Laparoscopic cholecystectomy performed by general surgery residents. Is it safe? How much does it cost?

OBJECTIVE: to evaluate the effectiveness and safety of laparoscopic cholecystectomies performed by residents of the first and second-year of a general surgery residency program. We studied the primary total cost of treatment and complication rates as primary outcomes, comparing the groups operated by senior and resident surgeons. METHODS: this was a retrospective cohort study of patients who underwent laparoscopic cholecystectomy performed in a training hospital of large surgical volume in Brazil, in the period between June 1, 2018 and May 31, 2019. The study population comprised patients who underwent elective cholecystectomy due to uncomplicated chronic calculous cholecystitis or to the presence of gallbladder polyps with surgical indication. We divided the cases into three groups, based on the graduation of the main surgeon at the time of the procedure: first-year residents (R1), second-year residents (R2), and trained general surgeons (GS). RESULTS: during the study period, 1,052 laparoscopic cholecystectomies were performed, of which 1,035 procedures met the inclusion criteria, with 78 (7.5%) patients operated on with the participation of first-year residents (R1), 500 (48.3%) patients with the participation of second-year residents (R2), and 457 (44.2%) with the participation of senior surgeons only. There was no difference in conversion rates, complications, and reporting of adverse events between groups. We observed a significant difference regarding hospitalization costs (p = 0.003), with a higher mean for the patients operated with the participation of R1, of US$ 2,671.13, versus US$ 2,414.60 and US$ 2,396.24 for the procedures performed by senior surgeons and R2, respectively. CONCLUSIONS: laparoscopic cholecystectomy with the participation of residents is safe, even in their first years of training. There is an additional cost of about 10% in the treatment of patient operated with the participation of first-year residents. There was no significant difference in the cost of the group operated by second-year residents.

Medication errors in emergency departments: is electronic medical record an effective barrier?

OBJECTIVE: To compare medication errors in two emergency departments with electronic medical record, to two departments that had conventional handwritten records at the same organization. METHODS: A cross-sectional, retrospective, descriptive, comparative study of medication errors and their classification, according to the National Coordinating Council for Medication Error Reporting and Prevention, associated with the use of electronic and conventional medical records, in emergency departments of the same organization, during one year. RESULTS: There were 88 events per million opportunities in the departments with electronic medical record and 164 events per million opportunities in the units with conventional medical records. There were more medication errors when using conventional medical record - in 9 of 14 categories of the National Coordinating Council for Medication Error Reporting and Prevention. CONCLUSION: The emergency departments using electronic medical records presented lower levels of medication errors, and contributed to a continuous improvement in patients´ safety.

Lipid profile and statin use in critical care setting: implications for kidney outcome.

OBJECTIVE: To determine whether pre-hospital statin use is associated with lower renal replacement therapy requirement and/or death during intensive care unit stay. METHODS: Prospective cohort analysis. We analyzed 670 patients consecutively admitted to the intensive care unit of an academic tertiary-care hospital. Patients with ages ranging from 18 to 80 years admitted to the intensive care unit within the last 48 hours were included in the study. RESULTS: Mean age was 66±16.1 years old, mean body mass index 26.6±4/9kg/m2 and mean abdominal circumference was of 97±22cm. The statin group comprised 18.2% of patients and had lower renal replacement therapy requirement and/or mortality (OR: 0.41; 95%CI: 0.18-0.93; p=0.03). The statin group also had lower risk of developing sepsis during intensive care unit stay (OR: 0.42; 95%CI: 0.22-0.77; p=0.006) and had a reduction in hospital length-of-stay (14.7±17.5 days versus 22.3±48 days; p=0.006). Statin therapy was associated with a protective role in critical care setting independently of confounding variables, such as gender, age, C-reactive protein, need of mechanical ventilation, use of pressor agents and presence of diabetes and/or coronary disease. CONCLUSION: Statin therapy prior to hospital admission was associated with lower mortality, lower renal replacement therapy requirement and sepsis rates.

Near-infrared spectroscopy parameters in patients undergoing continuous venovenous hemodiafiltration.

