Profile of patients in private home care who developed ventilator-associated pneumonia.

OBJECTIVES: to analyze the profile and clinical outcomes of patients who developed Ventilator-Associated Pneumonia (VAP) in private home care and to compare the incidence with national data. METHODS: this was a retrospective study with data collected from July 2021 to June 2022 from patient records at a private clinic. Patients using intermittent ventilation or without ventilatory support were excluded. RESULTS: the utilization rate of mechanical ventilation was 15.9%. The incidence density of pneumonia in pediatrics was 2.2 cases per 1000 ventilation-days and in adults was 1.7 cases per 1000 ventilation-days, figures lower than those reported by the National Health Surveillance Agency. There were 101 episodes of pneumonia in 73 patients, predominantly male (65.8%), adults (53.4%), and those with neurological diseases (57.5%). The treatment regimen predominantly took place at home (80.2%), and there was one death. CONCLUSIONS: patients in home care showed a low incidence and mortality rate from ventilator-associated pneumonia.

Home Care as a safe alternative during the COVID-19 crisis.

INTRODUCTION: There are several reports worldwide about the high mortality related to COVID-19 among residents of nursing homes. The worldwide concern about the safety of patients and professionals in these institutions is relevant. In Brasil, a large part of post-acute care and chronic patients is performed at home through Home Care (HC). OBJECTIVE: This study aims to evaluate the incidence of COVID-19 in Home Care patients and the clinical outcomes of these patients; it also aims to assess the impact of the epidemic on the number of patients, new admissions, and hospitalizations. METHODS: A descriptive study of the COVID-19 cases that affected the population in care by Home Doctor (a private company of Home Care), between the months of March 2020 and May 2020 and analysis of the total number of patients, the hospitalization and death rate in the period compared to the pre-epidemic period. RESULTS: There were 31 confirmed cases of COVID-19, 21 of which were male, mean age 73 years. All patients had multiple comorbidities, the most prevalent were: Systemic Arterial Hypertension (54%) and Stroke (35%). The incidence of COVID-19 was 1% in the studied population. There were 10 hospitalizations with 5 hospital deaths and one case of home death (lethality 19%). Safe care was maintained, with a low death rate (0.6%) and hospitalization (6.1%). CONCLUSION: Home Care is able to maintain safe care during the pandemic due to COVID-19, with a low incidence of COVID-19, low hospitalization rate, and low mortality when compared to nursing homes institutions.

Home Care as a safe alternative during the COVID-19 crisis

SUMMARY INTRODUCTION: There are several reports worldwide about the high mortality related to COVID-19 among residents of nursing homes. The worldwide concern about the safety of patients and professionals in these institutions is relevant. In Brasil, a large part of post-acute care and chronic patients is performed at home through Home Care (HC). OBJECTIVE: This study aims to evaluate the incidence of COVID-19 in Home Care patients and the clinical outcomes of these patients; it also aims to assess the impact of the epidemic on the number of patients, new admissions, and hospitalizations. METHODS: A descriptive study of the COVID-19 cases that affected the population in care by Home Doctor (a private company of Home Care), between the months of March 2020 and May 2020 and analysis of the total number of patients, the hospitalization and death rate in the period compared to the pre-epidemic period. RESULTS: There were 31 confirmed cases of COVID-19, 21 of which were male, mean age 73 years. All patients had multiple comorbidities, the most prevalent were: Systemic Arterial Hypertension (54%) and Stroke (35%). The incidence of COVID-19 was 1% in the studied population. There were 10 hospitalizations with 5 hospital deaths and one case of home death (lethality 19%). Safe care was maintained, with a low death rate (0.6%) and hospitalization (6.1%). CONCLUSION: Home Care is able to maintain safe care during the pandemic due to COVID-19, with a low incidence of COVID-19, low hospitalization rate, and low mortality when compared to nursing homes institutions.

