Pulmonary hypertension and associated outcomes in noncardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Some studies suggest that patients with pulmonary hypertension (PH) may be at higher risk of complications and death after noncardiac surgery. However, the magnitude of these associations is unclear. OBJECTIVES: To determine the associations between PH and adverse outcomes after noncardiac surgery. METHODS: We searched PUBMED and EMBASE for studies published from January 1970 to April 2022. We included studies that reported the association between PH and one or more outcomes of interest occurring after noncardiac surgery. Data were pooled using random-effects models and reported as summary odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Eighteen studies met eligibility criteria (n=18,214,760). PH was independently associated with mortality (adjusted odds ratio [OR] 2.09; 95% CI, 1.51-2.90; I2=98%; 8 studies). PH was associated with a higher unadjusted risk of deep venous thrombosis (OR 4.02; 95% CI, 2.14-7.54; I2=85%; 3 studies), pulmonary embolism (OR 4.16; 95% CI, 3.23-5.36; I2=69%; 7 studies), myocardial infarction (OR 1.49; 95% CI, 1.44-1.54; I2=0%; 5 studies), congestive heart failure or cardiogenic shock (OR 3.37; 95% CI, 1.73-6.60; I2=34%; 5 studies), length of hospital stay (mean difference 1.97 days; 95% CI, 0.81-3.12; I2=99%; 5 studies), and delayed extubation (OR 5.98; 95% CI, 1.70-21.02; I2=3%; 3 studies). PH was associated with lower unadjusted risk of postoperative stroke (OR 0.93; 95% CI, 0.88-0.98; I2=0%; 3 studies). CONCLUSION: PH is a predictor of morbidity and mortality after noncardiac surgery. High quality studies are needed to determine effective strategies for reducing postoperative complications in this population.

Perioperative Troponin Screening Identifies Patients at Higher Risk for Major Cardiovascular Events in Noncardiac Surgery.

Myocardial injury after noncardiac surgery (MINS) includes patients with traditional myocardial infarction and those with ischemic myocardial injury after surgery. This study evaluated the prognostic value of MINS on major cardiovascular events and 30-day mortality, and determined independent preoperative predictors of MINS in patients after noncardiac surgery. This multicenter prospective cohort study was part of the VISION Study. The sample consisted of 2504 patients who underwent noncardiac surgery at 2 tertiary hospitals in Brazil between September 2008 and July 2012. Troponin Ts were measured 6-12 hours, and on days 1-3 after surgery. Cox regression analyses were performed to identify independent variables of major outcomes. A total of 314 (13%) patients were diagnosed with MINS, of which 26 (8%) died. Length-of-hospital stay of MINS patients was 3 times higher (18 ± 22 days vs 5.8 ± 11 days). In multivariate analysis, 30-day mortality was significantly higher among patients with MINS (hazard ratio [HR] 3.17 (95% confidence interval [CI] 1.56-6.41)), and major bleeding (HR 5.76 (95% CI 2.75-12.05)), sepsis (HR 5.08 (95% CI 2.25-11.46)), active cancer (HR 4.22 (95% CI 1.98-8.98)), and general surgery (HR 3.11 (95% CI 1.51-6.41)). Multivariable analysis indicated a higher chance of MINS in patients ≥75 years of age, history of diabetes mellitus, hypertension, heart failure, coronary disease, and end-stage renal failure. The incidence of MINS within 30 days after noncardiac surgery is related to higher mortality. Postoperative troponin monitoring in elder patients and with risk factors for atherosclerotic disease may help reduce postoperative cardiovascular events.

Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study establishing diagnostic criteria and prognostic importance.

