An implementation analysis of a quality improvement project to reduce cesarean section in Brazilian private hospitals.

BACKGROUND: Brazil has one of the highest prevalence of cesarean sections in the world. The private health system is responsible for carrying out most of these surgical procedures. A quality improvement project called Adequate Childbirth Project ("Projeto Parto Adequado"- PPA) was developed to identify models of care for labor and childbirth, which place value on vaginal birth and reduce the frequency of cesarean sections without a clinical indication. This research aims to evaluate the implementation of PPA in private hospitals in Brazil. METHOD: Evaluative hospital-based survey, carried out in 2017, in 12 private hospitals, including 4,322 women. We used a Bayesian network strategy to develop a theoretical model for implementation analysis. We estimated and compared the degree of implementation of two major driving components of PPA-"Participation of women" and "Reorganization of care" - among the 12 hospitals and according to type of hospital (belonging to a health insurance company or not). To assess whether the degree of implementation was correlated with the rate of vaginal birth data we used the Bayesian Network and compared the difference between the group "Exposed to the PPA model of care" and the group "Standard of care model". RESULTS: PPA had a low degree of implementation in both components "Reorganization of Care" (0.17 - 0.32) and "Participation of Women" (0.21 - 0.34). The combined implementation score was 0.39-0.64 and was higher in hospitals that belonged to a health insurance company. The vaginal birth rate was higher in hospitals with a higher degree of implementation of PPA. CONCLUSION: The degree of implementation of PPA was low, which reflects the difficulties in changing childbirth care practices. Nevertheless, PPA increased vaginal birth rates in private hospitals with higher implementation scores. PPA is an ongoing quality improvement project and these results demonstrate the need for changes in the involvement of women and the care offered by the provider.

Predicting Reintubation After Unplanned Extubations in Children: Art or Science?

PURPOSE: Reintubation following unplanned extubation (UE) is often required and associated with increased morbidity; however, knowledge of risk factors leading to reintubation and subsequent outcomes in children is still lacking. We sought to determine the incidence, risk factors, and outcomes related to reintubation after UEs. METHODS: All mechanically ventilated children were prospectively tracked for UEs over a 7-year period in a pediatric intensive care unit. For each UE event, data associated with reintubation within 24 hours and outcomes were collected. RESULTS: Of 757 intubated patients, 87 UE occurred out of 11 335 intubation days (0.76 UE/100 intubation days), with 57 (65%) requiring reintubation. Most of the UEs that did not require reintubation were already weaning ventilator settings prior to UE (73%). Univariate analysis showed that younger children (<1 year) required reintubation more frequently after an UE. Patients experiencing UE during weaning experienced significantly fewer reintubations, whereas 90% of patients with full mechanical ventilation support required reintubation. Logistic regression revealed that requirement of full ventilator support (odds ratio: 37.5) and a COMFORT score <26 (odds ratio: 5.5) were associated with UE failure. There were no differences between reintubated and nonreintubated patients regarding the length of hospital stay, ventilator-associated pneumonia rate, need for tracheostomy, and mortality. Cardiovascular and respiratory complications were seen in 33% of the reintubations. CONCLUSION: The rate of reintubation is high in children experiencing UE. Requirement of full ventilator support and a COMFORT score <26 are associated with reintubation. Prospective research is required to better understand the reintubation decisions and needs.

Postextubation dysphagia in critically ill children: A prospective cohort study.

INTRODUCTION: Postextubation dysphagia (PED) is reported mainly in adults and is associated with poor outcomes. However, data on pediatric intensive care unit (PICU) patients are scarce. We aimed to assess the incidence, risk factors, and outcomes associated with PED in a PICU population. METHODS: Between 2019 and 2021, we conducted a prospective, observational cohort study of patients aged 1 month to 15 years. Within 24 h after extubation, a speech-language pathologist routinely screened all consecutive patients receiving mechanical ventilation (>24 h) for dysphagia. A Functional Oral Intake Scale (FOIS) score of less than 6 indicated dysphagia. RESULTS: A total of 161 patients were included, with a PED incidence of 69%. After adjusting for confounding variables, five variables were significantly associated with PED (odds ratio; 95% confidence interval): age <24 months (4.84; 1.5-15.60), neurological comorbidities (7.47; 1.36-40.96), iatrogenic withdrawal syndrome (5.52; 1.31-23.14), use of neuromuscular blocking agents (4.19; 1.18-14.82), and duration of intubation >72 h (3.22; 1.08-9.64). Dysphagia was significantly associated with longer PICU and hospital stays and a longer delay to oral feeding than patients without PED, 14 versus 7.5 days, 21 versus 15 days, and 6 versus 1 day, respectively. Ten participants (9%) failed to resume total oral intake at hospital discharge. CONCLUSIONS: These findings indicate that PED is highly prevalent in children and associated with adverse patient outcomes. Identifying a core of risk factors might improve prompt recognition of patients at risk for PED and implement preventive approaches and early interventions.

Factors associated to HIV prevalence among adolescent men who have sex with men in Salvador, Bahia State, Brazil: baseline data from the PrEP1519 cohort.

