Prevalence, predictors, and patient-reported outcomes of long COVID in hospitalized and non-hospitalized patients from the city of São Paulo, Brazil

Background

Robust data comparing long COVID in hospitalized and non-hospitalized patients in middle-income countries are limited.

Methods

A retrospective cohort study was conducted in Brazil, including hospitalized and non-hospitalized patients. Long COVID was diagnosed at 90-day follow-up using WHO criteria. Demographic and clinical information, including the depression screening scale (PHQ-2) at day 30, was compared between the groups. If the PHQ-2 score is 3 or greater, major depressive disorder is likely. Logistic regression analysis identified predictors and protective factors for long COVID.

Results

A total of 291 hospitalized and 1,118 non-hospitalized patients with COVID-19 were included. The prevalence of long COVID was 47.1% and 49.5%, respectively. Multivariable logistic regression showed female sex (odds ratio [OR] = 4.50, 95% confidence interval (CI) 2.51-8.37), hypertension (OR = 2.90, 95% CI 1.52-5.69), PHQ-2 > 3 (OR = 6.50, 95% CI 1.68-33.4) and corticosteroid use during hospital stay (OR = 2.43, 95% CI 1.20-5.04) as predictors of long COVID in hospitalized patients, while female sex (OR = 2.52, 95% CI 1.95-3.27) and PHQ-2 > 3 (OR = 3.88, 95% CI 2.52-6.16) were predictors in non-hospitalized patients.

Conclusion

Long COVID was prevalent in both groups. Positive depression screening at day 30 post-infection can predict long COVID. Early screening of depression helps health staff to identify patients at a higher risk of long COVID, allowing an early diagnosis of the condition.

Cost-effectiveness of a second opinion program on spine surgeries: an economic analysis

BACKGROUND

In this study we proposed a new strategy to measure cost-effectiveness of second opinion program on spine surgery, using as measure of effectiveness the minimal important change (MIC) in the quality of life reported by patients, including the satisfaction questionnaire regarding the treatment and direct medical costs.

METHODS

Retrospective analysis of patients with prior indication for spine surgery included in a second opinion program during May 2011 to May 2019. Treatment costs and outcomes were compared considering each patients' recommended treatment before and after the second opinion. Costs were measured under the perspective of the hospital, including hospital stay, surgical room, physician and staff fees and other costs related to hospitalization when surgery was performed and physiotherapy or injection costs when a conservative treatment was recommended. Reoperation costs were also included. For comparison analysis, we used data based on our clinical practice, using data from patients who underwent the same type of surgical procedure as recommended by the first referral. The measure of effectiveness was the percentage of patients who achieved the MIC in quality of life measured by the EQ-5D-3 L 2 years after starting treatment. An incremental cost-effectiveness ratio (ICER) was calculated.

RESULTS

Based upon the assessment of 1,088 patients that completed the entire second opinion process, conservative management was recommended for 662 (60.8%) patients; 49 (4.5%) were recommended to injection and 377 (34.7%) to surgery. Complex spine surgery, as arthrodesis, was recommended by second opinion in only 3.7% of cases. The program resulted in financial savings of -$6,705 per patient associated with appropriate treatment indication, with an incremental effectiveness of 0.077 patients achieving MIC when compared to the first referral, resulting in an ICER of $-87,066 per additional patient achieving the MIC, ranging between $-273,016 and $-41,832.

CONCLUSION

After 2 years of treatment, the second opinion program demonstrated the potential for cost-offsets associated with improved quality of life.

Impact of a quality programme on overindication of surgeries for endometriosis and cholecystectomies

Approximately 45% of patients receive medical services with minimal or no benefit (low-value care). In addition to the increasing costs to the health system, performing invasive procedures without an indication poses a potentially preventable risk to patient safety. This study aimed to determine whether a managed quality improvement programme could prevent cholecystectomy and surgery for endometriosis treatment with minimal or no benefit to patients.This before-and-after study was conducted at a private hospital in São Paulo, Brazil, which has a main medical remuneration model of fee for service. All patients who underwent cholecystectomy or surgery for endometriosis between 1 August 2020 and 31 May 2021 were evaluated.The intervention consisted of allowing the performance of procedures that met previously defined criteria or for which the indications were validated by a board of experts.A total of 430 patients were included in this analysis. The programme prevented the unnecessary performance of 13% of cholecystectomies (p=0.0001) and 22.2% (p=0.0006) of surgeries for the treatment of endometriosis. This resulted in an estimated annual cost reduction to the health system of US$466 094.93.In a hospital with a private practice and fee-for-service medical remuneration, the definition of clear criteria for indicating surgery and the analysis of cases that did not meet these criteria by a board of reputable experts at the institution resulted in a statistically significant reduction in low-value cholecystectomies and endometriosis surgeries.

Nucleocapsid single point-mutation associated with drop-out on RT-PCR assay for SARS-CoV-2 detection

BACKGROUND

Since its beginning, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been a challenge for clinical and molecular diagnostics, because it has been caused by a novel viral agent. Whole-genome sequencing assisted in the characterization and classification of SARS-CoV-2, and it is an essential tool to genomic surveillance aiming to identify potentials hot spots that could impact on vaccine immune response and on virus diagnosis. We describe two cases of failure at the N2 target of the RT-PCR test Xpert® Xpress SARS-CoV-2.

METHODS

Total nucleic acid from the Nasopharyngeal (NP) and oropharyngeal (OP) swab samples and cell supernatant isolates were obtained. RNA samples were submitted to random amplification. Raw sequencing data were subjected to sequence quality controls, removal of human contaminants by aligning against the HG19 reference genome, taxonomic identification of other pathogens and genome recovery through assembly and manual curation. RT-PCR test Xpert® Xpress SARS-CoV-2 was used for molecular diagnosis of SARS-CoV-2 infection, samples were tested in duplicates.

RESULTS

We identified 27 samples positive for SARS-CoV-2 with a nucleocapsid (N) gene drop out on Cepheid Xpert® Xpress SARS-CoV-2 assay. Sequencing of 2 of 27 samples revealed a single common mutation in the N gene C29197T, potentially involved in the failed detection of N target.

CONCLUSIONS

This study highlights the importance of genomic data to update molecular tests and vaccines.

Patient safety culture in South America: a cross-sectional study

BACKGROUND

Every year, millions of patients suffer injuries or die due to unsafe and poor-quality healthcare. A culture of safety care is crucial to prevent risks, errors and harm that may result from medical assistance. Measurement of patient safety culture (PSC) identifies strengths and weaknesses, serving as a guide to improvement interventions; nevertheless, there is a lack of studies related to PSC in Latin America.

AIM

To assess the PSC in South American hospitals.

METHODS

A multicentre international cross-sectional study was performed between July and September 2021 by the Latin American Alliance of Health Institutions, composed of four hospitals from Argentina, Brazil, Chile and Colombia. The Hospital Survey on Patient Safety Culture (HSOPSC V.1.0) was used. Participation was voluntary. Subgroup analyses were performed to assess the difference between leadership positions and professional categories.

RESULTS

A total of 5695 records were analysed: a 30.1% response rate (range 25%-55%). The highest percentage of positive responses was observed in items related to patient safety as the top priority (89.2%). Contrarily, the lowest percentage was observed in items regarding their mistakes/failures being recorded (23.8%). The strongest dimensions (average score ≥75%) were organisational learning, teamwork within units and management support for patient safety (82%, 79% and 78%, respectively). The dimensions 'requiring improvement' (average score <50%) were staffing and non-punitive responses to error (41% and 37%, respectively). All mean scores were higher in health workers with a leadership position except for the hospital handoff/transitions item. Significant differences were found by professional categories, mainly between physicians, nurses, and other professionals.