RESUMO INTRODUÇÃO: Diversos são os relatos mundiais a respeito da elevada mortalidade relacionada a COVID-19 entre os residentes de instituições de longa permanência. A preocupação demonstrada mundialmente sobre a segurança dos pacientes e profissionais nestas instituições é relevante. No Brasil grande parte dos cuidados pós-agudo e de pacientes crônicos é realizado no domicílio através da Atenção Domiciliar (AD). OBJETIVO: O estudo visa avaliar a incidência de COVID-19 em pacientes em Atenção Domiciliar e o desfecho clínico destes pacientes; objetiva avaliar o impacto da epidemia sobre número de pacientes totais, novas admissões e hospitalizações. MÉTODOS: Estudo descritivo dos casos de COVID-19 que acometeram população em atendimento pela Home Doctor (empresa privada de Atenção Domiciliar), entre os meses de março de 2020 a maio de 2020 e análise do número total de pacientes, da taxa de hospitalização e óbito no período comparado o período pré-epidemia. RESULTADOS: Ocorreram 31 casos confirmados de COVID-19, sendo 21 sexo masculino, idade média 73 anos. Todos os pacientes apresentavam múltiplas comorbidades, sendo as mais prevalentes: Hipertensão Arterial Sistêmica (54%) e Acidente Vascular Cerebral (35%). A incidência de COVID-19 foi de 1% na população estudada. Ocorreram 10 hospitalizações com 5 óbitos hospitalares e um caso de óbito domiciliar (letalidade 19%). A segurança do atendimento foi mantida, com baixa taxa de óbito (0,6%) e hospitalização (6,1%). CONCLUSÃO: A Atenção Domiciliar é capaz de manter atendimento seguro durante a pandemia por COVID-19, com baixa incidência de COVID-19, baixa taxa de hospitalização e baixa mortalidade quando comparada a instituições de longa permanência.

Fracture risk assessment in home care patients using the FRAX® tool.

OBJECTIVE: To assess the ten-year risk of hip and osteoporotic fracture in home care patients using the FRAX® tool. METHODS: A retrospective, cross-sectional observational study including patients aged ≥ 40 and ≤ 90 years and receiving home care from a private provider. The risk of fracture was calculated using an online calculator. High risk was defined as risk of hip fracture greater than 3% or risk of osteoporotic fracture greater than 20%. Data were expressed as absolute number (n), relative frequency (%), mean, standard deviation (±) and probability value (p). RESULTS: Eighty-three (37.7%) out of 222 patients were at high risk of fracture. Of these, 81 (36.7%) were at high risk of hip fracture, as follows: 18 patients aged 70-80 years (17 female) and 63 patients aged 80-90 years (51 female). High risk of osteoporotic fracture was limited to two female patients (0.1%) aged over 80 years. CONCLUSION: FRAX® analysis revealed similar fracture risks in the sample and the older adult population overall. Prospective investigation of fracture rates in home care patients, identification of true risk factors and construction of a home care patient-specific clinical score are warranted.

Fracture risk assessment in home care patients using the FRAX® tool / Estimativa do risco de fratura óssea em pacientes em Atenção Domiciliar por meio da ferramenta FRAX®

ABSTRACT Objective To assess the ten-year risk of hip and osteoporotic fracture in home care patients using the FRAX® tool. Methods A retrospective, cross-sectional observational study including patients aged ≥ 40 and ≤ 90 years and receiving home care from a private provider. The risk of fracture was calculated using an online calculator. High risk was defined as risk of hip fracture greater than 3% or risk of osteoporotic fracture greater than 20%. Data were expressed as absolute number (n), relative frequency (%), mean, standard deviation (±) and probability value (p). Results Eighty-three (37.7%) out of 222 patients were at high risk of fracture. Of these, 81 (36.7%) were at high risk of hip fracture, as follows: 18 patients aged 70-80 years (17 female) and 63 patients aged 80-90 years (51 female). High risk of osteoporotic fracture was limited to two female patients (0.1%) aged over 80 years. Conclusion FRAX® analysis revealed similar fracture risks in the sample and the older adult population overall. Prospective investigation of fracture rates in home care patients, identification of true risk factors and construction of a home care patient-specific clinical score are warranted.