BACKGROUND: We aimed to establish diagnostic criteria for bleeding independently associated with mortality after noncardiac surgery (BIMS) defined as bleeding during or within 30 days after noncardiac surgery that is independently associated with mortality within 30 days of surgery, and to estimate the proportion of 30-day postoperative mortality potentially attributable to BIMS. METHODS: This was a prospective cohort study of participants ≥45 yr old having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011. Cox proportional hazards models evaluated the adjusted relationship between candidate diagnostic criteria for BIMS and all-cause mortality within 30 days of surgery. RESULTS: Of 16 079 participants, 2.0% (315) died and 36.1% (5810) met predefined screening criteria for bleeding. Based on independent association with 30-day mortality, BIMS was identified as bleeding leading to a postoperative haemoglobin <70 g L-1, transfusion of ≥1 unit of red blood cells, or that was judged to be the cause of death. Bleeding independently associated with mortality after noncardiac surgery occurred in 17.3% of patients (2782). Death occurred in 5.8% of patients with BIMS (161/2782), 1.3% (39/3028) who met bleeding screening criteria but not BIMS criteria, and 1.1% (115/10 269) without bleeding. BIMS was associated with mortality (adjusted hazard ratio: 1.87; 95% confidence interval: 1.42-2.47). We estimated the proportion of 30-day postoperative deaths potentially attributable to BIMS to be 20.1-31.9%. CONCLUSIONS: Bleeding independently associated with mortality after noncardiac surgery (BIMS), defined as bleeding that leads to a postoperative haemoglobin <70 g L-1, blood transfusion, or that is judged to be the cause of death, is common and may account for a quarter of deaths after noncardiac surgery. CLINICAL TRIAL REGISTRATION: NCT00512109.

Association between complications and death within 30 days after noncardiac surgery.

BACKGROUND: Among adults undergoing contemporary noncardiac surgery, little is known about the frequency and timing of death and the associations between perioperative complications and mortality. We aimed to establish the frequency and timing of death and its association with perioperative complications. METHODS: We conducted a prospective cohort study of patients aged 45 years and older who underwent inpatient noncardiac surgery at 28 centres in 14 countries. We monitored patients for complications until 30 days after surgery and determined the relation between these complications and 30-day mortality using a Cox proportional hazards model. RESULTS: We included 40 004 patients. Of those, 715 patients (1.8%) died within 30 days of surgery. Five deaths (0.7%) occurred in the operating room, 500 deaths (69.9%) occurred after surgery during the index admission to hospital and 210 deaths (29.4%) occurred after discharge from the hospital. Eight complications were independently associated with 30-day mortality. The 3 complications with the largest attributable fractions (AF; i.e., potential proportion of deaths attributable to these complications) were major bleeding (6238 patients, 15.6%; adjusted hazard ratio [HR] 2.6, 95% confidence interval [CI] 2.2-3.1; AF 17.0%); myocardial injury after noncardiac surgery [MINS] (5191 patients, 13.0%; adjusted HR 2.2, 95% CI 1.9-2.6; AF 15.9%); and sepsis (1783 patients, 4.5%; adjusted HR 5.6, 95% CI 4.6-6.8; AF 12.0%). INTERPRETATION: Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality. Study registration: ClinicalTrials.gov, no. NCT00512109.

Efetividade da Terapia Medicamentosa e dos Procedimentos de Revascularização como Estratégia Inicial na Doença Arterial Coronariana Estável: Estudo de Coorte / Effectiveness of Medical and Revascularization Procedures as the Initial Strategy in Stable Coronary Artery Disease: A Cohort Study

Fundamento: A cirurgia de revascularização miocárdica (CRM) e a intervenção coronária percutânea (ICP) são estratégias amplamente utilizadas no manejo da doença arterial coronariana (DAC) estável. Objetivo: Avaliar o prognóstico de pacientes com DAC estável inicialmente tratada com terapia médica (TM), em comparação com os pacientes submetidos a procedimentos de revascularização. Métodos: Estudo prospectivo de coorte com 560 pacientes ambulatoriais de um hospital terciário com seguimento médio de 5 anos. Os pacientes foram classificados nos grupos TM (n = 288), ICP (n = 159) e CRM (n = 113) de acordo com sua estratégia inicial de tratamento. Os desfechos primários foram mortalidade global e eventos combinados de morte, síndrome coronária aguda e AVC. Resultados: Durante o seguimento, as taxas de mortalidade foram de 11,1% em TM, 11,9% em ICP e 15,9% em pacientes submetidos à CRM, sem diferença estatística (Hazard Ratio [HR] para ICP, 1,05; Intervalo de Confiança de 95% [IC95%], 0,59 a 1,84; e HR para CRM, 1,20; IC95%, 0,68 a 2,15). Os desfechos combinados ocorreram com maior frequência entre os pacientes inicialmente submetidos à ICP em relação à TM (HR 1,50, IC 95% 1,05 a 2,14) e não diferiram entre TM e CRM (HR 1,24, IC95% 0,84 a 1,83). Entre os pacientes com diabetes (n = 198), a ICP foi a única estratégia terapêutica preditiva de desfechos combinados (HR 2,14; IC 95%: 1,25 a 3,63). Conclusão: Neste estudo observacional de doença arterial coronariana estável, não houve diferença na mortalidade global entre as estratégias iniciais de terapia médico ou de cirurgia de revascularização. Os pacientes inicialmente tratados com ICP tiveram maior chance de desenvolver eventos cardiovasculares maiores combinados

