Validation of a yellow fever vaccine model using data from primary vaccination in children and adults, re-vaccination and dose-response in adults and studies with immunocompromised individuals.

BACKGROUND: An effective yellow fever (YF) vaccine has been available since 1937. Nevertheless, questions regarding its use remain poorly understood, such as the ideal dose to confer immunity against the disease, the need for a booster dose, the optimal immunisation schedule for immunocompetent, immunosuppressed, and pediatric populations, among other issues. This work aims to demonstrate that computational tools can be used to simulate different scenarios regarding YF vaccination and the immune response of individuals to this vaccine, thus assisting the response of some of these open questions. RESULTS: This work presents the computational results obtained by a mathematical model of the human immune response to vaccination against YF. Five scenarios were simulated: primovaccination in adults and children, booster dose in adult individuals, vaccination of individuals with autoimmune diseases under immunomodulatory therapy, and the immune response to different vaccine doses. Where data were available, the model was able to quantitatively replicate the levels of antibodies obtained experimentally. In addition, for those scenarios where data were not available, it was possible to qualitatively reproduce the immune response behaviours described in the literature. CONCLUSIONS: Our simulations show that the minimum dose to confer immunity against YF is half of the reference dose. The results also suggest that immunological immaturity in children limits the induction and persistence of long-lived plasma cells are related to the antibody decay observed experimentally. Finally, the decay observed in the antibody level after ten years suggests that a booster dose is necessary to keep immunity against YF.

Loss to follow-up in a cohort of HIV-infected patients in a regional referral outpatient clinic in Brazil.

One of the main aspects related to non-adherence to combined antiretroviral therapy (cART) for patients infected with the Human Immunodeficiency Virus (HIV) refers to the abandonment of outpatient care. This study was aimed to estimate the loss to follow-up in outpatient HIV care at a Regional Referral Clinic (SAE) for HIV/AIDS in the city of Juiz de Fora, Brazil, and to identify associated factors and predictors. This is a prospective cohort of patients older than 18 years, under cART and regular outpatient care. The study included patients who attended medical visits during July-August 2011. Those who did not return to the clinic for new medical appointments within 90 days after the sixth month of follow up were considered lost to follow-up in outpatient care. Variables with P value ≤0.25 in the univariate analysis were included in a logistic regression model, adopting a significance level of 0.05. Among the 250 patients included in the study, 44 (17.6 %) were lost to follow up in outpatient care. Among these, 38 (86.4 %) were located in the cART delivery database system (SICLOM). Younger patients (≤43 versus >43 years) (OR 2.30 CI 1.06-5.00, P = 0.04), and patients attended by physician "E", when compared with physicians "A", "B", "C" or "D" (OR 5.90 CI 2.64-13.18, P = 0.00) were more likely to be lost to follow-up. Patients admitted in the service for 7 years or more were also more likely to be to lost to follow-up (OR 2.27 CI 1.2-4.4, P = 0.01), although this association did not remain statistically significant in the multivariate analysis. Although the purpose of the study, to identify individual factors associated to loss to follow-up, positives associations with a specific physician and with patients admitted in the service for 7 years or more suggest organizational factors. Although the majority of patients lost to follow-up in outpatient care were detected by SICLOM, a detectable viral load in most of these patients suggest a quality of outpatient HIV care proved ineffective, despite the availability of cART. We conclude on the need for further studies to investigate structural factors associated to loss to follow-up when enhanced retention strategies should be implemented in order to maintain an effective outpatient HIV care.

Safe surgery checklist: filling adherence, inconsistencies, and challenges. / Checklist de cirurgia segura: adesão ao preenchimento, inconsistências e desafios.

OBJECTIVE: to identify adherence to the safe surgery checklist from its filling out in a general referral hospital in the interior of Minas Gerais state, as well as to verify factors associated with its use. METHODS: this is a retrospective, documentary, cross-sectional study with a quantitative approach. Data collection was performed through a retrospective review of medical records of patients undergoing surgery within one year. Patients of all specialties, aged 18 years or older, and with hospitalization period equal to or greater than 24 hours were included. The probabilistic sample was composed of 423 cases. RESULTS: the checklist was present in 95% of the medical records. However, only 67.4% of them were completely filled out. The presence of the checklist in the medical record was significantly associated with the anesthetic risk of the patient. There was no difference in the filling out percentage among the three checklist moments: before anesthetic induction (sign in), before surgical incision (time out or surgical pause), and before the patient leaves the operating room (sign out). There were also no significant differences regarding the filling out percentage of the surgeon's responsibility items. Considering the surgical procedure performed, inconsistencies were found in the laterality item. CONCLUSION: despite the high percentage of medical records with checklist, the presence of incompleteness and inconsistency may compromise the expected results in the safety of the surgical patient.

