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.

ANTS AS POTENTIAL VECTORS OF PATHOGENS IN HOSPITALS IN THE STATE OF SAO-PAULO, BRAZIL

Baiting studies performed in large, medium and small hospitals in Brazil revealed the presence of 14 ant species, with up to nine recorded in one hospital. Dominant species were exotic ants, and in the large hospital, Tapinoma melanocephalum was the most prevalent. Ants were not uniformly spread through the hospitals, but tended to be found in the more critical areas, particularly in nursery, intensive care, obstetrics, neurology and dermatology units. Bacteriological studies using specific media for bacteria associated with intra-hospital infections indicated the potential for the mechanical vectoring of species of Staphylococcus, Serratia, Klebsiella, Acinetobacter, Enterobacter, Candida and Enterococcus by ants. Although T. melanocephalum did not have the highest rate of association with these bacteria, its ubiquitous occurrences resulted in the highest overall potential as a vector of these bacteria. Because of a large number of ant species occurring in Brazilian hospitals, ants pose a potential problem to the spread of diseases in hospitals. Because of the number of associated ant species in hospitals, the control of this potential problem is much more difficult than in registered temperate areas.

Surveillance Programme for Healthcare Associated Infections in the State of São Paulo, Brazil. Implementation and the first three years' results

Governmental programmes should be developed to collect and analyse data on healthcare associated infections (HAIs). This study describes the healthcare setting and both the implementation and preliminary results of the Programme for Surveillance of Healthcare Associated Infections in the State of São Paulo (PSHAISP), Brazil, from 2004 to 2006. Characterisation of the healthcare settings was carried out using a national database. The PSHAISP was implemented using components for acute care hospitals (ACH) or long term care facilities (LTCF). The components for surveillance in ACHs were surgical unit, intensive care unit and high risk nursery. The infections included in the surveillance were surgical site infection in clean surgery, pneumonia, urinary tract infection and device-associated bloodstream infections. Regarding the LTCF component, pneumonia, scabies and gastroenteritis in all inpatients were reported. In the first year of the programme there were 457 participating healthcare settings, representing 51.1% of the hospitals registered in the national database. Data obtained in this study are the initial results and have already been used for education in both surveillance and the prevention of HAI. The results of the PSHAISP show that it is feasible to collect data from a large number of hospitals. This will assist the State of São Paulo in assessing the impact of interventions and in resource allocation. (C) 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

Teaching in the community: Changing and implementing a new curriculum

The Faculdade de Medicina de Botucatu is changing to, and implementing a new curriculum aimed at integrating teaching and learning in the community. Emphasis is on preparing the community settings for teaching, learning and providing health care. A particular task is staff development with emphasis on problem-based learning (PBL) and training medical and nursing students in the leadership to participate in this process. The new curriculum includes the gradual introduction of clinical practice during First Year, integration of the basic sciences with clinical sciences, through integrated modules studied in small groups, and maintenance of the two year clerkship. The undergraduates are introduced gradually to the community: 8% of the total curriculum during First Year, 10% during Second Year, 10% during Third Year, 20% during Fourth Year, 30% during Fifth and Sixth Years. The basic health units at primary care level, and the regional specialty outpatients and hospitals at the second level, are the main teaching sites. An Education Development Committee was established to discuss the strategies for supporting the changes and to structure the planning for promoting the gradual transformation of staff development. After 18 months of implementation of the curriculum, there followed discussions and monitoring of the objectives of changes in medical education at our school. Successful implementation of the new curriculum would fail, if the objectives were not absorbed by every member of the implementation Committee.

Minerals in the nutrition of extremely low birth weight infants

Objective: To review the literature on the role of calcium, phosphorus and trace elements in the nutrition of extremely low birth weight infants, considering their importance for metabolism, bone mineralization and as dietary components. Sources of data: MEDLINE, the Cochrane Database of Systematic Reviews and books on nutrition were searched between 1994 and 2004. Original research studies and reviews were selected. Summary of the findings: Extremely preterm infants are frequently growth-restricted at hospital discharge as a consequence of difficulties in the provision of adequate nutrition. The long-term effects of this growth restriction need to be determined. There is a paucity of studies about the role of minerals, especially micronutrients, in the nutrition of extremely preterm infants. The principal focus of this review was on calcium and phosphorus metabolism, bone mineralization and parenteral and enteral supplementation. A critical evaluation of post-discharge nutrition and its influence upon growth and bone mineralization was presented. Selenium and zinc requirements and the role of selenium as an antioxidant with possible effects on free radical diseases of the preterm infant were discussed. Conclusions: Extremely preterm infants have low mineral reserves and, as a consequence, may have deficiencies in the postnatal period if they do not receive parenteral or enteral supplementation. More studies are needed to elucidate the actual requirements and the appropriate supplementation of micronutrients. There are controversies about the outcome and the influence of post-discharge nutrition on bone disease of prematurity. Copyright © 2005 by Sociedade Brasileira de Pediatria.

