Maintaining Tissue Perfusion in High-Risk Surgical Patients: A Systematic Review of Randomized Clinical Trials

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Anesthesia-related mortality in pediatric patients: a systematic review

This systematic review of the Brazilian and worldwide literature aimed to evaluate the incidence and causes of perioperative and anesthesia-related mortality in pediatric patients. Studies were identified by searching EMBASE (1951-2011), PubMed (1966-2011), LILACS (1986-2011), and SciElo (1995-2011). Each paper was revised to identify the author(s), the data source, the time period, the number of patients, the time of death, and the perioperative and anesthesia-related mortality rates. Twenty trials were assessed. Studies from Brazil and developed countries worldwide documented similar total anesthesia-related mortality rates (<1 death per 10,000 anesthetics) and declines in anesthesia-related mortality rates in the past decade. Higher anesthesia-related mortality rates (2.4-3.3 per 10,000 anesthetics) were found in studies from developing countries over the same time period. Interestingly, pediatric perioperative mortality rates have increased over the past decade, and the rates are higher in Brazil (9.8 per 10,000 anesthetics) and other developing countries (10.7-15.9 per 10,000 anesthetics) compared with developed countries (0.41-6.8 per 10,000 anesthetics), with the exception of Australia (13.4 per 10,000 anesthetics). The major risk factors are being newborn or less than 1 year old, ASA III or worse physical status, and undergoing emergency surgery, general anesthesia, or cardiac surgery. The main causes of mortality were problems with airway management and cardiocirculatory events. Our systematic review of the literature shows that the pediatric anesthesia-related mortality rates in Brazil and in developed countries are similar, whereas the pediatric perioperative mortality rates are higher in Brazil compared with developed countries. Most cases of anesthesiarelated mortality are associated with airway and cardiocirculatory events. The data regarding anesthesia-related and perioperative mortality rates may be useful in developing prevention strategies.

Clinical Profile, Predictors of Mortality, and Treatment of Patients after Myocardial Infarction, in an Academic Medical Center Hospital

OBJECTIVE: To evaluate clinical profiles, predictors of 30-day mortality, and the adherence to international recommendations for the treatment of myocardial infarction in an academic medical center hospital. METHODS: We retrospectively studied 172 patients with acute myocardial infarction, admitted in the intensive care unit from January 1992 to December 1997. RESULTS: Most patients were male (68%), white (97%), and over 60 years old (59%). The main risk factor for coronary atherosclerotic disease was systemic blood hypertension (63%). Among all the variables studied, reperfusion therapy, smoking, hypertension, cardiogenic shock, and age were the predictors of 30-day mortality. Most commonly used medications were: acetylsalicylic acid (71%), nitrates (61%), diuretics (51%), angiotensin-converting enzyme inhibitors (46%), thrombolytic therapy (39%), and beta-blockers (35%). CONCLUSION: The absence of reperfusion therapy, smoking status, hypertension, cardiogenic shock, and advanced age are predictors of 30-day mortality in patients with acute myocardial infarction. In addition, some medications that are undoubtedly beneficial have been under-used after acute myocardial infarction.

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).

Low Apgar scores at 5 minutes in a low risk population: maternal and obstetrical factors and postnatal outcome

OBJETIVO: Avaliar a associação entre índice de Apgar menor que sete no 5º minuto, os fatores pré-natais e resultados pós-natais. MÉTODOS: Trata-se de estudo retrospectivo com 27.252 recém-nascidos em maternidade escola com população de baixo risco obstétrico, de janeiro de 2003 a dezembro de 2010. Prontuários de todos os casos com índice de Apgar < 7 no 5º minuto (n = 121; - 0,4%) e de 363 casos com Apgar > 7 no 5º minuto, escolhidos ao acaso, foram revisados. Os principais desfechos estudados foram: óbito neonatal, insuficiência respiratória neonatal, necessidade de intubação orotraqueal e de unidade terapia intensiva (UTI) neonatal e encefalopatia hipóxico-isquêmica. RESULTADOS: Após análise de regressão múltipla, desacelerações tardias (DIP II) (OR: 2,4; IC95%: 1,4-4,1) e período expulsivo prolongado (OR: 3,3; IC 95%: 1,3-8,3) se associaram com Apgar < 7 no 5º minuto; assim como com insuficiência respiratória ao nascimento (OR: 3,0; IC 95%: 1,3-6,9), intubação traqueal (OR: 2,5; IC 95%: 1,2-4,8), necessidade de UTI neonatal (OR: 9,5; IC 95%: 6,7-16,8) e encefalopatia hipóxico-isquêmica (OR: 14,1; IC 95%: 3,6-54,7). Nenhuma outra variável prénatal se associou com Apgar < 7 no 5º minuto (p < 0,05). CONCLUSÃO: DIP II e período expulsivo prolongado estão associados com Apgar < 7 no 5º minuto em população obstétrica de baixo risco; situação essa relacionada com maior risco de insuficiência respiratória no parto, necessidade de suporte ventilatório e encefalopatia hipóxico-isquêmica.

