Five-year evolution of drug prescribing in a university adult intensive care unit

Introduction: Drug prescription is difficult in ICUs as prescribers are many, drugs expensive and decisions complex. In our ICU, specialist clinicians (SC) are entitled to prescribe a list of specific drugs, negotiated with intensive care physicians (ICP). The objective of this investigation was to assess the 5-year evolution of quantity and costs of drug prescription in our adult ICU and identify the relative costs generated by ICP or SC. Methods: Quantities and costs of drugs delivered on a quarterly basis to the adult ICU of our hospital between 2004 and 2008 were extracted from the pharmacy database by ATC code, an international five-level classification system. Within each ATC first level, drugs with either high level of consumption, high costs or large variations in quantities and costs were singled out and split by type of prescriber, ICP or SC. Cost figures used were drug purchase prices by the hospital pharmacy. Results: Over the 5-year period, both quantities and costs of drugs increased, following a nonsteady, nonparallel pattern. Four ATC codes accounted for 80% of both quantities and costs, with ATC code B (blood and haematopoietic organs) amounting to 63% in quantities and 41% in costs, followed by ATC code J (systemic anti-infective, 20% of the costs), ATC code N (nervous system, 11% of the costs) and ATC code C (cardiovascular system, 8% of the costs). Prescription by SC amounted to 1% in drug quantities, but 19% in drug costs. The rate of increase in quantities and costs was seven times larger for ICP than for SC (Figure 1 overleaf ). Some peak values in costs and quantities were related to a very limited number of patients. Conclusions: A 5-year increase in quantities and costs of drug prescription in an ICU is a matter of concern. Rather unexpectedly, total costs and cost increases were generated mainly by ICP. A careful follow-up is necessary to try influencing this evolution through an institutional policy co-opted by all professional categories involved in the process.

The effects of day care at the kindergarten level : day care centre versus in-home care

Two groups of nonmaternal day care providers, one made up of in-horne caregivers, and the other of providers of day care in centres, were asked to focus on their goals for the children in their care. A group of kindergarten teachers was asked to consider any differences they noticed in children in· the two types of day care mentioned above. It was found that in-horne caregivers, through flexibility, meet the developmental goals of the children in their care. Providers of tlay care in centres used a more structured and social program in order to meet the overall developmental goals for the children in their care. It was found that the kindergarten teachers noticed differences in the children in their classes in terms of their attitude and social behaviour. The type and quality of care were seen as possible influences on this outlook of young children in kindergarten. The one common element that each group highlighted with respect to the effects of day care at the kindergarten level was the important role of the family in the child's development not only in day care, but also in kindergarten class. There is still a strong need to determine the effects of various types of day care at all levels, and specifically at the kindergarten level. The more the kindergarten teacher is able to understand about the child's day care experience, and his or her own life,the better off these children in day care will be. This study confirmed both the importance of quality in child care, and the important role of the family in the child care decision.

Occurrence of enteroparasites in day care centers in Botucatu (São Paulo State, Brazil) with emphasis on Cryptosporidium sp., Giardia duodenalis and Enterobius vermicularis

Verificou-se a prevalência dos enteroparasitas em 279 crianças (0 a 6 anos) de quatro creches municipais de Botucatu/SP. Foram coletadas três amostras de fezes de cada criança e processadas pelos métodos Hoffman, Faust e Ritchie e posterior coloração do esfregaço fecal pelos métodos de Auramina-O e Ziehl-Neelsen modificado para diagnóstico de Cryptosporidium sp. e método da fita gomada para diagnóstico de Enterobius vermicularis. Das crianças analisadas apresentaram-se parasitadas 53.40%, sendo que o parasita mais freqüente foi Giardia duodenalis (26.88%). Verificou-se associação significativa entre enteroparasitose, renda familiar, escolaridade materna e idade; quanto maior a renda e o grau escolar, menor a freqüência de enteroparasitas. Observou-se que G. duodenalis é mais prevalente em crianças de 0 a 4 anos e E. vermicularis em crianças entre três e quatro anos de idade. A elevada prevalência de enteroparasitas em creches sugere estrutura complexa em sua epidemiologia, onde fatores além do saneamento devem ser considerados.

Moving from reclusion to partial freedom: the experience of family caregivers for disabled elderly persons assisted in a day care center

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

Detection of anti-Giardia lamblia serum antibody among children of day care centers

OBJETIVOS: Detectar anticorpos séricos anti-Giardia lamblia entre crianças atendidas em creches e estimar a freqüência de infecção por Giardia lamblia em área endêmica. MÉTODOS: Foram coletadas três amostras de fezes de cada uma das 147 crianças de três creches da rede municipal de Botucatu, SP, com idade variando de 0 a 6 anos, e as amostras foram processadas pelos métodos de sedimentação espontânea e flutuação pelo sulfato de zinco. Amostras de sangue foram obtidas da polpa digital, coletadas em papel de filtro e testadas pelos métodos de imunofluorescência indireta (IFI) e de reação imunoenzimática (Elisa) para pesquisa de IgG anti-Giardia. RESULTADOS E CONCLUSÕES: de um total de 147 crianças, 93 (63,3%) apresentaram cistos de Giardia nas fezes. Dos 147 eluatos testados, 93 (63,3%) e 100 (68%) foram positivos para Giardia em IFI e em Elisa, respectivamente. A sensibilidade de IFI foi de 82% e de Elisa, 72%. Contudo, Elisa foi menos específica (39%) do que IFI (70%). A imunofluorescência indireta apresentou maior concordância com o exame de fezes do que Elisa.