OBJETIVO: identificar a adesão ao checklist de cirurgia segura, a partir do seu preenchimento, em um hospital geral de referência do interior do Estado de Minas Gerais, bem como, verificar os fatores associados à sua utilização. MÉTODOS: trata-se de estudo transversal, documental, retrospectivo de abordagem quantitativa. A coleta de dados foi realizada por meio da revisão retrospectiva de prontuários de uma amostra de pacientes operados no período de um ano. Foram incluídos os atendimentos de pacientes cirúrgicos de todas as especialidades, com idade de 18 anos ou mais, e período de internação igual ou maior do que 24 horas. A amostra probabilística foi de 423 casos. RESULTADOS: o checklist estava presente em 95% dos prontuários. Porém, apenas 67,4% deles estavam com preenchimento completo. A presença do checklist no prontuário apresentou associação significativa com o risco anestésico do paciente. Não houve diferença no percentual de preenchimento entre os três momentos do checklist: antes da indução anestésica (sign in), antes da incisão cirúrgica (time out ou parada cirúrgica) e antes do paciente deixar a sala de cirurgia (sign out). Também não foram encontradas diferenças significativas em relação ao percentual de preenchimento dos itens de responsabilidade do cirurgião. Considerando o procedimento cirúrgico realizado, foram encontradas incoerências no item lateralidade. CONCLUSÃO: apesar do elevado percentual de prontuários com checklist, a presença de incompletude e incoerência pode comprometer os resultados esperados na segurança do paciente cirúrgico.

Implementation of a rapid response team in a large nonprofit Brazilian hospital: improving the quality of emergency care through Plan-Do-Study-Act. / Implantação de um time de resposta rápida em um grande hospital filantrópico brasileiro: melhora na qualidade dos cuidados de emergência por meio do ciclo Planejar-Fazer-Estudar-Agir.

OBJECTIVE: To describe the implementation of a rapid response team in a large nonprofit hospital, indicating relevant issues for other initiatives in similar contexts, particularly in Latin America. METHODS: In general terms, the intervention consisted of three major components: (1) a tool to detect aggravation of clinical conditions in general wards; (2) the structuring of a rapid response team to attend to all patients at risk; and (3) the monitoring of indicators regarding the intervention. This work employed four half-year Plan-Do-Study-Act cycles to test and adjust the intervention from January 2013 to December 2014. RESULTS: Between 2013 and 2014, the rapid response team attended to 2,296 patients. This study showed a nonsignificant reduction in mortality from 8.3% in cycle 1 to 5.0% in cycle 4; however, death rates remained stable in cycles 3 and 4, with frequencies of 5.2% and 5.0%, respectively. Regarding patient flow and continuum of critical care, which is a premise of the rapid response system, there was a reduction in waiting time for intensive care unit beds with a decrease from 45.9% to 19.0% in the frequency of inpatients who could not be admitted immediately after indication (p < 0.001), representing improved patient flow in the hospital. In addition, an increase in the recognition of palliative care patients from 2.8% to 10.3% was noted (p = 0.005). CONCLUSION: Implementing a rapid response team in contexts where there are structural restrictions, such as lack of intensive care unit beds, may be very beneficial, but a strategy of adjustment is needed.

OBJETIVO: Descrever a implantação de um time de resposta rápida em um grande hospital filantrópico, indicando as questões relevantes para as iniciativas em contextos similares, particularmente na América Latina. MÉTODOS: Em termos gerais, a intervenção consistiu em três componentes principais: (1) uma ferramenta para detecção de agravamento das condições clínicas nas enfermarias gerais; (2) estruturação de time de resposta rápida capaz de atender a todos os pacientes em risco; e (3) monitoramento dos indicadores relacionados à intervenção. Este trabalho empregou quatro ciclos semestrais (Planejar-Fazer-Estudar-Agir), com a finalidade de testar e ajustar a intervenção, entre janeiro de 2013 e dezembro de 2014. RESULTADOS: Entre 2013 e 2014, o time de resposta rápida atendeu 2.296 pacientes. Houve redução não significante da mortalidade de 8,3% no ciclo 1, para 5,0% no ciclo 4; contudo, o número de óbitos permaneceu estável nos ciclos 3 e 4, com frequência de 5,2% e 5,0%, respectivamente. Com relação ao fluxo de pacientes e cuidados críticos continuados − uma premissa do time de resposta rápida −, houve decréscimo no tempo de espera por um leito na unidade de terapia intensiva, com diminuição de 45,9% para 19,0% na frequência de pacientes hospitalizados que não puderam ser imediatamente admitidos após a indicação (p < 0,001), representando melhora no fluxo de pacientes do hospital; ocorreu também aumento no reconhecimento de pacientes para cuidados paliativos, de 2,8% para 10,3% (p = 0,005). CONCLUSÃO: A implantação de um time de resposta rápida pode trazer benefícios nos contextos em que ocorrem restrições estruturais, como falta de leitos em unidades de terapia intensiva, porém há necessidade de alguns ajustes.

