The association between serum potassium at hospital admission and the case-fatality rate of leptospirosis in men

Severe leptospirosis affects predominantly males and presents a high susceptibility to hypokalemic acute renal failure. As hypokalemia and hyperkalemia induce severe complications, it is important to evaluate if the initial serum potassium is an independent risk factor for death in leptospirosis. The medical records of 1016 patients hospitalized with the diagnosis of leptospirosis were reviewed. The analysis was restricted to 442, according to the following criteria: male, 18 years or older, information about death or hospital discharge and recorded values of serum potassium, serum creatinine and duration of symptoms at admission. Potassium values lower than 3.5 mEq/L (hypoK), 3.5-5 mEq/L (normoK) and above 5 mEq/L (hyperK) were detected in 180, 245 and 17 patients, respectively. The death rate increased with serum potassium: 11.1% in the hypoK, 14.7% in the normoK and 47.1% in the hyperK group (p = 0.002). In a logistic regression model (normoK as referent), including age, creatinine and duration of symptoms, hypoK was not associated with increased death rate (odds ratio (OR) = 0.80; p > 0.1). On the other hand, hyperK showed a significant association with increased risk of death (OR = 3.95, p = 0.021). In conclusion, in this sample of men with leptospirosis initial serum potassium was positively and independently correlated with the risk of in-hospital death.

Causes of hospital admission of AIDS patients in southern Brazil, 2007 to 2012

IntroductionThe acquired immunodeficiency syndrome (AIDS) epidemic is a worldwide phenomenon that has been modified with the implementation of effective antiretroviral therapy. The objective of this study was to determine the leading causes of hospitalization among human immunodeficiency virus (HIV)-positive individuals.MethodsA cross-sectional study with patients admitted to a general hospital in southern Brazil, between January 2007 and May 2012.ResultsMedical records of 550 hospital admissions (230 patients) were reviewed, with an average of 2.4 hospitalizations per patient. Infectious diseases were the most prevalent causes of hospitalization. Overall, 44.8% patients died and their deaths were associated with longer hospital stays.ConclusionsOpportunistic infections remained the leading causes of hospitalization.

Probabilistic linkage in household survey on hospital care usage

OBJECTIVE: To evaluate the potential advantages and limitations of the use of the Brazilian hospital admission authorization forms database and the probabilistic record linkage methodology for the validation of reported utilization of hospital care services in household surveys. METHODS: A total of 2,288 households interviews were conducted in the county of Duque de Caxias, Brazil. Information on the occurrence of at least one hospital admission in the year preceding the interview was obtained from a total of 10,733 household members. The 130 records of household members who reported at least one hospital admission in a public hospital were linked to a hospital database with 801,587 records, using an automatic probabilistic approach combined with an extensive clerical review. RESULTS: Seventy-four (57%) of the 130 household members were identified in the hospital database. Yet only 60 subjects (46%) showed a record of hospitalization in the hospital database in the study period. Hospital admissions due to a surgery procedure were significantly more likely to have been identified in the hospital database. The low level of concordance seen in the study can be explained by the following factors: errors in the linkage process; a telescoping effect; and an incomplete record in the hospital database. CONCLUSIONS: The use of hospital administrative databases and probabilistic linkage methodology may represent a methodological alternative for the validation of reported utilization of health care services, but some strategies should be employed in order to minimize the problems related to the use of this methodology in non-ideal conditions. Ideally, a single identifier, such as a personal health insurance number, and the universal coverage of the database would be desirable.

Impact of urban atmospheric environment on hospital admissions in the elderly

OBJECTIVE: To analyze the impact of intra-urban atmospheric conditions on circulatory and respiratory diseases in elder adults. METHODS: Cross-sectional study based on data from 33,212 hospital admissions in adults over 60 years in the city of São Paulo, southeastern Brazil, from 2003 to 2007. The association between atmospheric variables from Congonhas airport and bioclimatic index, Physiological Equivalent Temperature, was analyzed according to the district's socioenvironmental profile. Descriptive statistical analysis and regression models were used. RESULTS: There was an increase in hospital admissions due to circulatory diseases as average and lowest temperatures decreased. The likelihood of being admitted to the hospital increased by 12% with 1ºC decrease in the bioclimatic index and with 1ºC increase in the highest temperatures in the group with lower socioenvironmental conditions. The risk of admission due to respiratory diseases increased with inadequate air quality in districts with higher socioenvironmental conditions. CONCLUSIONS: The associations between morbidity and climate variables and the comfort index varied in different groups and diseases. Lower and higher temperatures increased the risk of hospital admission in the elderly. Districts with lower socioenvironmental conditions showed greater adverse health impacts.