Adolescent men who have sex with men (AMSM) are at a heightened vulnerability for human immunodeficiency virus (HIV). This study aimed to estimate the prevalence of HIV and associated individual, social, and programmatic factors among AMSM in Salvador, Bahia State, Brazil. This is a cross-sectional study which analyzed baseline data from the PrEP1519 cohort in Salvador. Descriptive, bivariate, and multivariate analyses were conducted using the dimensions of vulnerability to HIV as hierarchical levels of analysis. Logistic regression models were used to estimate the odds ratios (OR) of the association between predictor variables and HIV infection. The prevalence of HIV infection among the 288 AMSM recruited to the project was 5.9% (95%CI: 3.7-9.3). Adjusted analysis showed a statistically significant association between self-identifying as a sex worker (OR = 3.74, 95%CI: 1.03-13.60) and HIV infection. Other associations with borderline statistical significance were the use of application programs to find sexual partners (OR = 3.30, 95%CI: 0.98-11.04), low schooling level (OR = 3.59, 95%CI: 0.96-13.41), failing to be hired or being dismissed from a job because of sexual orientation (OR = 2.88, 95%CI: 0.89-9.28), and not using health services as a usual source of care (OR = 3.14, 95%CI: 0.97-10.17). We found a high HIV prevalence among AMSM in Salvador. Furthermore, our study found that individual, social, and programmatic factors were associated with HIV infection among these AMSM. We recommend intensifying HIV combined-prevention activities for AMSM.

Association between genital intraepithelial lesions and anal squamous intraepithelial lesions in HIV-negative women.

OBJECTIVE: The objective of the study was to evaluate the risk of anal squamous intraepithelial lesions (ASILs) in immunocompetent women with genital squamous intraepithelial lesions (GSILs). STUDY DESIGN: This was a cross-sectional study that included 260 immunocompetent women divided into 2 study groups: 1 group included 184 women diagnosed with GSIL by genital colposcopy and biopsy, and the other included 76 controls. All subjects were submitted to anoscopy followed by a biopsy if pertinent. RESULTS: Of 184 GSIL women, 32 (17.4%) had ASIL (P<.001). The risk of ASIL was 13.1 times greater for GSIL women when there were 3 or 4 genital sites involved. All cases of high-grade ASIL were found in women with cervical GSILs. Among risk factors, anal intercourse without a condom demonstrated an important association with ASIL (prevalence ratio adjusted for age=2.6). CONCLUSION: There seems to be a strong association between ASIL and multicentric GSIL. Another factor related to ASIL was the practice of unprotected anal intercourse.

Study of the polymorphism rs3025058 of the MMP-3 gene and risk of pelvic organ prolapse in Brazilian women.

OBJECTIVE: To analyze the polymorphism -1171 5A / 6A rs3025058 of the MMP-3 gene and the risk for pelvic organ prolapse (POP). STUDY DESIGN: This is a cohort study. All patients attended the Urogynecology and Vaginal Surgery Section of the FMABC, from 2014 to 2016 and they were randomly recruited by the researchers at the first medical appointment. We selected 112 patients with symptomatic POPs and 180 patients with normal pelvic floors. The single nucleotide polymorphism (SNP) 5A / 6A of MMP-3 was determined by polymerase chain reaction (PCR) and analysis of the restriction fragments in both groups. Chi-squared test was used to compare the frequencies of polymorphisms between the groups. For those characteristics with statistical relevance, the crude odds ratio (OR) and its respective 95% confidence intervals were calculated; and, by logistic regression, were adjusted for each of the other characteristics, obtaining the adjusted OR. Hardy-Weinberg gene balance was determined using Pearson's Chi-squared test. Values of p < 0.05 were considered statistically significant. RESULTS: Logistic regression of factors associated with genital prolapse showed that age (adjusted OR = 11.89, 95% CI, 3.53-40) and home delivery (adjusted OR = 9.645, 95% CI, 3.35-27.7) remained risk factors for genital prolapse in the sample studied. There was no statistically significant difference between the groups in the distribution of genotypes, even after calculating the contribution of the 5A recessive allele in the aggregated genotypes (5A / 5A + 5A / 6A). CONCLUSION: The polymorphism -1171 5A / 6A rs3025058 of the MMP-3 gene was not associated with the risk for POP. Age and home delivery were significantly associated with increased risk for the disease.

