Vitamin D serum levels are associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture

Objectives: The aim of this study was to evaluate the association between serum levels of 25(OH) vitamin D-3 with midupper arm muscle circumference (MUAMC), handgrip strength and length of hospital stay (LOS) after hip fracture.Methods: In total, 102 consecutive patients with hip fracture over the age of 65 were admitted to the orthopedic unit and prospectively evaluated. All of the patients were treated according to specific protocols depending on the type of fracture. Anthropometric measurements and handgrip strength were performed, and blood samples were taken for serum biochemistry and 25(OH) vitamin D-3 analysis within the first 72 h of admission. All of the patients were followed during their hospital stay, and the length of stay was recorded.Results: Of the patients, two were excluded because of pathologic fractures. In total, 100 patients with a mean age of 80 +/- 7 y were included in the analysis. Among these patients, 73% were female, and 37% had vitamin D deficiency. The median LOS was 7 (5-11) d. Patients with vitamin D deficiency had lower handgrip strength in univariate analysis. In the multiple linear regression analysis with robust standard error, serum vitamin D levels adjusted by age and sex were associated with handgrip strength but not with MUAMC and LOS after hip fracture.Conclusions: In conclusion, vitamin D serum levels were associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture. (C) 2015 Elsevier Inc. All rights reserved.

Safety Assessment of Potentially Inappropriate Medications (PIM) use in Older People and the Factors Associated with Hospital Admission

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Red Blood Cell Transfusions are Independently Associated with Intra-Hospital Mortality in Very Low Birth Weight Preterm Infants

Objective To test the hypothesis that red blood cell (RBC) transfusions in preterm infants are associated with increased intra-hospital mortality.Study design Variables associated with death were studied with Cox regression analysis in a prospective cohort of preterm infants with birth weight <1500 g in the Brazilian Network on Neonatal Research. Intra-hospital death and death after 28 days of life were analyzed as dependent variables. Independent variables were infant demographic and clinical characteristics and RBC transfusions.Results of 1077 infants, 574 (53.3%) received at least one RBC transfusion during the hospital stay. The mean number of transfusions per infant was 3.3 +/- 3.4, with 2.1 +/- 2.1 in the first 28 days of life. Intra-hospital death occurred in 299 neonates (27.8%), and 60 infants (5.6%) died after 28 days of life. After adjusting for confounders, the relative risk of death during hospital stay was 1.49 in infants who received at least one RBC transfusion in the first 28 days of life, compared with infants who did not receive a transfusion. The risk of death after 28 days of life was 1.89 times higher in infants who received more than two RBC transfusions during their hospital stay, compared with infants who received one or two transfusions.Conclusion Transfusion was associated with increased death, and transfusion guidelines should consider risks and benefits of transfusion. (J Pediatr 2011; 159: 371-6).

Caracterização, confirmação diagnóstica e avaliação da gravidade dos pacientes com DPOC internados em hospital geral com recursos adequados para o geenciamneto da doença

Pós-graduação em Saúde Coletiva - FMB

Predictive factors of post-discharge surgical site infections among patients from a teaching hospital

Introduction Surgical site infections (SSIs) often manifest after patients are discharged and are missed by hospital-based surveillance. Methods We conducted a case-reference study nested in a prospective cohort of patients from six surgical specialties in a teaching hospital. The factors related to SSI were compared for cases identified during the hospital stay and after discharge. Results Among 3,427 patients, 222 (6.4%) acquired an SSI. In 138 of these patients, the onset of the SSI occurred after discharge. Neurological surgery and the use of steroids were independently associated with a greater likelihood of SSI diagnosis during the hospital stay. Conclusions Our results support the idea of a specialty-based strategy for post-discharge SSI surveillance.

Preoperative therapy restores ventilatory parameters and reduces length of stay in patients undergoing myocardial revascularization

Introduction: The frequency of surgical procedures has increased steadily in recent decades, including the myocardial revascularization.Objectives: To demonstrate the importance of physiotherapy in the preoperative period of cardiac surgery in relation to the reduction of hospital stay, changes in lung volumes and respiratory muscle strength.Methods: We conducted a prospective study with patients undergoing myocardial revascularization, the Hospital das Clinicas da Universidade Estadual Paulista (UNESP)/Botucatu - SP. We evaluated 70 patients of both genders, aged between 40 and 75 years, subdivided into two groups: group I - 35 patients of both genders, who received a written protocol guidance, breathing exercises and respiratory muscle training in the preoperative period and group II - 35 patients of both genders, who received only orientation of the ward on the day of surgery. This study was approved by the Ethics Committee of UNESP /Botucatu - SP.Results: Maximal inspiratory pressure in third postoperative day and fifth postoperative day and significant difference between groups, being better for the intervention group. Expiratory pressure was significant in fifth postoperative day in the intervention group compared to controls. The difference of length of hospital stay in the postoperative was found between the groups with shorter hospital stay in the group receiving preoperative therapy.Conclusion: Physical therapy plays an important role in the preoperative period, so that individuals in the intervention group more readily restored the parameters evaluated before surgery, in addition, there was a decrease in the time of the postoperative hospital stay. Thus, it is thought the cost-effectiveness of a program of preoperative physiotherapy.

