Comparison of Unplanned Intensive Care Unit Readmission Scores: A Prospective Cohort Study.

PURPOSE: Early discharge from the intensive care unit (ICU) may constitute a strategy of resource consumption optimization; however, unplanned readmission of hospitalized patients to an ICU is associated with a worse outcome. We aimed to compare the effectiveness of the Stability and Workload Index for Transfer score (SWIFT), Sequential Organ Failure Assessment score (SOFA) and simplified Therapeutic Intervention Scoring System (TISS-28) in predicting unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU. METHODS: We conducted a prospective cohort study in a single tertiary hospital in southern Brazil. All adult patients admitted to the ICU for more than 24 hours from January 2008 to December 2009 were evaluated. SWIFT, SOFA and TISS-28 scores were calculated on the day of discharge from the ICU. A stepwise logistic regression was conducted to evaluate the effectiveness of these scores in predicting unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU. Moreover, we conducted a direct accuracy comparison among SWIFT, SOFA and TISS-28 scores. RESULTS: A total of 1,277 patients were discharged from the ICU during the study period. The rate of unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU was 15% (192 patients). In the multivariate analysis, age (P = 0.001), length of ICU stay (P = 0.01), cirrhosis (P = 0.03), SWIFT (P = 0.001), SOFA (P = 0.01) and TISS-28 (P<0.001) constituted predictors of unplanned ICU readmission or unexpected death. The SWIFT, SOFA and TISS-28 scores showed similar predictive accuracy (AUC valueswere 0.66, 0.65 and 0.67, respectively; P = 0.58) [corrected]. CONCLUSIONS: SWIFT, SOFA and TISS-28 on the day of discharge from the ICU have only moderate accuracy in predicting ICU readmission or death. The present study did not find any differences in accuracy among the three scores.

Serum and liver lipids in rats and chicks fed with diets containing different oils.

OBJECTIVES: Because dietary fat composition is determinant for serum cholesterol level, which is related to cardiovascular disease, we evaluated the effects of diets containing saturated (coconut oil) or polyunsaturated fatty acids (soybean oil) supplemented or not with dietary cholesterol on serum and liver lipid composition in two animal species. METHODS: Male Wistar rats (21 d old) were assigned to one of seven groups and fed with commercial diet or diets containing 5% or 20% soybean oil or 20% coconut oil with or without 1% cholesterol. Chicks were assigned to one of four groups and fed with diets containing 15% soybean oil or 15% coconut oil with or without 1% cholesterol. RESULTS: In rats, the accumulations of hepatic cholesterol and triacylglycerols were higher in the group fed 20% soybean oil and 1% cholesterol than in the group fed 20% coconut fat and 1% cholesterol. The highest serum levels of cholesterol and triacylglycerols were observed in the group fed coconut oil and cholesterol, compared with the group fed soybean oil and cholesterol. Triacylglycerol, high-density lipoprotein, and total cholesterol serum levels increased with diet containing coconut oil and cholesterol. In chicks, the highest hepatic cholesterol accumulation occurred in the group fed 15% coconut fat and 1% cholesterol. Total and high-density lipoprotein cholesterol levels increased with diet containing coconut oil and cholesterol, although none of these diets modified serum triacylglycerol levels. CONCLUSIONS: The type of experimental animal model and the diet composition influence lipid metabolism.

Meningitis and infective endocarditis caused by Rhodotorula mucilaginosa in an immunocompetent patient. / Meningite e endocardite infecciosa causada por Rhodotorula mucilaginosa em paciente imunocompetente.

The authors report the case of an immunocompetent man who presented with acute impairment of the neurological system, hypertensive crisis and renal failure. The patient was eventually diagnosed with Rhodotorula mucilaginosa meningitis and infective endocarditis. To the best of our knowledge, this is the first description of simultaneous infection of the meninges and endothelium caused by Rhodotorula in a non-immunocompromised patient.

Safety of a training program for ultrasound-guided internal jugular vein catheterization in critically ill patients.