CONCLUSION

Our findings lead to a better overview of PSC in Latin America, serving as a baseline and benchmarking to facilitate the recognition of weaknesses and to guide quality improvement strategies regionally and globally. Despite South American PSC not being well-exploited, local institutions revealed a strengthened culture of safety care.

Clinical characteristics and outcomes of patients with COVID-19 admitted to the intensive care unit during the first and second waves of the pandemic in Brazil: a single-center retrospective cohort study

OBJECTIVE

To describe and compare the clinical characteristics and outcomes of patients admitted to intensive care units during the first and second waves of the COVID-19 pandemic.

METHODS

In this retrospective single-center cohort study, data were retrieved from the Epimed Monitor System; all adult patients admitted to the intensive care unit between March 4, 2020, and October 1, 2021, were included in the study. We compared the clinical characteristics and outcomes of patients admitted to the intensive care unit of a quaternary private hospital in São Paulo, Brazil, during the first (May 1, 2020, to August 31, 2020) and second (March 1, 2021, to June 30, 2021) waves of the COVID-19 pandemic.

RESULTS

In total, 1,427 patients with COVID-19 were admitted to the intensive care unit during the first (421 patients) and second (1,006 patients) waves. Compared with the first wave group [median (IQR)], the second wave group was younger [57 (46-70) versus 67 (52-80) years; p<0.001], had a lower SAPS 3 Score [45 (42-52) versus 49 (43-57); p<0.001], lower SOFA Score on intensive care unit admission [3 (1-6) versus 4 (2-6); p=0.018], lower Charlson Comorbidity Index [0 (0-1) versus 1 (0-2); p<0.001], and were less frequently frail (10.4% versus 18.1%; p<0.001). The second wave group used more noninvasive ventilation (81.3% versus 53.4%; p<0.001) and high-flow nasal cannula (63.2% versus 23.0%; p<0.001) during their intensive care unit stay. The intensive care unit (11.3% versus 10.5%; p=0.696) and in-hospital mortality (12.3% versus 12.1%; p=0.998) rates did not differ between both waves.

CONCLUSION

In the first and second waves, patients with severe COVID-19 exhibited similar mortality rates and need for invasive organ support, despite the second wave group being younger and less severely ill at the time of intensive care unit admission.

Value-based healthcare in Latin America: a survey of 70 healthcare provider organisations from Argentina, Brazil, Chile, Colombia and Mexico

OBJECTIVES

Value-based healthcare (VBHC) is a health system reform gradually being implemented in health systems worldwide. A previous national-level survey has shown that Latin American countries were in the early stages of alignment with VBHC. Data at the healthcare provider organisations (HPOs) level are lacking. This study aim was to investigate how HPOs in five Latin American countries are implementing VBHC.

DESIGN

Mixed-methods research was conducted using online questionnaire, semistructured interviews based on selected elements of the value agenda (from December 2018 to June 2020), analyses of aggregated data and documents. Qualitative analysis was performed using NVivo QSR International, 1.6.1 (4830). Quantitative analysis used Fisher's exact test. Univariate analysis was used to compare organisations in relation to the implementation of VBHC initiatives. A p≤0.05 was considered significant.

PARTICIPANTS

Top and middle-level executives from 70 HPOs from Argentina, Brazil, Chile, Colombia and Mexico.

RESULTS

The definition of VBHC varied across participating organisations. Although the value equation had been cited by 24% of participants, its composition differed in most case from the original Equation. Most VBHC initiatives were related to care delivery organisation (56.9%) and outcomes measurement (22.4%) but in most cases, integrated practice unit features had not been fully developed and outcome data was not used to guide improvement. Information, stakeholders buy-in, compensation and fragmented care delivery were the most cited challenges to VBHC implementation. Fee-for-service predominated, although one-third of organisations were experimenting with alternative payment models.

CONCLUSIONS

A wide variation in the definition and level of VBHC implementation existed across organisations. Our finding suggests investments in information systems and on education of key stakeholders will be key to foster VBHC implementation in the region. Further research is needed to identify successful implementation cases that may serve as regional benchmark for other Latin American organisations advancing with VBHC.

Clinical characteristics and outcomes of COVID-19 patients admitted to the intensive care unit during the first year of the pandemic in Brazil: a single center retrospective cohort study

Objective:

To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit.

Methods:

Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge.

Results:

During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p<0.001], had a higher Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53) points; p<0.001], and presented comorbidities more frequently. During the intensive care unit stay, 56.6% of patients received noninvasive ventilation, 32.9% received mechanical ventilation, 31.3% used high flow nasal cannula, 11.7% received renal replacement therapy, and 1.5% used extracorporeal membrane oxygenation. Independent predictors of in-hospital mortality included age, Sequential Organ Failure Assessment score, Charlson Comorbidity Index, need for mechanical ventilation, high flow nasal cannula, renal replacement therapy, and extracorporeal membrane oxygenation support.

Conclusion:

Patients with severe COVID-19 admitted to the intensive care unit exhibited a considerable morbidity and mortality, demanding substantial organ support, and prolonged intensive care unit and hospital stay.

Impact of the COVID-19 pandemic on emergency department visits: experience of a Brazilian reference center

Objective

To analyze the impact of COVID-19 on emergency department metrics at a large tertiary reference hospital in Brazil.

Methods

A retrospective analysis of consecutive emergency department visits, from January 1, 2020, to November 21, 2020, was performed and compared to the corresponding time frame in 2018 and 2019. The volume of visits and patients’ demographic and clinic characteristics were compared. All medical conditions were included, except confirmed cases of COVID-19.

Results

A total of 138,138 emergency department visits occurred during the study period, with a statistically significant (p<0.01) reduction by 52% compared to both 2018 and 2019. This decrease was more pronounced for pediatric visits – a drop by 71% in comparison to previous years. Regarding clinical presentation, there was a decrease of severe cases by 34.7% and 37.6%, whereas mild cases decreased by 55.2% and 56.2% when comparing 2020 to 2018 and 2019, respectively. A 30% fall in the total volume of hospital admission from emergency department patients was observed during the study period, but accompanied by a proportional increase in monthly admission rates since April 2020.

Conclusion

The COVID-19 pandemic led to a 52% fall in attendance at our emergency department for other conditions, along with a proportional increase in hospital admission rates of COVID-19 patients. Healthcare providers should raise patient awareness not to delay seeking medical treatment of severe conditions that require care at the emergency department.

It takes two to dance the VBHC tango: A multiple case study of the adoption of value-based strategies in Sweden and Brazil

Although Value-Based Health Care (VBHC) is widely debated and cited, there are few empirical studies focused on how its concepts are understood and applied in real-world contexts. This comparative case study of two prominent adopters in Brazil and Sweden, situated at either end of the spectrum in terms of contextual prerequisites, provides insights into the complex interactions involved in the adoption of value-based strategies. We found that the adoption of VBHC emphasized either health outcomes or costs - not both as suggested by the value equation. This may be linked to broader health system and societal contexts. Implementation can generate tensions with traditional business models, suggesting that providers should first analyze how these strategies align with their internal context. Adoption by a single provider organization is challenging, if not impossible. An effective VBHC transformation seems to require a systematic and systemic approach where all stakeholders need to clearly define the purpose and the scope of the transformation, and together steer their actions and decisions accordingly.

Impact of COVID-19 pandemic on care of oncological patients: experience of a cancer center in a Latin American pandemic epicenter

Objective

Since the rising of coronavirus disease 2019 (COVID-19) pandemic, there is uncertainty regarding the impact of transmission to cancer patients. Evidence on increased severity for patients undergoing antineoplastic treatment is posed against deferring oncologic treatment. We aimed to evaluate the impact of COVID-19 pandemic on patient volumes in a cancer center in an epicenter of the pandemic.

