Food insecurity of HIV/AIDS patients at a unit of outpatient healthcare system in Brasilia, Federal District, Brazil

INTRODUCTION: Food security remains to be one of the world's biggest problems and is found to be related to HIV/AIDS. The objective was to examine food insecurity in HIV/AIDS patients from Brasilia, Brazil. METHODS: Short version of the Food Security Scale was applied to patients with HIV/AIDS. RESULTS: A total of 103 patients participated (65 HIV+ and 38 with AIDS). Food insecurity was found in 33.8% of HIV+ patients and 36.8% of patients with AIDS. A relation between food insecurity and low educational and social levels was established. CONCLUSIONS: Food security should be an important component in HIV/AIDS treatment programs.

Acute kidney injury in a tropical country: a cohort study of 253 patients in an infectious diseases intensive care unit

Introduction: Acute kidney injury (AKI) is a frequent and potentially fatal complication in infectious diseases. The aim of this study was to investigate the clinical aspects of AKI associated with infectious diseases and the factors associated with mortality. Methods: This retrospective study was conducted in patients with AKI who were admitted to the intensive care unit (ICU) of a tertiary infectious diseases hospital from January 2003 to January 2012. The major underlying diseases and clinical and laboratory findings were evaluated. Results: A total of 253 cases were included. The mean age was 46±16 years, and 72% of the patients were male. The main diseases were human immunodeficiency virus (HIV) infection, HIV/acquired immunodeficiency syndrome (AIDS) (30%), tuberculosis (12%), leptospirosis (11%) and dengue (4%). Dialysis was performed in 70 cases (27.6%). The patients were classified as risk (4.4%), injury (63.6%) or failure (32%). The time between AKI diagnosis and dialysis was 3.6±4.7 days. Oliguria was observed in 112 cases (45.7%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in patients with HIV/AIDS (57±20, p-value=0.01) and dengue (68±11, p-value=0.01). Death occurred in 159 cases (62.8%). Mortality was higher in patients with HIV/AIDS (76.6%, p-value=0.02). A multivariate analysis identified the following independent risk factors for death: oliguria, metabolic acidosis, sepsis, hypovolemia, the need for vasoactive drugs, the need for mechanical ventilation and the APACHE II score. Conclusions: AKI is a common complication in infectious diseases, with high mortality. Mortality was higher in patients with HIV/AIDS, most likely due to the severity of immunosuppression and opportunistic diseases.

Evaluation of the Medical Care of Patients with Hypertension in an Emergency Department and in Ambulatory Hypertension Unit

OBJECTIVE: To evaluate the characteristics of the patients receiving medical care in the Ambulatory of Hypertension of the Emergency Department, Division of Cardiology, and in the Emergency Unit of the Clinical Hospital of the Ribeirão Preto Medical School. METHODS: Using a protocol, we compared the care of the same hypertensive patients in on different occasions in the 2 different places. The characteristics of 62 patients, 29 men with a mean age of 57 years, were analyzed between January 1996 and December 1997. RESULTS: The care of these patients resulted in different medical treatment regardless of their clinical features and blood pressure levels. Thus, in the Emergency Unit, 97% presented with symptoms, and 64.5% received medication to rapidly reduce blood pressure. In 50% of the cases, nifedipine SL was the elected medication. Patients who applied to the Ambulatory of Hypertension presenting with similar features, or, in some cases, presenting with similar clinically higher levels of blood pressure, were not prescribed medication for a rapid reduction of blood pressure at any of the appointments. CONCLUSION: The therapeutic approach to patients with high blood pressure levels, symptomatic or asymptomatic, was dependent on the place of treatment. In the Emergency Unit, the conduct was, in the majority of cases, to decrease blood pressure immediately, whereas in the Ambulatory of Hypertension, the same levels of blood pressure, in the same individuals, resulted in therapeutic adjustment with nonpharmacological management. These results show the need to reconsider the concept of hypertensive crises and their therapeutical implications.