OBJECTIVES: Evaluate the safety and effectiveness of a training program for performing ultrasound-guided internal jugular vein cannulation in critically ill patients. METHODS: Cohort prospective study, evaluating adult patients admitted in a teaching intensive care unit (ICU). Catheter placement was performed by an ICU medical resident. The patient's baseline characteristics, vessel's position and operator experience were the evaluated variables. The main outcomes were cannulation success rate and incidence of major complications. RESULTS: A total of 118 consecutive patients were enrolled between May 2008 and November 2009. The success rate of ultrasound guided catheter placement was 90% (106/118), 77% in the first attempt. Major complications occurred in 4% of the cases (n = 5) and were not associated with the analyzed variables. Inability to place the guide wire was the reason for 58% (7/12) of the failures. Operators with more than 15 previous ultrasound guided cannulations had an increased success rate (95% vs. 79%, p = 0.01) and increased failure was related to previous catheterization (26% vs. 7%, p = 0.02). CONCLUSION: Learning ultrasound guidance for IJV vein cannulation was safe and feasible in ICU patients. This process was not associated to complications and better results were achieved across the spectrum of operator experience.

Appropriate medical professionals communication reduces intensive care unit mortality. / A adequada comunicação entre os profissionais médicos reduz a mortalidade no centro de tratamento intensivo.

OBJECTIVES: Communication issues between healthcare professionals in intensive care units may be related to critically ill patients’ increased mortality. This study aimed to evaluate if communication issues involving assistant physicians and routine intensive care unit physicians would impact critically ill patients’ morbidity and mortality. METHODS: This was a cohort study that included non-consecutive patients admitted to the intensive care unit for 18 months. The patients were categorized in 3 groups according to their assistant doctors’ versus routine doctors communication uses: DC - daily communication during the stay (>75% of the days); EC - eventual communication (25 to 75% of the days); RC - rare communication (< 25% of the days). Demographic data, severity scores, reason for admission to the intensive care unit and interventions were recorded. The consequences of the medical professionals communication failures (delayed procedures, diagnostic tests, antibiotics, ventilatory weaning, vasopressors) and medical prescriptions inadequacies (no bed head elevation, no stress ulceration and deep venous thrombosis drug prophylaxis), and their relationship with the patients outcomes were analyzed. RESULTS: 792 patients were included, and categorized as follows: DC (n=529); EC (n=187) and RC (n=76). The mortality was increased in the RC patients group (26.3%) versus the remainder groups (DC = 13.6% and EC = 17.1%; p<0.05). A multivariate analysis showed that delayed antibiotics [RR 1.83 (CI95%: 1.36 -2.25)], delayed ventilatory weaning [RR 1.63 (CI95%: 1.25-2.04)] and no deep venous thrombosis prophylaxis [RR 1.98 (CI95%: 1.43 - 3.12)] contributed independently for the increased mortality. CONCLUSION: The failure in the assistant and routine intensive care doctors communication may increase the patients’ mortality, particularly due to delayed antibiotics and ventilation weaning, and lack of deep venous thrombosis prophylaxis prescription.

Meningite e endocardite infecciosa causada por Rhodotorula mucilaginosa em paciente imunocompetente / Meningitis and infective endocarditis caused by Rhodotorula mucilaginosa in an immunocompetent patient

Os autores relatam o caso de um homem imunocompetente admitido com comprometimento agudo do sistema nervoso, crise hipertensiva e insuficiência renal, vindo a receber diagnóstico de meningite e endocardite infecciosa por Rhodotorula mucilaginosa. Até onde sabemos, esta é a primeira descrição de infecção simultânea das meninges e do endotélio causada por Rhodotorula em um paciente sem comprometimento imunológico.

The authors report the case of an immunocompetent man who presented with acute impairment of the neurological system, hypertensive crisis and renal failure. The patient was eventually diagnosed with Rhodotorula mucilaginosa meningitis and infective endocarditis. To the best of our knowledge, this is the first description of simultaneous infection of the meninges and endothelium caused by Rhodotorula in a non-immunocompromised patient.