Predation risk and jumping behavior in Pseudopaludicola aff. falcipes tadpoles

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Mortality rate in children caused by traffic accidents according to geographical regions : Brazil, 1997 - 2005

Lesões fatais em crianças causadas por acidentes de trânsito representam um problema em muitos países. Este estudo analisou a taxa de mortalidade em crianças passageiras de automóveis menores de 10 anos de idade no Brasil, entre 1997 e 2005. Para isso, o número de mortes foi obtido diretamente no banco de dados do Sistema de Informação sobre Mortalidade (SIM) e os dados da população são projeções intercensitárias a partir censo demográfico do Instituto Brasileiro de Geografia e Estatística (IBGE) disponíveis pelo site do DATASUS. Foram calculadas, para os triênios compreendidos no período em estudo, as taxas de mortalidade por acidente de trânsito entre crianças passageiras de automóveis segundo faixa etária (menor que 1 ano, 1 a 4 e 5 a 9) e região geográfica. Os resultados mostraram taxas de mortalidade de 5,68, 7,32 e 6,78 (por 1.000.000), respectivamente, para os períodos 1997-1999, 2000-2002 e 2003-2005 para todo o Brasil. Crianças menores de 1 ano de idade apresentam taxa de mortalidade de 10,18 (por 1,000,000), maior que as observadas para as outras faixas etárias. Para o período 1997-2005, as maiores taxas foram observadas nas regiões Centro-Oeste e Sul, representando, respectivamente, 13,88 e 11,47 (por 1.000.000). Tais resultados mostram a situação de risco da criança em relação a acidentes de trânsito como passageiras de automóveis e contribuem para a elaboração de campanhas educativas de prevenção de lesões.

Influence of sedation on morbidity and mortality in the intensive care unit

CONTEXTO: Embora cerca de 30% a 50% dos pacientes hospitalizados em unidades de terapia intensiva (UTI) recebam algum tipo de sedativo, existe escassez de informações sobre efeitos adversos desta prática, especialmente no Brasil. Estes efeitos podem ser significantes e o uso de sedativos é associado a elevação de infecção e mortalidade, mesmo sendo difícil avaliar o impacto clínico deste procedimento. OBJETIVO: Avaliar o impacto da sedação sobre incidência de complicações e mortalidade em doentes graves durante internação em unidade de terapia intensiva. TIPO DE ESTUDO: Estudo prospectivo. LOCAL: Unidade de Terapia Intensiva Cirúrgica da Universidade Federal de São Paulo (UNIFESP) - Escola Paulista de Medicina. PARTICIPANTES: Após excluídos pacientes que permaneceram menos de 24 horas ou sem exames indispensáveis para o cálculo do índice de gravidade (APACHE II), restaram 307 pacientes. Estes foram divididos em dois grupos: Grupo Sedado e Grupo Não Sedado. Constatada heterogeneidade com relação ao APACHE II, foram pareados 97 sedados e 97 não sedados com idênticos índices de gravidade. VARIÁVEIS ESTUDADAS: Impacto da sedação e das técnicas sobre a mortalidade, tempo de internação, além da incidência de escara de decúbito ou pressão, trombose venosa profunda e infecção. RESULTADOS: Não houve diferença na incidência de trombose venosa profunda, entre os grupos Sedado e Não Sedado, enquanto que escara de decúbito foi significativamente maior nos sedados (p = 0,03). Infecção foi detectada em 45,4% dos pacientes com sedação e em 21,6% dos pacientes sem sedação (p = 0,006). A mortalidade para os pacientes que não receberam qualquer tipo de sedativo foi de 20,6% e, para aqueles que foram sedados durante a internação, foi de 52,6% (p < 0,0001). CONCLUSÕES: Conclui-se que a sedação está associada a maior duração da internação, morbidade e mortalidade significativas. Apesar da intensidade das associações encontradas, não é possível estabelecer relação causal entre sedação e mortalidade.