A mini review of Candida species in hospital infection: epidemiology, virulence factor and drugs resistance and prophylaxis

The introduction of more efficient diagnostic methods, new techniques in surgery and transplantation, antibiotics and chemotherapeutics more potent and novel materials for prostheses, catheters and probes significantly increased the life expectancy and quality of life of critically ill patients, on the other hand, hospital-acquired infections emerged as important iatrogenic complications. Invasive infections are a growing problem in public health hospitals in Brazil and worldwide. Among the various etiological agents found in the hospital environment, the genus Candida has been the third most frequently isolated pathogen. In general, invasive fungal infections are associated with high morbidity and mortality, difficulties in diagnosis, antimicrobial resistance, length of hospital stay and increased hospital costs. This mini review of the literature describes about epidemiology of hospital infection of Candida species, as well as its virulence factors and drugs resistance

Qualidade do serviço prestado aos pacientes de cirurgia cardíaca do Sistema Único de Saúde - SUS

OBJETIVO: Avaliar qualidade do serviço prestado aos pacientes de cirurgia cardíaca no período hospitalar, em serviço do SUS, identificando as expectativas e percepções dos pacientes. Relacionar qualidade de serviço com gênero, faixa etária e circulação extracorpórea. MÉTODOS: Estudaram-se 82 pacientes (52,4% do sexo feminino e 47,6% do masculino) submetidos a cirurgia cardíaca eletiva, operados por toracotomia médio-esternal, idade: 31 a 83 anos (média 60,4 ± 13,2 anos), período: março a setembro de 2006. Avaliou-se a qualidade do serviço em dois momentos: expectativas no pré-operatório e percepções do atendimento recebido no 6º dia de pós-operatório; mediante aplicação da escala SERVQUAL modificada (SERVQUAL-Card). O resultado foi obtido pela diferença da somatória das notas das percepções e expectativas por meio de análise estatística. RESULTADOS: A escala SERVQUAL-Card foi validada estatisticamente, apresentando adequado índice de consistência interna. Encontrou-se maior frequência de revascularização do miocárdio 55 (67,0%); primeira cirurgia cardíaca 72 (87,8%) e utilização de CEC 69 (84,1%). Verificaram-se altos valores para expectativas e percepções, com resultados significantes (P<0,05). Observou-se relação significante entre qualidade de serviço com gênero, na empatia (P=0,04) e faixa etária, na confiabilidade (P=0,02). Não se observou significância entre CEC e qualidade de serviço. CONCLUSÃO: A qualidade dos serviços foi satisfatória. O paciente demonstrou expectativa alta ao serviço médicohospitalar. Mulheres apresentaram maior percepção da qualidade na empatia, jovens na confiabilidade. A utilização de CEC não está relacionada com qualidade do serviço nesta amostra. Os dados obtidos sugerem que a qualidade deste serviço de saúde pode ser monitorada pelo emprego periódico da escala SERQUAL.

Profilaxia do prurido causado pela administração subaracnóidea de sufentanil: efeitos do droperidol, da nalbufina, do ondansetron e da combinação deles

JUSTIFICATIVA E OBJETIVOS: O uso espinhal de opióides pode causar alguns efeitos indesejáveis, dentre os quais, o mais freqüente é o prurido que, apesar de sua baixa morbidade, pode proporcionar desconforto intenso ao paciente e prolongar o período de internação. O objetivo deste estudo foi avaliar diversas opções terapêuticas no tratamento profilático do prurido após administração de sufentanil por via subaracnóidea. MÉTODO: Foram distribuídos de maneira aleatória, por sorteio, 100 pacientes a serem submetidos à intervenção cirúrgica não-obstétricas em cinco grupos, de acordo com o tratamento utilizado: controle (ausência de tratamento - C); droperidol 2,5 mg (D); nalbufina 10 mg (N); associação dos medicamentos anteriores (DN) e ondansetron 8 mg (O). O prurido foi avaliado quantitativamente 30 minutos, 1, 2, e 3 horas após a administração subaracnóidea de sufentanil. RESULTADOS: Os grupos C e O apresentaram incidência significativamente maior de prurido em relação aos grupos D, N e DN. Entretanto, não houve diferença significativa na necessidade de tratamento específico com naloxona entre os grupos tratados. CONCLUSÕES: O tratamento profilático do prurido neste estudo, independentemente do fármaco utilizado, diminuiu sua intensidade e limitou a necessidade de tratamento específico com naloxona.