Inappropriate Prescribing in Older Hospitalized Adults: A Comparison of Medical Specialties.

OBJECTIVES: To evaluate the prevalence and number of potentially inappropriate medications (PIMs) in hospitalized older adults, comparing prescription patterns of medical specialties. DESIGN: Retrospective cohort study. SETTING: Tertiary general hospital. PARTICIPANTS: All older adults hospitalized from January through May 2015 (N = 1,900). MEASUREMENTS: Information on medications prescribed during the first and last days of hospitalization was collected and evaluated regarding PIMs using Beers and Screening Tool of Older People's Prescriptions (STOPP) criteria. Medical specialties (internal medicine, cardiology, gastroenterology, infectious disease, nephrology, neurology, pneumology) were compared regarding the prevalence of PIMs and the increase in the number of PIMs during hospitalization. RESULTS: The number of individuals with PIMs increased significantly according to both criteria (62.3% to 66.6% according to Beers criteria, 43.4% to 50.0% according to STOPP criteria). The most common PIMs were sliding-scale insulin (26.9%), clonazepam (9.5%), and periciazine (6.4%) using Beers criteria and spironolactone (10.3%), acetylsalicylic acid (9.8%), and periciazine (8.7%) using STOPP criteria. Neurology, infectious disease, and pneumology had the highest numbers of PIMs, and neurology, pneumology, and cardiology had a greater increase in PIMs during hospitalization than the other specialties. CONCLUSION: This study demonstrates the high and growing prevalence of PIMs in the hospital environment, according to Beers and STOPP criteria. Educational measures and specific pharmaceutical interventions for each specialty are needed to change this situation.

Operational research principles for a routine service process for monitoring the human immunodeficiency virus/acquired immunodeficiency syndrome treatment cascade: data from a cohort in Brazil.

INTRODUCTION:: Bottlenecks still exist during human immunodeficiency virus care that may delay the achievement of better outcomes. METHODS:: We established a monitoring system to trace patients throughout the human immunodeficiency virus/acquired immunodeficiency syndrome care process in Juiz de Fora, Brazil, to identify potential bottlenecks. RESULTS:: Among 250 patients, 17.6% abandoned follow-up. Our monitoring system tracked 86.4% of patients through the medication logistics control system and 2.3% through the mortality information system. Two percent of patients were not located by our monitoring system. CONCLUSIONS:: A pathway care process contributes to a better understanding of the barriers to the treatment cascade.

Mathematical modeling based on ordinary differential equations: A promising approach to vaccinology.

New contributions that aim to accelerate the development or to improve the efficacy and safety of vaccines arise from many different areas of research and technology. One of these areas is computational science, which traditionally participates in the initial steps, such as the pre-screening of active substances that have the potential to become a vaccine antigen. In this work, we present another promising way to use computational science in vaccinology: mathematical and computational models of important cell and protein dynamics of the immune system. A system of Ordinary Differential Equations represents different immune system populations, such as B cells and T cells, antigen presenting cells and antibodies. In this way, it is possible to simulate, in silico, the immune response to vaccines under development or under study. Distinct scenarios can be simulated by varying parameters of the mathematical model. As a proof of concept, we developed a model of the immune response to vaccination against the yellow fever. Our simulations have shown consistent results when compared with experimental data available in the literature. The model is generic enough to represent the action of other diseases or vaccines in the human immune system, such as dengue and Zika virus.