Background: Coronary artery bypass grafting surgery (CABG) and percutaneous coronary intervention (PCI) are widely-used strategies in the management of stable coronary artery disease (CAD). Objective: To evaluate the prognosis of patients with stable CAD initially treated by medical therapy (MT), compared to the patients who were submitted to revascularization procedures. Methods: We conducted a prospective cohort study of 560 patients from an outpatient clinic in a tertiary hospital, with a mean follow-up of 5 years. Patients were classified into MT (n = 288), PCI (n = 159) and CABG (n=113) groups according to their initial treatment strategy. Primary endpoints were overall mortality and combined events of death, acute coronary syndrome, and stroke. Results: During follow-up, death rates were 11.1% in MT, 11.9% in PCI and 15.9% in CABG patients, with no statistical difference (hazard ratio [HR] for PCI, 1.05; 95% confidence interval [95%CI], 0.59 to 1.84; and HR for CABG, 1.20; 95% CI: 0.68 to 2.15). Combined outcomes occurred more often among patients initially submitted to PCI compared to MT (HR 1.50, 95% CI 1.05 to 2.14), and did not differ between MT and CABG patients (HR 1.24, 95% CI 0.84 to 1.83). Among patients with diabetes (n=198), PCI was the only therapeutic strategy predictive of combined outcomes (HR 2.14; 95% CI 1.25 to 3.63). Conclusion: In this observational study of stable coronary artery disease, there was no difference in overall mortality between initial medical therapy or revascularization surgery strategies. Patients initially treated with PCI had greater chance to develop combined major cardiovascular events

Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery.

IMPORTANCE: Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after noncardiac surgery (MINS). OBJECTIVE: To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality). DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013. EXPOSURES: Patients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement. MAIN OUTCOMES AND MEASURES: A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality. RESULTS: Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom. CONCLUSIONS AND RELEVANCE: Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.

Descalonamento, adequação antimicrobiana e positividade de culturas em pacientes sépticos: estudo observacional / De-escalation, adequacy of antibiotic therapy and culture positivity in septic patients: an observational study

RESUMO Objetivo: Avaliar a prevalência de descalonamento antibiótico em pacientes com diagnóstico de sepse grave ou choque séptico em hospital acadêmico, público e terciário, além da adequação antibiótica e da positividade de culturas. Métodos: Foram analisadas prevalência de descalonamento, adequação antibiótica e positividade de culturas entre portadores de sepse grave e choque séptico, entre abril e dezembro de 2013, em uma unidade de terapia intensiva de um hospital universitário terciário. Resultados: Entre os 224 pacientes incluídos, o descalonamento era possível em 29,4% dos casos (66 pacientes), mas foi implementado em 19,6% deles (44 pacientes). Entre os pacientes que receberam descalonamento, metade foi por estreitamento de espectro antimicrobiano. A mortalidade foi de 56,3%, não havendo diferença entre pacientes com ou sem descalonamento (56,8% versus 56,1%; p = 0,999), assim como no tempo de internação. Terapia antimicrobiana empírica foi adequada em 89% dos casos. Houve isolamento de germe em 30% de todas as culturas e em 26,3% das hemoculturas. Conclusão: A taxa de adequação antibiótica empírica foi alta, refletindo ativa política institucional de monitorização do perfil epidemiológico e protocolos institucionais de uso de antimicrobianos. No entanto, o descalonamento antimicrobiano poderia ter sido maior do que o registrado. O descalonamento não impactou mortalidade.