Retrospective Study of the Survival of Patients who Underwent Cardiopulmonary Resuscitation in an Intensive Care Unit

OBJECTIVE: To evaluate clinical and evolutive characteristics of patients admitted in an intensive care unit after cardiopulmonary resuscitation, identifying prognostic survival factors.METHODS: A retrospective study of 136 patients admitted between 1995 and 1999 to an intensive care unit, evaluating clinical conditions, mechanisms and causes of cardiopulmonary arrest, and their relation to hospital mortality.RESULTS: A 76% mortality rate independent of age and sex was observed. Asystole was the most frequent mechanism of death, and seen in isolation pulmonary arrest was the least frequent. Cardiac failure, need for mechanical ventilation, cirrhosis and previous stroke were clinically significant (p<0.01) death factors.CONCLUSION: Prognostic factors supplement the doctor's decision as to whether or not a patient will benefit from cardiopulmonary resuscitation.

BNP was Associated with Ischemic Myocardial Scintigraphy and Death in Patients at Chest Pain Unit

Background:Recent studies have suggested that B-type Natriuretic Peptide (BNP) is an important predictor of ischemia and death in patients with suspected acute coronary syndrome. Increased levels of BNP are seen after episodes of myocardial ischemia and may be related to future adverse events.Objectives:To determine the prognostic value of BNP for major cardiac events and to evaluate its association with ischemic myocardial perfusion scintigraphy (MPS).Methods:This study included retrospectively 125 patients admitted to the chest pain unit between 2002 and 2006, who had their BNP levels measured on admission and underwent CPM for risk stratification. BNP values were compared with the results of the MPS. The chi-square test was used for qualitative variables and the Student t test, for quantitative variables. Survival curves were adjusted using the Kaplan-Meier method and analyzed by using Cox regression. The significance level was 5%.Results:The mean age was 63.9 ± 13.8 years, and the male sex represented 51.2% of the sample. Ischemia was found in 44% of the MPS. The mean BNP level was higher in patients with ischemia compared to patients with non-ischemic MPS (188.3 ± 208.7 versus 131.8 ± 88.6; p = 0.003). A BNP level greater than 80 pg/mL was the strongest predictor of ischemia on MPS (sensitivity = 60%, specificity = 70%, accuracy = 66%, PPV = 61%, NPV = 70%), and could predict medium-term mortality (RR = 7.29, 95% CI: 0.90-58.6; p = 0.045) independently of the presence of ischemia.Conclusions:BNP levels are associated with ischemic MPS findings and adverse prognosis in patients presenting with acute chest pain to the emergency room, thus, providing important prognostic information for an unfavorable clinical outcome.

The functional outcome and recovery of patients admitted to an intensive care unit following drug overdose: a follow-up study.

Patients who have overdosed on drugs commonly present to emergency departments, with only the most severe cases requiring intensive care unit (ICU) admission. Such patients typically survive hospitalisation. We studied their longer term functional outcomes and recovery patterns which have not been well described. All patients admitted to the 18-bed ICU of a university-affiliated teaching hospital following drug overdoses between 1 January 2004 and 31 December 2006 were identified. With ethical approval, we evaluated the functional outcome and recovery patterns of the surviving patients 31 months after presentation, by telephone or personal interview. These were recorded as Glasgow outcome score, Karnofsky performance index and present work status. During the three years studied, 43 patients were identified as being admitted to our ICU because of an overdose. The average age was 34 years, 72% were male and the mean APACHE II score was 16.7. Of these, 32 were discharged from hospital alive. Follow-up data was attained on all of them. At a median of 31 months follow-up, a further eight had died. Of the 24 surviving there were 13 unemployed, seven employed and four in custody. The median Glasgow outcome score of survivors was 4.5, their Karnofsky score 80. Admission to ICU for treatment of overdose is associated with a very high risk of death in both the short- and long-term. While excellent functional recovery is achievable, 16% of survivors were held in custody and 54% unemployed.This resource was contributed by The National Documentation Centre on Drug Use.