OBJECTIVE: To investigate the impacts of continuous venovenous hemodiafiltration on the microcirculation in patients with acute kidney injury. METHODS: A prospective observational pilot study conducted in a 40-bed, open clinical-surgical intensive care unit of a private tertiary care hospital located in the city of São Paulo (SP), Brazil. Microcirculation was assessed using near-infrared spectroscopy by means of a 15mm probe placed over the thenar eminence. Vascular occlusion test was performed on the forearm to be submitted to near-infrared spectroscopy by inflation of a sphygmomanometer cuff to 30mmHg higher than the systolic arterial pressure. The primary endpoint was the assessment of near-infrared spectroscopy-derived parameters immediately before, 1, 4 and 24 hours after the initiation of continuous venovenous hemodiafiltration. RESULTS: Nine patients were included in this pilot study over a period of 2 months. Minimum tissue oxygen saturation measured during the vascular occlusion test was the only near-infrared spectroscopy-derived parameter to differed over the time (decrease compared to baseline values up to 24 hours after initiation of continuous venovenous hemodiafiltration). CONCLUSION: The impacts of microcirculatory dysfunction on clinical outcomes of patients undergoing to continuous venovenous hemodiafiltration need to be further investigated.

Laparoscopic cholecystectomy performed by general surgery residents. Is it safe? How much does it cost? / Colecistectomia laparoscópica realizada por residentes de cirurgia geral. É seguro? Quanto custa?

ABSTRACT Objective: to evaluate the effectiveness and safety of laparoscopic cholecystectomies performed by residents of the first and second-year of a general surgery residency program. We studied the primary total cost of treatment and complication rates as primary outcomes, comparing the groups operated by senior and resident surgeons. Methods: this was a retrospective cohort study of patients who underwent laparoscopic cholecystectomy performed in a training hospital of large surgical volume in Brazil, in the period between June 1, 2018 and May 31, 2019. The study population comprised patients who underwent elective cholecystectomy due to uncomplicated chronic calculous cholecystitis or to the presence of gallbladder polyps with surgical indication. We divided the cases into three groups, based on the graduation of the main surgeon at the time of the procedure: first-year residents (R1), second-year residents (R2), and trained general surgeons (GS). Results: during the study period, 1,052 laparoscopic cholecystectomies were performed, of which 1,035 procedures met the inclusion criteria, with 78 (7.5%) patients operated on with the participation of first-year residents (R1), 500 (48.3%) patients with the participation of second-year residents (R2), and 457 (44.2%) with the participation of senior surgeons only. There was no difference in conversion rates, complications, and reporting of adverse events between groups. We observed a significant difference regarding hospitalization costs (p = 0.003), with a higher mean for the patients operated with the participation of R1, of US$ 2,671.13, versus US$ 2,414.60 and US$ 2,396.24 for the procedures performed by senior surgeons and R2, respectively. Conclusions: laparoscopic cholecystectomy with the participation of residents is safe, even in their first years of training. There is an additional cost of about 10% in the treatment of patient operated with the participation of first-year residents. There was no significant difference in the cost of the group operated by second-year residents.

RESUMO Objetivo: avaliar a efetividade e segurança da realização de colecistectomias laparoscópicas por residentes do primeiro e segundo ano do programa de cirurgia geral. Foram estudados como desfechos primários o custo médio total de tratamento e os índices de complicações, comparando os grupos operados por cirurgiões seniores e residentes. Métodos: trata-se de estudo de coorte retrospectivo de pacientes submetidos a colecistectomias laparoscópicas realizadas em hospital escola de grande volume cirúrgico, no Brasil, no período entre 01 de junho de 2018 e 31 de maio de 2019. A população do estudo compreendeu pacientes que realizaram colecistectomias eletivas por colecistite calculosa crônica não complicada ou por presença de pólipos de vesícula biliar com indicação cirúrgica. Os casos foram divididos em 3 grupos, baseados na graduação do cirurgião principal no momento do procedimento: residentes do primeiro ano (R1), residentes do segundo ano (R2) e cirurgiões formados (CG). Resultados: no período do estudo, foram realizadas 1.052 colecistectomias videolaparoscópicas, sendo que, após aplicados os critérios de exclusão, foram incluídos no estudo 1.035 procedimentos, com 78 (7,5%) pacientes operados com a participação de residentes do primeiro ano (R1), 500 (48,3%) pacientes com a participação de residentes do segundo ano (R2) e 457 (44,2%) apenas com a participação somente de cirurgiões seniores. Não houve diferença nas taxas de conversão, de complicações e de notificações de eventos adversos entre os grupos. Foi evidenciada diferença com relação aos custos de internação (p= 0,003), sendo observado maior custo médio de internação para os pacientes operados com participação dos R1, com custo médio de US$ 2.671,13, versus US$ 2.414,60 e US$ 2.396,24 das operações realizadas pelos cirurgiões seniores e R2, respectivamente. Conclusões: é segura a realização de colecistectomia videolaparoscópica com a participação de residentes, mesmo em seus primeiros anos de formação. Existe custo adicional de cerca de 10% no tratamento de pacientes operados com a participação de residentes do primeiro ano. Não foi observada diferença significativa no custo do grupo operado por residentes do segundo ano.