Comparison of Bothropoides jararaca bites with and without envenoming treated at the Vital Brazil Hospital of the Butantan Institute, State of São Paulo, Brazil

INTRODUCTION: This study analyses the cases of all bites (including dry bites) caused by Bothropoides jararaca attended at the Vital Brazil Hospital of the Butantan Institute, State of São Paulo, Brazil. METHODS: A retrospective study was conducted of patients bitten by Bothropoides jararaca (n=792) from January 1990 to December 2004. The characteristics of the snake specimen, data related to the accident and clinical manifestations on admission were obtained from patient medical records. RESULTS: The majority of the cases in this study were caused by female and juvenile snakes. No stomach contents were found in 93.4% of the snake specimens after dissection. No statistical difference was observed between the occurrence of dry bites and the maturity or sex of the snake. The median SVL of snakes in mild and moderate cases was 40.5cm and in severe cases, SVL increased to 99cm. Necrosis was more common in the digits of the feet and hands (4.8%) compared to the other body regions (1.8%). A significant difference was verified between severity and a time interval greater than six hours from the bite to hospital admission. A significant association was verified between gingival bleeding and abnormal blood coagulability. In accidents caused by adult snakes, necrosis was more frequent (7.2%) compared to accidents caused by juvenile snakes (1%). CONCLUSIONS: In this work, the association between certain epidemiological data and the evolution of biological parameters in the clinical course of Bothrops sensu latu accidents were highlighted, contributing to the improvement of snake bite assistance.

Is female sex an independent predictor of in-hospital mortality in acute myocardial infarction?

OBJECTIVE: To assess whether female sex is a factor independently related to in-hospital mortality in acute myocardial infarction. METHODS: Of 600 consecutive patients (435 males and 165 females) with acute myocardial infarction, we studied 13 demographic and clinical variables obtained at the time of hospital admission through uni- and multivariate analysis, and analyzed their relation to in-hospital death. RESULTS: Females were older (p<0.001) and had a higher incidence of hypertension (p<0.001). Males were more frequently smokers (p<0.001). The remaining risk factors had a similar incidence among both sexes. All variables underwent uni- and multivariate analysis. Through univariate analysis, the following variables were found to be associated with in-hospital death: female sex (p<0.001), age >70 years (p<0.001), the presence of previous coronary artery disease (p=0.0004), previous myocardial infarction (p<0.001), infarction in the anterior wall (p=0.007), presence of left ventricular dysfunction (p<0.001), and the absence of thrombolytic therapy (p=0.04). Through the multivariate analysis of logistic regression, the following variables were associated with in-hospital mortality: female sex (p=0.001), age (p=0.008), the presence of previous myocardial infarction (p=0.02), and left ventricular dysfunction (p<0.001). CONCLUSION: After adjusting for all risk variables, female sex proved to be a variable independently related to in-hospital mortality in acute myocardial infarction.

Very Long-Term Prognostic Role of Admission BNP in Non-ST Segment Elevation Acute Coronary Syndrome

