Trends of Stroke Incidence from 1995 to 2013 in Joinville, Brazil.

BACKGROUND: Temporal trends on the incidence of stroke and its subtypes could help assess on-going public health policies and point to further targets for action among middle- and low-income countries, where the stroke burden is very high. This study aimed at evaluating longitudinal trends of stroke incidence in Joinville, Brazil. METHODS: We ascertained the incidence of all first-ever strokes occurred in 1995, 2005-2006 and 2012-2013, which were extracted from Joinville Stroke Registry, a prospective epidemiological data bank, launched in 1995. RESULTS: From 1995 to 2013, the age-adjusted incidence of all strokes decreased 37% (95% CI 32-42). From 2005 to 2013, the haemorrhagic stroke (HS) incidence decreased 60% (95% CI 13-86), ischemic stroke (IS) incidence decreased 15% (95% CI 1-28), and subarachnoid haemorrhage incidence remained stable. The proportion of IS and HS patients with regularly treated hypertension increased by 60% (p = 0.01) and 33% (p = 0.01), respectively. The proportion of IS and HS patients that quit smoking increased 8% (p = 0.03) and 17% (p = 0.03), respectively. CONCLUSIONS: Stroke incidence has been decreasing in Joinville over the last 18 years, more so for HS than IS. Better control of hypertension and tobacco use might explain these findings.

Transient ischemic attack incidence in joinville, Brazil, 2010: a population-based study.

BACKGROUND AND PURPOSE: There are scarce data on transient ischemic attack incidence in low- and middle-income countries. We aimed to measure transient ischemic attack incidence and the distribution of the ABCD2 risk score in Joinville, Brazil. METHODS: In 2009 to 2010, using a multiple overlapping sources, we ascertained all first ever probable and definite transient ischemic attacks. RESULTS: We recorded 74 definite and probable transient ischemic attacks. The crude incidence was 15 (12-18) per 100 000 population. Age adjusted to European population the incidence was 28 (22-35). One fourth was in the higher risk of stroke by the ABCD2 scale. CONCLUSIONS: The transient ischemic attack incidence in Joinville, Brazil, is lower than other well-designed studies. New studies could clarify whether the measured rates were due to underascertainment or reflect a truly low incidence.

The Brazilian Family Health Program and secondary stroke and myocardial infarction prevention: a 6-year cohort study.

OBJECTIVES: We compared the incidence of recurrent or fatal cardiovascular disease in patients using Brazil's government-run Family Health Program (FHP) with those using non-FHP models of care. METHODS: From 2005 to 2010, we followed outpatients discharged from city public hospitals after a first ever stroke for stroke recurrence and myocardial infarction, using data from all city hospitals, death certificates, and outpatient monitoring in state-run and private units. RESULTS: In the follow-up period, 103 patients in the FHP units and 138 in the non-FHP units had exclusively state-run care. Stroke or myocardial infarction occurred in 30.1% of patients in the FHP group and 36.2% of patients in non-FHP care (rate ratio [RR] = 0.85; 95% confidence interval [CI] = 0.61, 1.18; P = .39); 37.9% of patients in FHP care and 54.3% in non-FHP care (RR = 0.68; 95% CI = 0.50, 0.92; P = .01) died. FHP use was associated with lower hazard of death from all causes (hazard ratio [HR] = 0.58; P = .005) after adjusting for age and stroke severity. The absolute risk reduction for death by all causes was 16.4%. CONCLUSIONS: FHP care is more effective than is non-FHP care at preventing death from secondary stroke and myocardial infarction.

Education level explains differences in stroke incidence among city districts in Joinville, Brazil: a three-year population-based study.

BACKGROUND: Current evidence suggests an inverse association between socioeconomic status and stroke incidence. Our aim was to measure the variation in incidence among different city districts (CD) and their association with socioeconomic variables. METHODS: We prospectively ascertained all possible stroke cases occurring in the city of Joinville during the period 2005-2007. We determined the incidence for each of the 38 CD, age-adjusted to the population of Joinville. By linear regression analysis, we correlated incidence data with mean years of education (MYE) and mean income per month (MIPM). RESULTS: Of the 1,734 stroke cases registered, 1,034 were first-ever strokes. In the study period, the crude incidence in Joinville was 69.5 per 100,000 (95% confidence interval, 65.3-73.9). The stroke incidence among CD ranged from 37.5 (22.2-64.6) to 151.0 per 100,000 (69.0-286.6). The stroke incidence was inversely correlated with years of education (r = -0.532; p < 0.001). MYE and MIPM were strongly related (R = 0.958), resulting in exclusion of MIPM by collinearity. CONCLUSIONS: Years of education can explain a wide incidence variation among CD. These results may be useful to guide the allocation of resources in primary prevention policies.

The Effect of Reconnection to Mechanical Ventilation for 1 Hour After Spontaneous Breathing Trial on Reintubation Among Patients Ventilated for More Than 12 Hours: A Randomized Clinical Trial.