Measuring hand hygiene compliance rates at hospital entrances.

BACKGROUND: Despite the importance of hand hygiene in the health care setting, there are no studies evaluating hand hygiene compliance at hospital entrances. METHODS: The study was prospectively performed over a 33-week period from March 30, 2014-November 15, 2014, to evaluate hand hygiene compliance in 2 hospital reception areas. We compared electronic handwash counters with the application of radiofrequency identification (GOJO SMARTLINK) (electronic observer) that counts each activation of alcohol gel dispensers to direct observation (human observer) via remote review of video surveillance. RESULTS: We found low hand hygiene compliance rates of 2.2% (99/4,412) and 1.7% (140/8,277), respectively, at reception areas A and D, detected by direct observation. Using the electronic observer, we measured rates of 17% (15,624/91,724) and 7.1% (51,605/730,357) at reception areas A and D, respectively. For the overall time period of simultaneous electronic and human observation, the human observer captured 1% of the hand hygiene episodes detected by the electronic observer. CONCLUSIONS: Our study showed very low hand hygiene compliance in hospital reception areas, and we found an electronic hand hygiene system to be a useful method to monitor hand hygiene compliance.

Association between participation and compliance with Continuing Medical Education and care production by physicians: a cross-sectional study.

OBJECTIVE: Physician participation in Continuing Medical Education programs may be influenced by a number of factors. To evaluate the factors associated with compliance with the Continuing Medical Education requirements at a private hospital, we investigated whether physicians' activity, measured by volumes of admissions and procedures, was associated with obtaining 40 Continuing Medical Education credits (40 hours of activities) in a 12-month cycle. METHODS: In an exclusive and non-mandatory Continuing Medical Education program, we collected physicians' numbers of hospital admissions and numbers of surgical procedures performed. We also analyzed data on physicians' time since graduation, age, and gender. RESULTS: A total of 3,809 credentialed, free-standing, private practice physicians were evaluated. Univariate analysis showed that the Continuing Medical Education requirements were more likely to be achieved by male physicians (odds ratio 1.251; p=0.009) and who had a higher number of hospital admissions (odds ratio 1.022; p<0.001). Multivariate analysis showed that age and number of hospital admissions were associated with achievement of the Continuing Medical Education requirements. Each hospital admission increased the chance of achieving the requirements by 0.4%. Among physicians who performed surgical procedures, multivariate analysis showed that male physicians were 1.3 time more likely to achieve the Continuing Medical Education requirements than female physicians. Each surgical procedure performed increased the chance of achieving the requirements by 1.4%. CONCLUSION: The numbers of admissions and number of surgical procedures performed by physicians at our hospital were associated with the likelihood of meeting the Continuing Medical Education requirements. These findings help to shed new light on our Continuing Medical Education program.

Medication errors in emergency departments: is electronic medical record an effective barrier? / Erros de medicação em unidades de pronto atendimento: prontuário eletrônico, barreira eficaz?

ABSTRACT Objective: To compare medication errors in two emergency departments with electronic medical record, to two departments that had conventional handwritten records at the same organization. Methods: A cross-sectional, retrospective, descriptive, comparative study of medication errors and their classification, according to the National Coordinating Council for Medication Error Reporting and Prevention, associated with the use of electronic and conventional medical records, in emergency departments of the same organization, during one year. Results: There were 88 events per million opportunities in the departments with electronic medical record and 164 events per million opportunities in the units with conventional medical records. There were more medication errors when using conventional medical record - in 9 of 14 categories of the National Coordinating Council for Medication Error Reporting and Prevention. Conclusion: The emergency departments using electronic medical records presented lower levels of medication errors, and contributed to a continuous improvement in patients´ safety.