Abstract Background: BNP has been extensively evaluated to determine short- and intermediate-term prognosis in patients with acute coronary syndrome, but its role in long-term mortality is not known. Objective: To determine the very long-term prognostic role of B-type natriuretic peptide (BNP) for all-cause mortality in patients with non-ST segment elevation acute coronary syndrome (NSTEACS). Methods: A cohort of 224 consecutive patients with NSTEACS, prospectively seen in the Emergency Department, had BNP measured on arrival to establish prognosis, and underwent a median 9.34-year follow-up for all-cause mortality. Results: Unstable angina was diagnosed in 52.2%, and non-ST segment elevation myocardial infarction, in 47.8%. Median admission BNP was 81.9 pg/mL (IQ range = 22.2; 225) and mortality rate was correlated with increasing BNP quartiles: 14.3; 16.1; 48.2; and 73.2% (p < 0.0001). ROC curve disclosed 100 pg/mL as the best BNP cut-off value for mortality prediction (area under the curve = 0.789, 95% CI= 0.723-0.854), being a strong predictor of late mortality: BNP < 100 = 17.3% vs. BNP ≥ 100 = 65.0%, RR = 3.76 (95% CI = 2.49-5.63, p < 0.001). On logistic regression analysis, age >72 years (OR = 3.79, 95% CI = 1.62-8.86, p = 0.002), BNP ≥ 100 pg/mL (OR = 6.24, 95% CI = 2.95-13.23, p < 0.001) and estimated glomerular filtration rate (OR = 0.98, 95% CI = 0.97-0.99, p = 0.049) were independent late-mortality predictors. Conclusions: BNP measured at hospital admission in patients with NSTEACS is a strong, independent predictor of very long-term all-cause mortality. This study allows raising the hypothesis that BNP should be measured in all patients with NSTEACS at the index event for long-term risk stratification.

Air pollution and cardiovascular hospital admissions in a medium-sized city in São Paulo State, Brazil

The objective of the present study was to estimate the contribution of environmental pollutants to hospital admissions for cardiovascular disease. A time series ecological study was conducted on subjects aged over 60 years and living in São José dos Campos, Brazil, with a population near 700,000 inhabitants. Hospital admission data of public health patients (SUS) were obtained from DATASUS for the period between January 1, 2004 and December 31, 2006, according to the ICD-10 diagnoses I20 to I22 and I24. Particulate matter with less than 10 µm in aerodynamic diameter, sulfur dioxide and ozone were the pollutants examined, and the control variables were mean temperature and relative humidity. Data on pollutants were obtained from the São Paulo State Sanitary Agency. The generalized linear model Poisson regression with lags of up to 5 days was used. There were 1303 hospital admissions during the period. Exposure to particulate matter was significantly associated with hospitalization for cardiovascular disease 3 days after exposure (RR = 1.006; 95%CI = 1.000 to 1.010) and an increase of 16 µg/m³ was associated with a 10% increase in risk of hospitalization; other pollutants were not associated with hospitalization. Thus, it was possible to identify the role of exposure to particulate matter as an environmental pollutant in hospitalization for cardiovascular disease in a medium-sized city inSoutheastern Brazil.

Prevalence of child malnutrition at a university hospital using the World Health Organization criteria and bioelectrical impedance data

Malnutrition constitutes a major public health concern worldwide and serves as an indicator of hospitalized patients’ prognosis. Although various methods with which to conduct nutritional assessments exist, large hospitals seldom employ them to diagnose malnutrition. The aim of this study was to understand the prevalence of child malnutrition at the University Hospital of the Ribeirão Preto Medical School, University of São, Brazil. A cross-sectional descriptive study was conducted to compare the nutritional status of 292 hospitalized children with that of a healthy control group (n=234). Information regarding patients’ weight, height, and bioelectrical impedance (i.e., bioelectrical impedance vector analysis) was obtained, and the phase angle was calculated. Using the World Health Organization (WHO) criteria, 35.27% of the patients presented with malnutrition; specifically, 16.10% had undernutrition and 19.17% were overweight. Classification according to the bioelectrical impedance results of nutritional status was more sensitive than the WHO criteria: of the 55.45% of patients with malnutrition, 51.25% exhibited undernutrition and 4.20% were overweight. After applying the WHO criteria in the unpaired control group (n=234), we observed that 100.00% of the subjects were eutrophic; however, 23.34% of the controls were malnourished according to impedance analysis. The phase angle was significantly lower in the hospitalized group than in the control group (P<0.05). Therefore, this study suggests that a protocol to obtain patients’ weight and height must be followed, and bioimpedance data must be examined upon hospital admission of all children.