Safety of a training program for ultrasound-guided internal jugular vein catheterization in critically ill patients / Segurança de um programa de treinamento para punção de veia jugular interna guiada por ultrassom em pacientes críticos

OBJECTIVES: Evaluate the safety and effectiveness of a training program for performing ultrasound-guided internal jugular vein cannulation in critically ill patients. METHODS: Cohort prospective study, evaluating adult patients admitted in a teaching intensive care unit (ICU). Catheter placement was performed by an ICU medical resident. The patient's baseline characteristics, vessel's position and operator experience were the evaluated variables. The main outcomes were cannulation success rate and incidence of major complications. RESULTS: A total of 118 consecutive patients were enrolled between May 2008 and November 2009. The success rate of ultrasound guided catheter placement was 90 percent (106/118), 77 percent in the first attempt. Major complications occurred in 4 percent of the cases (n = 5) and were not associated with the analyzed variables. Inability to place the guide wire was the reason for 58 percent (7/12) of the failures. Operators with more than 15 previous ultrasound guided cannulations had an increased success rate (95 percent vs. 79 percent, p = 0.01) and increased failure was related to previous catheterization (26 percent vs. 7 percent, p = 0.02). CONCLUSION: Learning ultrasound guidance for IJV vein cannulation was safe and feasible in ICU patients. This process was not associated to complications and better results were achieved across the spectrum of operator experience.

OBJETIVO: Avaliar a segurança e efetividade de um programa de treinamento para cateterização da veia jugular interna guiada por ultrassom em pacientes críticos. MÉTODOS: Estudo de coorte prospectivo, avaliando pacientes adultos internados em uma unidade de terapia intensiva com programa de ensino. Os médicos residentes do serviço realizaram as punções de veia jugular interna guiadas por ultrassom. Foram avaliadas as características de base dos pacientes, sintopia dos vasos e experiência dos operadores. Os desfechos primários foram a taxa de sucesso da cateterização e a incidência de complicações graves. RESULTADOS: No período entre maio de 2008 e novembro de 2009 foram avaliados 118 pacientes. A taxa de sucesso da punção guiada por ultrassom foi 90 por cento (106/118), 77 por cento dessas na primeira tentativa. Complicações graves ocorreram em 4 por cento dos casos (n = 5) e não foram associadas às variáveis analisadas. Incapacidade de progredir o fio-guia foi a razão de 58 por cento (7/12) das falhas. Operadores com mais de 15 punções guiadas por ultrassom obtiveram uma maior taxa de sucesso (95 por cento vs. 79 por cento, p = 0,01) e pacientes com cateterização prévia apresentaram um maior número de falhas (26 por cento vs. 7 por cento, p = 0,02). CONCLUSÃO: O aprendizado da técnica de punção de veia jugular interna guiada por ultrasssom é seguro e efetivo em pacientes críticos. Este processo não esteve associado a um aumento da taxa de complicações e melhores resultados são obtidos à medida que aumenta a experiência do operador.

A adequada comunicação entre os profissionais médicos reduz a mortalidade no centro de tratamento intensivo / Appropriate medical professionals communication reduces intensive care unit mortality

OBJETIVOS: A falha de comunicação entre os profissionais de saúde em centros de tratamento intensivo pode estar relacionada ao aumento de mortalidade dos pacientes criticamente doentes. Este estudo teve como objetivo avaliar se falhas de comunicação entre os médicos assistentes e os médicos rotineiros do centro de tratamento intensivo teriam impacto na morbidade e mortalidade dos pacientes críticos. MÉTODOS: Estudo de coorte incluindo pacientes não consecutivos admitidos no centro de tratamento intensivo durante 18 meses. Os pacientes foram divididos em 3 grupos conforme o hábito de comunicação de seus médicos assistentes com os médicos rotineiros: CD - comunicação diária da conduta (>75 por cento dos dias); CE - comunicação eventual (25 a 75 por cento dos dias); RC - rara comunicação (<25 por cento dos dias). Foram coletados dados demográficos, escores de gravidade, motivo de internação no centro de tratamento intensivo, tempo de internação no centro de tratamento intensivo e intervenções realizadas nos pacientes. Foram analisadas as conseqüências da falha na comunicação entre os profissionais médicos (atraso na realização de procedimentos, na realização de exames diagnósticos, no início de antibioticoterapia, no desmame do suporte ventilatório e no uso de vasopressores) e inadequações de prescrição médica (ausência de cabeceira elevada, ausência de profilaxia medicamentosa para úlcera de estresse e para trombose venosa profunda) relacionando-as com o desfecho dos pacientes. RESULTADOS: Foram incluídos 792 pacientes no estudo, sendo agrupados da seguinte maneira: CD (n =529), CE (n =187) e RC (n =76). A mortalidade foi maior nos pacientes pertencentes ao grupo RC (26,3 por cento) comparada aos demais (CD =13,6 por cento e CE =17,1 por cento; p <0,05). A análise multivariada demonstrou que o atraso no início de antibióticos [RR 1,83 (IC95 por cento: 1,36 - 2,25)], o atraso no início do desmame ventilatório [RR 1,63 (IC95 por cento:...

