HIGH BODY MASS INDEX AMONG PATIENTS UNDERGOING HEMATOPOIETIC STEM CELL TRANSPLANTATION: RESULTS OF A CROSS-SECTIONAL EVALUATION OF NUTRITIONAL STATUS IN A PRIVATE HOSPITAL.

BACKGROUND: nutritional status before hematopoietic stem cell transplantation (HSCT) affects prognosis: better nourished patients have shorter time to engraftment, while malnutrition is associated with increase of mortality rates, complications, medical costs, poor quality of life and hospitalization stay. Furthermore, underweight patients have increased risk of death in the early post- HSCT period, and non-relapse mortality is greater for those who are extremely underweight, overweight and obese. Obesity is associated with treatment-related toxicity, higher incidence of grade II-IV acute graft-versus- host disease (GVHD), infections and mortality. The objective of this study was to investigate the nutritional status of patients undergoing HSCT between 2007-2013 in a private hospital, by calculating the body mass index (BMI), to verify the prevalence of any nutritional imbalances, especially obesity. METHODS: in this retrospective study, based on medical records, we analyzed data from all patients with malignant and nonmalignant diseases who underwent HSCT from January 2007 to February 2014 in the Hematology- Oncology and Bone Marrow Transplantation Center at a large, tertiary referral center in Brazil. RESULTS: a total of 257 cases were treated in the period and analyzed, of which 79% were aged up to 65 years old. Among these, 56% were overweight or obese. We observed a higher prevalence of obesity in elderly patients (P < 0.001). The mean BMI of the total sample was 26.4 kg/m2. BMI was significantly different between genders, with higher prevalence of overweight among men (P < 0.001). CONCLUSION: differently from other studies, our investigation has shown low rates of underweight and more overweight and obesity rates in men and elderly patients undergoing HSCT.

Introducción: el estado nutricional previo al trasplante de células madre hematopoyéticas (HSCT) afecta al pronóstico: los pacientes con una mejor nutrición necesitan un menor tiempo de injerto, mientras que una nutrición pobre estaría asociada a un aumento de la tasa de mortalidad, complicaciones, costes médicos, mala calidad de vida y hospitalización. Además, los pacientes con bajo peso presentan un mayor riesgo de muerte al principio del periodo post-HSCT, y la tasa de mortalidad sin recaída es mayor en aquellos con bajo peso extremo, sobrepeso y obesidad. La obesidad está relacionada con una toxicidad asociada al tratamiento, una incidencia más alta de enfermedad de injerto-huésped de grado II-IV (GVHD), infecciones y mortalidad. El objetivo de este estudio fue investigar el estado nutricional de pacientes que se sometieron a HSCT entre 2007 y 2013 en un hospital privado, calculando el índice de masa corporal (IMC), para comprobar la prevalencia de posibles desajustes nutricionales, especialmente obesidad. Métodos: en este estudio retrospectivo, basado en informes médicos, analizamos datos de todos los pacientes con enfermedades tumorales y no tumorales que se sometieron a HSCT desde enero de 2007 hasta febrero de 2014 en el Centro de hematología-oncología y trasplante de médula ósea en un gran centro de especialidades médicas en Brasil. Resultados: en el periodo se trató y analizó un total de 257 casos, de los cuales el 79% tenían edades de hasta 65 años. Entre estos, el 56% tenían sobrepeso u obesidad. Observamos una mayor prevalencia de obesidad en pacientes ancianos (P < 0,001). El IMC medio de la muestra total fue 26,4 kg/m2. El IMC fue significativamente diferente entre géneros, con una prevalencia mayor de sobrepeso entre los hombres (P < 0,001). Conclusión: a diferencia de otros estudios, nuestra investigación ha mostrado bajas tasas de tasas de bajo peso y altas tasas de sobrepeso y de obesidad en los hombres y pacientes ancianos sometidos a HSCT.

Smart Care™ versus respiratory physiotherapy-driven manual weaning for critically ill adult patients: a randomized controlled trial.

