Predicting Hospital Mortality in Critically Ill Cancer Patients according to Acute Kidney Injury Severity

Background: Acute kidney injury (AKI) is a frequent complication in hospitalized patients, especially in those in intensive care units (ICU). The RIFLE classification might be a valid prognostic factor for critically ill cancer patients. The present study aims to evaluate the discriminatory capacity of RIFLE versus other general prognostic scores in predicting hospital mortality in critically ill cancer patients. Methods: This is a single-center study conducted in a cancer-specialized ICU in Brazil. All of the 288 patients hospitalized from May 2006 to June 2008 were included. RIFLE classification, APACHE II, SOFA, and SAPS II scores were calculated and the area under receiver operating characteristic (AROC) curves and logistic multiple regression were performed using hospital mortality as the outcome. Results: AKI, defined by RIFLE criteria, was observed in 156 (54.2%) patients. The distribution of patients with any degree of AKI was: risk, n = 96 (33.3%); injury, n = 30 (10.4%), and failure, n = 30 (10.4%). Mortality was 13.6% for non-AKI patients, 49% for RIFLE `R` patients, 62.3% for RIFLE `I` patients, and 86.8% for RIFLE `F` patients (p = 0.0006). Logistic regression analysis showed that RIFLE criteria, APACHE II, SOFA, and SAPS II were independent factors for mortality in this population. The discrimination of RIFLE was good (AROC 0.801, 95% CI 0.748-0.854) but inferior compared to those of APACHE II (AROC 0.940, 95% CI 0.915-0.966), SOFA (AROC 0.910, 95% CI 0.876-0.943), and SAPS II (AROC 0.869, 95% CI 0.827-0.912). Conclusion: AKI is a frequent complication in ICU patients with cancer. RIFLE was inferior to commonly used prognostic scores for predicting mortality in this cohort of patients. Copyright (C) 2011 S. Karger AG, Basel

Nutrition Therapy in a Pediatric Intensive Care Unit: Indications, Monitoring, and Complications

Background: Nutrition therapy (NT) is essential for the care of critically ill children. Inadequate feeding leads to malnutrition and may increase the patient`s risk of morbidity and mortality. The aim of this study was to describe the NT used in a tertiary pediatric intensive care unit (PICU). Methods: The authors evaluated NT administered to 90 consecutive patients who were hospitalized for 7 days in the PICU of Instituto da Crianca, Hospital das Clinicas, Universidade de Sao Paulo, Brazil. NT was established according to the protocol provided by the institution`s NT team. NT provided a balance of fluids and nutrients and was monitored with a weekly anthropometric nutrition assessment and an evaluation of complications. Results: NT was initiated, on average, within 72 hours of hospitalization. Most children (80%) received enteral nutrition (EN) therapy; of these, 35% were fed orally and the rest via nasogastric or postpyloric tube. There were gastrointestinal complications in patients (5%) who needed a postpyloric tube. Parenteral nutrition (PN) was used in only 10% of the cases, and the remaining 10% received mixed NT (EN + PN). The average calorie and protein intake was 82 kcal/kg and 2.7 g/kg per day. Arm circumference and triceps skinfold thickness decreased. Conclusions: The use of EN was prevalent in the tertiary PICU, and few clinical complications occurred. There was no statistically significant change in most anthropometric indicators evaluated during hospitalization, which suggests that NT probably helped patients maintain their nutrition status. (JPEN J Parenter Enteral Nutr. 2011;35:523-529)

Outcomes of newborns admitted in the intensive care unit at a public hospital

Background: We evaluated the outcome of newborns admitted in the neonatal Intensive Care Unit (ICU) in Diadema, Brazil. Methods: We evaluated 72 newborns, data were extracted from research forms, newborns` hospital records, mothers interviews, domiciliary inquiry made with the responsible for the newborn care, and paediatric accompaniment cards. Results: 48.93% presented low birth weight, 48% were considered to have normal birth weight and 2% had a birth weight higher than 4000g. Concerning gestational age, 57.44% were younger than 37 weeks old. During hospitalisation, newborn had appointments with doctors from other specialties (inter-appointments), around 40% were cardiologists. After hospital discharge 82.98% were referred to local primary health care units, and the main specialities were cardiology and neurology. Among the newborns evaluated 85.11% were accompanied by paediatric health care units. Conclusion: The implementation of a specialised newborn health accompaniment program in Brazil after ICU discharge is important for positive outcomes regarding newborns growth and development.

End-of-life practices in seven Brazilian pediatric intensive care units

Objective: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). Design. Cross-sectional multicenter retrospective study based on medical chart review. Setting: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in Sao Paulo (southeastern region), and three in Salvador (northeastern region). Patients. Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. Interventions: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (K = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Student`s t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. Measurements and Main Results. Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p =.0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. Conclusions. The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.