Methods

Outpatient and inpatient volumes were extracted from electronic health record database. Two intervals were compared: pre-COVID-19 (March to May 2019) and COVID-19 pandemic (March to May 2020) periods.

Results

The total number of medical appointments declined by 45% in the COVID-19 period, including a 56.2% decrease in new visits. There was a 27.5% reduction in the number of patients undergoing intravenous systemic treatment and a 57.4% decline in initiation of new treatments. Conversely, there was an increase by 309% in new patients undergoing oral chemotherapy regimens and a 5.9% rise in new patients submitted to radiation therapy in the COVID-19 period. There was a 51.2% decline in length of stay and a 60% reduction in the volume of surgical cases during COVID-19. In the stem cell transplant unit, we observed a reduction by 36.5% in length of stay and a 62.5% drop in stem cell transplants.

Conclusion

A significant decrease in the number of patients undergoing cancer treatment was observed after COVID-19 pandemic. Although this may be partially overcome by alternative therapeutic options, avoiding timely health care due to fear of getting COVID-19 infection might impact on clinical outcomes. Our findings may help support immediate actions to mitigate this hypothesis.

Epidemiologic and clinical features of patients with COVID-19 in Brazil

Objective

This study describes epidemiological and clinical features of patients with confirmed infection by SARS-CoV-2 diagnosed and treated at Hospital Israelita Albert Einstein , which admitted the first patients with this condition in Brazil.

Methods

In this retrospective, single-center study, we included all laboratory confirmed COVID-19 cases at Hospital Israelita Albert Einstein , São Paulo, Brazil, from February until March 2020. Demographic, clinical, laboratory and radiological data were analyzed.

Results

A total of 510 patients with a confirmed diagnosis of COVID-19 were included in this study. Most patients were male (56.9%) with a mean age of 40 years. A history of a close contact with a positive/suspected case was reported by 61.1% of patients and 34.4% had a history of recent international travel. The most common symptoms upon presentation were fever (67.5%), nasal congestion (42.4%), cough (41.6%) and myalgia/arthralgia (36.3%). Chest computed tomography was performed in 78 (15.3%) patients, and 93.6% of those showed abnormal results. Hospitalization was required for 72 (14%) patients and 20 (27.8%) were admitted to the Intensive Care Unit. Regarding clinical treatment, the most often used medicines were intravenous antibiotics (84.7%), chloroquine (45.8%) and oseltamivir (31.9%). Invasive mechanical ventilation was required by 65% of Intensive Care Unit patients. The mean length of stay was 9 days for all patients (22 and 7 days for patients requiring or not intensive care, respectively). Only one patient (1.38%) died during follow-up.

Conclusion

These results may be relevant for Brazil and other countries with similar characteristics, which are starting to deal with this pandemic.

Benchmarking as a quality of care improvement tool for patients with ST-elevation myocardial infarction: an NCDR ACTION Registry experience in Latin America

OBJECTIVE

We aim to examine the effect of benchmarking on quality-of-care metrics in patients presenting with ST-elevation myocardial infarction (STEMI) through the implementation of the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) ACTION Registry.

DESIGN

From January 2005 to December 2017, 712 patients underwent primary percutaneous coronary intervention PCI-499 before NCDR ACTION Registry implementation (prior to 2013) and 213 after implementation.

SETTING

STEMI.

PARTICIPANTS

712 patients.

INTERVENTION(S)

Primary PCI.

MAIN OUTCOME MEASURE(S)

We examined hospital performance for the quality indicators in processes and outcomes of the management of patients presenting with STEMI. Outcome measures include door-to-balloon time (DBT), antiplatelet therapy and anti-ischemic drugs prescribed at discharge from pre-NCDR ACTION Registry to post-implementation.

RESULTS

There was improvement in DBT, decreasing from 94 min in 2012 (before NCDR adoption) to reach a median of 47 min in 2017 (Ptrend < 0.001). The percentage of cases with the optimal DBT of < 90 min increased from 55.8% before to 90.1% after the implementation of the NCDR ACTION Registry (Ptrend < 0.001). The rate of aspirin (90.3-100%, P < 0.001), P2Y12 inhibitor (70.1-78.4%, P = 0.02), beta-blocker (76.8-100%, P < 0.001) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (60.1-99.5%, P < 0.001) prescribed at discharge increased from pre-NCDR ACTION Registry to post-implementation. Adjusted mortality before and after NCDR ACTION Registry implementation showed significant change (from 9.04 to 5.92%; P = 0.027).

CONCLUSIONS

The introduction of the ACC NCDR ACTION Registry led to incremental gains in the quality in STEMI management through the benchmarking of process of care and clinical outcomes, achieving reduced DBT, improving guideline-directed medication adherence and increasing patient safety, treatment efficacy and survival.

Near-infrared spectroscopy parameters in patients undergoing continuous venovenous hemodiafiltration

OBJECTIVE

To investigate the impacts of continuous venovenous hemodiafiltration on the microcirculation in patients with acute kidney injury.

METHODS

A prospective observational pilot study conducted in a 40-bed, open clinical-surgical intensive care unit of a private tertiary care hospital located in the city of São Paulo (SP), Brazil. Microcirculation was assessed using near-infrared spectroscopy by means of a 15mm probe placed over the thenar eminence. Vascular occlusion test was performed on the forearm to be submitted to near-infrared spectroscopy by inflation of a sphygmomanometer cuff to 30mmHg higher than the systolic arterial pressure. The primary endpoint was the assessment of near-infrared spectroscopy-derived parameters immediately before, 1, 4 and 24 hours after the initiation of continuous venovenous hemodiafiltration.

RESULTS

Nine patients were included in this pilot study over a period of 2 months. Minimum tissue oxygen saturation measured during the vascular occlusion test was the only near-infrared spectroscopy-derived parameter to differed over the time (decrease compared to baseline values up to 24 hours after initiation of continuous venovenous hemodiafiltration).

CONCLUSION

The impacts of microcirculatory dysfunction on clinical outcomes of patients undergoing to continuous venovenous hemodiafiltration need to be further investigated.

Abstract WP337: Septic Shock is Associated with Poor Clinical Outcomes in Patients with Ischemic Stroke

Background: Medical complications are potential barriers to optimal recovery after acute ischemic stroke. Hypotension and shock can be particularly deleterious to the recovery of the penumbral tissue. The frequency of shock in patients admitted with acute stroke has not been systematically evaluated. We assessed the hypothesis that shock is not uncommon after ischemic stroke and is related to clinical prognosis.

Methods: We evaluated a prospectively collected database of consecutive patients admitted to a tertiary hospital with acute ischemic stroke from January 2010 to December 2015. Shock was defined as persisting hypotension requiring vasopressors to maintain mean arterial pressure ≥65 mmHg.

Results: A total of 1145 patients (mean age 72 +/-16 years, 56% males) were evaluated. Shock was diagnosed in 15 patients (1.3%). These patients were similar in age, gender, blood pressure at hospital admission, and previous history of coronary artery disease to patients without shock. Sepsis was the most common single etiology of the shock (93%). Septic source was pulmonary in 60%, abdominal in 13%, undetermined in 20% and blood borne in 6.6%. Septic shock was diagnosed at a median of 14 days [8,20] after hospital admission. Patients who developed shock had a higher National Institutes of Health Stroke Scale (NIHSS) at admission (12 [8,20] vs 3 [1,10], p<0.01), a higher frequency of diabetes (60% vs 30%, p=0.01), urinary tract infection (27% vs 4.8%, p<0.01), pneumonia (47% versus 4.5%, p<0.01), acute renal (33% vs 0.7%, p<0.01) and respiratory (53% vs 1.8%, p<0.01) failures. Length of hospital stay (39 [29,156] vs 8 days [4, 15], p<0.01) and ICU stay (19[7, 27.5] vs 0 days [0,3], p<0.01) were higher in patients with shock. Shock was associated with a hospital mortality of 80% vs 9% in patients without shock (p<0.01). In multivariate logistic regression analysis, only pneumonia (OR: 16.9, [4.1-69.4],p<0.01) and NIHSS 1.07 [1.01-1.15, p=0.04] at admission were predictors of developing shock during hospital admission.