Análise de custo-efetividade do uso de inibidores da via de sinalização mTOR x micofenolato em receptores de transplante renal sem profilaxia para citomegalovírus s / Cost-effectiveness analysis of the use of mTOR signaling pathway inhibitors x mycophenolate in kidney transplantation recipients without cytomegalovirus prophylaxis

Objetivo: Avaliar a relação de custo-efetividade dos regimes imunossupressores utilizados em pacientes receptores de transplante renal, no Hospital Santa Casa de Misericórdia de Juiz de Fora, MG, basiliximabe, micofenolato de sódio, tacrolimo e prednisona (Grupo 1 = 93 pacientes), comparados com a associação de timoglobulina, everolimo, tacrolimo e prednisona (Grupo 2 = 91 pacientes). Métodos: Para a análise farmacoeconômica, foi utilizado o modelo de Árvore de Decisão, desenvolvido no software Treeage Suite 2011. Foi considerada uma coorte real de pacientes submetidos ao transplante renal entre janeiro de 2013 e março de 2017, os quais foram acompanhados por um período de um ano, sendo mensurados os benefícios clínicos, bem como os custos associados, na perspectiva do Sistema Único de Saúde. O método de custeio utilizado foi o botton-up. Foram adotados os limiares de custo-efetividade (LCEs) equivalentes a 1 PIB per capita e 1 a 3 PIB, considerando o ano de 2017. Resultados: No que diz respeito à sobrevida, a RCEI foi de cerca de R$ 214.234,12 para 1 ano de vida ganho. Em relação aos eventos adversos, a RCEI foi de cerca de R$ 43.682,98 para 1 ano sem incidência de eventos adversos. Conclusões: Ao avaliar a sobrevida e a incidência de eventos adversos, timoglobulina+everolimo não é considerado custo-efetivo em relação ao esquema contendo basiliximabe+micofenolato de sódio diante do LCE de 1 PIB per capita. No entanto, ao adotarmos o LCE até 3 PIB per capita, o regime contendo moglobulina+everolimo é custo-efetivo, ultrapassando cerca de 38% do PIB per capita.

Objective: Evaluate the cost-effectiveness of immunosuppressive regimens used in kidney transplant recipients at the Santa Casa de Misericórdia, Hospital in Juiz de Fora, MG, compared with basiliximab, mycophenolate sodium, tacrolimus and prednisone (Group 1 = 93 patients) with the association of thymoglobulin, everolimus, tacrolimus and prednisone (Group 2 = 91 patients). Methods: For the pharmacoeconomic analysis, the Decision Tree model was used, developed in the TreeAge Suite 2011 software. A real cohort of patients undergoing kidney transplantation between January 2013 and March 2017 was considered, they were followed up for a period of 1 year, where the clinical benefits were measured, as well as the associated costs, from the perspective

Análise do impacto das ações judiciais em um setor de referência de um hospital de grande porte de Juiz de Fora / Analysis of the impact of legal actions on a reference sector of a large hospital in Juiz de Fora

Objetivo: Avaliar o impacto das ações judiciais no setor de ortopedia da Santa Casa de Juiz de Fora/MG. Métodos: Foi realizada análise dos prontuários dos pacientes que passaram por cirurgia no setor de ortopedia da Santa Casa de Juiz de Fora no ano de 2016. E, logo após, os pacientes advindos de ação judicial foram identificados, dividindo-se, assim, a amostra em dois grupos. As variáveis analisadas foram: sexo e idade do paciente; tempo de internação, desfecho e custos, os quais foram desmembrados em diárias, honorários, procedimentos e materiais e medicamentos. Resultados: Os resultados demonstraram que os pacientes que realizaram cirurgias por via judicial são, em sua maioria, idosos, com leve predominância do sexo masculino. A maior das demandas é para a garantia de cirurgias do sistema osteomuscular de membros inferiores, representando 65,9% das cirurgias realizadas por ação judicial em 2016, que também são as cirurgias mais demandadas por via convencional. O custo direto das cirurgias por processos judiciais foi estimado em R$ 2.340.301,68. As diárias apresentaram o maior custo, sendo responsáveis por 90,7% de todo o custo estimado. Conclusão: A judicialização neste estudo expõe deficiências do Sistema Único de Saúde quanto à oferta de serviços, uma vez que todas as cirurgias demandadas por meio de ação judicial já são contempladas pelo sistema público de saúde. Assim, os aspectos judiciais da saúde, tais como a individualidade e os prazos para cumprimento, prevalecem sobre o coletivo e os que esperam nas filas.