Factors associated to HIV prevalence among adolescent men who have sex with men in Salvador, Bahia State, Brazil: baseline data from the PrEP1519 cohort / Fatores associados à prevalência do HIV entre homens adolescentes que fazem sexo com homens em Salvador, Bahia, Brasil: dados da linha de base da coorte PrEP1519 / Factores asociados a la prevalencia de VIH entre hombres adolescentes que tienen sexo con hombres en Salvador, Bahia, Brasil: datos de referencia de la cohorte PrEP1519

Adolescent men who have sex with men (AMSM) are at a heightened vulnerability for human immunodeficiency virus (HIV). This study aimed to estimate the prevalence of HIV and associated individual, social, and programmatic factors among AMSM in Salvador, Bahia State, Brazil. This is a cross-sectional study which analyzed baseline data from the PrEP1519 cohort in Salvador. Descriptive, bivariate, and multivariate analyses were conducted using the dimensions of vulnerability to HIV as hierarchical levels of analysis. Logistic regression models were used to estimate the odds ratios (OR) of the association between predictor variables and HIV infection. The prevalence of HIV infection among the 288 AMSM recruited to the project was 5.9% (95%CI: 3.7-9.3). Adjusted analysis showed a statistically significant association between self-identifying as a sex worker (OR = 3.74, 95%CI: 1.03-13.60) and HIV infection. Other associations with borderline statistical significance were the use of application programs to find sexual partners (OR = 3.30, 95%CI: 0.98-11.04), low schooling level (OR = 3.59, 95%CI: 0.96-13.41), failing to be hired or being dismissed from a job because of sexual orientation (OR = 2.88, 95%CI: 0.89-9.28), and not using health services as a usual source of care (OR = 3.14, 95%CI: 0.97-10.17). We found a high HIV prevalence among AMSM in Salvador. Furthermore, our study found that individual, social, and programmatic factors were associated with HIV infection among these AMSM. We recommend intensifying HIV combined-prevention activities for AMSM.

Homens adolescentes que fazem sexo com homens (AHSH) apresentam vulnerabilidade aumentada ao HIV. O estudo teve como objetivo estimar a prevalência de HIV e fatores individuais, sociais e programáticos entre AHSH em Salvador, Bahia, Brasil. O estudo transversal foi baseado na análise dos dados da linha de base da coorte PrEP1519 em Salvador. Foram realizadas análises descritivas, bivariadas e multivariadas, usando as dimensões de vulnerabilidade ao HIV como níveis analíticos hierárquicos. Foram usados modelos de regressão logística para estimar as razões de chances (OR) da associação entre as variáveis preditoras e a infecção pelo HIV. A prevalência de infecção pelo HIV entre os 288 AHSH recrutados pelo projeto foi de 5,9% (IC95%: 3,7-9,3). A análise ajustada mostrou uma associação estatisticamente significativa entre a autoidentificação como profissional do sexo (OR = 3,74, IC95%: 1,03-13,60) e a infecção pelo HIV. Outras associações com significância estatística limítrofe foram: uso de aplicativos para achar parceiros sexuais (OR = 3,30, IC95%: 0,98-11,04), menor escolaridade (OR = 3,59, IC95%: 0,96-13,41), história de não ter sido contratado ou de ter sido demitido em função da orientação sexual (OR = 2,88, IC95%: 0,89-9,28) e falta de uso de serviços de saúde como fonte usual de cuidados (OR = 3,14, IC95%: 0,97-10,17). Foi encontrada uma alta prevalência de HIV entre AHSH em Salvador. Além disso, o estudo mostrou que fatores encontrados nas dimensões individual, social e programática estiveram associados à infecção pelo HIV entre esses AHSH. Recomendamos a intensificação das atividades de prevenção combinada entre AHSH.

Los hombres adolescentes que tienen sexo con hombres (AHSH) sufren más vulnerabilidad ante el VIH. El objetivo de este estudio fue estimar la prevalencia de VIH y los factores asociados individuales, sociales, y programáticos asociados entre AHSH en Salvador, Bahia, Brasil. Se trata de un estudio transversal, basado en el análisis de los datos de referencia de la cohorte PrEP1519 en Salvador. Se realizaron análisis descriptivos, bivariados, y multivariados usando las dimensiones de vulnerabilidad respecto al VIH, como los niveles jerárquicos de análisis. Los modelos de regresión logística se usaron para estimar las odds ratios (OR) de la asociación entre las variables predictoras y la infección por VIH. La prevalencia de infección por VIH entre los 288 AHSH reclutados para el proyecto fue 5,9% (IC95%: 3,7-9,3). El análisis ajustado reveló una asociación estadísticamente significativa entre autoidentificarse como un trabajador sexual (OR = 3,74, IC95%: 1,03-13,60) y la infección por VIH. Otras asociaciones con una significación estadística marginal fueron: uso de apps para encontrar pareja sexual (OR = 3,30, IC95%: 0,98-11,04), menos años de educación (OR = 3,59, IC95%: 0,96-13,41), no estar contratado o ser despedido de un trabajo debido a la orientación sexual (OR = 2,88, IC95%: 0,89-9,28), y no usar los servicios de salud como recurso habitual de atención sanitaria (OR = 3,14, IC95%: 0,97-10,17). Se identificó una alta prevalencia de VIH entre AHSH en Salvador. Asimismo, nuestro estudio halló que los factores desde una perspectiva individual, dimensión social, y dimensión programática estuvieron asociados con una infección por VIH entre AHSH. Recomendamos que se intensifiquen las actividades combinadas de prevención contra el VIH para AHSH.