Conclusion: In conclusion, shock was an infrequent but severe complication in patients with stroke and was associated with a very high mortality. Sepsis was the most important etiology.

Georeferencing of deaths from sepsis in the city of São Paulo

Objective

The aim of the present study was to obtain information about deaths due to sepsis in São Paulo from 2004 to 2009 and their relationship with geographical distribution.

Methods

Causes of death, both main and secondary, were defined according to the codes of the International Classification of Disease version 10 (ICD-10) contained in the database. Sepsis, septic shock, multiple organ failure, pneumonia, urinary tract infection, peritonitis and other intraabdominal infections, skin and soft tissue infections (including surgical wound infection) and meningitis were considered as immediate cause of death or as the condition leading to the immediate cause of death related or associated to sepsis.

Results

In the analyzed period, there was a 15.3% increase in the absolute number of deaths from sepsis in São Paulo. The mean number of deaths during this period was 28,472 ± 1566. Most deaths due to sepsis and sepsis-related diseases over the studied period occurred in a hospital or health care facility, showing that most of the patients received medical care during the event that led to death. We observed a significant concentration of deaths in the most populous regions, tending more toward the center of the city.

Conclusions

Georeferencing data from death certificates or other sources can be a powerful tool to uncover regional epidemiological differences between populations. Our study revealed an even distribution of sepsis all over the inhabited areas of São Paulo.

Impact of screening and monitoring of capillary blood glucose in the detection of hyperglycemia and hypoglycemia in non-critical inpatients

OBJECTIVE

To evaluate the impact of screening hyper and hypoglycemia measured by capillary glycemia and standard monitorization of hyperglycemic patients hospitalized in regular care units of Hospital Israelita Albert Einstein.

METHODS

The capillary glycemia was measured by the Precision PCx (Abbott) glucosimeter, using the PrecisionWeb (Abbott) software. The detection of hyper and hypoglycemia during the months of May/June were compared to those of March/April in 2009 and to the frequency of the diagnosis of diabetes in 2007.

RESULTS

There was an increase in the glycemia screening from 27.7 to 77.5% of hospitalized patients (p < 0.001), of hyperglycemia detection (from 9.3 to 12.2%; p < 0.001) and of hypoglycemia (from 1.5 to 3.3%; p < 0.001) during the months of May/June 2009. According to this action 14 patients for each additional case of hyperglycemia and 26 cases for each case of hypoglycemia were identified. The detection of hyperglycemia was significantly higher (p < 0.001) than the frequency of registered diagnosis related do diabetes in the year of 2007.

CONCLUSIONS

the adoption of an institutional program of glycemia monitorization improves the detection of hyper and hypoglycemia and glycemia control in hospitalized patients in regular care units.

A new spectrophotometric method to detect residual amounts of peroxide after reprocessing hemodialysis filters

OBJECTIVE

Reuse of hemodialysis filters is a standard practice and the sterilizing chemical most often employed is peracetic acid. Before starting the dialysis session, filters and lines are checked for residual levels of peracetic acid by means of a non-quantitative colorimetric test that is visually interpreted. The objective of this study was to investigate a new quantitative spectrophotometric test for detection of peracetic acid residues.

METHODS

Peracetic acid solutions were prepared in concentrations ranging from 0.01 to 10 ppm. A reagent (potassium-titanium oxide + sulfuric acid) was added to each sample in proportions varying from 0.08 to 2.00 drops/mL of solution. Optical densities were determined in a spectrophotometer using a 405-nm filter and subjected to visual qualitative test by different observers.

RESULTS

A relation between peroxide concentrations and respective optical densities was observed and it was linear with R2 > 0.90 for all reagent/substrate proportions. The peak optical densities were obtained with the reagent/substrate ratio of 0.33 drops/mL, which was later standardized for all further experiments. Both qualitative and quantitative tests yielded a specificity of 100%. The quantitative test was more sensitive than the qualitative test and resulted in higher positive and negative predictive values. There was a difference between observers in the qualitative test and some samples with significant amounts of peroxide were not detected.

CONCLUSION

A quantitative spectrophotometric test may improve detection of residues of peracetic acid when compared to the standard visual qualitative test. This innovation may contribute to the development of safer standards for reuse of hemodialysis filters.

Georeferencing deaths from stroke in São Paulo: an intra-city stroke belt?

Background

The role of socioeconomic status in the worldwide stroke burden has been studied with various methods using vital statistics and research-generated data.

Aim

The objective of our study was to describe the stroke mortality rates and the stroke mortality distribution, and to evaluate the association between stroke mortality rates and geographical distribution with the human development index in São Paulo, Brazil.

Methods

This ecological study evaluated a historical series of stroke mortality in São Paulo, Brazil, from 2004 to 2010. Standard stroke mortality rate per 100 000 inhabitants at each year, the address of residence assumed as the place of living, and the human development index applied as a social indicator were used in order to evaluate if stroke mortality correlated with socioeconomic status.

Results

The mean standardized stroke mortality in São Paulo decreased from 66 to 46-7 per 100 000 inhabitants from 2004 to 2010. Stroke mortality differed according to human development index strata with an almost three times higher stroke mortality in the lowest when compared with the highest human development index stratum. Visual inspection of the map of the districts with high stroke mortality disclosed regional clusters with high mortality in the east, northwest, and south regions, a finding suggestive of the presence of a stroke belt inside the city of São Paulo.

Conclusions

In conclusion, between 2004 and 2010, stroke mortality rates decreased by 28-5% in São Paulo. A geographical pattern in stroke mortality could be observed, with considerable differences according the human development index level of the place of living.

Abstract W MP82: False Negative Results on Acute Stroke Recognition Tool Has No Impact on Stroke Prognosis

Introduction: Stroke recognition tools can be useful in expediting stroke care in the acute phase. The Los Angeles Prehospital Stroke Screen (LAPSS) is one such tool, an instrument designed to allow acute stroke identification with high sensitivity and specificity. Conversely, the impact of a negative result can potentially delay stroke recognition and treatment with unknown prognostic consequences. Hypothesis We assessed whether LAPSS status affect acute stroke care and prognosis.

Methods: We evaluated consecutive patients admitted to a tertiary hospital with acute ischemic stroke from February 2009 to March 2014. All triage nurses from the emergency department were trained in the application of LAPSS, which they documented at hospital arrival on all suspected stroke patients. When LAPSS criteria for stroke were met (LAPSS positive), the stroke code was activated. We used logistic regression analysis to investigate the influence of LAPSS results upon clinical outcome (modified Rankin Scale (mRs) < 3) at discharge.