Oral findings and dental care in a patient with myelomeningocele: case report of a 3-year-old child

Myelomeningocele (MMC) is a congenital malformation of the neural tube that occurs in the first weeks of pregnancy. This malformation refers to the caudal non-closure of the neural tube and neural tissue exposure, which lead to neurological problems, such as hydrocephalus, motor disability, genitourinary tract and skeletal abnormalities and mental retardation. Patients with MMC have an acknowledged predisposition to latex allergy and are usually at a high caries risk and activity due to poor oral hygiene, fermentable carbon hydrate-rich diet and prolonged use of sugar-containing medications. This paper addresses the common oral findings in pediatric patients with MMC, discusses the strategies and precautions to deal with these individuals and reports the dental care to a young child diagnosed with this condition.

Fatal adenoviral necrotizing bronchiolitis case in a post-cardiac surgery intensive care unit

We report a case of a 67 year-old-male patient admitted to the intensive care unit in the post-coronary bypass surgery period who presented cardiogenic shock, acute renal failure and three episodes of sepsis, the latter with pulmonary distress at the 30th post-operative day. The patient expired within five days in spite of treatment with vancomycin, imipenem, colistimethate and amphotericin B. At autopsy severe adenovirus pneumonia was found. Viral pulmonary infections following cardiovascular surgery are uncommon. We highlight the importance of etiological diagnosis to a correct treatment approach.

Recalled and recorded bowel habits confirm early onset and high frequency of constipation in day-care nursery children

CONTEXT: Mothers recall early-onset constipation in children attending gastroenterology clinics. OBJECTIVES: To study the bowel habit of young children in the community to determine, first, whether early-onset constipation is confirmed in this setting and, second, the agreement between recalled and recorded bowel habit. METHODS:Defecation data of 57 children aged 6.0-40.7 mo were obtained by maternal recall (questionnaire on predominant stool characteristics) and by record (1,934 defecations registered prospectively at home and in the nursery). The bowel habit was classified according to stool frequency and proportion of stool characteristics (soft, hard and/or runny). Two criteria were used to classify recorded data, since the cutoff point for hard stools to identify constipation is undefined in children: predominant criterion and adult criterion, respectively with >50% and >25% of stools with altered consistency. Bowel habit categories were: adequate, constipation, functional diarrhea and "other bowel habit". Nonparametric statistics, and the Kappa index for agreement between recalled and recorded bowel habit, were used. RESULTS: Constipation occurred in 17.5%, 10.5%, 19.3% of the children by recall, the predominant and the adult criteria, respectively. Constipation was the main recalled alteration, vs 12.3% "other bowel habit". Only one child classified as having functional diarrhea (by the adult criterion). Agreement between recalled and recorded bowel habit was fair for constipation, by the predominant and the adult criteria (K = 0.28 and 0.24, respectively), but only slight (K <0.16) for other bowel habit categories. Individual data, however, pointed to a better relationship between recalled constipation and the adult rather than the predominant criterion. CONCLUSIONS: Frequent early-onset constipation was confirmed. Fair agreement between recalled and recorded constipation by the two used criteria indicates that recalled data are quite reliable to detect constipation.

First cases of exclusive paternal care in stink bugs (Hemiptera: Pentatomidae)

We describe paternal care in two pentatomid bugs, Lopadusa (Lopadusa) augur Stål, 1860 and Edessa nigropunctata Berg, 1884. Field and laboratory observations showed that males remain with their eggs and early hatched nymphs, while females abandon the eggs after oviposition. Guarding males defensive behaviors towards their clutches were similar to those described for guarding females of pentatomids. Since there is no detailed information on the internal phylogeny of Pentatomidae, it is not possible to make a robust inference on whether paternal care in L. augur and E. nigropunctata has arisen independently or not. If the latter, the two new cases of paternal care we describe here represent the fifth event of independent evolution of this rare behavioral trait in Heteroptera.

Self-disclosure of HIV diagnosis to sexual partners by heterosexual and bisexual men: a challenge for HIV/AIDS care and prevention

This study investigated the disclosure of HIV-positive serostatus to sexual partners by heterosexual and bisexual men, selected in centers for HIV/AIDS care. In 250 interviews, we investigated disclosure of serostatus to partners, correlating disclosure to characteristics of relationships. The focus group further explored barriers to maintenance/establishment of partnerships and their association with disclosure and condom use. Fear of rejection led to isolation and distress, thus hindering disclosure to current and new partners. Disclosure requires trust and was more frequent to steady partners, to partners who were HIV-positive themselves, to female partners, and by heterosexuals, occurring less frequently with commercial sex workers. Most interviewees reported consistent condom use. Unprotected sex was more frequent with seropositive partners. Suggestions to enhance comprehensive care for HIV-positive men included stigma management, group activities, and human rights-based approaches involving professional education in care for sexual health, disclosure, and care of "persons living with HIV".