INTRODUCTION: A recent meta-analysis showed that weaning with SmartCare™ (Dräger, Lübeck, Germany) significantly decreased weaning time in critically ill patients. However, its utility compared with respiratory physiotherapist-protocolized weaning is still a matter of debate. We hypothesized that weaning with SmartCare™ would be as effective as respiratory physiotherapy-driven weaning in critically ill patients. METHODS: Adult critically ill patients mechanically ventilated for more than 24 hours in the adult intensive care unit of the Albert Einstein Hospital, São Paulo, Brazil, were randomly assigned to be weaned either by progressive discontinuation of pressure support ventilation (PSV) with SmartCare™. Demographic data, respiratory function parameters, level of PSV, tidal volume (VT), positive end-expiratory pressure (PEEP), inspired oxygen fraction (FIO2), peripheral oxygen saturation (SpO2), end-tidal carbon dioxide concentration (EtCO2) and airway occlusion pressure at 0.1 second (P0.1) were recorded at the beginning of the weaning process and before extubation. Mechanical ventilation time, weaning duration and rate of extubation failure were compared. RESULTS: Seventy patients were enrolled 35 in each group. There was no difference between the two groups concerning age, sex or diagnosis at study entry. There was no difference in maximal inspiratory pressure, maximal expiratory pressure, forced vital capacity or rapid shallow breathing index at the beginning of the weaning trial. PEEP, VT, FIO2, SpO2, respiratory rate, EtCO2 and P0.1 were similar between the two groups, but PSV was not (median: 8 vs. 10 cmH2O; p =0.007). When the patients were ready for extubation, PSV (8 vs. 5 cmH2O; p =0.015) and PEEP (8 vs. 5 cmH2O; p <0.001) were significantly higher in the respiratory physiotherapy-driven weaning group. Total duration of mechanical ventilation (3.5 [2.0-7.3] days vs. 4.1 [2.7-7.1] days; p =0.467) and extubation failure (2 vs. 2; p =1.00) were similar between the two groups. Weaning duration was shorter in the respiratory physiotherapy-driven weaning group (60 [50-80] minutes vs. 110 [80-130] minutes; p <0.001). CONCLUSION: A respiratory physiotherapy-driven weaning protocol can decrease weaning time compared with an automatic system, as it takes into account individual weaning difficulties. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02122016 . Date of Registration: 27 August 2013.

Georeferencing deaths from stroke in São Paulo: an intra-city stroke belt?

BACKGROUND: The role of socioeconomic status in the worldwide stroke burden has been studied with various methods using vital statistics and research-generated data. AIM: The objective of our study was to describe the stroke mortality rates and the stroke mortality distribution, and to evaluate the association between stroke mortality rates and geographical distribution with the human development index in São Paulo, Brazil. METHODS: This ecological study evaluated a historical series of stroke mortality in São Paulo, Brazil, from 2004 to 2010. Standard stroke mortality rate per 100 000 inhabitants at each year, the address of residence assumed as the place of living, and the human development index applied as a social indicator were used in order to evaluate if stroke mortality correlated with socioeconomic status. RESULTS: The mean standardized stroke mortality in São Paulo decreased from 66 to 46·7 per 100 000 inhabitants from 2004 to 2010. Stroke mortality differed according to human development index strata with an almost three times higher stroke mortality in the lowest when compared with the highest human development index stratum. Visual inspection of the map of the districts with high stroke mortality disclosed regional clusters with high mortality in the east, northwest, and south regions, a finding suggestive of the presence of a stroke belt inside the city of São Paulo. CONCLUSIONS: In conclusion, between 2004 and 2010, stroke mortality rates decreased by 28·5% in São Paulo. A geographical pattern in stroke mortality could be observed, with considerable differences according the human development index level of the place of living.

Impact of appropriate antimicrobial therapy for patients with severe sepsis and septic shock--a quality improvement study.

BACKGROUND: There is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis. In fact, the current state of debate surrounds the balance to be struck between prompt empirical therapy and care in the choice of appropriate antibiotics (both in terms of the susceptibility of infecting organism and minimizing resistance arising from use of broad-spectrum agents). The objective of this study is to determine sepsis bundle compliance and the appropriateness of antimicrobial therapy in patients with severe sepsis and septic shock and its impact on outcomes. MATERIAL: This study was conducted in the ICU of a tertiary care, private hospital in São Paulo, Brazil. A retrospective cohort study was conducted from July 2005 to December 2012 in patients with severe sepsis and septic shock. RESULTS: A total of 1,279 patients were identified with severe sepsis and septic shock, of which 358 (32.1%) had bloodstream infection (BSI). The inpatient mortality rate was 29%. In evaluation of the sepsis bundle, over time there was a progressive increase in serum arterial lactate collection, obtaining blood cultures prior to antibiotic administration, administration of broad-spectrum antibiotics within 1 hour, and administration of appropriate antimicrobials, with statistically significant differences in the later years of the study. We also observed a significant decrease in mortality. In patients with bloodstream infection, after adjustment for other covariates the administration of appropriate antimicrobial therapy was associated with a decrease in mortality in patients with severe sepsis and septic shock (p = 0.023). CONCLUSIONS: The administration of appropriate antimicrobial therapy was independently associated with a decline in mortality in patients with severe sepsis and septic shock due to bloodstream infection. As protocol adherence increased over time, the crude mortality rate decreased, which reinforces the need to implement institutional guidelines and monitor appropriate antimicrobial therapy compliance.