Delay for admission of unstable hospitalized patients to intensive care unit: a need for a medical emergency team?

INTRODUCTION. Patients admitted in Intensive Care Unit (ICU) from general wards are more severe and have a higher mortality than those admitted from emergency department as reported [1]. The majority of them develop signs of instability (e.g. tachypnea, tachycardia, hypotension, decreased oxygen saturation and change in conscious state) several hours before ICU admission. Considering this fact and that in-hospital cardiac arrests and unexpected deaths are usually preceded by warning signs, immediate on site intervention by specialists may be effective. This gave an impulse to medical emergency team (MET) implementation, which has been shown to decrease cardiac arrest, morbidity and mortality in several hospitals. OBJECTIVES AND METHODS. In order to verify if the same was true in our hospital and to determine if there was a need for MET, we prospectively collected all non elective ICU admissions of already hospitalized patients (general wards) and of patients remaining more than 3 h in emergency department (considered hospitalized). Instability criteria leading to MET call correspond to those described in the literature. The delay between the development of one criterion and ICU admission was registered. RESULTS. During an observation period of 12 months, 321 patients with our MET criteria were admitted to ICU. 88 patients came from the emergency department, 115 from the surgical and 113 from the medical ward. 65% were male. The median age was 65 years (range 17-89). The delay fromMETcriteria development to ICU admission was higher than 8 h in 155 patients, with a median delay of 32 h and a range of 8.4 h to 10 days. For the remaining 166 patients, an early MET criterion was present up to 8 h (median delay 3 h) before ICU admission. These results are quite concordant with the data reported in the literature (ref 1-8). 122 patients presented signs of sepsis or septic shock, 70 patients a respiratory failure, 58 patients a cardiac emergency. Cardiac arrest represent 5% of our collective of patients. CONCLUSIONS.Similar to others observations, the majority of hospitalized patients admitted on emergency basis in our ICU have warning signs lasting for several hours. More than half of them were unstable for more than 8 h. This shows there is plenty of time for early acute management by dedicated and specialized team such as MET. However, further studies are required to determine if MET implementation can reduce in-hospital cardiac arrests and influence the morbidity, the length of stay and the mortality.

Prospective monitoring of cefepime in intensive care unit adult patients

Rapport de synthèse :Le céfépime a été associé à un taux de mortalité supérieur à celui des autres bêta-lactamines chez les patients traités pour un sepsis sévère. Une des hypothèses avancées pour expliquer ces échecs thérapeutiques sont de possibles effets secondaires cachés (par ex. neurologiques) ou des paramètres pharmacocinétiques/pharmacodynamiques (PK/PD) inadaptés. Le présent travail a étudié cette problématique en mesurant prospectivement la pharmacocinétique du céfépime chez 21 patients consécutifs hospitalisés aux soins intensifs adultes (SIAD) pour une pneumonie nosocomiale. La population étudiée avec un âge médian 55,1 ans, a reçu par voie intraveineuse du céfépime à raison de 2 g toutes les 12 heures pour une clairance de la créatinine (Clcr)>50 mI/ min, et 2 g toutes les 24 heures ou 36 heures pour une Clcr<50 ml /min. Les taux plasmatiques de céfépime ont été mesurés à plusieurs reprises avant et après administration du médicament après la lèoe dose et à l'état d'équilibre par chromatographie en phase liquide à haute pression. Les taux plasmatiques ont considérablement varié entre les patients. Cent pour cent (21/21) des patients ont eu une durée appropriée d'antibiothérapie avec des taux plasmatiques supérieures à la CMI du céfépime (T>CMI>50%) pour les agents pathogènes retrouvés dans cette étude (CMI<4 mg/I), mais seulement 45-65% d'entre eux ont eu une couverture appropriée pour les agents pathogènes potentiels présentant une CMI> 8 mg/I pour le céfépime. Deux patients avec une insuffisance rénale (Clcr<30 ml/min) ont présenté des symptômes compatibles avec une épilepsie non-convulsive (état confusionnel et myoclonies) attribuée dans un 2ème temps à une toxicité du céfépime après que les taux plasmatiques aient été communiqués aux soignants qui ont suspendu l'antibiothérapie avec disparition des symptômes. Les résultats de cette étude empirique confirment l'existence d'effets secondaires cachés et de paramètres PK/PD inappropriés (pour les agents pathogènes ayant des CMI de limite supérieure) dans notre population de SIAD. En outre, ils mettent en évidence une fenêtre thérapeutique efficace pour une posologie de céfépime de 2 g toutes les 12 heures chez les patients ayant une Clcr>50 ml/min infectés par des pathogènes avec des CMI pour le céfépime <4 mg/I. Les échecs thérapeutiques constatés dans cette étude sont probablement liés à des taux sériques inadaptés, résultant de la difficulté de prescription dans les situations cliniques complexes. Dans ce contexte, un prompt dosage plasmatique du céfépime doit être considéré en cas de diminution de la Clcr ou en présence de CMI élevées.