RESUMO Objetivo Avaliar o risco de fratura de quadril e fratura osteoporótica, em 10 anos, em pacientes em atenção domiciliar, de acordo com a ferramenta FRAX®. Métodos Estudo transversal, retrospectivo, observacional realizados com pacientes de uma empresa de Assistência Domiciliar com idade ≥40 e ≤90 anos. Foi avaliado o risco de fratura por meio da calculadora on-line, tendo sido considerado elevado risco de fratura de quadril acima de 3% e elevado risco de fratura osteoporótica quando acima de 20%. Os dados foram expressos em número absoluto (n), frequência relativa (%), média, desvio padrão (±) e valor de significância (p). Resultados Dos 222 pacientes, 83 (37,7%) apresentaram alto risco de fratura, sendo 81 (36,7%) casos por elevado risco de fratura de quadril. Destes, 18 deles tinham idade entre 70 e 80 anos (sendo 17 do sexo feminino) e 63 entre 80 e 90 anos (sendo 51 do sexo feminino). O risco elevado de fratura osteoporótica ocorreu em apenas duas pacientes do sexo feminino (0,1%), ambas com idade acima de 80 anos. Conclusão O risco de fratura óssea verificado pela ferramenta FRAX® foi semelhante na população do estudo em relação ao da população idosa em geral. A avaliação prospectiva da incidência de fraturas nos pacientes em Atenção Domiciliar, a identificação dos reais fatores de risco e a personalização do escore clínico para este grupo de pacientes se fazem necessárias.

Impacto do tratamento precoce guiado por metas sobre a morbidade e mortalidade da sepse grave e do choque séptico em crianças / Impact of early goal-directed therapy on morbidity and mortality of children with severe sepsis and septic shock

Introdução: O fluxograma de tratamento ACCM/PALS objetiva a reversão precoce do choque séptico pediátrico utilizando medidas convencionais. Na evolução destas recomendações, foram adicionadas medidas indiretas do equilíbrio entre oferta e demanda de oxigênio utilizando saturação venosa central de oxigênio (ScvO2 70%), dentro de uma abordagem direcionada a metas. Entretanto, enquanto que estas recomendações adicionadas baseiam-se em evidências de estudos em adultos, a extrapolação para o paciente pediátrico permanece sem validação. Objetivo: O objetivo deste estudo é comparar o fluxograma ACCM/PALS com ou sem terapia guiada pela ScvO2 sobre a morbidade e a mortalidade de crianças com sepse grave e choque séptico. MÉTODOS: Crianças e adolescentes com sepse grave ou choque séptico refratário a volume foram randomizados para receber o tratamento ACCM/PALS com ou sem ressuscitação guiada pela ScvO2. Mortalidade em vinte e oito dias foi o desfecho primário. Resultados: Dos 102 paciente incluídos, 51 receberam tratamento ACCM/PALS guiado pela ScvO2 e 51 receberam tratamento ACCM/PALS sem orientação pela ScvO2. Tratamento guiado pela ScvO2 resultou em menor mortalidade (11,8% vs. 39,2%, p = 0,002), e menor incidência de disfunções orgânicas (p = 0,03). O tratamento guiado pela ScvO2 resultou em mais cristalóide (28 [20-40] vs. 5 [0-20] mL/kg, p < 0,0001), transfusões de hemáceas (45,1% vs. 15,7%, p = 0,002) e suporte inotrópico (29,4% vs. 7,8%, p = 0,01) nas primeiras seis horas. Conclusões: Este estudo reforça o fluxograma ACCM/PALS. Tratamento guiado pela ScvO2 70% possui impacto significativo e aditivo sobre o prognóstico de crianças e adolescentes com choque séptico.

