Treatment-resistant depression increases health costs and resource utilization

Objective: Major Depressive Disorder (MDD) is a debilitating condition with a marked social impact. The impact of MDD and Treatment-Resistant Depression (TRD+) within the Brazilian health system is largely unknown. The goal of this study was to compare resource utilization and costs of care for treatment-resistant MDD relative to non-treatment-resistant depression (TRD-). Methods: We retrospectively analyzed the records of 212 patients who had been diagnosed with MDD according to the ICD-10 criteria. Specific criteria were used to identify patients with TRD+. Resource utilization was estimated, and the consumption of medication was annualized. We obtained information on medical visits, procedures, hospitalizations, emergency department visits and medication use related or not to MDD. Results: The sample consisted of 90 TRD+ and 122 TRD-patients. TRD+ patients used significantly more resources from the psychiatric service, but not from non-psychiatric clinics, compared to TRD-patients. Furthermore, TRD+ patients were significantly more likely to require hospitalizations. Overall, TRD+ patients imposed significantly higher (81.5%) annual costs compared to TRD-patients (R$ 5,520.85; US$ 3,075.34 vs. R$ 3,042.14; US$ 1,694.60). These findings demonstrate the burden of MDD, and especially of TRD+ patients, to the tertiary public health system. Our study should raise awareness of the impact of TRD+ and should be considered by policy makers when implementing public mental health initiatives.

Assessment of referrals to an OT consultation-liaison service: a retrospective and comparative study

The objective was to conduct a retrospective and comparative study of the requests for consultation-liaison (RCLs), during a period of six years, sent to the Occupational Therapy (OT) team that acts as the Consultation-liaison Service in Mental Health. During the studied period 709 RCLs were made and 633 patients received OT consultations. The comparison group was extended to 1 129 consecutive referrals to the psychiatric CL service, within the same period and that were also retrospectively reviewed. Regarding to RCLs to the OT team, most of the subjects were women with incomplete elementary schooling, with a mean age of 39.2 years, and were self-employed or retired. Internal Medicine was responsible for most of the RCLs. The mean length of hospitalization was 51 days and the mean rate of referral was 0.5%, with the most frequent reason for the request being related to the emotional aspects and the most frequent psychiatric diagnosis was mood disorder. It is concluded that there is a clear demand for the development of consultation-liaison in OT, particularly with regard to the promotion of mental health in general hospitals.

Therapeutic Project at Extra-Hospital Mental Health Services: a critical reflection on the elaboration and management of services' therapeutic projects

Based on a study conducted in Ribeirao Preto, SP, Brazil in extra-hospital mental health services that addressed the organization of these services, therapeutic projects and the inclusion of psychosocial rehabilitation in health actions available, a theoretical-critical reflection concerning the development process of the therapeutic projects by the services' teams is presented. The qualitative study was conducted in an outpatient clinic and a Psychosocial Care Center. Data were collected through semi-structured interviews and focal groups. Data analysis was based on the hermeneutic dialectic philosophy of Jurgen Habermas according to the techniques of reconstruction and interpretation. Data analysis revealed that professionals have difficulty developing and managing therapeutic projects. Health actions are made available without being concretely supported by a proposal guiding the service's practical activities. The therapeutic projects are referred by professionals as the result of guidelines provided by management levels or technical orientations inherent to each profession but not as an activity that represents a philosophy of work of the health team. When the therapeutic project is focused on as a type of consensus that results from a communicative action directed to a mutual and intersubjective understanding among the members of the mental health extra-hospital team, the difficulties of the services' team dialogically organizing themselves to collectively construct the therapeutic project is evidenced.

Nursing diagnoses in trauma victims with fatal outcomes in the emergency scenario

The objective of this study was to identify and analyze the nursing diagnoses that constitute risk factors for death in trauma victims in the first 6 hours post-event. This is a cross-sectional, descriptive and exploratory study using quantitative analysis. A total of 406 patients were evaluated over six months of data collection in a tertiary hospital in the municipality of Sao Paulo, according to an instrument created for this purpose. Of the total, 44 (10.7%) suffered death. Multivariate analysis indicated the nursing diagnoses ineffective respiratory pattern, impaired spontaneous ventilation, risk of bleeding and risk of ineffective gastrointestinal tissue perfusion as risk factors for death and ineffective airway clearance, impaired comfort, and acute pain as protective factors, data that can direct health teams for different interventionist actions faced with the complexity of the trauma.