Objective: Evaluate the impact of legal actions in the orthopedic sector of Santa Casa de Juiz de Fora/MG. Methods: An analysis was carried out of the medical records of patients who underwent surgery in the orthopedic sector of Santa Casa de Juiz de Fora in the year 2016. Soon afterwards, patients from a judicial action were identified, thus dividing the sample into two groups. The analyzed variables were: sex and age of the patient; time of hospitalization, outcome and costs, which were broken down into: daily, fees, procedures and materials and medicines. Results: The results showed that patients who underwent surgeries by judicial means are mostly elderly, with a slight predominance of males. The largest of the demands is to guarantee osteomuscular lower limb surgeries, accounting for 65.9% of surgeries performed by lawsuit in 2016, which are also the most commonly performed surgeries. The direct cost of surgeries for legal proceedings was estimated at R$ 2,340,301.68. The daily costs were those that presented the highest cost, accounting for 90.7% of the estimated cost. Conclusion: The judicialization in this study exposes deficiencies of the Unified Health System regarding the offer of services, once all the surgeries demanded by lawsuit are already contemplated by the public health system. Thus, the judicial aspects of health, such as: individuality and deadlines for compliance prevail over the collective and those waiting in the queues.

External validation of SAPS 3 and MPM0-III scores in 48,816 patients from 72 Brazilian ICUs.

BACKGROUND: The performance of severity-of-illness scores varies in different scenarios and must be validated prior of being used in a specific settings and geographic regions. Moreover, models' calibration may deteriorate overtime and performance of such instruments should be reassessed regularly. Therefore, we aimed at to validate the SAPS 3 in a large contemporary cohort of patients admitted to Brazilian ICUs. In addition, we also compared the performance of the SAPS 3 with the MPM0-III. METHODS: This is a retrospective cohort study in which 48,816 (medical admissions = 67.9%) adult patients are admitted to 72 Brazilian ICUs during 2013. We evaluated models' discrimination using the area under the receiver operating characteristic curve (AUROC). We applied the calibration belt to evaluate the agreement between observed and expected mortality rates (calibration). RESULTS: Mean SAPS 3 score was 44.3 ± 15.4 points. ICU and hospital mortality rates were 11.0 and 16.5%. We estimated predicted mortality using both standard (SE) and Central and South American (CSA) customized equations. Predicted mortality rates were 16.4 ± 19.3% (SAPS 3-SE), 21.7 ± 23.2% (SAPS 3-CSA) and 14.3 ± 14.0% (MPM0-III). Standardized mortality ratios (SMR) obtained for each model were: 1.00 (95% CI, 0.98-0.102) for the SAPS 3-SE, 0.75 (0.74-0.77) for the SAPS 3-CSA and 1.15 (1.13-1.18) for the MPM0-III. Discrimination was better for SAPS 3 models (AUROC = 0.85) than for MPM0-III (AUROC = 0.80) (p < 0.001). We applied the calibration belt to evaluate the agreement between observed and expected mortality rates (calibration): the SAPS 3-CSA overestimated mortality throughout all risk classes while the MPM0-III underestimated it uniformly. The SAPS 3-SE did not show relevant deviations from ideal calibration. CONCLUSIONS: In a large contemporary database, the SAPS 3-SE was accurate in predicting outcomes, supporting its use for performance evaluation and benchmarking in Brazilian ICUs.

Análise do custo-efetividade da implantação de uma Unidade de Prática Integrada no cuidado de idosos com fratura do quadril / Cost-effectiveness analysis of the implantation of a Multidisciplinary Unit for elderly with hip fracture

Objetivo: Avaliar o custo-efetividade da internação de idosos com fratura do quadril antes e após a implantação de uma unidade multidisciplinar em um serviço de Ortopedia. Métodos: Estudo observacional retrospectivo de caráter quantitativo. Cinquenta e três idosos foram submetidos ao tratamento usual e 219 foram assistidos pela equipe multidisciplinar. Para avaliação dos custos e efetividade, foram utilizados os testes t de Student e qui-quadrado, com nível de significância de 0,05. Para a análise de custo-efetividade, com perspectiva do prestador de saúde, considerando os custos diretos médicos, foi utilizado o modelo estatístico do tipo árvore de decisão. A comparação entre as duas alternativas foi medida pela razão de custo-efetividade incremental. Resultados: Após a introdução da unidade multidisciplinar, o tempo entre o trauma e a cirurgia diminuiu de 4,21 dias para 2,47 (p < 0,001), a permanência, de 8,78 dias para 6,58 (p = 0,041) e a mortalidade, de 22,6% para 8,2% (p < 0,001). O custo do tratamento nos dois grupos não apresentou diferença significativa (p = 0,838). Conclusão: A introdução da unidade multidisciplinar se mostrou custo-efetiva, uma vez que presultou em menor tempo de internação hospitalar e menor mortalidade intra-hospitalar.