Results: We evaluated 415 patients, 82 of whom (19%) had a negative LAPSS. Patients with positive and negative LAPSS had similar time from symptoms onset to hospital arrival. Patients with a negative LAPSS had lower National Institutes of Health Stroke Scale (NIHSS) at admission (7 [3,15] versus 0 [0,0], p<0.01), higher door to neuroimaging (42 [28,51] versus 27 [19, 44] minutes, p=0.02) and door to radiologic report times (54 [36,84] versus 37 [26, 55] minutes, p<0.01), as well as a lower length of stay (5 [2,5] versus 8 [5, 17] days, p<0.01). Only patients with a positive LAPPS (26.9%) received recanalization therapies, either intravenous thrombolysis or endovascular procedures. Age 0.98 [0.96-0.99] p=0.02, NIHSS at admission 0.78[0.73-0.82] p<0.01 and treatment with thrombolysis 2.07 [1.02-2.44] p=0.04 were independent predictors of good clinical outcome (mRS< 3) at discharge, but not LAPSS status.

Conclusion: In conclusion, patients with negative LAPPS had less severe strokes as compared to those with positive screen. Although time to neuroimaging was longer in patients with negative LAPSS, short term outcome did not seem to be affected by LAPSS status.

Abstract T P37: Routine CT Angiography in Acute Stroke Does Not Delay Acute Stroke Care

Introduction: Vascular imaging is increasingly used for diagnosis of arterial occlusions in acute ischemic stroke. Hypothesis:We hypothesized that time intervals using a CTA based acute ischemic stroke protocol are not increased when compared to an earlier non-CTA based protocol. Methods: We evaluated a database of consecutive patients admitted to a Brazilian tertiary hospital with acute ischemic stroke from February 2009 to March 2014 and reviewed our stroke quality measures data to determine if the time required to obtain CTA prolonged door-to-neuroimaging, door to radiology report and door-to-needle times. Patients were categorized into: Group 1 (February 2009 to October 2013) (Non-contrast CT Scan based acute stroke protocol) and Group 2 (November 2013 to August 2014) (CTA based acute stroke protocol). Time intervals were compared between the two groups.Results: We evaluated 415 consecutive patients, 20 of whom (4.8%) had a CTA in the acute phase (Group 2). Patients in groups 1 and 2 had similar onset-to-door times (1.86 [0.75-3.58] versus 2.75 hours [1.0-8.49], p=0.09); door to neuroimaging times (27.6 [18.6-46.8] versus 37.8 minutes [23.4-46.2], p=0.28 ) and door to radiology report intervals (39 [27-60.6] versus 53.4 minutes[35.4-61.2], p=0.09). The frequency of treatment with recanalization therapies ( either intravenous thrombolysis or endovascular procedures) was similar between groups 1 (30%) and 2 (21%), p=0.33, as well as door to needle times (p=0.09). Conclusions: CTA based acute stroke care does not significantly delay time to neuroimaging or thrombolysis in routine clinical practice.

Positive Deviance A New Strategy for Improving Hand Hygiene Compliance

Objective.

To evaluate the effectiveness of a positive deviance strategy for the improvement of hand hygiene compliance in 2 adult step-down units.

Design.

A 9-month, controlled trial comparing the effect of positive deviance on compliance with hand hygiene.

Setting.

Two 20-bed step-down units at a tertiary care private hospital.

Methods.

The first phase of our study was a 3-month baseline period (from April to June 2008) in which hand hygiene episodes were counted by use of electronic handwashing counters. From July to September 2008 (ie, the second phase), a positive deviance strategy was implemented in the east unit; the west unit was the control unit. During the period from October to December 2008 (ie, the third phase), positive deviance was applied in both units.

Results.

During the first phase, there was no statistically significant difference between the 2 step-down units in the number of episodes of hand hygiene per 1,000 patient-days or in the incidence density of healthcare-associated infections (HAIs) per 1,000 patient-days. During the second phase, there were 62,000 hand hygiene episodes per 1,000 patient-days in the east unit and 33,570 hand hygiene episodes per 1,000 patient-days in the west unit (P < .01). The incidence density of HAIs per 1,000 patient-days was 6.5 in the east unit and 12.7 in the west unit (P = .04). During the third phase, there was no statistically significant difference in hand hygiene episodes per 1,000 patient-days (P = .16) or in incidence density of HAIs per 1,000 patient-days.

Conclusion.

A positive deviance strategy yielded a significant improvement in hand hygiene, which was associated with a decrease in the overall incidence of HAIs.

Serum soluble-Fas is a predictor of red blood cell transfusion in critically ill patients

Objective:

To investigate the relation between the need for red blood cell transfusion and serum levels of soluble-Fas, erythropoietin and inflammatory cytokines in critically ill patients with and without acute kidney injury.

Methods:

We studied critically ill patients with acute kidney injury (n=30) and without acute kidney injury (n=13), end-stage renal disease patients on hemodialysis (n=25) and healthy subjects (n=21). Serum levels of soluble-Fas, erythropoietin, interleukin 6, interleukin 10, iron status, hemoglobin and hematocrit concentration were analyzed in all groups. The association between these variables in critically ill patients was investigated.

Results:

Critically ill patients (acute kidney injury and non-acute kidney injury patients) had higher serum levels of erythropoietin than the other groups. Hemoglobin concentration was lower in the acute kidney injury patients than in other groups. Serum soluble-Fas levels were higher in acute kidney injury and end-stage renal disease patients. Critically ill patients requiring red blood cell transfusions had higher serum levels of soluble-Fas (5,906±2,047 and 1,920±1,060; p<0.001), interleukin 6 (518±537 and 255+502; p=0.02) and interleukin 10 (35.8±30.7 and 18.5±10.9; p=0.02), better iron status and higher mortality rates in the first 28 days in intensive care unit. Serum soluble-Fas levels were independently associated with the number of red blood cell units transfused (p=0.02). Serum soluble-Fas behaved as an independent predictor of the need for red blood cell transfusion in critically ill patients (p=0.01).

Conclusions:

Serum soluble-Fas level is an independent predictor of the need for red blood cell transfusion in critically ill patients with or without acute kidney injury. Further studies are warranted to reconfirm this finding.

Abstract 101: Educational Level, Emergency Medical Services Activation and Hospital Arrival in Acute Stroke

Background: Several studies report that certain factors such as socioeconomic status, living alone or being alone at onset of symptoms play a role in late arrival at hospitals thereby decreasing the ultimate success of medical interventions for stroke patients. There is little research about the influence of educational level upon early arrival in patients with acute stroke. We hypothesized that higher educational level is associated with early arrivals in patients with acute stroke.

Methods: We conducted a prospective cohort study to evaluate consecutive patients admitted with a new stroke in 19 hospitals in Fortaleza, Brazil, from April 2009 to April 2012. Educational attainment was categorized into 5 levels: no school attendance, less than secondary school graduation, secondary school graduation, bachelor's degree and master's or doctorate degree. Multiple logistic regressions were used to investigate the influence of epidemiologic and clinical data on the frequency of early arrival (defined as hospital arrival within 4.5 hours from symptoms onset).

Results: We evaluated 4679 patients (48% males, mean age: 67.67± 14.48). Ischemic stroke was the most frequent subtype (74.9%) followed by intraparenchymal hemorrhage (14.5%), subarachnoid hemorrhage (5.1%), transient ischemic attack (2.8%), and undetermined stroke (2.7%). A total of 1128 (24.1%) patients arrived within 4.5 hours from symptoms onset. Higher educational level was a predictor of early hospital arrival (p= 0.01). Other univariate predictors of early hospital arrival included having a decreased level of consciousness at presentation OR 1.36 [1.17-1.58], p<0.01, having a hemorrhagic stroke OR 1.46 [1.19-1.79] p<0.01, having a transient ischemic attack OR 2.2 [1.50-3.49] and arriving by emergency medical services (EMS) OR 0.37 [0.31-0.44]. In the multivariate logistic regression analysis, educational level just remains as an independent predictor of early hospital arrival if arriving by EMS is not included in the model.

Conclusions: Educational level is associated with early hospital arrival in patients with acute stroke. The association between educational level and early hospital arrival seems to be mediated by activation of the EMS.