Handgrip strength predicts pressure ulcers in patients with hip fractures

Objective: Pressure ulcer (PU) is a frequent complication of hip fracture. Studies were carried out to identify the risk factors of PU development after hip fractures. The objective of the study was to determine the role of anthropometric measurements and handgrip strength as predictors of PUs in patients with hip fractures during their hospital stay and 30 d after discharge, which has not yet been established.Methods: Ninety-two consecutive patients with hip fractures who were older than 65 y old and admitted to an orthopedic unit were prospectively evaluated. Within the first 72 h of admission, each patient's characteristics were recorded, anthropometric measurements were taken (circumferences of the arm, waist, thigh, calf, triceps, and biceps and subscapular and suprailiac skinfolds), handgrip strength was measured, and blood samples were collected. PU evaluations were performed during the hospital stay and 30 d after hospital discharge.Results: Three patients were excluded because of PUs before hospitalization. Eighty-nine patients (average age 80.6 +/- 7.5 y) were studied; 70.8% were women, and 49.4% developed PUs during their hospital stay. In a univariate analysis, length of hospital stay (P = 0.001) and handgrip strength (P = 0.02), but not body circumferences and skinfolds, were associated with PUs during a hospital stay. Only handgrip strength (P = 0.007) was associated with PUs 30 d after hospital discharge. In a multivariate analysis, only handgrip strength was found to predict PU development at these points.Conclusion: Handgrip strength was found to predict PU development in patients with hip fractures during their hospital stay and 30 d after discharge. (C) 2012 Elsevier B.V. All rights reserved.

Injúria renal aguda em unidade de terapia intensiva: estudo prospectivo sobre a incidência, fatores de risco e mortalidade

OBJETIVO: Comparar características clínicas e evolução de pacientes com e sem injúria renal aguda adquirida em unidade de terapia intensiva geral de um hospital universitário terciário e identificar fatores de risco associados ao desenvolvimento de injúria renal aguda e à mortalidade. MÉTODOS: Estudo prospectivo observacional com 564 pacientes acompanhados diariamente durante a internação em unidade de terapia intensiva geral do Hospital das Clínicas da Faculdade de Medicina de Botucatu por 2 anos consecutivos (de maio de 2008 a maio de 2010), divididos em 2 grupos: com injúria renal aguda adquirida (G1) e sem injúria renal aguda adquirida (G2). RESULTADOS: A incidência de injúria renal aguda foi 25,5%. Os grupos diferiram quanto à etiologia da admissão em unidade de terapia intensiva (sepse: G1:41,6% x G2:24,1%, p<0,0001 e pós operatório neurológico 13,8% x 38,1%, p<0,0001), idade (56,8±15,9 x 49,8± 17,8 anos, p< 0,0001), APACHE II (21,9±6,9 x 14,1±4,6, p<0,0001), ventilação mecânica (89,2 x 69,1%, p<0,0001) e uso de drogas vasoativas (78,3 x 56,1%, p<0,0001). Com relação aos fatores de risco e às comorbidades, os grupos foram diferentes quanto à presença de diabetes mellitus, insuficiência cardíaca congestiva, insuficiência renal crônica e uso de anti-inflamatórios não hormonais (28,2 x 19,7%, p=0,03; 23,6 x 11,6%, p=0,0002, 21,5 x 11,5%, p< 0,0001 e 23,5 x 7,1%, p<0,0001, respectivamente). O tempo de internação e a mortalidade foram superiores nos pacientes que adquiriram injúria renal aguda (6,6 ± 2,7 x 12,9± 5,6 dias p<0,0001 e 62,5 x 16,4%, p<0,0001). À análise multivariada foram identificados como fatores de risco para injúria renal aguda, idade>55 anos, APACHE II>16, creatinina (cr) basal>1,2 e uso de anti-inflamatórios não hormonais (OR=1,36 IC:1,22-1,85, OR=1,2 IC:1,11-1,33, OR=5,2 IC:2,3-11,6 e OR=2,15 IC:1,1-4,2, respectivamente) e a injúria renal aguda esteve independentemente associada ao maior tempo de internação e à mortalidade (OR=1,18 IC:1,05-1,26 e OR=1,24 IC:1,09-1,99 respectivamente). À análise da curva de sobrevida, após 30 dias de internação, a mortalidade foi de 83,3% no G1 e 45,2% no G2 (p<0,0001). CONCLUSÃO: A incidência de injúria renal aguda é elevada em unidade de terapia intensiva, os fatores de riscos independentes para adquirir injúria renal aguda são idade >55 anos, APACHE II>16, Cr basal >1,2 e uso de anti-inflamatórios não hormonais e a injúria renal aguda é fator de risco independente para o maior tempo de permanência em unidade de terapia intensiva e mortalidade.