Construct validity of the French version of the PRWE (Patient Rated Wrist Evaluation) with the French version of the DASH (Disabilities Arm Shoulder and Hand) is good to very good in a population of patients with wrist injuries in an inpatient rehabilitation unit

Objective.- The Patient-Rated Wrist Evaluation is a specific questionnaire for the wrist [1]. It consists of 15 questions with a total score of 100. It was recently translated into French [2]. However, its validity has not been tested in this language. The Disabilities Arm Shoulder and Hand (DASH), with well-established psychometric properties, is considered as the reference questionnaire for the evaluation of upper extremities. The objective of this study is to measure the construct validity of the PRWE-F with the DASH-F in patients with wrist pathology.Patients and methods.- Fifty-one patients (40 m, 11 w, mean age 42 years), 25 fractures of the radius and 26 lesions of the carpus.Questionnaires PRWE-F and DASH-F at entry and at discharge (0 to 100). Calculation of the construct validity of the PRWE-F comparing with the DASH-F with Pearson correlation coefficients (r) at entry and at discharge. Level of significance (alpha) was set at 5%.Results.- Correlation DASH/PRWE at entry: r = 0.799 (95% CI 0.671 to 0.881), P < 0.0001. Correlation DASH/PRWE at discharge: r = 0.847 (95% CI: 0.745 to 0.910), P < 0.0001.Discussion.- The construct validity of the two instruments indicates that they measure the same concept. Our correlation between DASH-F and PRWE-F, going from 0.799 to 0.847, are comparable to those published in different languages (0.71 to 0.84) [3,4]. The questionnaires PRWE-F can thus be used in rehabilitation patients presenting with wrist pathologies; it is comparable to the DASH but described by MacDermid [1] to be more specific. Compared to the DASH it has the advantage of consisting of two dimensions. Its construct validity is excellent. This questionnaire should be evaluated in other populations, and it should be compared with hand questionnaires more specific than the DASH.

Delirium in elderly patients hospitalized in an acute care unit.