Epidemiology of total hip and knee replacement: a cross-sectional study

Objective:

To describe the epidemiologic characteristics and adverse events of patients submitted to total hip and total knee replacement.

Methods:

A cross-sectional study retrospectively assessing medical chart data of all total hip and total knee replacements performed at a private hospital, between January 2007 and December 2010 Patients submitted to total hip and total knee replacement, with consent of surgeons were included. Incomplete records and/or missing data of the hospital database were excluded. The categorical variables analyzed were age, gender, type of arthroplasty (primary or secondary), type of procedure, duration of surgery, use of drains, risk of infection, compliance to protocol for prevention of deep venous thrombosis and embolism pulmonary, and compliance to the protocol for prevention of infection. The outcomes assessed were adverse events after surgery.

Results:

A total of 510 patients were included; in that, 166 admissions for knee replacements (92 male) and 344 admissions for hip replacements (176 female). The mean age of patients was 71 years (range 31-99 years). Adverse events were reported in 76 patients (14.9%); there was no correlation between assessed variables and number of complications.

Conclusion:

The results showed no individual factors favoring complications in patients submitted to total hip and total knee replacement; hence, surgeons should consider prophylaxis to avoid complications.

Score for atrial fibrillation detection in acute stroke and transient ischemic attack patients in a Brazilian population: the acute stroke atrial fibrillation scoring system

OBJECTIVE

Atrial fibrillation is a common arrhythmia that increases the risk of stroke by four- to five-fold. We aimed to establish a profile of patients with atrial fibrillation from a population of patients admitted with acute ischemic stroke or transient ischemic attack using clinical and echocardiographic findings.

METHODS

We evaluated patients consecutively admitted to a tertiary hospital with acute ischemic stroke or transient ischemic attack. Subjects were divided into an original set (admissions from May 2009 to October 2010) and a validation set (admissions from November 2010 to April 2013). The study was designed as a cohort, with clinical and echocardiographic findings compared between patients with and without atrial fibrillation. A multivariable model was built, and independent predictive factors were used to produce a predictive grading score for atrial fibrillation (Acute Stroke AF Score-ASAS).

RESULTS

A total of 257 patients were evaluated from May 2009 to October 2010 and included in the original set. Atrial fibrillation was diagnosed in 17.5% of these patients. Significant predictors of atrial fibrillation in the multivariate analysis included age, National Institutes of Health Stroke Scores, and the presence of left atrial enlargement. These predictors were used in the final logistic model. For this model, the area under the receiver operating characteristic curve was 0.79. The score derived from the logistic regression analysis was The model developed from the original data set was then applied to the validation data set, showing the preserved discriminatory ability of the model (c statistic = 0.76).

CONCLUSIONS

Our risk score suggests that the individual risk for atrial fibrillation in patients with acute ischemic stroke can be assessed using simple data, including age, National Institutes of Health Stroke Scores at admission, and the presence of left atrial enlargement.

Reduced frequency of cardiopulmonary arrests by rapid response teams

OBJECTIVE

To evaluate the impact of the implementation of a rapid response team on the rate of cardiorespiratory arrests in mortality associated with cardiorespiratory arrests and on in-hospital mortality in a high complexity general hospital.

METHODS

A retrospective analysis of cardiorespiratory arrests and in-hospital mortality events before and after implementation of a rapid response team. The period analyzed covered 19 months before intervention by the team (August 2005 to February 2007) and 19 months after the intervention (March 2007 to September 2008).

RESULTS

During the pre-intervention period, 3.54 events of cardiorespiratory arrest/1,000 discharges and 16.27 deaths/1,000 discharges were noted. After the intervention, there was a reduction in the number of cardiorespiratory arrests and in the rate of in-hospital mortality; respectively, 1.69 events of cardiorespiratory arrest/1,000 discharges (p < 0.001) and 14.34 deaths/1,000 discharges (p = 0.029).

CONCLUSION

The implementation of the rapid response team may have caused a significant reduction in the number of cardiorespiratory arrests. It was estimated that during the period from March 2007 to September 2008, the intervention probably saved 67 lives.

Spine surgery cost reduction at a specialized treatment center

Objective

To compare the estimated cost of treatment of spinal disorders to those of this treatment in a specialized center.

Methods

An evaluation of average treatment costs of 399 patients referred by a Health Insurance Company for evaluation and treatment at the Spine Treatment Reference Center of Hospital Israelita Albert Einstein. All patients presented with an indication for surgical treatment before being referred for assessment. Of the total number of patients referred, only 54 underwent surgical treatment and 112 received a conservative treatment with motor physical therapy and acupuncture. The costs of both treatments were calculated based on a previously agreed table of values for reimbursement for each phase of treatment.

Results

Patients treated non-surgically had an average treatment cost of US$ 1,650.00, while patients treated surgically had an average cost of US$ 18,520.00. The total estimated cost of the cohort of patients treated was US$ 1,184,810.00, which represents a 158.5% decrease relative to the total cost projected for these same patients if the initial type of treatment indicated were performed.

Conclusion

Treatment carried out within a center specialized in treating spine pathologies has global costs lower than those regularly observed.

Platelet-rich plasma for long bone healing

OBJECTIVE

To evaluate effectiveness of the use of platelet-rich plasma as coadjuvant for union of long bones.

METHODS

The search strategy included the Cochrane Library (via Central) and MEDLINE (via PubMed). There were no limits as to language or publication media. The latest search strategy was conducted in December 2011. It included randomized clinical trials that evaluated the use of platelet-rich plasma as coadjuvant medication to accelerate union of long bones (acute fractures, pseudoarthrosis and bone defects). The outcomes of interest for this review include bone regeneration, adverse events, costs, pain, and quality of life. The authors selected eligible studies, evaluated the methodological quality, and extracted the data. It was not possible to perform quantitative analysis of the grouped studies (meta-analyses).

RESULTS

Two randomized prospective clinical trials were included, with a total of 148 participants. One of them compared recombinant human morphogenic bone protein-7 versus platelet-rich plasma for the treatment of pseudoarthrosis; the other evaluated the effects of three coadjuvant treatments for union of valgising tibial osteotomies (platelet-rich plasma, platelet-rich plasma plus bone marrow stromal cells, and no coadjuvant treatment). Both had low statistical power and moderate to high risk of bias.

CONCLUSION

There was no conclusive evidence that sustained the use of platelet-rich plasma as a coadjuvant to aid bone regeneration of fractures, pseudoarthrosis, or bone defects.

A multicenter study using positive deviance for improving hand hygiene compliance

BACKGROUND

Positive deviance (PD) can be a strategy for the improvement of hand hygiene (HH) compliance.

METHODS

This study was conducted in 8 intensive care units and 1 ward at 7 tertiary care, private, and public hospitals. Phase 1 was a 3-month baseline period (from August to October 2011) in which HH counts were performed by observers using iPods (iScrub program). From November 2011 to July 2012, phase 2, a PD intervention was performed in all the participating centers. We evaluated the consumption of HH products (alcohol gel and chlorhexidine) and the incidence density of health care-associated infections.

RESULTS

There was a total of 5,791 HH observations in the preintervention phase and 11,724 HH observations in the intervention phase (PD). A statistically significant difference was found in overall HH compliance with 46.5% in the preintervention phase and 62.0% in the PD phase (P < .001). There was a statistically significant reduction in the incidence of density of device-associated infections per 1,000 patient-days and also in the median of length of stay between the preintervention phase and the PD phase (13.2 vs 7.5 per 1,000 patient-days, respectively, P = .039; and 11.0 vs 6.8 days, respectively, P < .001, respectively).

