Review Board approved the research project. RESULTS Over half of the professionals (237) had been victims of one or more accidents (425 in total) involving biological material, and 23.76% of the accidents had not been officially reported using an occupational accident report. Among the underreported accidents, 53.47% were percutaneous and 67.33% were bloodborne. The main reason for nonreporting was that the accident had been considered low risk. CONCLUSIONS The under-reporting rate (23.76%) was low in comparison with other studies, but most cases of exposure were high risk.
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Affiliation(s)
- Luiza Tayar Facchin
- Ribeirăo Preto Nursing School, University of Săo Paulo, Ribeirăo Preto, Săo Paulo, Brazil.
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Cury Pavao MLR, Arfelli E, Scorzoni-Filho A, Silva-Jr JR, Pazin-Filho A, Marin-Neto JA, Schmidt A. Feasibility and safety of defibrillation threshold testing and fist event characteristics in patients with Chagas heart disease. Registry from a university hospital. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht308.p1412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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32
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Borges DGS, Monteiro RA, Schmidt A, Pazin-Filho A. World soccer cup as a trigger of cardiovascular events. Arq Bras Cardiol 2013; 100:546-52. [PMID: 23657272 DOI: 10.5935/abc.20130105] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 02/15/2013] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Acute coronary syndromes are the major cause of death in Brazil and in the world. External stimuli, known also as triggers, such as emotional state and activity, may generate physiopathological changes that can trigger acute coronary syndromes. Among the studied triggers, the impact of stressful events, such as soccer championships, are controversial in literature and there is no effective data on the Brazilian population. OBJECTIVE To evaluate the acute effects of environmental stress induced by soccer games of the World Soccer Cup on increased incidence of cardiovascular diseases in Brazil. METHODS Public data were obtained from the Unified Health System (Sistema Único de Saúde), regarding hospital admissions that had the International Code Disease of acute coronary syndromes from May to August, in 1998, 2002, 2006 and 2010 (155,992 admissions). Analysis was restricted to patients older than 35 years and admitted by clinical specialties. The incidence of myocardial infarction, angina and mortality were compared among days without World Cup soccer games (Group I: 144,166; 61.7 ± 12.3; 59.4% males); on days when there were no Brazil's soccer team matches (Group II: 9,768; 61.8 ± 12.3; 60.0% males); and days when there were Brazil's soccer team matches (Group III; 2,058; 61.6 ± 12.6; 57.8% males). Logistic regression was used to adjust to age, gender, population density and number of medical assistance units. RESULTS The incidence of myocardial infarction increased during the period of World Cup soccer games (1.09; 95%CI = 1.05-1.15) and days when there were Brazil's matches (1.16; 95%CI = 1.06-1.27). There was no impact on mortality during the Cup (1.00; CI 95% = 0.93-1.08) and Brazil's matches (1.04; 95%CI = 0.93-1.22). CONCLUSION World Cup soccer games and, specially, Brazil's matches have an impact on the incidence of myocardial infarction, but not on in-hospital mortality.
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Neves FF, Cupo P, Muglia VF, Elias Junior J, Nogueira-Barbosa MH, Pazin-Filho A. Body packing by rectal insertion of cocaine packets: a case report. BMC Res Notes 2013; 6:178. [PMID: 23641965 PMCID: PMC3679833 DOI: 10.1186/1756-0500-6-178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 04/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Body packing is used for international drug transport, immediate drug concealment during a police searching or introducing drugs inside prisons. Despite the high level of specialization of dealers who have started to manufacture more complex packs, up to 5% of patients could develop intoxication due to pack rupture. Bowel obstruction is another acute complication. CASE PRESENTATION A 27-year-old black male patient was sent to the hospital by court order for clinical evaluation and toxicological examination. The patient was conscious, oriented, had good color, normal arterial pressure and heart rate, and no signs of acute intoxication. Abdominal examination revealed discrete pain upon deep palpation and a small mass in the left iliac fossa. A plain abdominal radiograph revealed several oval structures located in the rectum and sigmoid. Fasting and a 50 g dose of activated charcoal every six hours were prescribed. After three days, the patient spontaneously evacuated 28 cocaine packs. CONCLUSION Adequate clinical management and prompt identification of potential complications are of fundamental importance in dealing with body packing.