Introduction: ACCM/PALS guidelines address early correction of pediatric septic shock using conventional measures. In the evolution of these recommendations indirect measures of the balance between systemic oxygen delivery and demands using central venous or superior vena cava oxygen saturation (ScvO2 70%) in a goal directed approach have been added. However, while these additional goal-directed endpoints are based on evidenced based adult studies, the extrapolation to the pediatric patient remains unvalidated. Objective: The purpose of this study is to compare ACCM/PALS guidelines performed with and without ScvO2 goal-directed therapy on the morbidity and mortality rate of children with severe sepsis and septic shock. Methods: Children and adolescents with severe sepsis or fluid-refractory septic shock were randomly assigned to ACCM/PALS with, or without ScvO2 goal directed resuscitation. Twenty-eight day mortality was the primary endpoint. Results: Of the 102 enrolled patients, 51 received ACCM/PALS with ScvO2 goal directed therapy and 51 received ACCM/PALS without ScvO2 goal directed therapy. ScvO2 goal directed therapy resulted in less mortality (28-day 11.8 vs. 39.2 percent, p = 0.002), and fewer new organ dysfunctions (p = 0.03). ScvO2 goal directed therapy resulted in more crystalloid (28 [20-40] vs. 5 [0-20] mL/kg, p < 0.0001), blood transfusion (45.1 vs. 15.7 percent, p = 0.002) and inotropic support (29.4 vs. 7.8 percent, p = 0.01) in the first 6 hours. Conclusions: This study supports the current ACCM/PALS guidelines. Goal directed therapy using the endpoint of a ScvO2 70% provides significant and additive impact on the outcome of children and adolescents with septic shock.

Enterococo resistente à vancomicina em UTI pediátrica: descrição de um caso e revisão da literatura / Vancomycin-resistant enterococci in Pediatric Intensive Care Unit: case and literature review

Objetivo: relatar caso pediátrico de infecção por enterococo resistente à vancomicina (VRE), discutir fatores de risco relacionados ao surgimento destes agentes, medidas profiláticas para p´revenção e transmissão de cepas multirresistentes com a racionalização do uso de antinicrobianos e educação da equipe. Relato de caso: criança de 10 anos com teratoma imaturo e antecedente de internações pregressas em unidade de terapia intensiva e quimioterapia. A biopsia demonstrou tratar-se de teratoma maduro. Paciente foi submetida à ressecção parcial do tumor, com abordagem intestinal e realização de ileostomia, havendo necessidade de nova internação em UTI. Necessitou de várias reabordagens cirúsrgicas, evoluindo com infecção intra-abdominal e choque séptico. No período, utilizou antibiotocterapia de largo espectro. Na terceira cirurgia, isolou-se Enrerococcus faecium em líquido ascítico. A criança faleceu um dia após esta intervenção. Comentários: a infecção por VRE pode ser atribuída à flora endógena do paciente, ao contato direto ou indireto, por meio das mãos dos profissionais de saúde,ou por ambiente contaminado.

Complications of tracheobronchial foreign body aspiration in children: report of 5 cases and review of the literature.

Foreign body aspiration (FBA) is one of leading causes of death in children, especially among those younger than 3 years of age. The inhalation of a foreign body may cause a wide variety of symptoms, and early diagnosis is highly associated with the successful removal of the inhaled foreign material. Despite the great advances in endoscopic procedures and anesthesia, a large number of difficulties and complications still result from foreign body aspiration. We describe 5 cases of serious acute complications following aspiration of foreign bodies that became lodged in the tracheobronchial tree, including pneumomediastinum, pneumothorax, total atelectasis, foreign body dislodgment, and need for thoracotomy in children admitted into our intensive care unit in 1999 and 2000; these were all situations that could have been prevented with early recognition and prompt therapeutic intervention.

Complications of tracheobronchial foreign body aspiration in children: report of 5 cases and review of the literature

Foreign body aspiration (FBA) is one of leading causes of death in children, especially among those younger than 3 years of age. The inhalation of a foreign body may cause a wide variety of symptoms, and early diagnosis is highly associated with the successful removal of the inhaled foreign material. Despite the great advances in endoscopic procedures and anesthesia, a large number of difficulties and complications still result from foreign body aspiration. We describe 5 cases of serious acute complications following aspiration of foreign bodies that became lodged in the tracheobronchial tree, including pneumomediastinum, pneumothorax, total atelectasis, foreign body dislodgment, and need for thoracotomy in children admitted into our intensive care unit in 1999 and 2000; these were all situations that could have been prevented with early recognition and prompt therapeutic intervention

O ensino medico na atencao primaria em pediatria: um programa para os residentes no Centro de Saude-Escola da FMUSP / The medical learn in primary care center: a program of pediatrics residence on Health Service

Avaliar o programa de ensino na atencao primaria para residentes de pediatria do Instituto da Crianca do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. O estudo foi realizado atraves da...