Comparison between intermittent mandatory ventilation and synchronized intermittent mandatory ventilation with pressure support in children

Objective: To compare intermittent mandatory ventilation (IMV) with synchronized intermittent mandatory ventilation plus pressure support (SIMV+PS) in terms of time on mechanical ventilation, duration of weaning and length of stay in a pediatric intensive care unit (PICU).Methods: This was a randomized clinical trial that enrolled children aged 28 days to 4 years who were admitted to a PICU between October of 2005 and June of 2007 and put on mechanical ventilation (MV) for more than 48 hours. These patients were allocated to one of two groups by drawing lots: IMV group (IMVG; n = 35) and SIMV+PS group (SIMVG; n = 35). Children were excluded if they had undergone tracheotomy or had chronic respiratory diseases. Data on oxygenation and ventilation were recorded at admission and at the start of weaning.Results: There were no statistical differences between the groups in terms of age, sex, indication for MV, PRISM score, Comfort scale, use of sedatives or ventilation and oxygenation parameters. The median time on MV was 5 days for both groups (p = 0.120). There were also no statistical differences between the two groups for duration of weaning [IMVG: 1 day (1-6) vs. SIMVG: 1 day (1-6); p = 0.262] or length of hospital stay [IMVG: 8 days (2-22) vs. SIMVG: 6 days (3-20); p = 0.113].Conclusion: Among the children studied here, there was no statistically significant difference between IMV and SIMV+ PS in terms of time on MV, duration of weaning or time spent in the PICU.ClinicalTrials.govID: NCT00549809.

Antibiotic treatment schemes for very severe community-acquired pneumonia in children: a randomized clinical study

Objective. To compare clinical response to initial empiric treatment with oxacillin plus ceftriaxone and amoxicillin plus clavulanic acid in hospitalized children diagnosed with very severe community-acquired pneumonia (CAP).Methods. A prospective randomized clinical study was conducted among children 2 months to 5 years old with a diagnosis of very severe CAP in the pediatric ward of São Paulo State University Hospital in Botucatu, São Paulo, Brazil, from April 2007 to May 2008. Patients were randomly divided into two groups by type of treatment: an oxacillin/ceftriaxone group (OCG, n = 48) and an amoxicillin/clavulanic acid group (ACG, n = 56). Analyzed outcomes were: time to clinical improvement (fever and tachypnea), time on oxygen therapy, length of stay in hospital, need to widen antimicrobial spectrum, and complications (including pleural effusion).Results. The two groups did not differ statistically for age, sex, symptom duration before admission, or previous antibiotic treatment. Time to improve tachypnea was less among ACG patients than OCG patients (4.8 +/- 2.2 versus 5.8 +/- 2.4 days respectively; P = 0.028), as was length of hospital stay (11.0 +/- 6.2 versus 14.4 +/- 4.5 days respectively; P = 0.002). There were no statistically significant differences between the two groups for fever improvement time, time on oxygen therapy, need to widen antimicrobial spectrum, or frequency of pleural effusion.Conclusions. Both treatment plans are effective in treating very severe CAP in 2-monthto 5-year-old hospitalized children. The only analyzed outcome that favored amoxicillin/clavulanic acid treatment was time required to improve tachypnea.

Retroperitoneoscopic renal biopsy in children

OBJECTIVE: We present our experience in a series of 17 consecutive pediatric patients submitted to retroperitoneal laparoscopic renal biopsy. MATERIALS and METHODS: Retroperitoneal laparoscopic renal biopsy (LRB) was performed in 5 boys and 12 girls. Mean age was 8.1 years and age range from 2 to 12. Two or three trocars were used to expose the inferior pole of the kidney, remove enough cortical parenchymal specimen and fulgurate the biopsy site. Assessment included surgical time, estimated blood loss, hospitalization period, analgesia requirements, complications and number of glomeruli present in the specimen. RESULTS: LRB was successfully performed in all 15 patients (88%). In two cases, LRB was not possible to be performed. One patient was converted to a transperitoneal laparoscopy due to tear in the peritoneum. The other patient had had previous abdominal surgery and, during retroperitoneal balloon dilation, the peritoneum was opened and the open biopsy was performed. A third patient had postoperatively a perirenal hematoma, which was solved spontaneously. Complication rate was 17.6% (3/17 cases). Mean operative time was 65 minutes, while mean estimated blood loss was 52 mL, mean hospital stay was 2.2 days and mean analgesic requirement was 100 mg of tramadol. The mean number of glomeruli present in the specimen was 60. CONCLUSION: Retroperitoneal laparoscopic renal biopsy in children is a simple, safe. Bleeding is still the most common complication. However, direct vision usually allows a safe control of this drawback. In our institution, laparoscopic approach is the chosen procedure in pediatric patients older than one - year - old.