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Barroso-Sousa R, Lobo RR, Mendonça PR, Memória RR, Spiller F, Cunha FQ, Pazin-Filho A. Decreased levels of alpha-1-acid glycoprotein are related to the mortality of septic patients in the emergency department. Clinics (Sao Paulo) 2013; 68:1134-9. [PMID: 24037010 PMCID: PMC3752623 DOI: 10.6061/clinics/2013(08)12] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 04/11/2013] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To determine the validity of alpha-1-acid glycoprotein as a novel biomarker for mortality in patients with severe sepsis. METHODS We prospectively included patients with severe sepsis or septic shock at the emergency department at a single tertiary referral teaching hospital. All of the patients were enrolled within the first 24 hours of emergency department admission, and clinical data and blood samples were obtained. As the primary outcome, we investigated the association of serum levels of alpha-1-acid glycoprotein and 96-hour mortality with logistic regression analysis and generalized estimating equations adjusted for age, sex, shock status and Acute Physiology and Chronic Health Evaluation II score. RESULTS Patients with septic shock had lower alpha-1-acid glycoprotein levels at the time of emergency department admission compared to patients without shock (respectively, 149.1 ±42.7 vs. 189.8 ±68.6; p = 0.005). Similarly, non-survivors in the first 96 hours were also characterized by lower levels of alpha-1-acid glycoprotein at the time of emergency department admission compared to survivors (respectively, 132.18 ±50.2 vs. 179.8 ±61.4; p = 0.01). In an adjusted analysis, alpha-1-acid glycoprotein levels ≤120 mg/dL were significantly associated with 96-hour mortality (odds ratio = 14.37; 95% confidence interval = 1.58 to 130.21). CONCLUSION Septic shock patients exhibited lower circulating alpha-1-acid glycoprotein levels than patients without shock. Alpha-1-acid glycoprotein levels were independently associated with 96-hour mortality in individuals with severe sepsis.
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Affiliation(s)
- Romualdo Barroso-Sousa
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP), Department of Internal Medicine, Ribeirão Preto/SPSP, Brazil
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Ribeiro KB, Miranda CH, Andrade JM, Galli LG, Tiezzi DG, Oliveira HF, Zola FE, Volpe G, Pazin-Filho A, Peria FM. Trastuzumab-induced myocardiotoxicity mimicking acute coronary syndrome. Case Rep Oncol 2012; 5:125-33. [PMID: 22666200 PMCID: PMC3364043 DOI: 10.1159/000337576] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Trastuzumab is an important biological agent in the treatment of HER2-positive breast cancer, with effects on response rates, progression-free survival, overall survival and quality of life. Although this drug is well tolerated in terms of adverse effects, trastuzumab-associated myocardiotoxicity has been described to have an incidence of 0.6–4.5% and in rare cases, the drug can trigger severe congestive heart failure with progression to death or even mimic acute coronary syndrome with complete left bundle branch blockade. In this paper is reported a case of trastuzumab-associated myocardiotoxicity manifesting as acute coronary syndrome in a 69-year-old female. The patient is currently undergoing a conservative clinical treatment that restricts overexertion. The majority of clinical studies report trastuzumab-induced cardiotoxicity as a rare event, and, when present, characterized by mild to moderate clinical signs, the ease of reversibility with pharmacological measures and the temporary discontinuation of the medication. Conversely, it is vital for the oncologist/cardiologist to consider the possibility that trastuzumab-induced cardiotoxicity may manifest itself as a severe clinical case, mimicking acute coronary syndrome, justifying careful risk stratification and adequate cardiac monitoring, especially in high-risk patients.