Unusual wooden foreign body in the palate

We report a case of a palatal calcified foreign body simulating an odontogenic lesion. Surgical exploration revealed a calcified mass that was analysed under light microscopy and identified as a vegetal foreign body. Further scanning electron microscopy analysis revealed that the foreign body was a piece of wood. Hard palate foreign bodies have been reported previously, however, it seems that this is the first case of its kind. © 2007 Nature Publishing Group.

Risk factors for low birth weight in Botucatu city, SP state, Brazil: A study conducted in the public health system from 2004 to 2008

Background: Low birth weight (LBW), defined as birth weight less than 2500 g, has a complex etiology and may be a result of premature interruption of pregnancy or intrauterine growth restriction. The objective of this study was to provide information on determinants of LBW and contribute to the understanding of the problem in Brazil. Methods. A case-control study was conducted in Botucatu city, SP state, Brazil. The study population consisted of 2 groups with 860 newborns in each group as follows: low weight newborns (LWNB) and a control group (weight ≤ 2500 g). Secondary data from 2004 to 2008 were collected using the Live Birth Certificate (LBC) and records from medical charts of pregnant women in Basic Health Units (BHU) and in the Public University Hospital (UH). Variables were as follows: maternal socio-demographic characteristics, pregnancy and birth conditions including quality of prenatal care according to 3 criteria. They were based on parameters established by the Ministry of Health (MH), one of them, the modified Kessner Index. The multivariable analysis by logistic regression was used to evaluate the association between variables and LBW. Results: According to the analysis, the factors associated with LBW were as follows: prematurity (OR = 56.98, 95% CI 29.52-109.95), twin pregnancy (OR = 20.00, 95% CI 6.25-100.00), maternal smoking (OR = 2.12, 95% CI 1.33-3.45), maternal malnourishment (OR = 2.30, 95% CI 1.08-5.00), maternal obesity (OR = 2.30, 95% IC 1.18-4.48), weight gain during pregnancy less than 5 kg (OR = 2.63, 95% CI 1.35-5.00) and weight gain during pregnancy more than 15 kg (OR = 2.26, 95% CI 1.16-4.41). Adequacy of prenatal care visits adjusted to gestational age was less frequent in the LBW group than in the control group (68.7% vs. 80.5%, x 2 p < 0.001). According to the modified Kessner Index, 64.4% of prenatal visits in the LWNB group were adequate. Conclusion: LWNB are a quite heterogeneous group of infants concerning their determinants and prevention actions against LBW and the follow-up of these infants have also been very complex. Therefore, improvement in the quality of care provided should be given priority through concrete actions for prevention of LBW. © 2012 Fonseca et al; licensee BioMed Central Ltd.

Trade openness and structural change in the Brazilian motor industry

Includes bibliography

Erythromycin versus neomycin in the treatment of hepatic encephalopathy in cirrhosis: A randomized double-blind study

Background: Hepatic encephalopathy (HE) is a severe complication in patients with hepatic cirrhosis, which causes numerous hospital admissions and deaths. Antibiotics are the best options in HE treatment, but head-to-head comparisons between these drugs are scarce. Erythromycin combines the antimicrobial effect and prokinetic properties in the same drug, but it has never been used in HE treatment. Our aim was to evaluate the efficacy of erythromycin as an HE treatment.Methods: We achieved a randomized controlled trial of adult patients with HE and hepatic cirrhosis admitted in our hospital. After randomization, the subjects received either erythromycin 250 mg or neomycin 1 g orally QID until hospital discharge or prescription of another antibiotic. All subjects were blindly evaluated every day towards quantifying clinical, neuropsychometric, hepatic and renal exams. Statistical analysis was employed to compare the groups and correlate the variables with hospitalization duration.Results: 30 patients were evaluated (15 treated with each drug). At hospital admission, the groups were homogeneous, but the erythromycin group subjects achieved a shorter hospitalization stay (p = 0.032) and a more expressive reduction in alanine aminotranspherase levels (p = 0.026). Hospitalization duration was positively correlated with C reactive protein levels measured previous to (p = 0.015) and after treatment (p = 0.01).Conclusions: In the sample evaluated erythromycin was associated with significant reductions in hospital stay and in alanine aminotranspherase values. Hospitalization time was positive correlated with C reactive protein levels measured before and after the treatments. © 2013 Romeiro et al.; licensee BioMed Central Ltd.