Qualifying instrument for evaluation of food and nutritional care in hospital

Establishing criteria for hospital nutrition care ensures that quality care is delivered to patients. The responsibility of the Hospital Food and Nutrition Service (HFNS) is not always well defined, despite efforts to establish guidelines for patient clinical nutrition practice. This study describes the elaboration of an Instrument for Evaluation of Food and Nutritional Care (IEFNC) aimed at directing the actions of the Hospital Food and Nutrition Service. This instrument was qualified by means of a comparative analysis of the categories related to hospital food and nutritional care, published in the literature. Elaboration of the IEFNC comprised the following stages: (a) a survey of databases and documents for selection of the categories to be used in nutrition care evaluation, (b) a study of the institutional procedures for nutrition practice at two Brazilian hospitals, in order to provide a description of the sequence of actions that should be taken by the HFNS as well as other services participating in nutrition care, (c) design of the IEFNC based on the categories published in the literature, adapted to the sequence of actions observed in the routines of the hospitals under study, (d) application of the questionnaire at two different hospitals that was mentioned in the item (b), in order to assess the time spent on its application, the difficulties in phrasing the questions, and the coverage of the instrument, and (e) finalization of the instrument. The IEFNC consists of 50 open and closed questions on two areas of food and nutritional care in hospital: inpatient nutritional care and food service quality. It deals with the characterization and structure of hospitals and their HFNS, the actions concerning the patients' nutritional evaluation and monitoring, the meal production system, and the hospital diets. "This questionnaire is a tool that can be seen as a portrait of the structure and characteristics of the HFNS and its performance in clinical and meal management dietitian activities." (Nutr Hosp. 2012;27:1170-1177) DOI:10.3305/nh.2012.27.4.5868

The 193 call center, a meaningful public service!

This article is the first part of an on-going ergonomic work analysis with the emergency services call center set up by the Fire Department of the Military Police of Sao Paulo. The final objective of the research is to identify the prescribed task, the real work executed and strategies used by workers to meet the demands of the job. Starting by identifying the tasks and activities developed, this article analyzes the work of the emergency services call center which is of vital importance to the organizational structure, since it is the start point for the process that results in fulfilling the corporation's mission.

Frequency and predictors of symptomatic intracranial hemorrhage after intravenous thrombolysis for acute ischemic stroke in a Brazilian public hospital

OBJECTIVE: Scarce data are available on the occurrence of symptomatic intracranial hemorrhage related to intravenous thrombolysis for acute stroke in South America. We aimed to address the frequency and clinical predictors of symptomatic intracranial hemorrhage after stroke thrombolysis at our tertiary emergency unit in Brazil. METHOD: We reviewed the clinical and radiological data of 117 consecutive acute ischemic stroke patients treated with intravenous thrombolysis in our hospital between May 2001 and April 2010. We compared our results with those of the Safe Implementation of Thrombolysis in Stroke registry. Univariate and multiple regression analyses were performed to identify factors associated with symptomatic intracranial transformation. RESULTS: In total, 113 cases from the initial sample were analyzed. The median National Institutes of Health Stroke Scale score was 16 (interquartile range: 10-20). The median onset-to-treatment time was 188 minutes (interquartile range: 155-227). There were seven symptomatic intracranial hemorrhages (6.2%; Safe Implementation of Thrombolysis in Stroke registry: 4.9%; p = 0.505). In the univariate analysis, current statin treatment and elevated National Institute of Health Stroke Scale scores were related to symptomatic intracranial hemorrhage. After the multivariate analysis, current statin treatment was the only factor independently associated with symptomatic intracranial hemorrhage. CONCLUSIONS: In this series of Brazilian patients with severe strokes treated with intravenous thrombolysis in a public university hospital at a late treatment window, we found no increase in the rate of symptomatic intracranial hemorrhage. Additional studies are necessary to clarify the possible association between statins and the risk of symptomatic intracranial hemorrhage after stroke thrombolysis.

The role of pneumonia scores in the emergency room in patients infected by 2009 H1N1 infection

Despite the severity of pneumonia in patients with pandemic influenza A infection (H1N1), no validated risk scores associated with H1N1 pneumonia were tested. In this prospective observational study, we analyzed data of consecutive patients in our emergency room, hospitalized because of pneumonia between July and August 2009 in a public hospital in Brazil. The following pneumonia scoring systems were applied: the SMART-COP rule; the Pneumonia Severity Index; and the CURB-65 rule. Of 105 patients with pneumonia, 53 had H1N1 infection. Among them, only 9.5% that had a low risk according to SMART-COP were admitted to ICU, compared with 36.8% of those with the Pneumonia Severity Index score of 1-2 and 49% of those with CURB-65 score of 0-1. The SMART-COP had an accuracy of 83% to predict ICU admission. The SMART-COP rule presented the best performance to indicate ICU admission in patients with H1N1 pneumonia. European Journal of Emergency Medicine 19: 200-202 (C) 2012 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

Alternative management of diabetic ketoacidosis in a Brazilian pediatric emergency department