Objective: Evaluating the cost-effectiveness of the hospitalization of elderly with hip fracture before and after the implantation of a multidisciplinary unit in a service of orthopedics. Methods: Quantitative retrospective observational study. Fifty-three elderly were submitted to the usual treatment and 219 were assisted by the multidisciplinary team. The t Student test and the chisquared test were used to assess factors associated with cost variation and effectiveness, with a significance level of 0.05. For the cost-effectiveness analysis, from the perspective of the health provider considering the direct medical costs, the decision tree statistical model was used. The comparison between the two alternatives was measured by the incremental cost-effectiveness ratio. Results: After introduction of the multidisciplinary unit, the time between trauma and surgery decreased from 4.21 days to 2.47 (p < 0.001), the length of stay from 8.78 days to 6.58 (p = 0.041) and mortality from 22.6% to 8.2% (p < 0.001). The cost of treatment in the two groups did not present a significant difference (p = 0.838). Conclusion: The introduction of the multidisciplinary unit was cost-effective, as it resulted in shorter hospital stay and lower in-hospital mortality

Checklist de cirurgia segura: adesão ao preenchimento, inconsistências e desafios / Safe surgery checklist: filling adherence, inconsistencies, and challenges

RESUMO Objetivo: identificar a adesão ao checklist de cirurgia segura, a partir do seu preenchimento, em um hospital geral de referência do interior do Estado de Minas Gerais, bem como, verificar os fatores associados à sua utilização. Métodos: trata-se de estudo transversal, documental, retrospectivo de abordagem quantitativa. A coleta de dados foi realizada por meio da revisão retrospectiva de prontuários de uma amostra de pacientes operados no período de um ano. Foram incluídos os atendimentos de pacientes cirúrgicos de todas as especialidades, com idade de 18 anos ou mais, e período de internação igual ou maior do que 24 horas. A amostra probabilística foi de 423 casos. Resultados: o checklist estava presente em 95% dos prontuários. Porém, apenas 67,4% deles estavam com preenchimento completo. A presença do checklist no prontuário apresentou associação significativa com o risco anestésico do paciente. Não houve diferença no percentual de preenchimento entre os três momentos do checklist: antes da indução anestésica (sign in), antes da incisão cirúrgica (time out ou parada cirúrgica) e antes do paciente deixar a sala de cirurgia (sign out). Também não foram encontradas diferenças significativas em relação ao percentual de preenchimento dos itens de responsabilidade do cirurgião. Considerando o procedimento cirúrgico realizado, foram encontradas incoerências no item lateralidade. Conclusão: apesar do elevado percentual de prontuários com checklist, a presença de incompletude e incoerência pode comprometer os resultados esperados na segurança do paciente cirúrgico.

ABSTRACT Objective: to identify adherence to the safe surgery checklist from its filling out in a general referral hospital in the interior of Minas Gerais state, as well as to verify factors associated with its use. Methods: this is a retrospective, documentary, cross-sectional study with a quantitative approach. Data collection was performed through a retrospective review of medical records of patients undergoing surgery within one year. Patients of all specialties, aged 18 years or older, and with hospitalization period equal to or greater than 24 hours were included. The probabilistic sample was composed of 423 cases. Results: the checklist was present in 95% of the medical records. However, only 67.4% of them were completely filled out. The presence of the checklist in the medical record was significantly associated with the anesthetic risk of the patient. There was no difference in the filling out percentage among the three checklist moments: before anesthetic induction (sign in), before surgical incision (time out or surgical pause), and before the patient leaves the operating room (sign out). There were also no significant differences regarding the filling out percentage of the surgeon's responsibility items. Considering the surgical procedure performed, inconsistencies were found in the laterality item. Conclusion: despite the high percentage of medical records with checklist, the presence of incompleteness and inconsistency may compromise the expected results in the safety of the surgical patient.