Factors associated to HIV prevalence among adolescent men who have sex with men in Salvador, Bahia State, Brazil: baseline data from the PrEP1519 cohort / Fatores associados à prevalência do HIV entre homens adolescentes que fazem sexo com homens em Salvador, Bahia, Brasil: dados da linha de base da coorte PrEP1519 / Factores asociados a la prevalencia de VIH entre hombres adolescentes que tienen sexo con hombres en Salvador, Bahia, Brasil: datos de referencia de la cohorte PrEP1519

Adolescent men who have sex with men (AMSM) are at a heightened vulnerability for human immunodeficiency virus (HIV). This study aimed to estimate the prevalence of HIV and associated individual, social, and programmatic factors among AMSM in Salvador, Bahia State, Brazil. This is a cross-sectional study which analyzed baseline data from the PrEP1519 cohort in Salvador. Descriptive, bivariate, and multivariate analyses were conducted using the dimensions of vulnerability to HIV as hierarchical levels of analysis. Logistic regression models were used to estimate the odds ratios (OR) of the association between predictor variables and HIV infection. The prevalence of HIV infection among the 288 AMSM recruited to the project was 5.9% (95%CI: 3.7-9.3). Adjusted analysis showed a statistically significant association between self-identifying as a sex worker (OR = 3.74, 95%CI: 1.03-13.60) and HIV infection. Other associations with borderline statistical significance were the use of application programs to find sexual partners (OR = 3.30, 95%CI: 0.98-11.04), low schooling level (OR = 3.59, 95%CI: 0.96-13.41), failing to be hired or being dismissed from a job because of sexual orientation (OR = 2.88, 95%CI: 0.89-9.28), and not using health services as a usual source of care (OR = 3.14, 95%CI: 0.97-10.17). We found a high HIV prevalence among AMSM in Salvador. Furthermore, our study found that individual, social, and programmatic factors were associated with HIV infection among these AMSM. We recommend intensifying HIV combined-prevention activities for AMSM.

Homens adolescentes que fazem sexo com homens (AHSH) apresentam vulnerabilidade aumentada ao HIV. O estudo teve como objetivo estimar a prevalência de HIV e fatores individuais, sociais e programáticos entre AHSH em Salvador, Bahia, Brasil. O estudo transversal foi baseado na análise dos dados da linha de base da coorte PrEP1519 em Salvador. Foram realizadas análises descritivas, bivariadas e multivariadas, usando as dimensões de vulnerabilidade ao HIV como níveis analíticos hierárquicos. Foram usados modelos de regressão logística para estimar as razões de chances (OR) da associação entre as variáveis preditoras e a infecção pelo HIV. A prevalência de infecção pelo HIV entre os 288 AHSH recrutados pelo projeto foi de 5,9% (IC95%: 3,7-9,3). A análise ajustada mostrou uma associação estatisticamente significativa entre a autoidentificação como profissional do sexo (OR = 3,74, IC95%: 1,03-13,60) e a infecção pelo HIV. Outras associações com significância estatística limítrofe foram: uso de aplicativos para achar parceiros sexuais (OR = 3,30, IC95%: 0,98-11,04), menor escolaridade (OR = 3,59, IC95%: 0,96-13,41), história de não ter sido contratado ou de ter sido demitido em função da orientação sexual (OR = 2,88, IC95%: 0,89-9,28) e falta de uso de serviços de saúde como fonte usual de cuidados (OR = 3,14, IC95%: 0,97-10,17). Foi encontrada uma alta prevalência de HIV entre AHSH em Salvador. Além disso, o estudo mostrou que fatores encontrados nas dimensões individual, social e programática estiveram associados à infecção pelo HIV entre esses AHSH. Recomendamos a intensificação das atividades de prevenção combinada entre AHSH.

Los hombres adolescentes que tienen sexo con hombres (AHSH) sufren más vulnerabilidad ante el VIH. El objetivo de este estudio fue estimar la prevalencia de VIH y los factores asociados individuales, sociales, y programáticos asociados entre AHSH en Salvador, Bahia, Brasil. Se trata de un estudio transversal, basado en el análisis de los datos de referencia de la cohorte PrEP1519 en Salvador. Se realizaron análisis descriptivos, bivariados, y multivariados usando las dimensiones de vulnerabilidad respecto al VIH, como los niveles jerárquicos de análisis. Los modelos de regresión logística se usaron para estimar las odds ratios (OR) de la asociación entre las variables predictoras y la infección por VIH. La prevalencia de infección por VIH entre los 288 AHSH reclutados para el proyecto fue 5,9% (IC95%: 3,7-9,3). El análisis ajustado reveló una asociación estadísticamente significativa entre autoidentificarse como un trabajador sexual (OR = 3,74, IC95%: 1,03-13,60) y la infección por VIH. Otras asociaciones con una significación estadística marginal fueron: uso de apps para encontrar pareja sexual (OR = 3,30, IC95%: 0,98-11,04), menos años de educación (OR = 3,59, IC95%: 0,96-13,41), no estar contratado o ser despedido de un trabajo debido a la orientación sexual (OR = 2,88, IC95%: 0,89-9,28), y no usar los servicios de salud como recurso habitual de atención sanitaria (OR = 3,14, IC95%: 0,97-10,17). Se identificó una alta prevalencia de VIH entre AHSH en Salvador. Asimismo, nuestro estudio halló que los factores desde una perspectiva individual, dimensión social, y dimensión programática estuvieron asociados con una infección por VIH entre AHSH. Recomendamos que se intensifiquen las actividades combinadas de prevención contra el VIH para AHSH.