Introduction: Delirium is frequent in hospitalized older people, with incidence rate up to 40% in acute care. Delirium is associated with several adverse consequences, including increased mortality and institutionalization. This study aims to investigate the prevalence, incidence, and consequences of delirium in patients hospitalized in an acute care unit for elderly (ACE unit). Methods: Over a 3 months period, every patient (N = 93, mean age 84.1 ± 7.8 years, 66/93(71%) women) admitted to a 28-bed ACE unit were systematically assessed for delirium. Trained nurses used the Confusion Assessment Method (CAM) instrument to determine the presence of delirium at admission and on each subsequent day over patients' stay. Delirium prevalence rate was defined as the proportion of patients with a positive CAM within 24 hours of admission to the ACE unit. Delirium incidence rate was defined as the proportion of patients with a negative CAM at admission whose CAM became positive at least once during their stay. This evaluation was part of a functional assessment, including Basic Activities of Daily Life (Katz BADL, from 0 to 6, higher score indicating better function). Delirium prevention interventions and specific treatment was provided if needed. Results: Overall,25/93(27%)patients had delirium during their stay. Prevalence of delirium at admission was 10/93 (11%), with an incidence of 15/83(18%). Compared with non-delirious patients, those with delirium were more frequently men (10/25(40%) vs 17/68(25%), p <.001) and had reduced functional status at admission(BADL 2.0 ± 1.9 vs 3.6 ± 2.1, p = .004). They tended to be older (86.0 ± 6.7 vs 83.3 ± 8.1 years, p = .110). At discharge, delirium was associated with reduced functional status (BADL 2.0 ± 2.1 vs 4.3 ± 1.9, p <.001), lower rate of home discharge (6/20(30%) vs 28/65 (43%), p = .009) and increased mortality (5/25 (20%) vs 3/68 (5%), p <.001). On average, patients with delirium stayed 5.7 days longer (17.0 ± 9.8 vs 11.31 ± 6.3, p = .011). Conclusion: Delirium occurred in almost a third of these older patients, even though its incidence was relatively low in this frail population. Despite specific management, delirium remained associated with higher risk for adverse outcomes at discharge. These results suggest that early preventive interventions, implemented as soon as possible after hospital admission, might be needed in similar population to achieve better outcomes. Effectiveness of such interventions will be evaluated in future studies.

Prospective monitoring of cefepime in intensive care unit adult patients.

INTRODUCTION: Cefepime has been associated with a greater risk of mortality than other beta-lactams in patients treated for severe sepsis. Hypotheses for this failure include possible hidden side-effects (for example, neurological) or inappropriate pharmacokinetic/pharmacodynamic (PK/PD) parameters for bacteria with cefepime minimal inhibitory concentrations (MIC) at the highest limits of susceptibility (8 mg/l) or intermediate-resistance (16 mg/l) for pathogens such as Enterobacteriaceae, Pseudomonas aeruginosa and Staphylococcus aureus. We examined these issues in a prospective non-interventional study of 21 consecutive intensive care unit (ICU) adult patients treated with cefepime for nosocomial pneumonia. METHODS: Patients (median age 55.1 years, range 21.8 to 81.2) received intravenous cefepime at 2 g every 12 hours for creatinine clearance (CLCr) >or= 50 ml/min, and 2 g every 24 hours or 36 hours for CLCr < 50 ml/minute. Cefepime plasma concentrations were determined at several time-points before and after drug administration by high-pressure liquid chromatography. PK/PD parameters were computed by standard non-compartmental analysis. RESULTS: Seventeen first-doses and 11 steady states (that is, four to six days after the first dose) were measured. Plasma levels varied greatly between individuals, from two- to three-fold at peak-concentrations to up to 40-fold at trough-concentrations. Nineteen out of 21 (90%) patients had PK/PD parameters comparable to literature values. Twenty-one of 21 (100%) patients had appropriate duration of cefepime concentrations above the MIC (T>MIC >or= 50%) for the pathogens recovered in this study (MIC <or= 4 mg/l), but only 45 to 65% of them had appropriate coverage for potential pathogens with cefepime MIC >or= 8 mg/l. Moreover, 2/21 (10%) patients with renal impairment (CLCr < 30 ml/minute) demonstrated accumulation of cefepime in the plasma (trough concentrations of 20 to 30 mg/l) in spite of dosage adjustment. Both had symptoms compatible with non-convulsive epilepsy (confusion and muscle jerks) that were not attributed to cefepime-toxicity until plasma levels were disclosed to the caretakers and symptoms resolved promptly after drug arrest. CONCLUSIONS: These empirical results confirm the suspected risks of hidden side-effects and inappropriate PK/PD parameters (for pathogens with upper-limit MICs) in a population of ICU adult patients. Moreover, it identifies a safety and efficacy window for cefepime doses of 2 g every 12 hours in patients with a CLCr >or= 50 ml/minute infected by pathogens with cefepime MICs <or= 4 mg/l. On the other hand, prompt monitoring of cefepime plasma levels should be considered in case of lower CLCr or greater MICs.