Time trends and predictors of mortality from ill-defined causes in old age: 9 year folllow-up of the Bambuí cohort study (Brazil)

The study objective was to examine differentials in time trends and predictors of deaths assigned to symptoms, signs and ill-defined conditions in comparison with other ill-defined conditions (ill-defined cardiovascular diseases, cancer and injury) in a population-based cohort study. Of 1,606 baseline participants aged 60 years and over, 524 died during 9-year follow-up and were included in this study. Deaths coded to "symptoms" declined by 77% in the period from 1997-1999 to 2003-2005. Deaths coded to other ill-defined conditions remained unchanged. The calendar period 2003-2005 (RR = 0.25; 95%CI: 0.09-0.70) and in-hospital deaths (RR = 0.16; 95%CI: 0.08-0.34) were independently associated with "symptoms", but not with other ill-defined conditions. Baseline socio-demographic characteristics and chronic diseases were not predictors of these outcomes. International and national agencies have focused on the reduction of deaths assigned to "symptoms" to improve the registration of vital statistics, while other ill-defined conditions have received little attention. Our data provide evidence supporting the need to redress this situation.

Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde

Os óbitos de menores de um ano foram classificados em causas evitáveis, mal definidas e não evitáveis empregando a Lista Brasileira de Mortes Evitáveis, entre 1997-2006. Foram calculados tendências dos coeficientes de mortalidade infantil por causas de morte e se usou regressão não linear para avaliação de tendência. As causas evitáveis e as causas mal definidas apresentaram significativa redução (p < 0,001). As causas reduzíveis de mortalidade apresentaram redução de 37%. A mortalidade por causas reduzíveis por adequada atenção ao parto declinou em 27,7%; adequada atenção ao recém-nascido, 42,5%; e por adequada atenção à gestação cresceu 28,3%. Concluiu-se que os serviços de saúde contribuíram para a redução da mortalidade infantil. O declínio das causas mal definidas de morte indica ampliação do acesso aos serviços de saúde. O aumento do acesso e atenção ao parto e aos cuidados com recém-nascido contribuíram para a redução de óbitos infantis. O aumento da mortalidade por adequada atenção à gestação revela a necessidade de aprimoramento da atenção pré-natal.

Influence of self-perceived oral health and socioeconomic predictors on the utilization of dental care services by schoolchildren

The influence of socioeconomic factors and self-rated oral health on children's dental health assistance was assessed. This study followed a cross-sectional design, with a multistage random sample of 792 12-year-old schoolchildren from Santa Maria, a city in southern Brazil. A dental examination provided information on the prevalence of dental caries (DMFT index). Data about the use of dental service, socioeconomic status, and self-perceived oral health were collected by means of structured interviews. These associations were assessed using Poisson regression models (prevalence ratio; 95% confidence interval). The prevalence of regular use of dental service was 47.8%. Children from low socioeconomic backgrounds and those who rated their oral health as "poor" used the service less frequently. The distribution of the kind of oral healthcare assistance used (public/private) varied across socioeconomic groups. The better-off children were less likely to have used the public service. Clinical, socioeconomic, and psychosocial factors were strong predictors for the utilization of dental care services by schoolchildren.

Brazilian scientific production on pharmaceutical care from 1990 to 2009

Brazilian scientific production on pharmaceutical care was identified based on articles indexed on the Medline, Embase, Lilacs, Web of Science and International Pharmaceutical Abstracts databases. Sixty-three articles published in both national and international journals were retrieved. With regard to authors, 72.3% were from the Southeast and South Regions, and 60.8% were affiliated to public universities. In relation to the type of studies, 85.7% were descriptive, and the most frequently researched fields were community pharmacies, hospitals and primary health care units. Articles were original in 65.1% of cases, updates in 20.6%, and reviews in 7.9%. An increase in publications commenced in 2006. In 31.7% of cases, authors had adopted a bibliographical study design, 28.6% qualitative study, 23.8% intervention, and 15.9% observational study design. The most researched subjects were elderly with chronic diseases. The importance of stimulating the conducting of experimental and qualitative studies, as well as amplifying authorship affiliated with the service area, foreign authors and with research in a wide variety of practice settings were highlighted. Despite the limited quantity of articles, an increase in their number as well as in their scope and quality is expected, so as to create further knowledge that contributes to the recognition of pharmacists' actions by patient healthcare teams.

Violência institucional em maternidades públicas sob a ótica das usuárias

Este artigo apresenta e discute os dados de uma pesquisa sobre violência institucional em maternidades públicas, realizada no município de São Paulo. Foram entrevistadas 21 puérperas, com roteiro semiestruturado contando com questões sobre experiências de parto e assistência recebida. Os dados revelaram que as entrevistadas relatam e reconhecem práticas discriminatórias e tratamento grosseiro no âmbito da assistência em maternidades públicas, reagindo com estratégias de resistência ou de acomodação. Essas experiências ocorrem com tal frequência que muitas parturientes já esperam sofrer algum tipo de maltrato, o que revela uma banalização da violência institucional.