RESUMO Objetivo: Comparar os erros de medicações de duas unidades de pronto atendimento que possuíam prontuário eletrônico aos de duas unidades que possuíam prontuário convencional manual em uma mesma instituição. Métodos: Estudo transversal, retrospectivo, descritivo, que comparou a incidência de erros de medicações e sua classificação, segundo o National Coordinating Council for Medication Error Reporting and Prevention, associado ao uso do prontuário eletrônico e do convencional, em unidades de pronto atendimento de uma mesma instituição por um ano. Resultados: Foram observados 88 eventos por milhão de oportunidades nas unidades com prontuário eletrônico e 164 por milhão de oportunidades nas unidades com prontuário convencional. Houve mais erros de medicações nas unidades com prontuário convencional − em 9 das 14 categorias da National Coordinating Council for Medication Error Reporting and Prevention analisadas. Conclusão: Com a utilização do prontuário eletrônico, as unidades de pronto atendimento apresentaram menores índices de erros de medicações, contribuindo para melhoria continuada na segurança do paciente.

SeptiFast for diagnosis of sepsis in severely ill patients from a Brazilian hospital.

OBJECTIVE: To test and validate a multiplex real-time polymerase chain reaction method for bloodstream infections, as well as to compare the results with conventional blood culture. METHODS: A total of 114 consecutive patients with clinical evidence of sepsis were submitted to blood culture and LightCycler™ SeptiFast tests. RESULTS: More positive specimens (23; 20.2%) were detected using the LightCycler™ SeptiFast than the blood culture (17; 14.9%), with an agreement of 86.8%. Discordant results were seen in four patients positive only to blood culture, ten positive only to LightCycler™ SeptiFast and one to different pathogens found by each test. Infections with microorganisms detected only using blood culture reassured the need to perform both tests. The mean time to results for blood culture was 5 days for negative and 3.5 days for positive results. LightCycler™ SeptiFast results were achieved in less than 8 hours. CONCLUSION: LightCycler™ SeptiFast showed a high potential as a test to be carried out concomitantly with blood culture for sepsis diagnosis in severely ill patients. This test allowed a faster diagnosis of bacterial and fungal infections that helped to reduce hospital stay and to control the use of antibiotics. LightCycler™ SeptiFast can also eventually detect microorganism and infections that are hardly detected by blood culture, especially Candida non-albicans infections.

Lipid profile and statin use in critical care setting: implications for kidney outcome / Perfil lipídico e uso de estatina em terapia intensiva: implicações no desfecho renal

ABSTRACT Objective: To determine whether pre-hospital statin use is associated with lower renal replacement therapy requirement and/or death during intensive care unit stay. Methods: Prospective cohort analysis. We analyzed 670 patients consecutively admitted to the intensive care unit of an academic tertiary-care hospital. Patients with ages ranging from 18 to 80 years admitted to the intensive care unit within the last 48 hours were included in the study. Results: Mean age was 66±16.1 years old, mean body mass index 26.6±4/9kg/m2 and mean abdominal circumference was of 97±22cm. The statin group comprised 18.2% of patients and had lower renal replacement therapy requirement and/or mortality (OR: 0.41; 95%CI: 0.18-0.93; p=0.03). The statin group also had lower risk of developing sepsis during intensive care unit stay (OR: 0.42; 95%CI: 0.22-0.77; p=0.006) and had a reduction in hospital length-of-stay (14.7±17.5 days versus 22.3±48 days; p=0.006). Statin therapy was associated with a protective role in critical care setting independently of confounding variables, such as gender, age, C-reactive protein, need of mechanical ventilation, use of pressor agents and presence of diabetes and/or coronary disease. Conclusion: Statin therapy prior to hospital admission was associated with lower mortality, lower renal replacement therapy requirement and sepsis rates.