OBJECTIVES: Communication issues between healthcare professionals in intensive care units may be related to critically ill patients’ increased mortality. This study aimed to evaluate if communication issues involving assistant physicians and routine intensive care unit physicians would impact critically ill patients’ morbidity and mortality. METHODS: This was a cohort study that included non-consecutive patients admitted to the intensive care unit for 18 months. The patients were categorized in 3 groups according to their assistant doctors’ versus routine doctors communication uses: DC - daily communication during the stay (>75 percent of the days); EC - eventual communication (25 to 75 percent of the days); RC - rare communication (< 25 percent of the days). Demographic data, severity scores, reason for admission to the intensive care unit and interventions were recorded. The consequences of the medical professionals communication failures (delayed procedures, diagnostic tests, antibiotics, ventilatory weaning, vasopressors) and medical prescriptions inadequacies (no bed head elevation, no stress ulceration and deep venous thrombosis drug prophylaxis), and their relationship with the patients outcomes were analyzed. RESULTS: 792 patients were included, and categorized as follows: DC (n=529); EC (n=187) and RC (n=76). The mortality was increased in the RC patients group (26.3 percent) versus the remainder groups (DC = 13.6 percent and EC = 17.1 percent; p<0.05). A multivariate analysis showed that delayed antibiotics [RR 1.83 (CI95 percent: 1.36 -2.25)], delayed ventilatory weaning [RR 1.63 (CI95 percent: 1.25-2.04)] and no deep venous thrombosis prophylaxis [RR 1.98 (CI95 percent: 1.43 - 3.12)] contributed independently for the increased mortality. CONCLUSION: The failure in the assistant and routine intensive care doctors communication may increase the patients’ mortality, particularly due to delayed antibiotics and ventilation weaning,...

Glucose and lactate utilization by the amygdala of male and female rats.

Gonadal hormones appear to modulate brain energy metabolism, and morphological and functional sexual differences are found in the amygdaloid complex (AC) of rats. Our aim was to study the CO2 production and lipid synthesis, measured by the rate of L-[U-14C]lactate or D-[U-14C]glucose utilization (in pmol x hr(-1) x mg(-1)), by AC slices in vitro of male and female rats. Lactate was more used than glucose as energy substrate (p < 0.01) but no sex-related difference was observed in glucose or lactate oxidation to CO2 (p > 0.05) or on lipid synthesis obtained from both substrates (p > 0.05). In addition, there was no effect of the estrous cycle on lactate oxidation to CO2 by the AC of females (p > 0.05). Based on the present data, it appears that the endogenous normal levels of gonadal hormones are not able to promote sex-related differences in the in vitro glucose or lactate utilization by the AC of rats.

High extracellular K+ levels stimulate acetate oxidation in brain slices from well and malnourished rats.

We investigated the effect of high (12, 20, and 50 mM) extracellular K+ concentrations ([K+]0) on [U-14C] acetate oxidation to CO2 in cerebral cortex slices of control and perinatal malnourished rats. High [K+]o increased the acetate oxidation, compared with a medium containing 2.7 mM [K+]0. By investigating the mechanisms involved in this stimulation, it was shown that (i) ouabain (1 mM) and monensin (10 microM) prevented this increase; (ii) in a medium with physiological [K+]0 (2.7 mM), the decreasing of [Na+]0 stimulated acetate oxidation. These results suggest that the stimulatory effect of [K+]0 on acetate oxidation was due to the decreasing of Na1 levels. Considering that malnutrition could alter the activity of Na+,K(+)-ATPase and/or other pertinent proteins, its effect on acetate oxidation was investigated. The malnutrition, which altered the body and cerebral weight of rats, did not modify the acetate oxidation in any protocol.