BR-EMS 2021 life table for the Brazilian insured population / Tábuas de mortalidade BR-EMS 2021 do mercado segurador brasileiro / Tabla de vida BR-EMS 2021 para la población asegurada brasileña

Abstract This article presents the Brazilian private insurance market's actuarial life tables, BR- EMS 2021. Using Bayesian inference on the parameters of the Heligman- Pollard law of mortality and data from 23 insurance groups over 15 years, totaling 3.5 billion registers, the data were corrected through a two hidden-layer neural network. The resulting tables show that the insured population exhibits lower mortality rates than the general Brazilian population, even lower than the national populations of well-developed countries such as the USA. Moreover, besides the expected gender gap in mortality rates, there is a clear distance between the death and survivorship insurance coverage groups. Likewise, the insured population characteristics mitigate well-known regional structural discrepancies in the Brazilian population, indicating that being part of the selected population of insured individuals is thus associated with a more effective protection against death than other outstanding factors such as geographic region of residence.

Resumo Este artigo apresenta as tábuas de vida do mercado de seguros privados brasileiro, BR-EMS 2021. Os dados obtidos de 23 grupos seguradores ao longo de 15 anos, totalizando 3,5 bilhões de registros, foram corrigidos por meio de rede neural com duas camadas ocultas. Usando a inferência bayesiana para estimar os parâmetros sob a lei de mortalidade Heligman-Pollard, as tábuas obtidas mostram que a população segurada apresenta probabilidades de morte mais baixas do que a população brasileira em geral e até mesmo em relação a populações nacionais de países desenvolvidos, como os EUA. Além da esperada diferença de gênero nas taxas de mortalidade, há uma clara distância entre as probabilidades de morte dos grupos de cobertura de risco e cobertura de sobrevivência. Da mesma forma, é demonstrado que as tábuas regionais da população segurada não apresentam as discrepâncias regionais conhecidas no Brasil, indicando que fazer parte da população selecionada de segurados está associado a um fator de proteção mais eficaz do que outros fatores, como a região geográfica de residência.

Resumen Este artículo presenta las tablas de vida del mercado de seguros privados brasileño, BR-EMS 2021. Los datos, obtenidos de 23 grupos de seguros a lo largo de 15 años, totalizando 3,5 mil millones de registros, fueron corregidos usando una red neuronal con dos capas ocultas. Mediante la inferencia bayesiana para estimar los parámetros bajo la ley de mortalidad de Heligman-Pollard, las tablas obtenidas muestran que la población asegurada tiene tasas de mortalidad más bajas que la población general brasileña e incluso más bajas que las poblaciones nacionales de países desarrollados, como los Estados Unidos de Norteamérica. Además de la diferencia de género esperada en las tasas de mortalidad, hay una clara distinción entre las tablas de grupos de cobertura de riesgo y cobertura de sobrevivientes. Asimismo, se demuestra que las tablas regionales de población asegurada no presentan las conocidas discrepancias estructurales regionales en Brasil, lo que indica que participar de la población de asegurados está asociado con una protección contra la muerte más efectiva que otros factores como la región geográfica de residencia.

[The effect of chronic diseases on functional status of the elderly living in the city of São Paulo, Brazil]. / A influência das doenças crônicas na capacidade funcional dos idosos do Município de São Paulo, Brasil.

The main focus of this study was the effect of chronic disease (hypertension, diabetes mellitus, heart disease, lung disease, cancer, and arthropathy) on the functional status (activities of daily living - ADL, instrumental activities of daily living - IADL) among the elderly, controlling for age, gender, living arrangements, education, and comorbidity. The analysis was based on information provided by the SABE Project, from the city of São Paulo, Brazil, including individuals 60 years of age and over (n = 1,769), from January 2000 to March 2001. A multinomial logistic regression model was used. Compared to the absence of dependency category, heart disease (OR = 1.82), arthropathy (OR = 1.59), lung disease (OR = 1.50), and hypertension (OR = 1.39) were the main diseases that affected the IADL dependency category. Lung disease (OR = 2.58), arthropathy (OR = 2.27), hypertension (OR = 2.13), and heart disease (OR = 2.10) had important impact on the IADL and ADL dependency categories. The results were statistically significant (p < 0.05).

Opioid and Benzodiazepine Withdrawal Syndrome in PICU Patients: Which Risk Factors Matter?