RESUMO Objetivo: Determinar se o uso pré-admissão hospitalar de estatina está associado com menor necessidade de diálise e/ou óbito durante internação em unidade de terapia intensiva. Métodos: Análise de coorte prospectiva. Foram incluídos consecutivamente 670 pacientes admitidos na unidade de terapia intensiva de um hospital acadêmico de cuidados terciários. Os pacientes incluídos deveriam ter entre 18 e 80 anos e ter sido admitidos na unidade de terapia intensiva nas últimas 48 horas. Resultados: A média da idade dos pacientes foi de 66±16,1 anos. O índice de massa corporal foi de 26,6±4/9kg/m2 e a circunferência abdominal média foi de 97±22cm. O grupo que fez uso de estatina pré-admissão hospitalar (18,2% dos pacientes) necessitou menos de terapia de substituição renal e/ou evoluiu para óbito (OR: 0,41; IC95%: 0,18-0,93; p=0,03). O grupo que fez uso de estatina também apresentou menor risco de evoluir com sepse durante a internação na unidade de terapia intensiva (OR: 0,42; IC95%: 0,22-0,77; p=0,006) e teve menor duração da hospitalização (14,7±17,5 dias versus 22,3±48 dias; p=0,006). A terapia pré-admissão hospitalar com estatina foi associada a papel protetor no cenário da terapia intensiva independentemente de variáveis confundidoras, como sexo, idade, proteína C-reativa, necessidade de ventilação mecânica, uso de vasopressores e diagnóstico de diabetes e/ou coronariopatia. Conclusão: A terapia com estatina antes da admissão hospitalar foi associada a menor mortalidade, menor necessidade de terapia de substituição renal e taxa de ocorrência de sepse.

Near-infrared spectroscopy parameters in patients undergoing continuous venovenous hemodiafiltration / Espectroscopia no infravermelho próximo em pacientes sob hemodiafiltração venovenosa contínua

ABSTRACT Objective To investigate the impacts of continuous venovenous hemodiafiltration on the microcirculation in patients with acute kidney injury. Methods A prospective observational pilot study conducted in a 40-bed, open clinical-surgical intensive care unit of a private tertiary care hospital located in the city of São Paulo (SP), Brazil. Microcirculation was assessed using near-infrared spectroscopy by means of a 15mm probe placed over the thenar eminence. Vascular occlusion test was performed on the forearm to be submitted to near-infrared spectroscopy by inflation of a sphygmomanometer cuff to 30mmHg higher than the systolic arterial pressure. The primary endpoint was the assessment of near-infrared spectroscopy-derived parameters immediately before, 1, 4 and 24 hours after the initiation of continuous venovenous hemodiafiltration. Results Nine patients were included in this pilot study over a period of 2 months. Minimum tissue oxygen saturation measured during the vascular occlusion test was the only near-infrared spectroscopy-derived parameter to differed over the time (decrease compared to baseline values up to 24 hours after initiation of continuous venovenous hemodiafiltration). Conclusion The impacts of microcirculatory dysfunction on clinical outcomes of patients undergoing to continuous venovenous hemodiafiltration need to be further investigated.

RESUMO Objetivo Avaliar o impacto da hemodiafiltração venovenosa contínua na microcirculação de pacientes com lesão renal aguda. Métodos Estudo piloto, prospectivo e observacional conduzido em uma unidade de terapia intensiva clínico-cirúrgica aberta, com 40 leitos, localizada em um hospital terciário, privado, na cidade de São Paulo (SP), Brasil. A microcirculação foi avaliada empregando-se a espectroscopia no infravermelho próximo, por meio de uma sonda de 15mm posicionada sobre a eminência tenar. O teste de oclusão vascular foi realizado no antebraço a ser submetido à espectroscopia no infravermelho próximo, inflando-se o manguito de um esfigmomanômetro a um valor 30mmHg acima da pressão arterial sistólica. O desfecho primário foi a avaliação dos parâmetros derivados por espectroscopia no infravermelho próximo imediatamente antes, 1, 4 e 24 horas após o início da hemodiafiltração venovenosa contínua. Resultados Foram incluídos nove pacientes neste estudo piloto ao longo de 2 meses. A saturação de oxigênio tecidual mínima mensurada durante o teste de oclusão vascular foi o único parâmetro derivado por espectroscopia no infravermelho próximo que diferiu ao longo do tempo, com queda em relação aos valores iniciais nas primeiras 24 horas após o início da hemodiafiltração venovenosa contínua. Conclusão A influência da disfunção microcirculatória sobre os desfechos clínicos de pacientes submetidos à hemodiafiltração venovenosa contínua precisa ser melhor investigada.