Blastocystis hominis: occurrence in children and staff members of municipal day-care centers from Botucatu, São Paulo State, Brazil

To study the frequency of Blastocystis hominis among healthy individuals, feces were collected from 153 children and 20 staff members of some municipal day-care centers. Three separate stool specimens of each individual were processed by Lutz and Faust methods. From 173 studied individuals, 60 (34.7%) showed B. hominis, frequently in association with other intestinal parasites and/or commensals. B. hominis was found mainly in adults and children between 36 and 72 months old. All positive cases were detected only by Lutz method and the use of three stool specimens increased the positivity of the parasitological diagnostic.

Diversity and Adaptation of Human Respiratory Syncytial Virus Genotypes Circulating in Two Distinct Communities: Public Hospital and Day Care Center

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

VERIFICATION of THE PRESENCE of CAPSULE GENE SEQUENCES IN NASOPHARYNGEAL ISOLATES of NONTYPEABLE HAEMOPHILUS INFLUENZAE FROM HEALTHY CHILDREN AT A BRAZILIAN DAY CARE CENTER

Cinqüenta e oito cepas de Haemophilus influenzae foram isoladas da nasofaringe de crianças saudáveis que freqüentam uma creche, e através da técnica de Southern blot foi pesquisada nas cepas acapsuladas a presença de seqüências do gene capsular. Sete cepas (12%) caracterizadas sorologicamente como acapsuladas mostraram homologia com seqüências específicas da cápsula. Uma cepa foi caracterizada com uma linhagem H. influenzae tipo b cápsula deficiente.

Effect of fortification of drinking water with iron plus ascorbic acid or with ascorbic acid alone on hemoglobin values and anthropometric indicators in preschool children in day-care centers in Southeast Brazil

Background. Iron-deficiency anemia currently is the most frequently occurring nutritional disorder worldwide. Previous Brazilian studies have demonstrated that drinking water fortified with iron and ascorbic acid is an adequate vehicle for improving the iron supply for children frequenting day-care centers. Objective. The objective of this study was to clarify the role of ascorbic acid as a vehicle for improving iron intake in children in day-care centers in Brazil. Methods. A six-month study was conducted on 150 children frequenting six day-care centers divided into two groups of three day-care centers by drawing lots: the iron-C group (3 day-care centers, n = 74), which used water fortified with 10 mg elemental iron and 100 mg ascorbic acid per liter, and the comparison group (3 day-care centers, n = 76), which used water containing only 100 mg ascorbic acid per liter. Anthropometric measurements and determinations of capillary hemoglobin were performed at the beginning of the study and after six months of intervention. The food offered at the day-care centers was also analyzed. Results. The fo od offered at the day-care center was found to be deficient in ascorbic acid, poor in heme iron, and adequate in non-heme iron. Supplementation with fortified drinking water resulted in a decrease in the prevalence of anemia and an increase in mean hemoglobin levels associated with height gain in both groups. Conclusions. Fortification of drinking water with iron has previously demonstrated effectiveness in increasing iron supplies. This simple strategy was confirmed in the present study. The present study also demonstrated that for populations receiving an abundant supply of non-heme iron, it is possible to control anemia in a simple, safe, and inexpensive manner by adding ascorbic acid to drinking water. © 2005, The United Nations University.

Preschool children and excess weight: the impact of a low complexity intervention in public day care centers

Introduction: childhood obesity is a major public health problem, affecting children even at early ages. Objective: to assess the impact of dietary intervention and relatively simple physical activity on the nutritional state of preschoolers. Method: this was an intervention study in public daycare centers targeting children from 2 to 4 years of age, in the State of São Paulo. The sample consisted of 9 daycare centers covering 578 children, with 264 children in the intervention group (IG) and 314 in the comparison group (CG). Intervention was focused on modifications in diet and physical activity, avoiding overloading the routine of daycare centers, for duration of one year. A zBMI score > 1 (zBMI) and < 2 was considered risk of being overweight, and > 2 zBMI was considered excess weight (overweight and obese). Analysis was done by frequency calculations, comparisons of proportions by χ2, mean comparisons by t-student and calculations according to Pearson’s correlation coefficient. Results: IG showed an inverse correlation between the initial zBMI of the children and the difference with the zBMI at the end of the intervention (rP = -0.39, p <0.0001). The mean difference of zBMI of the overweight children in IG between the beginning and the end of the study period was negative (-0.46 z score), indicating weight reduction, while the children in the CG was positive (+0. 17 z score) (p = 0.0037). Conclusion: intervention in diet and physical activity in overweight preschool children in daycare centers could have a favorable impact on the evolution of their nutritional state.