The 844ins68 cystathionine beta-synthase and C677T MTHFR gene polymorphism and the vaso-occlusive event risk in sickle cell disease

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Anemia at one year is an independent risk factor of graft survival

Background Post-transplant anemia is multifactorial and highly prevalent. Some studies have associated anemia with mortality and graft failure. The purpose of this study was to assess whether the presence of anemia at 1 year is an independent risk factor of mortality and graft survival. Methods All patients transplanted at a single center who survived at least 1 year after transplantation and showed no graft loss (n = 214) were included. Demographic and clinical data were collected at baseline and at 1 year. Patients were divided into two groups (anemic and nonanemic) based on the presence of anemia (hemoglobin<130 g/l in men and 120 g/l in women). Results Baseline characteristics such as age, gender, type of donor, CKD etiology, rejection, andmismatches were similar in both groups. Creatinine clearance was similar in both anemic and nonanemic groups (69.32 ± 29.8 × 75.69 ± 30.5 ml/mim; P = 0.17). A Kaplan- Meier plot showed significantly poorer death-censored graft survival in the anemic group, P = 0.003. Multivariate analysis revealed that anemic patients had a hazard ratio for the graft loss of 3.85 (95% CI: 1.49-9.96; P = 0.005). Conclusions In this study, anemia at 1 year was independently associated with death-censored graft survival and anemic patients were 3.8-fold more likely to lose the graft. © 2010 Springer Science+Business Media, B.V.

Could albumin level explain the higher mortality in hemodialysis patients with pulmonary hypertension?

Background: The pathogenesis of pulmonary hypertension (PH) in hemodialysis is still unclear. The aim of thisstudy was to identify the risk factors associated with the presence of PH in chronic hemodialysis patients and toverify whether these factors might explain the highest mortality among them.Methods: We conducted a retrospective study of hemodialysis patients who started treatment from August 2001to October 2007 and were followed up until April 2011 in a Brazilian referral medical school. According to theresults of echocardiography examination, patients were allocated in two groups: those with PH and those withoutPH. Clinical parameters, site and type of vascular access, bioimpedance, and laboratorial findings were comparedbetween the groups and a logistic regression model was elaborated. Actuarial survival curves were constructed andhazard risk to death was evaluated by Cox regression analysis.Results: PH > 35 mmHg was found in 23 (30.6%) of the 75 patients studied. The groups differed in extracellularwater, ventricular thickness, left atrium diameter, and ventricular filling. In a univariate analysis, extracellular waterwas associated with PH (relative risk = 1.194; 95% CI of 1.006 1.416; p = 0.042); nevertheless, in a multiple model,only left atrium enlargement was independently associated with PH (relative risk =1.172; 95% CI of 1.010 1.359;p = 0.036). PH (hazard risk = 3.008; 95% CI of 1.285 7.043; p = 0.011) and age (hazard risk of 1.034 per year of age;95% CI of 1.000 7.068; p = 0.047) were significantly associated with mortality in a multiple Cox regression analysis.However, when albumin was taken in account the only statistically significant association was between albuminlevel and mortality (hazard risk = 0.342 per g/dL; 95% CI of 0.119 0.984; p = 0.047) while the presence of PH lost itsstatistical significance (p = 0.184). Mortality was higher in patients with PH (47.8% vs 25%) who also had astatistically worse survival after the sixth year of follow up.Conclusions: PH in hemodialysis patients is associated with parameters of volume overload that sheds light on itspathophysiology. Mortality is higher in hemodialysis patients with PH and the low albumin level can explain thisassociation.© 2012 Greenfield et al.; licensee BioMed Central Ltd.

Pathological and behavioral risk factors for higher serum c-reactive protein concentrations in free-living adults - A Brazilian community-based study

Low-grade chronic systemic inflammation is often associated with chronic non-communicable diseases, and its most frequently used marker, the C-reactive protein (CRP), has become an identifier of such diseases as well as an independent predictor for cardiovascular disorders and mortality. CRP is produced in response to pro-inflammatory signaling and to individual and behavioral factors, leading to pathological states. The aim of this study was to rank the predicting factors of high CRP concentrations in free-living adults from a community-based sample. We evaluated 522 adults (40-84 years old; 381 women) for anthropometric characteristics, dietary intake, clinical and physical tests, and blood analysis. Subjects were assigned to groups, according to CRP concentrations, as normal CRP (G1;<3.0 mg/L; n = 269), high CRP (G2; 3.0-6.0 mg/L; n = 139), and very high CRP (G3; >6.0 mg/dL; n = 116). Statistical comparison between groups used one-way ANOVA or Kruskal-Wallis tests, and prediction of altered values in increasing CRP was evaluated by proportional hazard models (odds ratio). CRP distribution was influenced by gender, body mass index, body and abdominal fatness, blood leukocytes, and neutrophil counts. The higher CRP group was discriminated by the above variables in addition to lower VO2max, serum metabolic syndrome components (triglycerides, glucose, and HDL cholesterol), higher insulin, homeostasis assessment of insulin resistance, uric acid, gamma-GT, and homocysteine. After adjustments, only fatness, blood leukocytes, and hyperglycemia remained as independent predictors for increased serum CRP concentrations. Intervention procedures to treat low-grade chronic inflammation in overweight women would mainly focus on restoring muscle mass and functions in addition to an antioxidant-rich diet. © 2012 Springer Science+Business Media, LLC.