Psychological distress in survivors of the 2010 Haiti earthquake.

OBJECTIVE: To investigate the presence of depression and anxiety symptoms in survivors of the Haiti earthquake who were assisted by a healthcare team from the Hospital Israelita Albert Einstein, and to evaluate the impact that losing a family member during this catastrophe could have on the development of these symptoms. METHODS: Forty survivors of the Haiti earthquake who were assisted by the healthcare team between February and March of 2010 were included in this study. All subjects underwent a semi-structured interview. The group was divided into Group A (individuals who had some death in the family due to the disaster) and Group B (those who did not lose any family member). RESULTS: A total of 55% of the subjects had depression symptoms whereas 40% had anxiety symptoms. The individuals who lost a family member were five times more likely to develop anxiety and depression symptoms than those who did not. CONCLUSION: Catastrophe victims who lost at least one family member due to the disaster were more likely to develop anxiety and depression symptoms. To these individuals, as well as others showing psychological distress, should be offered early mental health care to help them cope with the great emotional distress inherent in these situations.

Platelet-rich plasma for long bone healing.

OBJECTIVE: To evaluate effectiveness of the use of platelet-rich plasma as coadjuvant for union of long bones. METHODS: The search strategy included the Cochrane Library (via Central) and MEDLINE (via PubMed). There were no limits as to language or publication media. The latest search strategy was conducted in December 2011. It included randomized clinical trials that evaluated the use of platelet-rich plasma as coadjuvant medication to accelerate union of long bones (acute fractures, pseudoarthrosis and bone defects). The outcomes of interest for this review include bone regeneration, adverse events, costs, pain, and quality of life. The authors selected eligible studies, evaluated the methodological quality, and extracted the data. It was not possible to perform quantitative analysis of the grouped studies (meta-analyses). RESULTS: Two randomized prospective clinical trials were included, with a total of 148 participants. One of them compared recombinant human morphogenic bone protein-7 versus platelet-rich plasma for the treatment of pseudoarthrosis; the other evaluated the effects of three coadjuvant treatments for union of valgising tibial osteotomies (platelet-rich plasma, platelet-rich plasma plus bone marrow stromal cells, and no coadjuvant treatment). Both had low statistical power and moderate to high risk of bias. CONCLUSION: There was no conclusive evidence that sustained the use of platelet-rich plasma as a coadjuvant to aid bone regeneration of fractures, pseudoarthrosis, or bone defects.

Spine surgery cost reduction at a specialized treatment center.

OBJECTIVE: To compare the estimated cost of treatment of spinal disorders to those of this treatment in a specialized center. METHODS: An evaluation of average treatment costs of 399 patients referred by a Health Insurance Company for evaluation and treatment at the Spine Treatment Reference Center of Hospital Israelita Albert Einstein. All patients presented with an indication for surgical treatment before being referred for assessment. Of the total number of patients referred, only 54 underwent surgical treatment and 112 received a conservative treatment with motor physical therapy and acupuncture. The costs of both treatments were calculated based on a previously agreed table of values for reimbursement for each phase of treatment. RESULTS: Patients treated non-surgically had an average treatment cost of US$ 1,650.00, while patients treated surgically had an average cost of US$ 18,520.00. The total estimated cost of the cohort of patients treated was US$ 1,184,810.00, which represents a 158.5% decrease relative to the total cost projected for these same patients if the initial type of treatment indicated were performed. CONCLUSION: Treatment carried out within a center specialized in treating spine pathologies has global costs lower than those regularly observed.

Serum soluble-Fas is a predictor of red blood cell transfusion in critically ill patients.