ABSTRACT Objective: To evaluate the prevalence of antibiotic de-escalation in patients diagnosed with severe sepsis or septic shock at a public academic tertiary hospital and to evaluate antibiotic adequacy and culture positivity. Methods: The prevalence of antibiotic de-escalation, the adequacy of antibiotic treatment and the rates of culture positivity were analyzed in patients with severe sepsis and septic shock between April and December 2013 at an intensive care unit in a tertiary university hospital. Results: Among the 224 patients included in the study, de-escalation was appropriate in 66 patients (29.4%) but was implemented in 44 patients (19.6%). Among the patients who underwent de-escalation, half experienced narrowing of the antimicrobial spectrum. The mortality rate was 56.3%, with no differences between the patients with or without de-escalation (56.8% versus 56.1%; p = 0.999) nor in the length of hospital stay. Empirical antibiotic therapy was appropriate in 89% of cases. Microorganisms were isolated from total cultures in 30% of cases and from blood cultures in 26.3% of cases. Conclusion: The adequacy rate of empirical antibiotic therapy was high, reflecting an active institutional policy of monitoring epidemiological profiles and institutional protocols on antimicrobial use. However, antibiotic de-escalation could have been implemented in a greater number of patients. De-escalation did not affect mortality rates.

Solitary fibrous tumor of the pleura mimicking pleural effusion

Solitary fibrous tumor of the pleura is a rare mesenchymal neoplasm of fibroblastic origin and represents less than 5% of primary tumors of the pleura. There are few reports in the literature about this disease, therefore the data on its presentation and management are derived from reports and retrospective analysis of case series from referral centers. In this report, we describe a case of a patient who presented this diagnosis during hospitalization, and following we briefly review the published literature of this pathology...

Perfil dos pacientes colonizados por enterobactérias produtoras de KPC em hospital terciário de Porto Alegre, Brasil / Characteristics of patients colonized by KPC-producing enterobacteriaceae in a tertiary hospital from Porto Alegre, Brazil

Enterobactérias produtoras de carbapenemase do tipo Klebsiella pneumoniae (KPC) são cada vez mais identificadas em pacientes hospitalizados, porém pouco se conhece sobre o perfil e o prognóstico dos pacientes colonizados por elas. Este estudo objetiva avaliar o perfil epidemiológico e a mortalidade total intra-hospitalar dos pacientes colonizados por KPC em um centro de referência. Métodos: Estudo de coorte retrospectivo em adultos colonizados por KPC em internação clínica de novembro/2012 a março/2013 no Hospital Nossa Senhora da Conceição, Porto Alegre (RS). Foram definidos como colonizados pacientes com exame de rastreio (swab) positivo para bactérias produtoras de KPC durante a internação. Resultados: Foram incluídos 75 pacientes, sendo 40 homens, com mediana de 52 anos. O tempo desde o início da internação até a positivação do swab apresentou uma mediana e amplitude interquartil de 18 (9-33) dias, com período de internação de 36 (24-56) dias. Foi identificado uso de cateter central em 93%, sondagem vesical de demora 88%, sondagem nasogástrica/nasoentérica 87%, ventilação mecânica 81% e hemodiálise 40%. Dois terços dos pacientes apresentaram pelo menos um evento infeccioso após a colonização. O escore de Charlson (OR 1,53 por cada ponto; IC95% 1,25-1,97) e diálise prévia (OR 4,35; IC95% 1,39-15,37) foram preditores independentes de mortalidade. Óbito ocorreu em 56% dos pacientes (n=42). Conclusão: Pacientes colonizados por KPC apresentam mortalidade total intra-hospitalar elevada. Comorbidades prévias à colonização foram associadas com mortalidade. O presente estudo não permite definir qual o papel da colonização no desfecho clínico dos pacientes...

Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae have been increasingly identified in hospitalized patients, but little is known about the profile and prognosis of patients colonized by these bacteria. This study aims to assess the epidemiological profile and overall in-hospital mortality of patients colonized by KPC in a reference center. Methods: This is a retrospective cohort study in adult patients colonized by KPC and admitted to clinical units of Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil, between November/2012 and March/2013. Those patients with screening culture test positive for KPC-producing bacteria during hospitalization were defined as colonized. Results: Seventy-five patients were included, 40 of which were males, and the median age was 52 years. The median and interquartile range of time from onset of hospitalization until colonization was 18 [9-33] days, with a median hospital stay of 36 (24-56) days. Considering the other risk factors for colonization, there was a high prevalence in the use of central access catheter (93%), indwelling catheter (88%), nasogastric/enteral tube (87%), mechanical ventilation (81%), and need for hemodialysis (40%). Two thirds of patients had at least one infectious event after colonization. Charlson score (OR 1.53 for each point; 95%CI1.25-1.97) and previous dialysis (OR 4.35; 95%CI1.39-15.37) were independent predictors for mortality. In hospital mortality was 56%. Conclusion: Patients colonized by KPC have high in-hospital overall mortality. Comorbidities were associated with mortality. This study does not enable to define the role of colonization in defining patients’ clinical outcomes...

