Avaliação do impacto do tempo de espera para admissão em Unidade de Terapia Intensiva no desfecho clínico do paciente crítico / Assessment of the impact of waiting time until admission in the Intensive Care Unit on the clinical outcome of critical patients

RESUMO: Este estudo tem por base a premissa de que com um maior número de leitos de Unidade de Terapia Intensiva (UTI) disponíveis o tempo de espera para admissão em UTI é menor, o que resulta no melhor desfecho clínico, justifi-cando, portanto, a importância do presente estudo. Objetivo: Avaliar se o tempo de espera no Departamento de Emergência até a admissão em UTI tem influência no desfecho clínico do paciente crítico. Metodologia: Estudo ob-servacional, retrospectivo, do tipo antes e depois, realizado em um hospital público do município de Joinville/SC no ano de 2019. Foram incluídos os dados referentes aos pacientes adultos admitidos na UTI com até 72 horas de es-pera no Departamento de Emergência desde a chegada ao hospital. Comparou-se o último trimestre de 2017 (fase 1), período durante o qual havia 14 leitos de UTI no hospital, e último trimestre de 2018 (fase 2), período durante o qual havia 30 leitos de UTI. Resultados: Analisaram-se 173 prontuários elegíveis de 2017 e 2018. Houve diferen-ça estatisticamente significativa no tempo decorrido na emergência até a admissão em UTI entre 2017 e 2018 (me-diana de 22 vs. 15; p=0,0002). A diferença estatística também foi relevante para a mortalidade em até 24 horas após a admissão em UTI, comparando-se os dois anos em questão (9,61% vs. 2,47%; p=0,04). Não houve diferen-ça estatística significante na mortalidade hospitalar entre 2017 e 2018 (34,6% vs. 35,5%; p=0,57). Também não houve diferença estatisticamente relevante entre os demais parâmetros analisados. Conclusão: Comparando-se 2017 a 2018, percebeu-se que o tempo de espera pelo leito de UTI diminuiu, bem como a mortalidade em até 24h da admissão intensiva. No entanto, isto não se refletiu na mortalidade hospitalar. (AU)

ABSTRACT: The premise that underpins this study is that the more Intensive Care Unit (ICU) beds available, the shorter the waiting time for ICU admission, resulting in better clinical outcomes, which justifies the relevance of this study. Objective: Assess if the waiting time in the Emergency Room until ICU admission influences on the clinical outcome of critical patients. Methods: An observational longitudinal retrospective study performed in a public hospital in Joinville/SC in 2019. This study analyzed data from patients admitted to the ICU with up to 72h of waiting time in the Emergency Room. It compares Q4'2017 (phase 1), when there were 14 ICU beds in the hospital vs. Q4'2018 (phase 2), when there were 30 ICU beds. Results: 173 medical records were analyzed in 2017-2018. There was a statistically significant difference in the time for ICU admission between 2017 and 2018 (median 22h vs. 15h; p=0.0002). There was also a statistically significant difference for mortality rates up to 24h of admission (9.61% vs. 2.47%; p=0.04). There was no statistically significant difference for hospital mortality rates (34.6% vs. 35.5%; p=0.57). There was also no statistically significant difference between the other parameters analyzed. Conclusion:Comparing 2017 and 2018, waiting time for an ICU bed was shorter in 2018, and the mortality rates up to 24 hours of ICU admission were lower. However, waiting time in the Emergency Room until ICU admission did not show as-sociation with hospital mortality rates. (AU)

Outbreak of Salmonella Newport associated with internationally distributed raw goats' milk cheese, France, 2018.