Evaluation of the Video Intubation Unit in morbid obese patients.

BACKGROUND: Tracheal intubation may be more difficult in morbidly obese (MO) patients than in the non-obese. The aim of this study was to evaluate clinically if the use of the Video Intubation Unit (VIU), a video-optical intubation stylet, could improve the laryngoscopic view compared with the standard Macintosh laryngoscope in this specific population. METHODS: We studied 40 MO patients (body mass index >35 kg/m(2)) scheduled for bariatric surgery. Each patient had a conventional laryngoscopy and a VIU inspection. The laryngoscopic grades (LG) using the Cormack and Lehane scoring system were noted and compared. Thereafter, the patients were randomised to be intubated with one of the two techniques. In one group, the patients were intubated with the help of the VIU and in the control group, tracheal intubation was performed conventionally. The duration of intubation, as well as the minimal SpO(2) achieved during the procedure, were measured. RESULTS: Patient characteristics were similar in both groups. Seventeen patients had a direct LG of 2 or 3 (no patient had a grade of 4). Out of these 17 patients, the LG systematically improved with the VIU and always attained grade 1 (P<0.0001). The intubation time was shorter within the VIU group, but did not attain significance. There was no difference in the SpO(2) post-intubation. CONCLUSION: In MO patients, the use of the VIU significantly improves the visualisation of the larynx, thereby improving the intubation conditions.

L'incontinence urinaire chez des personnes âgées hospitalisées en unité de gériatrie: est-ce vraiment une priorité pour les infirmières [Urinary incontinence in hospitalized geriatric patients : is it really a priority for nurses?].

INTRODUCTION: urinary incontinence (UI) is a phenomenon with high prevalence in hospitalized elderly patients, effecting up to 70% of patients requiring long term care. However, despite the discomfort it causes and its association with functional decline, it seems to be given insufficient attention by nurses in geriatric care. OBJECTIVES: to assess the prevalence of urinary incontinence in geriatric patients at admission and the level of nurse involvement as characterized by the explicit documentation of UI diagnosis in the patient's record, prescription of nursing intervention, or nursing actions related to UI. METHODS: cross-sectional retrospective chart review. One hundred cases were randomly selected from those patients 65 years or older admitted to the geriatric ward of a university hospital. The variables examined included: total and continence scores on the Measure of Functional Independence (MIF), socio-demographic variables, presence of a nursing diagnosis in the medical record, prescription of or documentation of a nursing intervention related to UI. RESULTS: the prevalence of urinary incontinence was 72 % and UI was positively correlated with a low MIF score, age and status of awaiting placement. Of the examined cases, nursing diagnosis of UI was only documented in 1.4 % of cases, nursing interventions were prescribed in 54 % of cases, and at least one nursing intervention was performed in 72 % of cases. The vast majority of the interventions were palliative. DISCUSSION: the results on the prevalence of IU are similar to those reported in several other studies. This is also the case in relation to nursing interventions. In this study, people with UI were given the same care regardless of their MIF score MIF, age or gender. One limitation of this study is that it is retrospective and therefore dependent on the quality of the nursing documentation. CONCLUSIONS: this study is novel because it examines UI in relation to nursing interventions. It demonstrates that despite a high prevalence of UI, the general level of concern for nurses remains relatively low. Individualized care is desirable and clinical innovations must be developed for primary and secondary prevention of UI during hospitalization.