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Affiliation(s)
- K B Ribeiro
- Clinical Oncology Division, University of São Paulo - FMRP-USP, São Paulo, Brazil
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Izeli NL, Crescencio JC, Pazin-Filho A, Gallo L, Schmidt A. Effects of cardiac rehabilitation on left ventricle function and mass evaluated by cardiac magnetic resonance imaging in post myocardial infarction patients. J Cardiovasc Magn Reson 2011. [PMCID: PMC3106928 DOI: 10.1186/1532-429x-13-s1-p167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Lascala T, Pazin-Filho A, Dias Romano M, Almeida Filho O, Schmidt A, Marin Neto J, Maciel B. 39 Value of 2D-Echocardiography in Patients With Chest Pain and Suspected Acute Coronary Syndromes. Ann Emerg Med 2011. [DOI: 10.1016/j.annemergmed.2011.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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38
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Neves F, Pazin-Filho A. 171 Rationing Critical Care Access From Emergency Department: Electronic Classification System for Critical Care Admission. Ann Emerg Med 2011. [DOI: 10.1016/j.annemergmed.2011.06.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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39
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Adolfi Júnior MS, Pallini FM, Pessotti H, Wolf CM, Patelli HT, Capeli RD, Poli-Neto OB, Neves FF, Scarpelini S, Marques PMDA, Pazin-Filho A. Emergency medical coordination using a web platform: a pilot study. Rev Saude Publica 2011; 44:1063-71. [PMID: 21107504 DOI: 10.1590/s0034-89102010000600011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 04/26/2010] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To describe a management system for emergency medical coordination based on the worldwide web of computers. METHODS The emergency coordination system was developed according to an evolving software model for prototype development. Communication between users and the system was implemented by means of web technologies. The system was developed on a personal homepage and the database was developed using MySQL. The prototype was based on the medical coordination process of the Thirteenth Regional Healthcare Division of the State of São Paulo (Southeastern Brazil) and was applied to 26 municipalities within this regional division, for four consecutive weeks in September 2009. The system made it possible to document requests in chronological order, without allowing editing of data already entered, and ensured hierarchical confidential access to the information for each participant in the system. RESULTS The system presented 100% availability, reliability and integrity of information. A total of 1,046 requests were made to the system, of which 703 (68%) were completed. The solicitants already presented 98% adherence to the system in the first week of application, while adherence among service providers gradually increased (37% in the fourth week). The municipalities closest to Ribeirão Preto that did not have high-complexity providers were the ones that most used the system. CONCLUSIONS Medical coordination of emergency requests through the worldwide web of computers was shown to be feasible and reliable, and it enabled transparency within the process and direct access to information for managers. It allowed indicators to be constructed in order to monitor and improve the process, from the perspective of creating semi-automated coordination and advances in system organization.
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Affiliation(s)
- Mário Sérgio Adolfi Júnior
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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Garrido FD, Romano MMD, Schmidt A, Pazin-Filho A. Can course format influence the performance of students in an advanced cardiac life support (ACLS) program? Braz J Med Biol Res 2010; 44:23-8. [PMID: 21085890 DOI: 10.1590/s0100-879x2010007500131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 10/21/2010] [Indexed: 11/22/2022] Open
Abstract
Advanced cardiac life support (ACLS) is a problem-based course that employs simulation techniques to teach the standard management techniques of cardiovascular emergencies. Its structure is periodically revised according to new versions of the American Heart Association guidelines. Since it was introduced in Brazil in 1996, the ACLS has been through two conceptual and structural changes. Detailed documented reports on the effect of these changes on student performance are limited. The objective of the present study was to evaluate the effect of conceptual and structural changes of the course on student ACLS performance at a Brazilian training center. This was a retrospective study of 3266 students divided into two groups according to the teaching model: Model 1 (N = 1181; 1999-2003) and Model 2 (N = 2085; 2003-2007). Model 2 increased practical skill activities to 75% of the total versus 60% in Model 1. Furthermore, the teaching material provided to the students before the course was more objective than that used for Model 1. Scores greater than 85% in the theoretical evaluation and approval in the evaluation of practice by the instructor were considered to be a positive outcome. Multiple logistic regression was used to adjust for potential confounders (specialty, residency, study time, opportunity to enhance practical skills during the course and location where the course was given). Compared to Model 1, Model 2 presented odds ratios (OR) indicating better performance in the theoretical (OR = 1.34; 95%CI = 1.10-1.64), practical (OR = 1.19; 95%CI = 0.90-1.57), and combined (OR = 1.38; 95%CI = 1.13-1.68) outcomes. Increasing the time devoted to practical skills did not improve the performance of ACLS students.