DKA is a severe metabolic derangement characterized by dehydration, loss of electrolytes, hyperglycemia, hyperketonemia, acidosis and progressive loss of consciousness that results from severe insulin deficiency combined with the effects of increased levels of counterregulatory hormones (catecholamines, glucagon, cortisol, growth hormone). The biochemical criteria for diagnosis are: blood glucose > 200 mg/dl, venous pH <7.3 or bicarbonate <15 mEq/L, ketonemia >3 mmol/L and presence of ketonuria. A patient with DKA must be managed in an emergency ward by an experienced staff or in an intensive care unit (ICU), in order to provide an intensive monitoring of the vital and neurological signs, and of the patient's clinical and biochemical response to treatment. DKA treatment guidelines include: restoration of circulating volume and electrolyte replacement; correction of insulin deficiency aiming at the resolution of metabolic acidosis and ketosis; reduction of risk of cerebral edema; avoidance of other complications of therapy (hypoglycemia, hypokalemia, hyperkalemia, hyperchloremic acidosis); identification and treatment of precipitating events. In Brazil, there are few pediatric ICU beds in public hospitals, so an alternative protocol was designed to abbreviate the time on intravenous infusion lines in order to facilitate DKA management in general emergency wards. The main differences between this protocol and the international guidelines are: intravenous fluid will be stopped when oral fluids are well tolerated and total deficit will be replaced orally; if potassium analysis still indicate need for replacement, it will be given orally; subcutaneous rapid-acting insulin analog is administered at 0.15 U/kg dose every 2-3 hours until resolution of metabolic acidosis; approximately 12 hours after treatment initiation, intermediate-acting (NPH) insulin is initiated at the dose of 0.6-1 U/kg/day, and it will be lowered to 0.4-0.7 U/kg/day at discharge from hospital.

Avaliação da qualidade do atendimento ao traumatizado através do estudo das mortes em um hospital terciário

OBJETIVO: Caracterizar os óbitos decorrentes de trauma em um hospital terciário e avaliar a qualidade do atendimento prestado a essas vítimas. MÉTODOS: Tratou-se de um estudo retrospectivo realizado em um centro de referência em trauma no período de um ano. Através da metodologia Trauma Score - Injury Severity Score e da revisão de prontuários foram identificadas e estudadas as mortes evitáveis, potencialmente evitáveis e inevitáveis. RESULTADOS: Setenta e cinco pacientes foram incluídos no estudo. Houve predomínio de mortes em pacientes jovens, do sexo masculino, vítimas de acidentes de trânsito. As médias do Revised Trauma Score, Injury Severity Score e Trauma Score - Injury Severity Score foram 5,60, 30,7 e 62,2%, respectivamente. A taxa de mortes consideradas evitáveis foi de 61,3%, potencialmente evitáveis, 24%, e inevitáveis, 14,7%. CONCLUSÃO: A amostra do estudo apresentou características epidemiológicas semelhantes às amostras de outros estudos, exceto pela alta taxa de mortes evitáveis e pelos altos valores do Revised Trauma Score. Houve dificuldades na obtenção de dados em prontuários, laudos de exames de imagem e laudos de necropsia. A qualidade do atendimento prestado às vítimas de trauma na Instituição se mostrou insatisfatória por problemas na coleta e armazenamento dos dados.

Accessibility and demand at an Emergency Care Unit: the user's perspective

AIM: To analyze the search for Emergency Care (EC) in the Western Health District of Ribeirão Preto (São Paulo), in order to identify the reasons why users turn to these services in situations that are not characterized as urgencies and emergencies. METHODS: A qualitative and descriptive study was undertaken. A guiding script was applied to 23 EC users, addressing questions related to health service accessibility and welcoming, problem solving, reason to visit the EC and care comprehensiveness. RESULTS: The subjects reported that, at the Primary Health Care services, receiving care and scheduling consultations took a long time and that the opening hours of these services coincide with their work hours. At the EC service, access to technologies and medicines was easier. CONCLUSION: Primary health care services have been unable to turn into the entry door to the health system, being replaced by emergency services, putting a significant strain on these services' capacity.

Impact of the rapid antigen detection test in diagnosis and treatment of acute pharyngotonsillitis in a Pediatric emergency room

OBJECTIVE: To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS: This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS: 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS: The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

Frequency of Toxocara infection in children attended by the health public service of Maringá, south Brazil.

The lack of specific laboratorial diagnosis methods and precise symptoms makes the toxocariasis a neglected disease in Public Health Services. This study aims to determine the frequency of Toxocara spp. infection in children attended by the Health Public Service of Hospital Municipal de Maringá, South Brazil. To evaluate the association of epidemiological and clinical data, and observational and cross-section study was carried out. From 14,690 attended children/year aged from seven month to 12 years old, 450 serum samples were randomly collected from September/2004 to September/2005. A questionnaire was used to evaluate epidemiological, clinical and hematological data. An ELISA using Toxocara canis larval excretory-secretory products as antigen detected 130 (28.8%) positive sera, mainly between children from seven month to five years old (p = 0.0016). Significant correlation was observed between positive serology for Toxocara, and frequent playing in sandbox at school or daycare center (p = 0.011) and the presence of a cat at home (p = 0.056). From the families, 50% were dog owners which exposed soil backyards. Eosinophilia (p = 0.776), and signs and symptoms analyzed (fever p = 0.992, pneumonia p = 0.289, cold-like symptoms p = 0.277, cough p =0.783, gastrointestinal problems p = 0.877, migraine p = 0.979, abdominal pain p = 0.965, joint pain p = 0.686 and skin rash p = 0.105) could not be related to the presence of anti-Toxocara antibodies. Therefore, two asthmatics children showed titles of1:10,240 and accentuated eosinophilia (p = 0.0001). The authors emphasize the needs of prevention activities.