Filamentous fungi vectored by ants (Hymenoptera: Formicidae) in a public hospital in north-eastern Brazil

Background: The increase in opportunistic fungal infections has led to the search for putative sources of contamination in hospital environments. Aim: Ants in a public hospital in Itabuna, north-eastern Brazil were examined for carriage of filamentous fungi. Methods: During a year-long survey, ants from different hospital areas were sampled. Preference was given to locations where it was possible to observe ants actively foraging. The fungi found on the ants' integument were cultured and identified. Findings: A total of 106 ant workers belonging to 12 species in 11 genera were collected. A total of 47 fungal strains was isolated from 40% of the ants (. N = 42). We found 16 fungal species in 13 genera associated with the ant workers. The prevalent fungal genera were . Aspergillus, . Purpureocillium and . Fusarium. The ants . Tapinoma melanocephalum, . Paratrechina longicornis and . Pheidole megacephala were associated with six fungal genera; and four genera of fungi were associated with . Solenopsis saevissima workers. Fungal diversity was higher in the following hospital areas: nursery, hospital beds, breastmilk bank and paediatrics. Conclusion: Ants act as carriers of soil and airborne fungal species, and ant control in hospital areas is necessary to prevent the dissemination of such micro-organisms. © 2012 The Healthcare Infection Society.

Anthropometric changes in the brazilian cohort of older adults: SABE survey (Health, Well-Being, and Aging)

The aim of the present study was to analyze the anthropometric changes in a home-based cohort of Brazilian older adults who participated in the SABE Survey, conducted in 2000 and 2006. A total of 1030 men and women were examined by age group: 60-69, 70-79, and ≥80 years. This representative sample consists of the survivors of the 2000 cohort. The following anthropometric variables were assessed: body mass, arm muscle, waist and calf circumferences, triceps skinfold thickness, body mass index, waist-hip ratio, and arm muscle area according to mean values and percentile distribution. Except for body mass and body mass index, a significant difference (P<0.05) was observed among the assessed anthropometric variables during the follow-up period. The older adults ≥80 years presented the lowest values. The reduction in the mean values of triceps skinfold thickness was greater (30%) than that of waist circumference (9%) and was more pronounced in women (21%) than in men (9%). Arm muscle circumference and area reduced by 8% and 19%, respectively, in men and 1% and 3%, correspondingly, in women. Our findings revealed reductions in the mean values for all anthropometric variables in the follow-up period from 2000 to 2006 among older adults. © 2013 Manuela Ferreira de Almeida et al.

Influenza among the elderly in the Americas: A consensus statement

Influenza exacts a heavy burden on the elderly, a segment of the population that is estimated to experience rapid growth in the near future. In the past decade most developed and several developing countries have recommended influenza vaccination for those > 65 years of age. The World Health Organization (WHO) set a goal of 75% influenza vaccination coverage among the elderly by 2010, but it was not achieved. In 2011, the Technical Advisory Group at the Pan American Health Organization, Regional Office of WHO for the Americas, reiterated the influenza vaccine recommendation for older adults. Relatively little information has been compiled on the immunological aspect of aging or on reducing its impact, information particularly relevant for clinicians and gerontologist with firsthand experience confronting its effects. To fill this data gap, in 2012 the Americas Health Foundation (Washington, D.C., United States) and the nonprofit, Fighting Infectious Diseases in Emerging Countries (Miami, Florida, United States), convened a panel of Latin American clinicians and gerontologists with expertise in influenza to discuss key issues and develop a consensus statement. The major recommendations were to improve influenza surveillance throughout Latin America so that its impact can be quantified; and to conduct laboratory confirmation of influenza for all patients who have flu-like symptoms and are frail, immunosuppressed, have comorbidities, are respiratory compromised, or have been admitted to a hospital. The panel also noted that: since evidence for antivirals in the elderly is unclear, their use should be handled on a case-by-case basis; despite decreased immunological response, influenza vaccination in older adults is still crucial; indirect immunization strategies should be encouraged; and traditional infection control measures are essential in long-term care facilities.