Valor prognóstico do fragmento N-terminal do peptídeo natriurético tipo B em cirurgia não-cardíaca / Prognostic value of perioperative N-terminal pro-B-type natriuretic peptide in noncardiac surgery

FUNDAMENTO: Já foi demonstrado o uso do NT-proBNP pré-operatório para prever resultado cardíaco adverso, embora estudos recentes tenham sugerido que a determinação do NT-proBNP pós-operatório possa fornecer um valor adicional em pacientes submetidos à cirurgia não cardíaca. OBJETIVO: Avaliar o valor prognóstico perioperatório do NT-proBNP em pacientes de intermediário e alto risco cardiovascular submetidos à cirurgia não cardíaca. MÉTODOS: Este estudo incluiu prospectivamente 145 pacientes com idade > 45 anos, com pelo menos um fator de risco do Índice de Risco Cardíaco Revisado e submetidos à cirurgia de médio ou alto risco não-cardíaca. Os níveis de NTproBNP foram medidos no pré e pós-operatório. Preditores cardíacos de curto prazo foram avaliados por modelos de regressão logística. RESULTADOS: Durante uma mediana de acompanhamento de 29 dias, 17 pacientes (11,7%) apresentaram eventos cardíacos adversos importantes (MACE - 14 infartos do miocárdio não fatais, 2 paradas cardíacas não-fatais e 3 mortes cardíacas). Os níveis ótimos de limiar discriminatório para o NT-proBNP pré e pós-operatório foram 917 e 2962 pg/ mL, respectivamente. O NT-proBNP pré e pós-operatório (OR = 4,7, IC 95%: 1,62-13,73, p = 0,005 e OR 4,5, IC 95%: 1,53-13,16, p = 0,006) foram associados de forma significativa com MACE (eventos cardíacos adversos maiores). O NTproBNP pré-operatório foi significativa e independentemente associado com eventos cardíacos adversos em análise de regressão multivariada (OR ajustado 4,2, IC 95%: 1,38-12,62, p = 0,011). CONCLUSÃO: O NT-proBNP é um importante marcador de curto prazo de eventos cardiovasculares perioperatórios em pacientes de alto risco. Os níveis pós-operatórios foram menos informativos do que os níveis pré-operatórios. Uma única medição de NT-proBNP pré-operatório deve ser considerada na avaliação de risco pré-operatório.

BACKGROUND: Preoperative NT-proBNP has been shown to predict adverse cardiac outcomes, although recent studies suggested that postoperative NT-proBNP determination could provide additional information in patients submitted to noncardiac surgery. OBJECTIVE: To evaluate the prognostic value of perioperative NT-proBNP in intermediate and high risk cardiovascular patients undergoing noncardiac surgery. METHODS: This study prospectively enrolled 145 patients aged >45 years, with at least one Revised Cardiac Risk Index risk factor and submitted to intermediate or high risk noncardiac surgery. NT-proBNP levels were measured pre- and postoperatively. Short-term cardiac outcome predictors were evaluated by logistic regression models. RESULTS: During a median follow-up of 29 days, 17 patients (11.7%) experienced major adverse cardiac events (MACE- 14 nonfatal myocardial infarctions, 2 nonfatal cardiac arrests and 3 cardiac deaths). The optimum discriminatory threshold levels for pre- and postoperative NT-proBNP were 917 and 2962 pg/mL, respectively. Pre- and postoperative NT-proBNP (OR 4.7; 95% CI 1.62-13.73; p=0.005 and OR 4.5; 95% CI 1.53-13.16; p=0.006) were significantly associated with MACE. Preoperative NT-proBNP was significantly and independently associated with adverse cardiac events in multivariate regression analysis (adjusted OR 4.2; 95% CI 1.38-12.62; p=0.011). CONCLUSION: NT-proBNP is a powerful short-term marker of perioperative cardiovascular events in high risk patients. Postoperative levels were less informative than preoperative levels. A single preoperative NT-proBNP measurement should be considered in the preoperative risk assessment.