OBJECTIVE: To investigate the relation between the need for red blood cell transfusion and serum levels of soluble-Fas, erythropoietin and inflammatory cytokines in critically ill patients with and without acute kidney injury. METHODS: We studied critically ill patients with acute kidney injury (n=30) and without acute kidney injury (n=13), end-stage renal disease patients on hemodialysis (n=25) and healthy subjects (n=21). Serum levels of soluble-Fas, erythropoietin, interleukin 6, interleukin 10, iron status, hemoglobin and hematocrit concentration were analyzed in all groups. The association between these variables in critically ill patients was investigated. RESULTS: Critically ill patients (acute kidney injury and non-acute kidney injury patients) had higher serum levels of erythropoietin than the other groups. Hemoglobin concentration was lower in the acute kidney injury patients than in other groups. Serum soluble-Fas levels were higher in acute kidney injury and end-stage renal disease patients. Critically ill patients requiring red blood cell transfusions had higher serum levels of soluble-Fas (5,906±2,047 and 1,920±1,060; p<0.001), interleukin 6 (518±537 and 255+502; p=0.02) and interleukin 10 (35.8±30.7 and 18.5±10.9; p=0.02), better iron status and higher mortality rates in the first 28 days in intensive care unit. Serum soluble-Fas levels were independently associated with the number of red blood cell units transfused (p=0.02). Serum soluble-Fas behaved as an independent predictor of the need for red blood cell transfusion in critically ill patients (p=0.01). CONCLUSIONS: Serum soluble-Fas level is an independent predictor of the need for red blood cell transfusion in critically ill patients with or without acute kidney injury. Further studies are warranted to reconfirm this finding.

Positive deviance: using a nurse call system to evaluate hand hygiene practices.

BACKGROUND: Many approaches have been taken to increase compliance with hand hygiene by health care professionals. We evaluated a nurse call system used as a tool in a positive deviance (PD) approach to improving compliance. METHODS: We conducted a quasi-experimental study between September 2008 and December 2010 in 2 step-down units (SDUs). The consumption of alcohol-based sanitizers for hand hygiene was monitored by electronic handwash counters installed in each room as of January 2009. The number of nurse visits to patient rooms was measured by the nurse call system, which provides information on each instance of nursing care provided to the patients. RESULTS: The use of alcohol hand rubs was increased in both units after implementation of the PD approach, with higher rates sustained for more than 2 years. The rate of device-related infections showed a decreasing trend, especially for catheter-associated urinary infection in the east SDU. In both units, the ratio of alcohol hand rub uses to nurse visits was >2.5, indicating increased use of alcohol rubs, especially in the east SDU, which had a ratio of 3 for 2010. CONCLUSIONS: The PD approach to hand hygiene produced increased compliance, as measured by increased consumption of alcohol hand sanitizer, an improved ratio of alcohol hand rub uses to nurse visits, and a reduced rate of device-related infections, with results sustained over 2 years.

Association between participation and compliance with Continuing Medical Education and care production by physicians: a cross-sectional study / Associação entre participação e cumprimento de um programa de Educação Médica Continuada e produção assistencial dos médicos: estudo transversal

Objective Physician participation in Continuing Medical Education programs may be influenced by a number of factors. To evaluate the factors associated with compliance with the Continuing Medical Education requirements at a private hospital, we investigated whether physicians’ activity, measured by volumes of admissions and procedures, was associated with obtaining 40 Continuing Medical Education credits (40 hours of activities) in a 12-month cycle. Methods In an exclusive and non-mandatory Continuing Medical Education program, we collected physicians’ numbers of hospital admissions and numbers of surgical procedures performed. We also analyzed data on physicians’ time since graduation, age, and gender. Results A total of 3,809 credentialed, free-standing, private practice physicians were evaluated. Univariate analysis showed that the Continuing Medical Education requirements were more likely to be achieved by male physicians (odds ratio 1.251; p=0.009) and who had a higher number of hospital admissions (odds ratio 1.022; p<0.001). Multivariate analysis showed that age and number of hospital admissions were associated with achievement of the Continuing Medical Education requirements. Each hospital admission increased the chance of achieving the requirements by 0.4%. Among physicians who performed surgical procedures, multivariate analysis showed that male physicians were 1.3 time more likely to achieve the Continuing Medical Education requirements than female physicians. Each surgical procedure performed increased the chance of achieving the requirements by 1.4%. Conclusion The numbers of admissions and number of surgical procedures performed by physicians at our hospital were associated with the likelihood of meeting the Continuing Medical Education requirements. These findings help to shed new light on our Continuing Medical Education program. .