An assessment of the economic and social impacts of climate change on the tourism sector in the Caribbean

There are significant, fundamental changes taking place in global air and sea surface temperatures and sea levels. The Fourth Assessment Report of the Intergovernmental Panel on Climate Change noted that many of the warmest years on the instrumental record of global surface temperatures have occurred within the last twelve years, i.e. 1995-2006 (IPCC, 2007). The Caribbean tourism product is particularly vulnerable to climate change. On the demand side, mitigation measures in other countries – for example, measures to reduce the consumption of fossil fuels – could have implications for airfares and cruise prices and, therefore, for the demand for travel, particularly to long-haul destinations such as the Caribbean (Clayton, 2009). On the supply side, sea level rise will cause beaches to disappear and damage coastal resorts. Changes in the frequency and severity of hurricanes are likely to magnify that damage. Other indirect impacts on the tourism product include rising insurance premiums and competition for water resources (Cashman, Cumberbatch, & Moore, 2012). The present report has used information on historic and future Caribbean climate data to calculate that the Caribbean tourism climatic index (TCI) ranges from −20 (impossible) to +100 (ideal). In addition to projections for the Caribbean, the report has produced TCI projections for the New York City area (specifically, Central Park), which have been used as comparators for Caribbean country projections. The conditions in the source market provide a benchmark against which visitors may judge their experience in the tourism destination. The historical and forecasted TCIs for the Caribbean under both the A2 and B2 climate scenarios of the IPCC suggest that climatic conditions in the Caribbean are expected to deteriorate, and are likely to become less conducive to tourism. More specifically, the greatest decline in the TCI is likely to occur during the northern hemisphere summer months from May to September. At the same time, the scenario analysis indicates that home conditions during the traditional tourist season (December – April) are likely to improve, which could make it more attractive for visitors from these markets to consider ‘staycations’ as an alternative to overseas trips.

Socio-demographic analysis of youth in the Caribbean- a three country case study

Many Caribbean youth are doing reasonably well. They live in loving and caring families, attend school and are involved in various social activities in their communities. The health and well-being of the children and youth1 in the Caribbean is, and has been, the centre of attention of many studies, meetings and policy directives set at the regional, subregional and national levels. Programmes have been put in place to address the basic needs of young children in the areas of health and education and to provide guidance and directives to youth and adolescents in the area of professional formation and transition to adulthood. Critical issues such as reproductive health and family planning combined with access to education and information on these topics have been promoted to some extent. And finally, the Caribbean is known for rather high school enrolment rates in primary education that hardly show any gender disparities. While the situation is still good for some, growing numbers of children and youth cannot cope anymore with the challenges experienced quite early in their lives. Absent parents, instable care-taking arrangements, violence and aggression subjected to at home, in schools and among their friends, lack of a perspective in schools and the labour-market, early sexual initiation and teenage pregnancies are some of those issues faced by a rising number of young persons in this part of the world. Emotional instability, psychological stress and increased violence are one of the key triggers for increased violence and involvement in crime exhibited by ever younger youth and children. Further, the region is grappling with rising drop-out rates in secondary education, declining quality schooling in the classrooms and increasing numbers of students who leave school without formal certification. Youth unemployment in the formal labour market is high and improving the quality of professional formation along with the provision of adequate employment opportunities would be critical to enable youth to complete consistently and effectively the transition into adulthood and to take advantage of the opportunities to develop and use their human capital in the process. On a rather general note, the region does not suffer from a shortage of policies and programmes to address the very specific needs of children and youth, but the prominent and severe lack of systematic analysis and monitoring of the situation of children, youth and young families in the Caribbean does not allow for targeted and efficient interventions that promise successful outcomes on the long term. In an effort to assist interested governments to fill this analytical gap, various initiatives are underway to enhance data collection and their systematic analysis2. Population and household censuses are conducted every decade and a variety of household surveys, such as surveys of living conditions, labour force surveys and special surveys focusing on particular sub-groups of the population are conducted, dependent on the resources available, to a varying degree in the countries of the region. One such example is the United Nations Children’s Fund (UNICEF)-funded Multi-Indicator Cluster Surveys (MICS) that assess the situation of children and youth in a country. Over the past years and at present, UNICEF has launched a series of surveys in a number of countries in the Caribbean3. But more needs to be done to ensure that the data available is analyzed to provide the empirical background information for evidence-based policy formulation and monitoring of the efficiency and effectiveness of the efforts undertaken.