BACKGROUND AND AIMS: Although iatrogenic withdrawal syndrome (IWS) has been recognized in patients exposed to opioids and benzodiazepines, very few studies have used a validated tool for diagnosis and assessment of IWS in critically ill children. We sought to determine IWS rate, risk factors, and outcomes of IWS patients. METHODS: Prospective observational study conducted in a pediatric intensive care unit. A total of 137 patients (31 with IWS and 106 with no IWS) received a continuous infusion of fentanyl and midazolam for 3 or more days. The Sophia Observation withdrawal Symptoms scale was repeatedly applied when children were weaned off sedation/analgesia. RESULTS: The overall incidence of IWS was 22.6%. Of the 31 IWS patients, 6 showed IWS with less than 5 days sedation or analgesia. Logistic regression showed that the median peak dose of midazolam was associated with IWS development (odds ratio 1.4). Receiver-operating curve showed a cut-off value of 0.35 mg/kg/h for midazolam peak dose (sensitivity 96.7%, specificity 51%, positive predictive value 36.6%, and negative predictive value 98.2%), with area under the curve of 0.80. IWS patients had a longer time on mechanical ventilation, prolonged pediatric intensive care unit, and hospital stays, and required prolonged period to have drugs discontinued. CONCLUSIONS: Although length of sedation/analgesia for at least5 days has been widely proposed for monitoring IWS, our data suggest that initiating monitoring after 3 sedation days is highly recommended. In addition, patients requiring infusion rates of midazolam above 0.35 mg/kg/h should be considered at high risk for IWS.

Do in-hours or off-hours matter for extubating children in the pediatric intensive care unit?

PURPOSE: Several studies have suggested worse outcomes for patients requiring medical care at night or on weekends. However, whether or not children should be extubated only during in-hours has not been studied yet. We sought to compare outcomes and complications of in-hours versus off-hours extubated patients. METHODS: We prospectively included all children receiving invasive mechanical ventilation (MV) in a pediatric intensive care unit. Off-hours extubations included patients who were extubated at nighttime (8:00 pm-7:59 am) plus weekends/holidays whereas the in-hours extubations included regular daytime weekdays (Monday to Friday: 8:00 am-7:59 pm). RESULTS: Of the 480 patients, 346 (72%) were extubated during in-hours period and 134 (28%) were extubated during off-hours. In-hours patients spent a longer time to have planned extubation and had a longer MV duration and pediatric intensive care unit stay compared to those extubated at off-hours. Kaplan-Meier curve showed that in-hours patients were more likely to have a longer time until the first extubation (log-rank test: P=.006, HR: 5.05). CONCLUSION: Patients extubated at off-hours had more favorable outcomes with similar complications rate compared with those extubated at in-hours. These results provide no support for delaying extubations until in-hours period. Further studies are required to confirm these findings.

Distribuição dos óbitos por câncer de colo do útero no Brasil / Distribution of deaths from cervical cancer in Brazil

Objetivo: descrever a distribuição dos óbitos por câncer de colo do útero no Brasil. Métodos: trata-se de um estudo ecológico e descritivo, com uma abordagem quantitativa. Foram utilizados dados secundários, disponibilizados no Sistema de Informações sobre Mortalidade e no Instituto Brasileiro de Geografia e Estatística, dos anos de 2010 a 2019. As variáveis utilizadas no estudo foram ano, localização geográfica, raça/cor, escolaridade e faixa etária. Os dados foram apresentados em tabelas, gráfico e mapa, por meio de frequências absolutas e relativas, sendo utilizados os softwares Excel e o SIG QGIS 3.16. Resultados: o Brasil apresentou uma tendência crescente para o número de óbitos e Taxa de Mortalidade por Câncer de Colo do Útero. A prevalência foi maior na população negra (53,66%); na faixa etária de 40 a 59 anos (42,00%) e 60 anos ou mais (42,47%); e com apenas 1 a 3 anos de escolaridade (23,69%). Além disso, em relação à distribuição geográfica das taxas de mortalidade, nota-se que não é uniforme no território nacional. No geral, destacam-se os estados das regiões Norte e Nordeste, em especial, o estado do Amazonas. Conclusões: a análise da distribuição dos óbitos por câncer de colo do útero é uma estratégia para identificação de populações vulneráveis, contribuindo para o direcionamento das políticas públicas voltadas para a prevenção da neoplasia.

Objective: to describe the distribution of deaths from cervical cancer in Brazil. Methods: This is an ecological and descriptive study, with a quantitative approach. Secondary data were used, made available in the Mortality Information System and the Brazilian Institute of Geography and Statistics, from 2010 to 2019. The variables used in the study were year, geographic location, race/color, education, and age group. The data were presented in tables, graphs and maps, using absolute and relative frequencies, and the software Excel and the SIG QGIS 3.16 were used. Results: Brazil showed an increasing trend for the number of deaths and mortality rate from cervical cancer. The prevalence was higher in the black population (53,66%); in the age group of 40 to 59 years old (42,00%) and 60 years or more (42,47%); and with only 1 to 3 years of schooling (23,69%). Furthermore, regarding the geographic distribution of mortality rates, it is noted that it is not uniform across the national territory. In general, the states of the North and Northeast regions stand out, especially the state of Amazonas. Conclusions: The analysis of the distribution of deaths from cervical cancer is a strategy for identifying vulnerable populations, contributing to the direction of public policies aimed at preventing cancer.