Prognostic value of perioperative N-terminal pro-B-type natriuretic peptide in noncardiac surgery.

BACKGROUND: Preoperative NT-proBNP has been shown to predict adverse cardiac outcomes, although recent studies suggested that postoperative NT-proBNP determination could provide additional information in patients submitted to noncardiac surgery. OBJECTIVE: To evaluate the prognostic value of perioperative NT-proBNP in intermediate and high risk cardiovascular patients undergoing noncardiac surgery. METHODS: This study prospectively enrolled 145 patients aged ≥ 45 years, with at least one Revised Cardiac Risk Index risk factor and submitted to intermediate or high risk noncardiac surgery. NT-proBNP levels were measured pre- and postoperatively. Short-term cardiac outcome predictors were evaluated by logistic regression models. RESULTS: During a median follow-up of 29 days, 17 patients (11.7%) experienced major adverse cardiac events (MACE- 14 nonfatal myocardial infarctions, 2 nonfatal cardiac arrests and 3 cardiac deaths). The optimum discriminatory threshold levels for pre- and postoperative NT-proBNP were 917 and 2962 pg/mL, respectively. Pre- and postoperative NT-proBNP (OR 4.7; 95% CI 1.62-13.73; p=0.005 and OR 4.5; 95% CI 1.53-13.16; p=0.006) were significantly associated with MACE. Preoperative NT-proBNP was significantly and independently associated with adverse cardiac events in multivariate regression analysis (adjusted OR 4.2; 95% CI 1.38-12.62; p=0.011). CONCLUSION: NT-proBNP is a powerful short-term marker of perioperative cardiovascular events in high risk patients. Postoperative levels were less informative than preoperative levels. A single preoperative NT-proBNP measurement should be considered in the preoperative risk assessment.

Clinical use of ultrasensitive cardiac troponin I assay in intermediate- and high-risk surgery patients.

BACKGROUND: Cardiac troponin levels have been reported to add value in the detection of cardiovascular complications in noncardiac surgery. A sensitive cardiac troponin I (cTnI) assay could provide more accurate prognostic information. METHODS: This study prospectively enrolled 142 patients with at least one Revised Cardiac Risk Index risk factor who underwent noncardiac surgery. cTnI levels were measured postoperatively. Short-term cardiac outcome predictors were evaluated. RESULTS: cTnI elevation was observed in 47 patients, among whom 14 were diagnosed as having myocardial infarction (MI). After 30 days, 16 patients had major adverse cardiac events (MACE). Excluding patients with a final diagnosis of MI, predictors of cTnI elevation included dialysis, history of heart failure, transoperative major bleeding, and elevated levels of pre- and postoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP). Maximal cTnI values showed the highest sensitivity (94%), specificity (75%), and overall accuracy (AUC 0.89; 95% CI 0.80-0.98) for postoperative MACE. Postoperative cTnI peak level (OR 9.4; 95% CI 2.3-39.2) and a preoperative NT-proBNP level ≥917 pg/mL (OR 3.47; 95% CI 1.05-11.6) were independent risk factors for MACE. CONCLUSIONS: cTnI was shown to be an independent prognostic factor for cardiac outcomes and should be considered as a component of perioperative risk assessment.

Adrenal Failure due to Adrenal Metastasis of Lung Cancer: A Case Report.

We report a case of a patient with adrenal failure due to bilateral adrenal metastasis of lung cancer. This is a rare presentation of lung cancer. We review the differential diagnosis of weight loss and how to make diagnosis of adrenal insufficiency.