Raw milk cheeses are commonly consumed in France and are also a common source of foodborne outbreaks (FBOs). Both an FBO surveillance system and a laboratory-based surveillance system aim to detect Salmonella outbreaks. In early August 2018, five familial FBOs due to Salmonella spp. were reported to a regional health authority. Investigation identified common exposure to a raw goats' milk cheese, from which Salmonella spp. were also isolated, leading to an international product recall. Three weeks later, on 22 August, a national increase in Salmonella Newport ST118 was detected through laboratory surveillance. Concomitantly isolates from the earlier familial clusters were confirmed as S. Newport ST118. Interviews with a selection of the laboratory-identified cases revealed exposure to the same cheese, including exposure to batches not included in the previous recall, leading to an expansion of the recall. The outbreak affected 153 cases, including six cases in Scotland. S. Newport was detected in the cheese and in the milk of one of the producer's goats. The difference in the two alerts generated by this outbreak highlight the timeliness of the FBO system and the precision of the laboratory-based surveillance system. It is also a reminder of the risks associated with raw milk cheeses.

Unusual increase in reported cases of paratyphoid A fever among travellers returning from Cambodia, January to September 2013.

From January to September 2013, a marked increase in notifications of Salmonella Paratyphi A infections among travellers returning from Cambodia occurred in France. An investigation revealed 35 cases without a common source: 21 in France, five in Germany, three in the Netherlands, one in Norway, one in the United Kingdom, four in New-Zealand. Data suggest an ongoing event that should trigger further investigation. Travellers to Cambodia should observe preventive measures including good personal hygiene and food handling practices.

Size and shape variability in the skull of the bottlenose dolphin, Tursiops truncatus (Montagu, 1821).

The bottlenose dolphin (Tursiops truncatus) is a widely spread cetacean species. We present a quantitative analysis of age dimorphism variation in the skull of T. truncatus assessed by geometric morphometrics (GM) methods. Differences in size and shape of skulls were investigated using eight landmarks plotted on 2-D images of ventral views of 14 museum specimens. The results of GM revealed differences in size, but not in shape. The left side appears more variable, which is probably an effect of telescoping.

[Spectral analysis of the electroencephalogram in children with systemic lupus erythematosus]. / Análisis espectral del electroencefalograma en niños con lupus eritematoso sistémico.

INTRODUCTION: Systemic lupus erythematosus (SLE) is an autoimmune disease that affects different systems and organs, including the central nervous system (CNS). It has been suggested that about 40% of the cases of neuropsychiatric lupus (NPSLE) develop before SLE is diagnosed or at the same time it is being carried out, and 63% appear during the first year following diagnosis. AIMS: The aim of this study was to check the hypothesis that the electroencephalogram (EEG) may be sensitive to the damage to the CNS in children with SLE in whom there is still no clinical evidence of NPSLE. PATIENTS AND METHODS: EEG recordings were performed in 30 children with a diagnosis of SLE with or without signs of a neuropsychiatric syndrome. The results of the EEG were evaluated visually and analysed quantitatively. RESULTS: The visual inspection of the EEG showed the presence of alterations in 44.5% of the children with SLE and in 76.9% of those with NPSLE. There were significant differences in Student's t test (p = 0.0055) between the two groups for the analysis of the broadband spectral measurements. The narrow band analysis revealed a significant increase in the theta and delta frequencies in children with SLE as compared to standard values, whereas in children with NPSLE significant differences were found in the fast bands in frontal regions. CONCLUSIONS: Spectral analysis of the narrow band could help to confirm diagnoses of NPSLE, while anomalies in the slow bands could be an early marker of damage to the CNS although there are still no symptoms of the disease.

Anàlisis espectral del encefalograma en niños con lupus eritematoso sistèmico / s. t

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects different systems and organs, including the central nervous system (CNS). It has been suggested that about 40 percent of the cases of neuropsychiatric lupus (NPSLE) develop before SLE is diagnosed or at the same time it is being carried out, and 63 percent appear during the first year following diagnosis. AIMS: The aim of this study was to check the hypothesis that the electroencephalogram (EEG) may be sensitive to the damage to the CNS in children with SLE in whom there is still no clinical evidence of NPSLE...(AU)

Análisis espectral del electroencefalograma en niños con lupus eritematoso sistémico / Spectral analysis of the electroencephalogram in children with systemic lupus erythematosus