O território e as implicações da violência urbana no processo de trabalho dos agentes comunitários de saúde em uma unidade básica / The territory and implications of urban violence for the work process of community health agents in a primary healthcare unit

Resumo No contexto da atenção primária à saúde, a violência urbana é um desafio que tem impactado diretamente o setor por conta da localização geográfica dos equipamentos de saúde em áreas de vulnerabilidade e da maior interação dos trabalhadores com situações que colocam em perigo, implícita ou explicitamente, sua segurança. O artigo discute as implicações desse fenômeno no trabalho e na construção dos vínculos estabelecidos entre os agentes comunitários de saúde (ACS) com a população em um território. Foi utilizada a metodologia qualitativa e o referencial teórico das representações sociais para compreender como a execução das políticas de saúde se concretiza no cotidiano à luz das interações, dos conflitos e das decisões que permeiam os contatos com o público na produção do serviço. Como resultado, destacamos que a violência e as representações em torno desta interferem na produção de estratégias de promoção e prevenção e na produção dos vínculos, tornando os canais de negociações mais restritos. É fundamental que o processo de trabalho das equipes de saúde esteja fortalecido com discussões e articulação em rede na minimização dos riscos individuais sobre seus trabalhadores e como possibilidade de efetivação dos pressupostos da integralidade do cuidado e redução das iniquidades.

Abstract In the context of Primary Health Care, urban violence is characterized as a challenge that has direct impact on the health sector due to the geographical localization of health equipment in vulnerable areas and strong interaction of the workers with situations that endanger them, implicit or explicit to their safety. In this study we discuss the implications of this phenomenon for the work and the development of the bonds established between the Community Health Agents and the population within a territory. We used a qualitative methodology and theoretical approach of the social representations, aiming at increasing the understanding of how health policies are implemented on the daily routine in the light of interactions, conflicts and decisions that permeate the contacts with the public in the provision of the service. As a result, we emphasize that community violence and its representations interfere in the development of healthcare promotion and prevention strategies and in the development of bonds, making negotiation channels more restricted. It is fundamental to strengthen the work process of the health team through collective discussion and networking in the prevention and minimizing individual risks about their workers and with a possibility of accomplishing a straight work with the assumptions of integrality of care and reduction of inequalities.

Transplante Dental Autógeno como Alternativa à Reabilitação Oral / Autogenous Transplantation Dental as Alternative to Oral Rehabilitation

Objetivo: Reportar um caso clínico de transplante dentário autógeno associado à contenção com fio de sutura e descrição dos passos cirúrgicos. Materiais e métodos: Um indivíduo submetido a transplante de terceiro molar inferior para um alvéolo de primeiro molar inferior com comprometimento de erupção por dilaceração radicular avançada, através de exodontia pela técnica de incisão em envelope, seguido de contenção com fio de sutura por um período de uma semana. Resultados: O dente transplantado obteve satisfatória acomodação no novo alvéolo, uma vez que ao acompanhamento de 12 meses apresentou seguimento da rizogênese, ausência de bolsas periodontais, anormalidade pulpar e inexistência de mobilidade dentária. Conclusões: Perante a técnica cirúrgica utilizada e indicações adequadas, observou-se terapêutica de baixo custo e biologicamente viável - por não comprometer o seguimento da formação radicular - como solução em caso de reabilitação oral.

Objective: To report a clinical case of autogenous dental transplantation associated to contention with suture thread and description of the surgical steps. Materials and methods: An individual submitted to lower third molar transplantation for a lower first molar alveolus with compromised eruption by advanced root laceration, through exodontia by the envelope incision technique, followed by containment with a suture thread during a week. Results: The transplanted tooth obtained satisfactory accommodation in the new alveolus: during 1-year follow-up, the tooth presented rhizogenesis, absence of periodontal pockets, pulp abnormality and lack of dental mobility. Conclusions: Over the surgical technique used and appropriate indications, it was considered the low cost and biologically viable therapy - for not compromising the root formation - as a solution in case of oral rehabilitation.

Recovery of cognitive reserve in eldery with the Alzheimer’s dementia: report of experience / Resgate de reservas cognitivas em idosos com demência de Alzheimer: relato de Experiência / Recuperación de la reserva cognitiva en ancianos con demencia de Alzheimer: relato de la experiencia

Objective: to stimulate cognitive reserves in older adults with Alzheimer's Dementia (AD) in an attempt to recover still existent potentialities, and awaken a new perspective on family, health professionals and caregivers. Method: Experience report study carried out with an elderly woman with 90 years of age. The ethical requirements adopted were approved in the CEP/HUAP with protocol No. 258/08. Results: Stimulation of the potentialities was then performed by the adoption of strategies, such as: touch, exchange of emotions, interactive communication, and redemption of old photos, encounter of different generations and conducting recreational and manual activities. All were shown to produce significant responses for the life of the elderly with AD. Conclusion: The phenomenon of the increasing elderly population is a current issue and challenging due to the injuries which may arise such as AD. Diagnosis of the disease brings the need for family restructuring based on different strategies for dealing with this disease.