CONCLUSION

PD demonstrated great promise for improving HH in multiple inpatient settings and was associated with a decrease in the median length of stay and the incidence of device-associated HAIs.

Positive Deviance: A New Tool for Infection Prevention and Patient Safety

Positive deviance (PD) may have an important role in infection prevention and patient safety in the hospital. There are many descriptions of successful stories of PD in different sectors from public health to education to business. PD has been applied in the healthcare setting to improve hand hygiene compliance, reduce methicillin-resistant Staphylococcus aureus, and reduce bloodstream infections in an outpatient hemodialysis center. PD promotes dialogue among leaders, managers and healthcare workers, which is a key factor in establishing a safety culture. It also enables cultural changes aimed at empowering frontline workers (the positive deviants) to innovate and improve compliance with infection prevention measures. The structure and the process of PD, and its ability to offer a space for experience discussions, changing ideas and making plans that emerge from team participation will also be discussed.

Physicians' attitude towards tobacco dependence in a private hospital in the city of São Paulo, Brazil

Objective:

To investigate how often physicians identify and treat tobacco dependence and whether characteristics as gender, age, marital status, medical specialty and smoking status can influence their attitude towards this question.

Methods:

A cross-sectional study was performed on 515 physicians working in a private hospital in São Paulo, Brazil, using a confidential voluntary questionnaire sent and answered electronically.

Results:

We found that 89% of physicians who answered the research questionnaire often or always asked their patients about smoking habits, but only 39% often or always treated patients' tobacco dependence. In our sample, 5.8% of individuals were current smokers. Tobacco dependent physicians provided less treatment for smoking dependence compared with those who had never smoked, or were former smokers. Being a clinician was associated with higher probability to treat tobacco dependence.

Conclusion:

Physicians should not only address patients' smoking habits but also provide treatment whenever tobacco dependence is diagnosed. To understand physicians' attitude towards smoking may help to develop strategies to stimulate patients' treatment. The development of smoking cessation programs meant specifically for physicians may also be a strategy to enhance patients' treatment.

Impact of acute kidney injury exposure period among liver transplantation patients

Background

Acute kidney injury is a common complication of liver transplantation. In this single-centre retrospective observational study, we investigated the impact of acute kidney disease on liver recipient survival.

Methods

The study population consisted of patients who underwent a liver engraftment between January 2002 and November 2006, at a single transplantation centre in São Paulo, Brazil. Acute kidney injury diagnosis and staging were according to the recommendations of the Acute Kidney Injury Network and consisted of scanning the daily serum creatinine levels throughout the hospital stay. Patients requiring renal replacement therapy prior to transplantation, those who developed acute kidney injury before the procedure or those receiving their second liver graft were excluded from the study.

Results

A total of 444 liver transplantations were performed during the study period, and 129 procedures (29%) were excluded. The remaining 315 patients constituted the study population. In 207 procedures, the recipient was male (65%). The mean age of the population was 51 years. Cumulative incidence of acute kidney injury within 48 h, during the first week after transplantation, and throughout the hospital stay was 32, 81 and 93%, respectively. Renal replacement therapy was required within a week after the transplantation in 31 procedures (10%), and another 17 (5%) required replacement therapy after that period. Mean follow-up period was 2.3 years. Time in days from acute kidney injury diagnosis to initiation of replacement therapy or reaching serum creatinine peak was associated with lower overall survival even when adjusted for significant potential confounders (HR 1.03; 95% CI 1.01, 1.05; p=0.002). Overall, patients experiencing acute kidney injury lasting for a week or more before initiation of replacement therapy experienced a threefold increase in risk of death (HR 3.02; 95% CI 2.04, 4.46; p<0.001).

Conclusions

Acute kidney injury after liver transplantation is remarkably frequent and has a substantial impact on patient survival. Delaying the initiation of renal replacement therapy in such population may increase mortality by more than 20% per day.

Predicting mortality and cost of hematopoietic stem-cell transplantation

OBJECTIVE

To evaluate whether the Pretransplantion Assesment of Mortality risk score is associated to transplant costs and can be used not only to predict mortality but also as a cost management tool.

METHODS

We evaluated consecutively patients submitted to allogeneic (n = 27) and autologous (n = 89) hematopoietic stem cell-transplantation from 2004 to 2006 at Hospital Israelita Albert Einstein (SP), Brazil. Participants mean age at hematopoietic stem cell-transplantation was 42 (range 1 to 72) years; there were 69 males and 47 females; 30 patients had multiple myeloma; 41 had non-Hodgkin and Hodgkin's lymphomas; 22 had acute leukemia; 6 had chronic leukemia; and 17 had non-malignant disease. The Pretransplantion Assesment of Mortality risk score was applied in all patients using the available web site (http://cdsweb.fhcrc.org/ pam/).

RESULTS

Patients could be classified in three risk categories: high, intermediate and low, having significant difference in survival (p = 0.0162). The median cost in US dollars for each group was $ 281.000, $ 73.300 and $ 54.400 for high, intermediate and low risk, respectively. The cost of hematopoietic stem cell-transplantation significantly differed for each Pretransplantin Assesment of Mortality risk group (p = 0.008).

CONCLUSION

The validation of the Pretransplantion Assesment of Mortality risk score in our patients confirmed that this system is an important tool to be used in transplantation units, being easy to apply and fully reproducible.

Get with the guidelines stroke performance indicators in a brazilian tertiary hospital

BACKGROUND

Stroke is the fourth leading killer in the US, the first in Brazil and a leading cause of adult long-term disability in both countries. In spite of widespread recommendation, clinical practice guidelines have had limited effect on changing physician behavior. Recognizing that both knowledge and acceptance of guidelines do not necessarily imply guideline adherence, the American Heart Association/American Stroke Association (AHA/ASA) developed a national stroke quality improvement program, the 'Get With The Guidelines (GWTG) stroke'. Even though GWTG has produced remarkable results in the US, other countries have not adopted the program.

METHODS

We compared the stroke treatment quality indicators from a private Brazilian tertiary hospital to those published by the GWTG stroke program. Seven predefined performance measures selected by the GWTG stroke program as targets for stroke quality improvement were evaluated: (1) tissue plasminogen activator use in patients who arrived <2 h from symptom onset; (2) antithrombotic medication use within 48 h of admission; (3) deep vein thrombosis prophylaxis within 48 h of admission for nonambulatory patients; (4) discharge use of antithrombotics; (5) discharge use of anticoagulation for atrial fibrillation; (6) dosing of LDL and treatment for LDL >100 mg/dl in patients meeting the National Cholesterol Education Program Adult Treatment Panel (NCEP) III guidelines, and (7) counseling for smoking cessation.

RESULTS

A total of 343 consecutive patients with acute ischemic stroke (70.8%) or transient ischemic attack (29.2%) were evaluated from August 2008 to December 2010. Antithrombotic medication within 48 h was used in 98.5% of the eligible patients and deep vein thrombosis prophylaxis in 100%. A total of 123 patients arrived within 2 h from symptoms onset, 23 were eligible for intravenous thrombolysis and 16 were treated (69.5%). All eligible patients were discharged using antithrombotic medication, and 86.9% of the eligible patients who had atrial fibrillation received anticoagulation. Only 56.1% of the eligible patients were treated according to the NCEP III guidelines. Counseling for smoking cessation was done in 63.6% of the eligible patients.

CONCLUSIONS

Our study is the first in Brazil and the second outside the US to analyze compliance with the GWTG recommendations. Close attention to a better implementation of these measures may produce an improvement in such results similar to what happened after the full implementation of the program in the US. Whether or not a US disease-based registry such as GWTG can be adopted with success beyond the US is still a matter of debate.