Introducción. El lupus eritematoso sistémico (LES) es una enfermedad autoinmunitaria que afecta a diferentes sistemas y órganos, incluido el sistema nervioso central (SNC). Se ha postulado que aproximadamente el 40% de las manifestaciones de lupus neuropsiquiátrico (LESNP) se desarrolla antes de que se diagnostique el LES o en el mismo momento en el que se realiza el mismo, y el 63% aparece durante el primer año después del diagnóstico. Objetivos. Evaluar la hipótesis de que el electroencefalograma (EEG) puede ser sensible al daño del SNC en niños con LES, aun sin evidencia clínica de LESNP. Pacientes y métodos. Se registró el EEG de 30 niños con diagnóstico de LES, con o sin manifestaciones de síndrome neuropsiquiátrico. Se realizó la evaluación visual y el análisis cuantitativo del EEG. Resultados. La inspección visual del EEG mostró la presencia de alteraciones en el 44,5% de los niños con LES y en el 76,9% con LESNP. La t de Student fue significativamente diferente (p 0,0055) entre ambos grupos para el análisis de las medidas espectrales de banda ancha. El análisis de banda estrecha mostró un incremento significativo en las frecuencias theta y delta en los niños con LES con respecto a los valores normativos, mientras que en los niños con LESNP las diferencias significativas se encontraron en las bandas rápidas en las regiones frontales. Conclusiones. El análisis espectral de banda estrecha podría ayudar a confirmar el diagnóstico de LESNP, mientras que las anomalías en las bandas lentas podría ser un marcador temprano de daño del SNC, aun en ausencia de síntomas de la enfermedad

Introduction. Systemic lupus erythematosus (SLE) is an autoimmune disease that affects different systems and organs, including the central nervous system (CNS). It has been suggested that about 40% of the cases of neuropsychiatric lupus (NPSLE) develop before SLE is diagnosed or at the same time it is being carried out, and 63% appear during the first year following diagnosis. Aims. The aim of this study was to check the hypothesis that the electroencephalogram (EEG) may be sensitive to the damage to the CNS in children with SLE in whom there is still no clinical evidence of NPSLE. Patients and methods. EEG recordings were performed in 30 children with a diagnosis of SLE with or without signs of a neuropsychiatric syndrome. The results of the EEG were evaluated visually and analysed quantitatively. Results. The visual inspection of the EEG showed the presence of alterations in 44.5% of the children with SLE and in 76.9% of those with NPSLE. There were significant differences in Student’s t test (p = 0.0055) between the two groups for the analysis of the broadband spectral measurements. The narrow band analysis revealed a significant increase in the theta and delta frequencies in children with SLE as compared to standard values, whereas in children with NPSLE significant differences were found in the fast bands in frontal regions. Conclusions. Spectral analysis of the narrow band could help to confirm diagnoses of NPSLE, while anomalies in the slow bands could be an early marker of damage to the CNS although there are still no symptoms of the disease

Value of predictive genetic testing in management of hereditary non-polyposis colorectal cancer (HNPCC)

OBJECTIVE: To investigate the impact of predictive genetic testing on colonoscopic surveillance in an extended family with hereditary non-polyposis colorectal cancer (HNPCC). SETTING: Familial Bowel Cancer Service, The Royal Melbourne Hospital, Victoria. SUBJECTS: 96 people registered with the Service who were apparently unaffected members of an extended family that met the classic Amsterdam criteria for HNPCC and carried an MLH1 gene mutation (IVS9 + 3insT). INTERVENTION: Predictive genetic testing was offered in a cascade manner to at-risk family members; mutation-positive individuals were advised to have annual colonoscopic surveillance, while mutation-negative individuals were withdrawn from surveillance. MAIN OUTCOME MEASURES: Previous compliance with recommended colonoscopic surveillance; uptake and results of genetic testing; expected effect of genetic test results on number of colonoscopies over five years. RESULTS: 22 of the 96 family members (23%) were not complying with recommended surveillance. Of 48 individuals offered predictive genetic testing, 41 (85%) responded and 39 (81%) underwent testing. Seven of the 39 (18%) were positive for the family-specific mutation, and 32 (82%) were negative. The 39 tested individuals and 37 of their descendants who were registered with the screening program had undergone 70 colonoscopies in the five years before genetic testing. In the five years after testing, only 37 surveillance colonoscopies were planned (annual or two-yearly colonoscopies for the six mutation-positive individuals and five-yearly colonoscopies for four mutation-negative individuals with previously identified adenoma), an almost 50% reduction in colonoscopies. CONCLUSION: Predictive genetic testing in HNPCC families allows many individuals to be withdrawn from regular colonoscopic surveillance. It may therefore reduce costs, as well as have emotional benefits for many individuals.