Assessment of a strategy for the control of respiratory diseases in children

A programme for the control of respiratory diseases in children was conceived for the State of S. Paulo, Brazil, in 1986. Its progress thereafter and the epidemiology of the diseases concerned are examined. Apart from an inquiry into the 64 existing State local health authorities, a sample of 18,255 cases of children assisted by the programme at different levels, including both in-patient and outpatient care, is analysed. Each case record included information about identification (child, doctor and health facility), reasons for calling, diagnoses made and outcome of treatment. Further data were also sought from hospitals and from State mortality records. The programme was found to be poorly implemented in the State but, where implemented, it showed itself capable of resolving problems (only 0.5% of the cases could not be handled) as also of changing ongoing trends (more than 50% reduction in hospital admission rates). Individual assessment of each item of the programme indicated its bottlenecks. Regarding the epidemiology of respiratory diseases, it is observed that the major burden to health services comes from children aged less than five, and that the most important diseases are wheezing illnesses and pneumonia. Morevoer, they were found to be significantly associated (p = 0.000) so that a child in the community presenting wheezing diseases is 5 times more likely to develop pneumonia than a child with any other respiratory diagnosis. Similarly, among the under five deaths it was found that the risk for pneumonia is 3 times greater for children who died presenting wheezing diseases than it is for children with any other sort of diagnosis. In conclusion, the programme is deemed to be efficient and effective but its efficacy is marred by administrative flaws. The successful control of respiratory problems in childhood is related to a proper appreciation of the importance of wheezing diseases.

Predicting the revolving door phenomenon among patients with schizophrenic, affective disorders and non-organic psychoses

OBJECTIVE: The aim of the study was to identify the variables that predict the revolving door phenomenon in psychiatric hospital at the moment of a second admission. METHODS: The sample consisted of 3,093 patients who have been followed during 5 to 24 years after their first hospital admission due to schizophrenia, and affective or psychotic disorders. Those who had had four or more admissions during the study period were considered as revolving door patients. Logistic regression analyses were used to assess the impact of gender, age, marital status, urban conditions, diagnosis, mean period of stay on the first admission, interval between the first and second admissions on the patterns of hospitalization. RESULTS: The variables with the highest predictive power for readmission were the interval between first and second admissions, and the length of stay in the first admission. CONCLUSIONS: These data may help public health planners in providing optimal care to a small group of patients with more effective utilization of the available services.

Comorbidity adjustment index for the international classification of diseases, 10

OBJECTIVE: To develop a Charlson-like comorbidity index based on clinical conditions and weights of the original Charlson comorbidity index. METHODS: Clinical conditions and weights were adapted from the International Classification of Diseases, 10th revision and applied to a single hospital admission diagnosis. The study included 3,733 patients over 18 years of age who were admitted to a public general hospital in the city of Rio de Janeiro, southeast Brazil, between Jan 2001 and Jan 2003. The index distribution was analyzed by gender, type of admission, blood transfusion, intensive care unit admission, age and length of hospital stay. Two logistic regression models were developed to predict in-hospital mortality including: a) the aforementioned variables and the risk-adjustment index (full model); and b) the risk-adjustment index and patient's age (reduced model). RESULTS: Of all patients analyzed, 22.3% had risk scores >1, and their mortality rate was 4.5% (66.0% of them had scores >1). Except for gender and type of admission, all variables were retained in the logistic regression. The models including the developed risk index had an area under the receiver operating characteristic curve of 0.86 (full model), and 0.76 (reduced model). Each unit increase in the risk score was associated with nearly 50% increase in the odds of in-hospital death. CONCLUSIONS: The risk index developed was able to effectively discriminate the odds of in-hospital death which can be useful when limited information is available from hospital databases.