Objetivo: Estimular as reservas cognitivas em idosos com Demência de Alzheimer (DA) na tentativa de resgatar potencialidades ainda existentes, e despertar um novo olhar na família, profissionais de saúde e cuidadores. Método: Estudo tipo relato de experiência realizado com uma idosa de 90 anos. Adotou os requisitos éticos sendo aprovado no CEP/HUAP com número 258/08. Resultados: A estimulação das potencialidades efetivaram-se pela adoção de estratégias como: o toque, a troca de emoções, a comunicação interativa, o resgate de fotos antigas, o encontro de diferentes gerações e a realização de atividades lúdicas e manuais. Todas se mostraram produtoras de respostas significativas para a vida de idosos com DA. Conclusão: O fenômeno do aumento da população idosa constitui uma temática atual e desafiadora, devido aos agravos que podem advir como a DA. O diagnóstico da doença traz a necessidade de reestruturação familiar baseada em estratégias diferenciadas para lidar com essa patologia.

Objetivo: Estimular las reservas cognitivas en ancianos con Demencia de Alzheimer (DA) en un intento de rescatar el potencial todavia presente, y despertar una nueva perspectiva en la família, en los profesionales y en los cuidadores. Método: Estudio tipo informe de experiencias realizadas con una señora de 90 años de edad. Se adoptaron los requisitos éticos con la aprobación del CEP / HUAP con el número 258/08. Resultados: El estímulo del potencial se llevó a cabo mediante la adopción de estrategias tales como el tacto, el intercambio emocional, la comunicación interactiva, el rescate de viejas fotografías, el encuentro de diferentes generaciones y la realización de actividades recreativas y manuales. Todas mostraron producir respuestas significativas para la vida de ancianos con la DA. Conclusión: El fenómeno de envejecimiento de la población es un tema actual y desafiante, debido a las lesiones que puedan surgir como el AD. El diagnóstico lleva a la necesidad de reestructurar la familia sobre la base de diferentes estrategias para hacer frente a esta enfermedad.

Rosalda Paim: a nurse before her time

This is the biography of the nurse, educator, professor, researcher and state deputy, Rosalda Cruz Nogueira Paim. Aim: The aim is to describe the personal and professional trajectory of this nurse who greatly contributed to the fluminense and to Brazilian nursing. Method: This is a historical and social narrative study. Results: Description of the facts and the phenomena of the biography in an analytical, contextual and thematic course. Discussion: The data are presented by themes: personal and professional trajectory: a personal and professional development guided by dedication to health and nursing; in defense of a broad social and political project: in defense of life; the title of emeritus professor: professional recognition; theoretical contributions: the systemism is a theory which established a new way of thinking and engaging in health and nursing. Conclusion: Paim created a model of methodological and theoretical systematization for Brazilian nursing which had an impact on health in particular and society in general.

A influência das doenças crônicas na capacidade funcional dos idosos do Município de São Paulo, Brasil / The effect of chronic diseases on functional status of the elderly living in the city of São Paulo, Brazil

O objetivo principal deste estudo foi investigar a influência de doenças crônicas (hipertensão arterial, diabetes mellitus, doença cardíaca, doença pulmonar, câncer e artropatia) na capacidade funcional (atividades de vida diária - AVDs - e atividades instrumentais de vida diária - AIVDs) dos idosos, controlando por idade, sexo, arranjo familiar, educação e presença de outras comorbidades. Os dados foram obtidos do Projeto SABE que inclui pessoas de 60 anos e mais, residentes no Município de São Paulo, Brasil, entre janeiro de 2000 e março de 2001. A amostra foi constituída de 1.769 idosos. Para a análise dos dados foi utilizada a regressão logística multinomial múltipla. Em comparação com a categoria de referência independente, as doenças que exercem uma significativa influência na categoria dependente nas AIVDs são a doença cardíaca (OR = 1,82), a artropatia (OR = 1,59), a doença pulmonar (OR = 1,50) e a hipertensão arterial (OR = 1,39). Quanto à resposta na categoria dependente nas AIVDs e AVDs, os resultados mostram que a doença pulmonar (OR = 2,58), a artropatia (OR = 2,27), a hipertensão arterial (OR = 2,13) e a doença cardíaca (OR = 2,10) demonstram um forte efeito. Os resultados são estatisticamente significativos (p < 0,05).

The main focus of this study was the effect of chronic disease (hypertension, diabetes mellitus, heart disease, lung disease, cancer, and arthropathy) on the functional status (activities of daily living - ADL, instrumental activities of daily living - IADL) among the elderly, controlling for age, gender, living arrangements, education, and comorbidity. The analysis was based on information provided by the SABE Project, from the city of São Paulo, Brazil, including individuals 60 years of age and over (n = 1,769), from January 2000 to March 2001. A multinomial logistic regression model was used. Compared to the absence of dependency category, heart disease (OR = 1.82), arthropathy (OR = 1.59), lung disease (OR = 1.50), and hypertension (OR = 1.39) were the main diseases that affected the IADL dependency category. Lung disease (OR = 2.58), arthropathy (OR = 2.27), hypertension (OR = 2.13), and heart disease (OR = 2.10) had important impact on the IADL and ADL dependency categories. The results were statistically significant (p < 0.05).