Stroke Epidemiology, Patterns of Management, and Outcomes in Fortaleza, Brazil

Background and Purpose—

Little information exists on the epidemiology and patterns of treatment of patients admitted to Brazilian hospitals with stroke. Our objective was to describe the frequency of risk factors, patterns of management, and outcome of patients admitted with stroke in Fortaleza, the fifth largest city in Brazil.

Methods—

Data were prospectively collected from consecutive patients admitted to 19 hospitals in Fortaleza with a diagnosis of stroke or transient ischemic attack from June 2009 to October 2010.

Results—

We evaluated 2407 consecutive patients (mean age, 67.7±14.4 years; 51.8% females). Ischemic stroke was the most frequent subtype (72.9%) followed by intraparenchymal hemorrhage (15.2%), subarachnoid hemorrhage (6.0%), transient ischemic attack (3%), and undetermined stroke (2.9%). The median time from symptoms onset to hospital admission was 12.9 (3.8–32.5) hours. Hypertension was the most common risk factor. Only 1.1% of the patients with ischemic stroke received thrombolysis. The median time from hospital admission to neuroimaging was 3.4 (1.2–26.5) hours. In-hospital mortality was 20.9% and the frequency of modified Rankin Scale score ≤2 at discharge was less than 30%. Older age, prestroke disability, and having a depressed level of consciousness at admission were independent predictors of poor outcome; conversely, male gender was a predictor of good outcome.

Conclusions—

The prevalence of stroke risk factors and clinical presentation in our cohort were similar to previous series. Treatment with thrombolysis and functional independency after a stroke admission were infrequent. We also found long delays in hospital admission and in evaluation with neuroimaging and high in-hospital mortality.

Effects of simvastatin on cytokines secretion from mononuclear cells from critically ill patients with acute kidney injury

PURPOSE

To assess the in vitro effects of simvastatin on IL-10 and TNF-α secretion from peripheral blood mononuclear cells (PBMC) of critically ill patients with and without acute kidney injury (AKI).

METHODS

PBMC were collected from 63 patients admitted to the intensive care unit (ICU) and from 20 healthy controls. Patients were divided in 3 subgroups: with AKI, with sepsis and without AKI and with AKI and sepsis. After isolation by ficoll-gradient centrifugation cells were incubated in vitro with LPS 1 ng/mL, simvastatin (10(-8)M) and with LPS plus simvastatin for 24h. TNF-α and IL-10 concentrations on cells surnatant were determined by ELISA.

RESULTS

Cells isolated from critically ill patients showed a decreased spontaneous production of TNF-α and IL-10 compared to healthy controls (6.7 (0.2-12) vs 103 (64-257) pg/mL and (20 (13-58) vs 315 (105-510) pg/mL, respectively, p<0.05). Under LPS-stimulus, IL-10 production remains lower in patients compared to healthy control (451 (176-850) vs 1150 (874-1521) pg/mL, p<0.05) but TNF-α production was higher (641 (609-841) vs 406 (201-841) pg/mL, p<0.05). The simultaneous incubation with LPS and simvastatin caused decreased IL-10 production in cells from patients compared to control (337 (135-626) vs 540 (345-871) pg/mL, p<0.05) and increased TNF-α release (711 (619-832) vs 324 (155-355) pg/mL, p<0.05). Comparison between subgroups showed that the results observed in TNF-α and IL-10 production by PBMC from critically ill patients was independent of AKI occurrence.

CONCLUSIONS

The PBMC treatment with simvastatin resulted in attenuation on pro-inflammatory cytokine spontaneous production that was no longer observed when these cells were submitted to a second inflammatory stimulus. Our study shows an imbalance between pro and anti-inflammatory cytokine production in PBMC from critically ill patients regardless the presence of AKI.

Positive deviance: a program for sustained improvement in hand hygiene compliance

BACKGROUND

There is a paucity of data evaluating whether positive deviance (PD) can sustain improvement in hand hygiene compliance.

METHODS

An observational study comparing the effect of PD on compliance with hand hygiene was conducted in two 20-bed step-down units (SDUs) at a private tertiary care hospital. In a 3-month baseline period (April-June 2008), hand hygiene counts were performed by electronic handwashing counters. Between July 1, 2008, and November 30, 2009, (East SDU) and between September 30, 2008, and December 2009 (West SDU), PD was applied in both units.

RESULTS

There was more than a 2-fold difference in the number of alcohol gel aliquots dispensed per month from April 2008 (before PD) to November 2009 (last month in PD) in the East SDU. There was also a 2-fold difference in the number of alcohol gel aliquots dispensed per month from September 2008 (before PD) to December 2009 (last month in PD) in the West SDU. The difference in the rate of health care‒associated infections (HAIs) between the baseline period and 2009 was statistically significant in the East SDU (5.8 vs 2.8 per 1,000 device-days; P = .008) and in the West SDU (3.7 vs 1.7 per 1,000 device-days; P = .023).

CONCLUSIONS

PD was responsible for a sustained improvement in hand hygiene in the inpatient setting and was associated with a decrease in the incidence of device-associated HAIs.

Temperature variation in the 24 hours before the initial symptoms of stroke

A few studies have performed to evaluate the temperature variation influences over on the stroke rates in Brazil.

METHOD

176 medical records of inpatients were analyzed after having had a stroke between 2004 and 2006 at Hospital Israelita Albert Einstein. The temperature preceding the occurrence of the symptoms was recorded, as well as the temperature 6, 12 and 24 hours before the symptoms in 6 different weather substations, closest to their houses in São Paulo.

RESULTS

Strokes occurred more frequently after a variation of 3 C between 6 and 24 hours before the symptoms. There were most hospitalizations between 23-24 C.

CONCLUSION

Incidence of stroke on these patients was increased after a variation of 3 masculine Celsius within 24 hours before the ictus. The temperature variations could be an important factor in the occurrence of strokes in this population.

Surgical removal of small petroclival meningiomas

Treatment of large petroclival meningiomas causing brain stem compression is surgical removal followed by radiotherapy or radiosurgery if the lesion was partially resected. The management of small petroclival meningiomas is, however, controversial. Clinical observation, radiosurgery and surgical removal are the options of treatment. The natural history of these tumours is not well known. Published series of patients treated with radiosurgery are not comparable with surgical series because the latter also includes large size tumours. In this paper we present a series of 18 patients with small petroclival meningiomas (diameter <or= 2.8 cm) treated with radical surgical removal. Total resection (Simpson's Grade 1) [43] was possible with minimal morbidity and no mortality.

BACKGROUND

We present a series of small petroclival meningiomas (SPM) treated by radical surgical removal and compare the outcome with other management modalities proposed for these lesions.

METHODS

Eighteen patients with SPM were surgically treated at our department of neurological surgery. The tumours were classified as small when they had a diameter < 3.0 cm. Headaches (n = 12), diplopia (n = 8), facial hypoaesthesia (n = 3) and tinnitus (n = 6) were the most frequent symptoms at presentation. The approaches used were retrosigmoid (n = 14), fronto-orbito-zygomatic (n = 3) and presigmoid (n = 1). The post-operative follow-up ranged from 1 to 110 months (mean 41.8 months).

FINDINGS

Radical tumour resection (Simpson's Grades 1 and 2) was achieved in all patients. There was no major morbidity or mortality related to the surgical procedure. Transient abducent nerve palsy was the only post-operative complication. The pre-operative cranial nerves deficits improved after surgery. Only one patient had persistent diplopia postoperatively.

CONCLUSION

Radical surgical removal of SPM is possible with minimal morbidity and may cure the patient. The effectiveness and outcome of surgery for small petroclival meningiomas should be compared with series treated by radiosurgery.