HIV rapid testing as a key strategy for prevention of mother-to-child transmission in Brazil

OBJECTIVE: To assess the feasibility of HIV rapid testing for pregnant women at maternity hospital admission and of subsequent interventions to reduce perinatal HIV transmission. METHODS: Study based on a convenience sample of women unaware of their HIV serostatus when they were admitted to delivery in public maternity hospitals in Rio de Janeiro and Porto Alegre, Brazil, between March 2000 and April 2002. Women were counseled and tested using the Determine HIV1/2 Rapid Test. HIV infection was confirmed using the Brazilian algorithm for HIV infection diagnosis. In utero transmission of HIV was determined using HIV-DNA-PCR. There were performed descriptive analyses of sociodemographic data, number of previous pregnancies and abortions, number of prenatal care visits, timing of HIV testing, HIV rapid test result, neonatal and mother-to-child transmission interventions, by city studied. RESULTS: HIV prevalence in women was 6.5% (N=1,439) in Porto Alegre and 1.3% (N=3.778) in Rio de Janeiro. In Porto Alegre most of women were tested during labor (88.7%), while in Rio de Janeiro most were tested in the postpartum (67.5%). One hundred and forty-four infants were born to 143 HIV-infected women. All newborns but one in each city received at least prophylaxis with oral zidovudine. It was possible to completely avoid newborn exposure to breast milk in 96.8% and 51.1% of the cases in Porto Alegre and Rio de Janeiro, respectively. Injectable intravenous zidovudine was administered during labor to 68.8% and 27.7% newborns in Porto Alegre and Rio de Janeiro, respectively. Among those from whom blood samples were collected within 48 hours of birth, in utero transmission of HIV was confirmed in 4 cases in Rio de Janeiro (4/47) and 6 cases in Porto Alegre (6/79). CONCLUSIONS: The strategy proved feasible in maternity hospitals in Rio de Janeiro and Porto Alegre. Efforts must be taken to maximize HIV testing during labor. There is a need of strong social support to provide this population access to health care services after hospital discharge.

A clinico-epidemiological study of bites by spiders of the genus Phoneutria

From January, 1984 to December, 1996, 422 patients (ages 9 m-99 y, median 29 y) were admitted after being bitten by spiders which were brought and identified as Phoneutria spp. Most of the bites occurred at March and April months (29.2%), in the houses (54.5%), during the day (76.5%), and in the limbs (feet 40.9%, hands 34.3%). Upon hospital admission, most patients presented only local complaints, mainly pain (92.1%) and edema (33.1%) and were classified as presenting mild (89.8%), moderate (8.5%) and severe (0.5%) envenomation. Few patients (1.2%) did not present signs of envenomation. Severe accidents were only confirmed in two children (9 m, 3 y). Both developed acute pulmonary edema, and the older died 9 h after the accident. Patients more than 70 year-old had a significantly greater (p<0.05) frequency of moderate envenomations compared to the 10-70-year-old individuals. Proceedings to relief local pain were frequently performed (local anesthesia alone 32.0%, local anesthesia plus analgesics 20.6% and oral analgesics alone 25.1%). Only 2.3% of the patients (two cases classified as severe and eight as moderate, eight of them in children) were treated with i.v. antiarachnid antivenom. No antivenom early reaction was observed. In conclusion, accidents involving the genus Phoneutria are common in the region of Campinas, with the highest risk groups being children under 10 years of age and adults over 70 years of age. Cases of serious envenomation are rare (0.5%).

Evaluation of penicillin therapy in patients with leptospirosis and acute renal failure

The effectiveness of specific antibiotic treatment in severe leptospirosis is still under debate. As part of a prospective study designed to evaluate renal function recovery after leptospirosis acute renal failure (ARF) (ARF was defined as Pcr > or = 1.5 mg/dL), the clinical evolutions of 16 treated patients (T) were compared to those of 18 untreated patients (nT). Treatment or non-treatment was the option of each patient's attending infectologist. The penicillin treatment was always with 6 million IU/day for 8 days. No difference was found between the two groups in terms of age, gender, number of days from onset of symptoms to hospital admission, or results of laboratory tests performed upon admission and during hospitalization, but proteinuria was higher in the treated group. There were no significant difference in the other parameters employed to evaluate patients' clinical evolution as: length of hospital stay, days of fever, days to normalization of renal function, days to total bilirubins normalized or reached 1/3 of maximum value and days to normalization of platelet counts. Dialytic treatment indication and mortality were similar between group T and nT. In conclusion, penicillin therapy did not provide better clinical outcome in patients with leptospirosis and ARF.