Objetivo A participação de médicos em programas de Educação Médica Continuada pode ser influenciada por inúmeros fatores. Para avaliar os fatores associados ao cumprimento dos requisitos para Educação Médica Continuada em um hospital privado, investigamos se a atividade médica, medida por volume de internações e procedimentos, esteve relacionada à obtenção de 40 créditos (40 horas-aula) em um ciclo do programa de 12 meses. Métodos Em um programa exclusivo e não obrigatório de Educação Médica Continuada, coletamos o número de admissões e de procedimentos realizados por médico. Analisamos dados como tempo de formado, idade e sexo. Resultados Foram analisados dados de 3.809 médicos credenciados e autônomos. A análise univariada mostrou que os requisitos de Educação Médica Continuada eram mais preenchidos por médicos do sexo masculino (odds ratio de 1,251; p=0,009) e que eles apresentavam números de internações mais significativos (odds ratio de 1,022; p<0,001). A análise multivariada mostrou que idade e número de admissões estiveram associados ao cumprimento das metas estabelecidas. Cada admissão aumentou a chance de atingir a meta em 0,4%. Entre os que realizaram procedimentos cirúrgicos, a análise multivariada mostrou que médicos do sexo masculino eram 1,3 vez mais propensos a atingir a meta estabelecida que seus pares do sexo feminino. Cada procedimento cirúrgico realizado elevou a chance de atingir a meta em 1,4%. Conclusão O número de admissões e de procedimentos cirúrgicos realizados por médicos em nosso hospital foi associado à probabilidade de alcançar a meta de Educação Médica Continuada. Estes achados lançaram uma nova luz sobre o nosso programa de Educação Médica Continuada. .

SeptiFast for diagnosis of sepsis in severely ill patients from a Brazilian hospital / Uso do SeptiFast para diagnóstico de sepse em doentes graves de um hospital brasileiro

Objective To test and validate a multiplex real-time polymerase chain reaction method for bloodstream infections, as well as to compare the results with conventional blood culture. Methods A total of 114 consecutive patients with clinical evidence of sepsis were submitted to blood culture and LightCycler™ SeptiFast tests. Results More positive specimens (23; 20.2%) were detected using the LightCycler™ SeptiFast than the blood culture (17; 14.9%), with an agreement of 86.8%. Discordant results were seen in four patients positive only to blood culture, ten positive only to LightCycler™ SeptiFast and one to different pathogens found by each test. Infections with microorganisms detected only using blood culture reassured the need to perform both tests. The mean time to results for blood culture was 5 days for negative and 3.5 days for positive results. LightCycler™ SeptiFast results were achieved in less than 8 hours. Conclusion LightCycler™ SeptiFast showed a high potential as a test to be carried out concomitantly with blood culture for sepsis diagnosis in severely ill patients. This test allowed a faster diagnosis of bacterial and fungal infections that helped to reduce hospital stay and to control the use of antibiotics. LightCycler™ SeptiFast can also eventually detect microorganism and infections that are hardly detected by blood culture, especially Candida non-albicans infections. .

Objetivo Testar e validar um método molecular multiplex para detecção de infecções sanguíneas, além de comparar os resultados com os obtidos pela hemocultura convencional. Métodos Os testes de hemocultura e o LightCycler® SeptiFast foram realizados em 114 pacientes consecutivos com evidência clínica de sepse. Resultados Mais amostras positivas (23; 20,2%) foram detectadas pelo LightCycler® SeptiFast do que pela hemocultura (17; 14,9%), mostrando concordância de 86,8%. Os resultados discordantes foram de quatro pacientes positivos apenas para hemocultura, dez positivos apenas para LightCycler® SeptiFast e um com patógenos diferentes encontrados em cada método. Infecções por micro-organismos não reconhecidos pelo LightCycler® SeptiFast e detectados apelas pela hemocultura confirmam a necessidade da realização dos dois métodos. O tempo médio para os resultados da hemocultura foi de 5 dias para amostras negativas e de 3,5 dias para as positivas. Os resultados pelo LightCycler® SeptiFast foram obtidos em menos de 8 horas. Conclusão O LightCycler® SeptiFast mostrou ser um teste de grande potencial para ser realizado simultaneamente à hemocultura para diagnóstico de sepse em doentes graves, permitindo um diagnóstico mais rápido de infecções por bactérias e fungos e, dessa forma, auxiliando a redução do tempo de hospitalização e racionalização do uso de antibióticos. Eventualmente, o LightCycler® SeptiFast pode detectar inclusive infecções por micro-organismos dificilmente detectáveis via hemocultura, especialmente aquelas causadas por Candida não albicans. .