Implantação de um time de resposta rápida em um grande hospital filantrópico brasileiro: melhora na qualidade dos cuidados de emergência por meio do ciclo Planejar-Fazer-Estudar-Agir / Implementation of a rapid response team in a large nonprofit Brazilian hospital: improving the quality of emergency care through Plan-Do-Study-Act

RESUMO Objetivo: Descrever a implantação de um time de resposta rápida em um grande hospital filantrópico, indicando as questões relevantes para as iniciativas em contextos similares, particularmente na América Latina. Métodos: Em termos gerais, a intervenção consistiu em três componentes principais: (1) uma ferramenta para detecção de agravamento das condições clínicas nas enfermarias gerais; (2) estruturação de time de resposta rápida capaz de atender a todos os pacientes em risco; e (3) monitoramento dos indicadores relacionados à intervenção. Este trabalho empregou quatro ciclos semestrais (Planejar-Fazer-Estudar-Agir), com a finalidade de testar e ajustar a intervenção, entre janeiro de 2013 e dezembro de 2014. Resultados: Entre 2013 e 2014, o time de resposta rápida atendeu 2.296 pacientes. Houve redução não significante da mortalidade de 8,3% no ciclo 1, para 5,0% no ciclo 4; contudo, o número de óbitos permaneceu estável nos ciclos 3 e 4, com frequência de 5,2% e 5,0%, respectivamente. Com relação ao fluxo de pacientes e cuidados críticos continuados − uma premissa do time de resposta rápida −, houve decréscimo no tempo de espera por um leito na unidade de terapia intensiva, com diminuição de 45,9% para 19,0% na frequência de pacientes hospitalizados que não puderam ser imediatamente admitidos após a indicação (p < 0,001), representando melhora no fluxo de pacientes do hospital; ocorreu também aumento no reconhecimento de pacientes para cuidados paliativos, de 2,8% para 10,3% (p = 0,005). Conclusão: A implantação de um time de resposta rápida pode trazer benefícios nos contextos em que ocorrem restrições estruturais, como falta de leitos em unidades de terapia intensiva, porém há necessidade de alguns ajustes.

ABSTRACT Objective: To describe the implementation of a rapid response team in a large nonprofit hospital, indicating relevant issues for other initiatives in similar contexts, particularly in Latin America. Methods: In general terms, the intervention consisted of three major components: (1) a tool to detect aggravation of clinical conditions in general wards; (2) the structuring of a rapid response team to attend to all patients at risk; and (3) the monitoring of indicators regarding the intervention. This work employed four half-year Plan-Do-Study-Act cycles to test and adjust the intervention from January 2013 to December 2014. Results: Between 2013 and 2014, the rapid response team attended to 2,296 patients. This study showed a nonsignificant reduction in mortality from 8.3% in cycle 1 to 5.0% in cycle 4; however, death rates remained stable in cycles 3 and 4, with frequencies of 5.2% and 5.0%, respectively. Regarding patient flow and continuum of critical care, which is a premise of the rapid response system, there was a reduction in waiting time for intensive care unit beds with a decrease from 45.9% to 19.0% in the frequency of inpatients who could not be admitted immediately after indication (p < 0.001), representing improved patient flow in the hospital. In addition, an increase in the recognition of palliative care patients from 2.8% to 10.3% was noted (p = 0.005). Conclusion: Implementing a rapid response team in contexts where there are structural restrictions, such as lack of intensive care unit beds, may be very beneficial, but a strategy of adjustment is needed.

Operational research principles for a routine service process for monitoring the human immunodeficiency virus/acquired immunodeficiency syndrome treatment cascade: data from a cohort in Brazil

Abstract INTRODUCTION: Bottlenecks still exist during human immunodeficiency virus care that may delay the achievement of better outcomes. METHODS: We established a monitoring system to trace patients throughout the human immunodeficiency virus/acquired immunodeficiency syndrome care process in Juiz de Fora, Brazil, to identify potential bottlenecks. RESULTS: Among 250 patients, 17.6% abandoned follow-up. Our monitoring system tracked 86.4% of patients through the medication logistics control system and 2.3% through the mortality information system. Two percent of patients were not located by our monitoring system. CONCLUSIONS: A pathway care process contributes to a better understanding of the barriers to the treatment cascade.

Neurological adverse events temporally associated to mass vaccination against yellow fever in Juiz de Fora, Brazil, 1999-2005.

The identification of adverse events following immunization (AEFI) and their prompt investigation are important to allow a timely and scientifically based response to the users of immunization services. This article presents an analysis of notified AEFI cases between 1999 and 2005 and their temporal association with 2001 yellow fever vaccination campaign, AEFI notification attributed to yellow fever vaccination rose from 0.06 to 1.32 per 100,000 vaccinees in Brazil, between 1998 and 2000. During the 2001 yellow fever mass vaccination campaign held in Juiz de Fora, Brazil, 12 cases of aseptic meningitis were temporally associated to yellow fever vaccination, but clinical and laboratory data were not available to confirm nor deny causality. Epidemiological studies associated to enhanced surveillance and standardized protocols should take advantage of public health interventions like mass vaccination campaigns and implementation of new vaccination strategies in order to assess and investigate vaccine safety.