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Affiliation(s)
- F D Garrido
- Departamento de Clínica Médica, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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41
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Sousa R, Souto F, Spiller F, Turato W, Lobo R, Mendonça P, Cunha F, Pazin-Filho A. 345: Reduction of the Expression of Membrane CXCR2 and BLT1 Receptors on Neutrophils Related to Increased Mortality of Septic Patients In the Emergency Department. Ann Emerg Med 2010. [DOI: 10.1016/j.annemergmed.2010.06.401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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42
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Lobo RR, Borges MC, Neves FF, Vidal de Moura Negrini B, Colleto FA, Romeo Boullosa JL, Camila de Miranda Cardoso M, Pazin-Filho A. Impact of implementing an exclusively dedicated respiratory isolation room in a Brazilian tertiary emergency department. Emerg Med J 2010; 28:754-7. [DOI: 10.1136/emj.2009.082321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Matsushita K, Blecker S, Pazin-Filho A, Bertoni A, Chang PP, Coresh J, Selvin E. The association of hemoglobin a1c with incident heart failure among people without diabetes: the atherosclerosis risk in communities study. Diabetes 2010; 59:2020-6. [PMID: 20484138 PMCID: PMC2911067 DOI: 10.2337/db10-0165] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVE This study sought to investigate an association of HbA1c (A1C) with incident heart failure among individuals without diabetes and compare it to fasting glucose. RESEARCH DESIGN AND METHODS We studied 11,057 participants of the Atherosclerosis Risk in Communities (ARIC) Study without heart failure or diabetes at baseline and estimated hazard ratios of incident heart failure by categories of A1C (<5.0, 5.0-5.4 [reference], 5.5-5.9, and 6.0-6.4%) and fasting glucose (<90, 90-99 [reference], 100-109, and 110-125 mg/dl) using Cox proportional hazards models. RESULTS A total of 841 cases of incident heart failure hospitalization or deaths (International Classification of Disease, 9th/10th Revision, 428/I50) occurred during a median follow-up of 14.1 years (incidence rate 5.7 per 1,000 person-years). After the adjustment for covariates including fasting glucose, the hazard ratio of incident heart failure was higher in individuals with A1C 6.0-6.4% (1.40 [95% CI, 1.09-1.79]) and 5.5-6.0% (1.16 [0.98-1.37]) as compared with the reference group. Similar results were observed when adjusting for insulin level or limiting to heart failure cases without preceding coronary events or developed diabetes during follow-up. In contrast, elevated fasting glucose was not associated with heart failure after adjustment for covariates and A1C. Similar findings were observed when the top quartile (A1C, 5.7-6.4%, and fasting glucose, 108-125 mg/dl) was compared with the lowest quartile (<5.2% and <95 mg/dl, respectively). CONCLUSIONS Elevated A1C (> or =5.5-6.0%) was associated with incident heart failure in a middle-aged population without diabetes, suggesting that chronic hyperglycemia prior to the development of diabetes contributes to development of heart failure.
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Affiliation(s)
- Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Rodrigues de Holanda-Miranda W, Furtado FM, Luciano PM, Pazin-Filho A. Lewis lead enhances atrial activity detection in wide QRS tachycardia. J Emerg Med 2009; 43:e97-9. [PMID: 20022196 DOI: 10.1016/j.jemermed.2009.08.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 06/28/2009] [Accepted: 08/29/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND The differential diagnosis of wide QRS tachycardia is a challenge for the emergency physician. The major tool is the electrocardiogram (ECG), even though the sensitivity and specificity may be variable, depending on presentation. Additional leads could be used to improve the diagnostic accuracy of the ECG. OBJECTIVE To document the use of the Lewis lead in improving the diagnostic accuracy of the ECG in wide QRS tachycardia. CASE REPORT A 52-year-old woman with rheumatoid arthritis, in treatment with methotrexate, was admitted with progressive dyspnea that evolved to acute respiratory distress and shock at arrival. Pneumonia was diagnosed as the infection and she received antibiotics, and respiratory and inotropic support. She was also using amiodarone for more than 10 years, but she couldn't state the reason. On cardiac monitoring, wide QRS tachycardia was detected and ventricular tachycardia was considered on the differential diagnosis. The standard 12-lead ECG was complemented with the Lewis lead, obtained with higher speed and amplitude, demonstrating atrioventricular concordance and excluding ventricular tachycardia. The patient was treated for septic shock, and she died 2 days later. CONCLUSION The Lewis lead is a simple and easy strategy to enhance atrial activity detection in wide QRS tachycardia.
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Pazin-Filho A, Peitz P, Pianta T, Carson KA, Russell SD, Boulware LE, Coresh J. Heart failure disease management program experience in 4,545 heart failure admissions to a community hospital. Am Heart J 2009; 158:459-66. [PMID: 19699871 DOI: 10.1016/j.ahj.2009.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 06/13/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Disease management programs (DMPs) are developed to address the high morbi-mortality and costs of congestive heart failure (CHF). Most studies have focused on intensive programs in academic centers. Washington County Hospital (WCH) in Hagerstown, MD, the primary reference to a semirural county, established a CHF DMP in 2001 with standardized documentation of screening and participation. Linkage to electronic records and state vital statistics enabled examination of the CHF population including individuals participating and those ineligible for the program. METHODS All WCH inpatients with CHF International Classification of Diseases, Ninth Revision code in any position of the hospital list discharged alive. RESULTS Of 4,545 consecutive CHF admissions, only 10% enrolled and of those only 52.2% made a call. Enrollment in the program was related to: age (OR 0.64 per decade older, 95% CI 0.58-0.70), CHF as the main reason for admission (OR 3.58, 95% CI 2.4-4.8), previous admission for CHF (OR 1.14, 95% CI 1.09-1.2), and shorter hospital stay (OR 0.94 per day longer, 95% CI 0.87-0.99). Among DMP participants mortality rates were lowest in the first month (80/1000 person-years) and increased subsequently. The opposite mortality trend occurred in nonenrolled groups with mortality in the first month of 814 per 1000 person-years in refusers and even higher in ineligible (1569/1000 person-years). This difference remained significant after adjustment. Re-admission rates were lower among participants who called consistently (adjusted incidence rate ratio 0.62, 95% CI 0.52-0.77). CONCLUSION Only a small and highly select group participated in a low-intensity DMP for CHF in a community-based hospital. Design of DMPs should incorporate these strong selective factors to maximize program impact.