BACKGROUND: The resting of the respiratory musculature after undergoing the spontaneous breathing trial (SBT) to prevent extubation failures in critically ill patients needs to be studied further. RESEARCH QUESTION: Is the reconnection to mechanical ventilation (MV) for 1 h after a successful SBT able to reduce the risk of reintubation? STUDY DESIGN AND METHODS: Randomized clinical trial conducted in four ICUs between August 2018 and July 2019. Candidates for tracheal extubation who met all screening criteria for weaning were included. After achieving success in the SBT using a T-tube, the patients were randomized to the following groups: direct extubation (DE) or extubation after reconnection to MV for 1 h (R1h). The primary outcome was reintubation within 48 h. RESULTS: Among the 336 patients studied (women, 41.1%; median age, 59 years [interquartile range, 45-70 years]), 12.9% (22/171) in the R1h group required reintubation within 48 h vs 18.2% (30/165) in the DE group (risk difference, 5.3 [95% CI, -2.49 to 13.12]; P = .18). No differences were found in mortality, length of ICU or hospital stay, causes of reintubation, or signs of extubation failure. A prespecified exploratory analysis showed that among the 233 patients (69.3%) who were ventilated for more than 72 h, the incidence of reintubation was 12.7% (15/118) in the R1h group compared with 22.6% (26/115) observed in the DE group (P = .04). INTERPRETATION: Reconnection to MV after a successful SBT, compared with DE, did not result in a statistically significant reduction in the risk of reintubation in mechanically ventilated patients. Subgroup exploratory findings suggest that the strategy may benefit patients who were ventilated for more than 72 h, which should be confirmed in further studies. TRIAL REGISTRY: Brazilian Clinical Trials Registry; No.: RBR-3x8nxn; URL: www.ensaiosclinicos.gov.br.

Intravenous rtPA versus mechanical thrombectomy in acute ischemic stroke: A historical cohort in Joinville, Brazil.

Groundbreaking results concerning ischemic stroke (IS) hyperacute treatment worldwide were published in 2014 and 2015. We aimed to compare functional status after 3 months in patients treated with intra-arterial thrombectomy (IAT) and those treated with intravenous thrombolysis (IVT) alone in Joinville, Brazil. From the Joinville Stroke Registry, we extracted and compared all consecutive IVT patients treated with r-tPA within 4.5 h in the period 2009-2011 versus all consecutive IAT treated within 6 h with the Solitaire FR device plus IVT in the period 2012-2014. We registered 82 patients in the IVT group and 31 patients in the IAT group. At hospital admission, patients in the IAT group were significantly younger (p < 0.001), had a higher educational level (p = 0.001), had a slightly higher prevalence of atrial fibrillation (p = 0.057) and had more severe strokes measured by the NIH stroke scale (p = 0.011). After 90 days, 45% of patients in the IAT group and 27% in the IVT group were independent (0-1 points) according to the modified Rankin scale (adjusted odds ratio: 4.53; 95% CI: 1.22 to 16.75). Symptomatic hemorrhage was diagnosed in 10% of patients in both groups (p = 1.0). The 90-day case-fatality was 39% (32/82) in the IVT group and 26% (8/31) in the IAT group (p = 0.27). In this small cohort, a greater rate of functional independence was achieved in patients treated with IAT plus IVT, compared with patients treated with IVT lysis alone. Our "real-world" findings are consistent with results of controlled, randomized clinical trials.

Trends of the Incidence of Ischemic Stroke Thrombolysis over Seven Years and One-Year Outcome: A Population-Based Study in Joinville, Brazil.

BACKGROUND: In a population-based setting, we aimed to measure the incidence trends of ischemic stroke (IS) thrombolysis, thrombolysis times, proportion of symptomatic intracerebral hemorrhage (sICH), 30-day case fatality and functional outcomes. We also compared the 12-month functional status between thrombolyzed and nonthrombolyzed patients. METHODS: Using data from the Joinville Population-Based Stroke Registry, we prospectively ascertained a cohort of all thrombolyses done in Joinville citizens, Southern Brazil, from 2005 to 2011. For the definition of sICH we used European Cooperative Acute Stroke Study (ECASS) II criteria. RESULTS: Over 7 years, 6% (220/3,552) of all IS were thrombolyzed. The thrombolysis incidence increased from 1.4 [95% confidence interval (CI), 0.6-2.9] in 2005 to 9.8 (7.3-12.9) per 100,000 population in 2011 (p < 0.0001). The thrombolysis incidence age-adjusted to the world population in 2011 was 11 (8.2-14.3) per 100,000. Only 30% (50/165) were thrombolyzed within 1 h of arrival at hospital. In 7 days, 6.4% (14/220) had sICH and 57% (8/14) of those died. In the 2009-2011 period, a favorable functional outcome [modified Rankin scale (mRS) 0-1] at 12 months among patients who received thrombolysis was more frequent [mRS 0-1; 36% (38/107)] than among patients who did not receive thrombolysis [mRS 0-1; 24% (131/544); p = 0.016]. The logistic regression showed that thrombolyzed IS patients had a more favorable outcome (mRS 0-1; HR 2.13; 95% CI, 1.2-3.7; p < 0.016) than nonthrombolyzed patients. CONCLUSION: In a population setting of a middle income country, the thrombolysis incidence and outcomes were similar to those of other well-structured services. After 1 year, patients thrombolyzed in the 4.5-hour time window had a better outcome. More than proportions, rates provide additional information and could be used to benchmark services against others.

Avaliacao da eficacia de um metodo educativo na rotina de lavar as maos em UTI / Evaluation of the efficacy of an educative method in the routine of hand washing in the ICU

Nosocomial infections are a great problem in the ICUs and hand washing is the best way to control it. The objective of this study is to evaluate the efficacy of an educative method in the routine of hand washing in the ICU before and after having contact with the patient The study was perfomed in a general ICU with eight beds and is composed of two parts. In the firs part an anonymous observer checked all the times an ICU professional had contact with the patients and washed or not his hands before and after this contact. This was repeated in the second part of the study after a doctor had oriented the professionals with lecture, written material and posters. At none part of the professionals were noticed about its existence. At the first part there were 515 contacts. Hand washing occurred in 25 (4,8 por cento) opportunities before and in 62 (12 por cento) after contact with the patients. In the second part there were 473 contacts with hand washing in 87 (18,5 por cento) times before and 141 (29,6 por cento) after having the contact. The aderence to hand washing was significantly better after orientation (p menor 0,0001) before and after the contacts but still is very unsatisfactory, showing the importance of frequently remembering the importance of this habit