Mini Nutritional Assessment predicts gait status and mortality 6 months after hip fracture.

The aim of the present study was to evaluate the Mini Nutritional Assessment (MNA), the Nutritional Risk Screening (NRS) 2002 and the American Society of Anesthesiologists Physical Status Score (ASA) as predictors of gait status and mortality 6 months after hip fracture. A total of eighty-eight consecutive patients over the age of 65 years with hip fracture admitted to an orthopaedic unit were prospectively evaluated. Within the first 72 h of admission, each patient's characteristics were recorded, and the MNA, the NRS 2002 and the ASA were performed. Gait status and mortality were evaluated 6 months after hip fracture. Of the total patients, two were excluded because of pathological fractures. The remaining eighty-six patients (aged 80·2 (sd 7·3) years) were studied. Among these patients 76·7 % were female, 69·8 % walked with or without support and 12·8 % died 6 months after the fracture. In a multivariate analysis, only the MNA was associated with gait status 6 months after hip fracture (OR 0·773, 95 % CI 0·663, 0·901; P= 0·001). In the Cox regression model, only the MNA was associated with mortality 6 months after hip fracture (hazard ratio 0·869, 95 % CI 0·757, 0·998; P= 0·04). In conclusion, the MNA best predicts gait status and mortality 6 months after hip fracture. These results suggest that the MNA should be included in the clinical stratification of patients with hip fracture to identify and treat malnutrition in order to improve the outcomes.

Genetic and non-genetic effects on calf vigor at birth and preweaning mortality in nellore calves

The objective of the present study was to evaluate the genetic and non-genetic effects that influencevigor at birth and preweaning mortality in Nellore calves. A total of 11,727 records of births that occurred between 1978 and 2006, offspring of 363 sires, were analyzed. Poor calf vigor at birth (VB) and preweaning mortality divided into stillbirth (SB), early mortality (EM) and total mortality (TM) were analyzed as binary variables. Generalized linear models were used for the evaluation of non-genetic effects and generalized linear mixed models for genetic effects (sire and animal models). The incidences were 4.75% for VB, 2.66% for SB, 5.28% for EM, and 7.99% for TM. Birth weight was the effect that most influenced the traits studied. Calves weighing less than 22kg(females) and less than 24kg (males) were at a higher risk of low vigor and preweaning mortality. Preweaning mortality was higher among calves born from cows aged .3 and .11 years at calving compared with cows aged 7 to 10 years. Male calves presented less vigor and higher preweaning mortality than female calves. Selection for postweaning weight did not influence preweaning mortality. The heritability estimates ranged between 0.01 and 0.09 for VB, 0.00 and 0.27 for SB, 0.03 and 0.17 for EM and 0.02 and 0.10 for TM. Stillbirth should be included as a selection criterion in breeding programs of Nellore cattle, alone or as part of a selection index, aiming to reduce preweaning mortality. © 2013 Sociedade Brasileira de Zootecnia.

Potentially inappropriate medications used by the elderly: Prevalence and risk factors in Brazilian care homes

Abstract. Background: The use of potentially inappropriate medications (PIM) among the elderly is a serious public health problem because it is intrinsically linked to increased morbidity and mortality, causing high costs to public health systems. This study's objective was to verify the prevalence of and the factors associated with the use of PIMs by elderly Brazilians in institutional settings. Methods. We performed a transversal study, by consulting the case files of elderly people living in Long Term Care for the Elderly (LTC) in towns in the State of São Paulo, Brazil, as well as structured interviews with the nurses responsible for them.We identified PIMs using the list of recently updated Beers criteria developed by a group of specialists from the American Geriatrics Society (AGS), who reviewed the criteria based on studies with high scientific evidence levels. We defined the factors studied to evaluate the association with PIM use prior to the statistical analyses, which were the chi-square test and multiple logistic regression. Results: Among the elderly who used drugs daily, 82.6% were taking at least one PIM, with antipsychotics (26.5%) and analgesics (15.1%) being the most commonly used. Out of all the medications used, 32.4% were PIMs, with 29.7% of these being PIMs that the elderly should avoid independent of their condition, 1.1% being inappropriate medication for older adults with certain illnesses or syndromes, and 1.6% being medications that older adults should use with caution. In the multivariate analysis, the factors associated with PIM use were: polypharmacy (p = 0.0187), cerebrovascular disease (p = 0.0036), psychiatric disorders (p < 0.0001) and dependency (p = 0.0404). Conclusions: The results of this study showed a high prevalence of PIM use in institutionalized elderly Brazilian patients. and the associated factors were polypharmacy, psychiatric disorders, cerebrovascular diseases and dependency. © 2013 Lima et al.; licensee BioMed Central Ltd.