Surveillance system of vaccine adverse events and local data analysis--the experience in a middle-sized city in Brazil, 1999-2001.

We reviewed all vaccine adverse events (VAE) notified in a middle-sized Brazilian city (n=247) to the National Immunisation Program between January 1999 and December 2001. Vaccine doses used in that period were considered for rate estimates. Aspects of the surveillance system (SS) and their influences on collected data were considered, searching for contributions of local data analysis to investigation of VAE and to the monitoring of vaccine safety. Notification rates in our study were higher when compared to national data. Changes in the notification pattern were observed following vaccination campaign periods. An increase in aseptic meningitis cases temporally associated to yellow fever vaccine was detected. The analysis of local data provided information unperceived in national consolidated data. Through this analysis we detected: events related to application technique and handling; people's perception changes on VAE; and the local SS's ability to raise new hypothesis. We suggested changes to the notification form regarding data entry criteria and analysis.

Síndrome de ativação macrofágica após uso de Leflunomida em paciente com doença de Still do adulto: relato de caso / Macrophage activation syndrome following the use of Leflunomide in a patient with adult-onset Still disease: case report

Paciente do sexo feminino, 32 anos de idade, com doença de Still do adulto, após 15 dias da introdução de leflunomida é admitida com quadro de febre persistente e crise convulsiva tônico-clônica generalizada, rapidamente evoluindo com hepatosplenomegalia, distúrbio da função hepática, trombocitopenia, elevação da lactato-desidrogenase, hipertrigliceridemia, hiperferritinemia e insuficiência renal, levando ao diagnóstico de síndrome de ativação macrofágica, uma complicação rara das doenças reumatológicas que resulta de ativação e proliferação incontrolada de linfócitos T e de excessiva ativação de macrófagos. Pode evoluir com coagulação intravascular disseminada, sendo o envolvimento renal raro. A terapêutica deve ser por meio de pulsoterapia com metilpredinisolona e ciclosporina.

A 32-year-old white female, with adult-onset Still disease, was admitted following a 15-day course of leflunomide, with persistent fever and a generalized tonic-clonic seizure. She quickly developed liver and spleen enlargement, impairment of liver function, thrombocytopenia, elevation of lactate-dehydrogenase, trylicerides and ferritin, and renal failure, being diagnosed with the macrophage activation syndrome, a rare complication of rheumatic diseases due to activation and uncontrolled proliferation of T lymphocytes and excessive macrophage activation. The syndrome may lead to disseminated intravascular coagulation, renal impairment being a rare event. Pulse therapy with methylprednisolone and cyclosporine are the therapeutic options.

Análise do perfil de reatogenicidade vacinal Juiz de Fora/MG - 1999-2001 / Analysis of the profile of reatogenicidade vacinal Juiz de Fora/MG 1999-2001

O objetivo desse estudo foi de analisar o sistema de vigilância de eventos adversos pós-vacinais (EAPV) e o perfil dos eventos notificados no período de 1999 a 2001 no município de Juiz de Fora (JF), considerando aspectos inerentes ao sistema de vigilância epidemiológica e as potenciais influências desses na variação dos dados obtidos, assim como seu papel para a monitorização da segurança dos procedimentos relacionados à imunização e manutenção de altas coberturas vacinais. O banco de dados contou com 228 casos de EAPV notificados entre janeiro de 1999 e dezembro de 2001. Houve um aumento do número de eventos notificados em 2001 devido especialmente às notificações durante a campanha de vacinação contra febre amarela. Os achados em relação às principais vacinas suspeitas de causar EAPV e as proporções encontradas nos eventos notificados foram semelhantes aos do Programa Nacional de Imunização (PNI). As vacinas BCG e antiamarílica apresentaram taxas de notificação superiores às encontradas pelo PNI, além de terem sido observadas mudanças no padrão de notificações entre os períodos de vacinação em rotina e em campanhas vacinais.A funcionalidade do sistema em JF para detecção de EAPV foi indicada pela obtenção de resultados semelhantes aos encontrados pelo PNI (EAPV esperados como o episódios hipotônico-hiporresponsivo). A análise de dados locais pode fornecer informações não perceptíveis em dados agregados em nível nacional tanto na detecção de eventos e surtos relacionados à técnica de aplicação e manuseio e mudanças na percepção da população e dos profissionais de saúde, quanto pela possibilidade do levantamento de novas hipóteses como o da associação temporal entre vacinação contra febre amarela e casos de meningite asséptica.