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Lobo R, Borges M, Neves F, Pazin-Filho A. 63: Respiratory Isolation Rooms in the Emergency Department. Ann Emerg Med 2009. [DOI: 10.1016/j.annemergmed.2009.06.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Franciscon A, Machado J, Schmidt A, Pazin-Filho A. 21: Oral Anticoagulation Quality Index as a Predictor for Bleeding. Ann Emerg Med 2009. [DOI: 10.1016/j.annemergmed.2009.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Cassani RSL, Nobre F, Pazin-Filho A, Schmidt A. Relationship between blood pressure and anthropometry in a cohort of Brazilian men: a cross-sectional study. Am J Hypertens 2009; 22:980-4. [PMID: 19498339 DOI: 10.1038/ajh.2009.104] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hypertension, a risk factor for cardiovascular diseases, and obesity are becoming a health problem in many developed and developing countries, as Brazil. Although hypertension and obesity are both closely associated, there is no universal anthropometric marker of this association. This is probably due to distinct population characteristics, and in the case of Brazil, the highly heterogeneous population. We evaluated which anthropometric measurement most closely relates to high blood pressure in a sample of Brazilian factory workers. METHODS A cross-sectional study was designed. In this study, multiple logistic regression and receiver operating characteristics analysis were performed in order to obtain the precise relevance of each anthropometric measurement as a blood pressure marker. Nine hundred and thirteen men, 36 +/- 8 years-old, were submitted to a standardized questionnaire of demographic and risk factors knowledge, anthropometric and conventional blood pressure measurements were taken, and blood sample evaluations of glucose, total cholesterol, LDL-Cholesterol, and triglycerides were performed. RESULTS Overweightness or obesity was identified in 64, 11.1% were smokers and hypertension was detected in 29.2% of the participants. A linear correlation was significant (P < 0.001) between both the systolic and diastolic blood pressure and all anthropometric measurements, except for the systolic blood pressure and waist-to-hip ratio. Waist circumference (WC) was the only independent anthropometric measurement related to hypertension. Hypertensive patients presented all anthropometric measurements larger than normotensives. CONCLUSIONS Age and WC were the only independent predictors of hypertension, indicating that this simple measurement may be useful as a marker of hypertension in the Brazilian male, younger adult population.
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Pazin-Filho A, de Jesus A, Magalhães P, Melato L, Campos D, Maciel B, Maciel L. How frequently should a patient taking amiodarone be screened for thyroid dysfunction? Braz J Med Biol Res 2009; 42:744-9. [DOI: 10.1590/s0100-879x2009000800009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 06/08/2009] [Indexed: 11/22/2022] Open
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Pazin-Filho A, Soares CS, Ferrais ADSN, Oliveira e Castro PDT, Bellissimo-Rodrigues F, Nogueira JDA, Passos ADC. Tuberculosis among health care workers in a Brazilian tertiary hospital emergency unit. Am J Emerg Med 2008; 26:796-8. [PMID: 18774046 DOI: 10.1016/j.ajem.2007.10.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2007] [Revised: 09/24/2007] [Accepted: 10/23/2007] [Indexed: 11/18/2022] Open
Abstract
The Brazilian emergency system is being reorganized as a hierarchy in the region of Ribeirão Preto, state of São Paulo. We found increased occupational risk for tuberculosis in this region tertiary reference center--a nurse technician (Incidence rate [IR] 526.3/100,000 inhabitants) had a risk of tuberculosis 12.6 (95% confidence interval [CI], 2.57-37.23) greater than the city population (41.8/100,000 inhabitants). The system reorganization will have to make the centers adequate to deal with this problem.
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Affiliation(s)
- Antonio Pazin-Filho
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of Sao Paulo, Sao Paulo, Brazil.
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