Diversity and Adaptation of Human Respiratory Syncytial Virus Genotypes Circulating in Two Distinct Communities: Public Hospital and Day Care Center

HRSV is one of the most important pathogens causing acute respiratory tract diseases as bronchiolitis and pneumonia among infants. HRSV was isolated from two distinct communities, a public day care center and a public hospital in Sao Jose do Rio Preto - SP, Brazil. We obtained partial sequences from G gene that were used on phylogenetic and selection pressure analysis. HRSV accounted for 29% of respiratory infections in hospitalized children and 7.7% in day care center children. On phylogenetic analysis of 60 HRSV strains, 48 (80%) clustered within or adjacent to the GA1 genotype; GA5, NA1, NA2, BA-IV and SAB1 were also observed. SJRP GA1 strains presented variations among deduced amino acids composition and lost the potential O-glycosilation site at amino acid position 295, nevertheless this resulted in an insertion of two potential O-glycosilation sites at positions 296 and 297. Furthermore, a potential O-glycosilation site insertion, at position 293, was only observed for hospital strains. Using SLAC and MEME methods, only amino acid 274 was identified to be under positive selection. This is the first report on HRSV circulation and genotypes classification derived from a day care center community in Brazil.

Prevalence of overweight preschool children in public day care centers: a cross-sectional study

CONTEXT AND OBJECTIVE: Brazil is undergoing a period of epidemiological transition associated with demographic and nutritional changes. The prevalence of obesity is also increasing in children and is causing numerous health problems that are becoming public health issues. The aim here was to evaluate the prevalence of overweight among children of two and three years of age. DESIGN AND SETTING: Cross-sectional study in municipal day care centers in Taubate, state of Sao Paulo, Brazil. METHODS: Weight and height measurements were made on 447 preschool children forming a probabilistic randomized sample. Their body mass index (BMI) was calculated. Their nutritional status was classified using the World Health Organization reference cutoff points (2006). Their mean weight, height and BMI were compared according to their age and sex. RESULTS: The mean values for the final sample (n = 447) were as follows: mean age: 38.6 months (+/- 3.5) and Z scores for: weight/height (W/H): 0.50 (+/- 1.22); height/age: -0.03 (+/- 1.07); weight/age (W/A): 0.51 (+/- 1.23); and BMI: 0.51(+/- 1.23). The prevalence of overweight children (BMI > 1 z) was 28.86%, while the prevalence of underweight children (BMI < -2 z) was 0.89%. There were no differences in mean BMI among the two and three-year age groups (P = 0.66). CONCLUSION: A high prevalence of overweight was observed in the sample of two and three-year-old children, with practically no malnutrition, thus showing that a significant nutritional transition may already be occurring, even in medium-sized cities of developing countries.

Nursing care time and quality indicators for adult intensive care: correlation analysis

The objective of this quantitative, correlational and descriptive study was to analyze the time the nursing staff spends to assist patients in Adult Intensive Care Units, as well as to verify its correlation with quality care indicators. The average length of time spent on care and the quality care indicators were identified by consulting management instruments the nursing head of the Unit employs. The average hours of nursing care delivered to patients remained stable, but lower than official Brazilian agencies' indications. The correlation between time of nursing care and the incidence of accidental extubation indicator indicated that it decreases with increasing nursing care delivered by nurses. The results of this investigation showed the influence of nursing care time, provided by nurses, in the outcome of care delivery.

Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes?

PURPOSE OF REVIEW: Critical incident reporting alone does not necessarily improve patient safety or even patient outcomes. Substantial improvement has been made by focusing on the further two steps of critical incident monitoring, that is, the analysis of critical incidents and implementation of system changes. The system approach to patient safety had an impact on the view about the patient's role in safety. This review aims to analyse recent advances in the technique of reporting, the analysis of reported incidents, and the implementation of actual system improvements. It also explores how families should be approached about safety issues. RECENT FINDINGS: It is essential to make as many critical incidents as possible known to the intensive care team. Several factors have been shown to increase the reporting rate: anonymity, regular feedback about the errors reported, and the existence of a safety climate. Risk scoring of critical incident reports and root cause analysis may help in the analysis of incidents. Research suggests that patients can be successfully involved in safety. SUMMARY: A persisting high number of reported incidents is anticipated and regarded as continuing good safety culture. However, only the implementation of system changes, based on incident reports, and also involving the expertise of patients and their families, has the potential to improve patient outcome. Hard outcome criteria, such as standardized mortality ratio, have not yet been shown to improve as a result of critical incident monitoring.