Reinternação hospitalar precoce: avaliação de um indicador de qualidade assistencial / Early hospital readmission: an indicator of hospital quality of care assessment

Introdução: A reinternação hospitalar precoce é um indicador de qualidade assistencial. Além de desconforto ao paciente, acarreta ônus ao sistema de saúde, fazendo-se necessária uma avaliação do perfil dos pacientes de maior risco. Objetivo: Definir o perfil dos pacientes com reinternação precoce em um hospital universitário. Metodologia: Seleção de todos pacientes clínicos, cirúrgicos e pediátricos que reinternaram em até 7 dias após alta hospitalar nos meses de janeiro a março de 2007. Resultados: Entre 5363 internações, 135 (3%) adultos e 71 (7%) crianças reinternaram em 7 dias. A maioria dos pacientes eram do sexo masculino, com internação nos últimos 3 meses pelo mesmo diagnóstico. As especialidades com maior taxa de reinternação na população adulta foram medicina interna (9,7%), hematologia (9,1%), cardiologia (5,7%), emergência adulto (5,5%), gastroenterologia (5,2%) e cirurgia geral (2,2%). A maioria das internações adultas se deveu a doenças cardiovasculares (20), gastrintestinais (18), respiratórias (17), neoplásicas (17) e urinárias (13). As comorbidades mais comuns nos adultos foram hipertensão arterial (39%), diabetes (24%), tabagismo (18,5%), insuficiência renal (17%), cardiopatia isquêmica (16%), doença pulmonar obstrutiva crônica (16%) e insuficiência cardíaca (15%). As reinternação pediátricas foram predominantemente na população oncológica (42,4%). A média de comorbidades foi de 2,7 por paciente adulto. Do total das reinternações, 13% das crianças e 5 % dos adultos foram a óbito. Conclusão: Os dados apresentados permitem um melhor conhecimento do perfil de pacientes com reinternação precoce, sendo na sua maioria pacientes portadores de neoplasias e múltiplas comorbidades clínicas, devido ao perfil de pacientes crônicos atendidos na instituição.

Background: Early hospital readmission is an indicator of hospital quality of care. It is important to assess readmission risk factors, as it imposes additional burden on patients, families and high cost to healthcare system. Objectives: To define the characteristics of patients with early readmission to a university hospital. Methods: Selection of all patients readmitted in 7 days after hospital discharge from January to March of 2007. Results: All 5363 patients admitted were assessed. 135 (3%) adults and 71 (7%) children were readmitted in 7 days. Most of them were males, with previous admission in the last 3 months with the same diagnosis. Specialities with most common readmission tax in adults were internal medicine (9.7%), hematology (9%), cardiology (5.7%), adult emergency (5.5%), gastroenterology (5%) and general surgery (2.2%). Main causes of adult readmissions were cardiovascular disease (20), gastrintestinal disease (18), respiratory disease (17), cancer (17) and urinary tract disease (13). Most common co-morbidities in adults were hypertension (39%), diabetes (24%), smoke (18.5%), renal failure (17%), ischemic heart disease (16%), chronic obstructive lung disease (16%) and heart failure (15%). Pediatric readmissions were mainly on oncology population (42.4%). Adults had co-morbidities rate of 2.7. Thirteen percent of children and 5 % of adults died during readmission. Conclusions: Patients characteristics may identify those at higher risk of early readmission. Most of them had multiple medical co-morbidities or had oncologic diagnosis. These findings reflect the chronic condition of patients admitted to our institution.

Avaliação dos fatores precipitantes de encefalopatia hepática em pacientes com cirrose / Factors precipitating hepatic encephalopathy in patients with cirrhosis

Objetivo: A maioria dos episódios de Encefalopatia Hepática (EH) em pacientes com doença hepática crônica possui algum evento clínico precipitante reconhecido. A proposta deste estudo foi determinar as manifestações clínicas e os fatores desencadeantes de EH em pacientes com cirrose. Métodos: Cirróticos admitidos na emergência do Hospital de Clínicas de Porto Alegre por episódio de EH (n=20) foram avaliados quanto à presença de fatores precipitantes tais como infecção (incluindo peritonite bacteriana), hemorragia gastrointestinal, constipação, dieta rica em proteína, azotemia, hipocalemia, uso de drogas psicoativas, desidratação, desenvolvimento de hepatoma e outros. Todos os pacientes foram acompanhados até alta hospitalar ou óbito. Resultados: Todos os pacientes tiveram pelo menos um fator desencadeante de EH. O principal fator contribuinte para o desenvolvimento de EH foi infecção (60 por cento), como infecção urinária (35 por cento), infecção respiratória (20 por cento) e Peritonite Bacteriana Espontânea (15 por cento). Conclusão: A medida terapêutica mais importante na EH é identificar os fatores precipitantes e corrigi-los prontamente. O estudo mostra que estes eventos são muito comuns e o diagnóstico precoce de infecção é importante nestes casos