Double-blind comparison of citalopram and placebo in depressed outpatients with melancholia.

This multicenter study compared the efficacy and safety of citalopram and placebo in a population of moderately to severely depressed patients with melancholia. This randomized, double-blind, parallel-group study compared citalopram (flexible dose; 20-80 mg/day) with placebo in 180 psychiatric outpatients with a DSM-III diagnosis of major depression or bipolar disorder, depressed, who also met DSM-III criteria for melancholia. Following a 1-week placebo washout period, patients meeting study entry criteria were randomized to 4 weeks of double-blind treatment with either citalopram or placebo. Efficacy measures included the Hamilton Rating Scale for Depression (HAM-D), the Clinical Global Impressions (CGI) Scale, and the Zung Self-Rating Depression Scale. Patients treated with citalopram showed significantly greater improvement at endpoint than placebo patients on the HAM-D, CGI, and Zung scales. On the HAM-D, citalopram patients exhibited significantly greater improvement than placebo patients after 1 week of double-blind treatment and at all subsequent study visits. Endpoint analyses of the HAM-D subscales demonstrated that citalopram produced significant improvement of the psychomotor retardation, cognitive disturbance, sleep disturbance, and melancholia symptom clusters. Nausea, dry mouth, somnolence, dizziness, and increased sweating were reported at higher rates by citalopram-treated patients than by placebo-treated patients, but there were no significant citalopram-placebo differences in the incidence of activation (e.g., anxiety, nervousness, insomnia) or sexual dysfunction. Analysis of electrocardiograms, vital signs, and laboratory tests did not reveal any clinically significant effects of citalopram treatment. The results of this study indicate that citalopram is safe and effective in the treatment of depressed patients with melancholia, and is associated with a favorable side effect profile and a potentially rapid onset of action.

Placebo-controlled study of the D4/5-HT2A antagonist fananserin in the treatment of schizophrenia.

OBJECTIVE: The authors' objective was to assess the potential efficacy of fananserin (RP62203), a potent antagonist at the D4 and serotonin2A (5-HT2A) receptors, on symptoms of schizophrenia. METHOD: A double-blind, placebo-controlled study was conducted in 97 patients. Doses of fananserin reached 250 mg b.i.d. over 28 days, starting with an 8-day escalation. Most of the patients were men with paranoid schizophrenia; they were approximately 38 years old. The primary outcome measure was the total Positive and Negative Syndrome Scale score. The patients' mean score on the Positive and Negative Syndrome Scale at entry was 91.8 (SD=16.5). A low dropout rate was observed in both groups of patients (19 [30%] of those given fananserin and nine [27%] of those given placebo). RESULTS: The total Positive and Negative Syndrome Scale score of the patients given fananserin decreased at endpoint by a mean of 4.2 points (SD=15.4); the score of the patients given placebo decreased by 6.7 points (SD=19.6). No differences between treatments were found on secondary measures such as the Clinical Global Impression, Positive and Negative Syndrome Scale subscores or individual items, and Brief Psychiatric Rating Scale total score. The patients' extrapyramidal symptoms did not worsen during the trial, but the patients given fananserin had an increase in akathisia. The safety profile was good in both groups of patients. CONCLUSIONS: The results of this study do not support the prediction that a selective D4 antagonist associated with strong 5-HT2A antagonism will exhibit an antipsychotic effect.

A randomized, placebo-controlled, dose-response trial of venlafaxine hydrochloride in the treatment of major depression.

BACKGROUND: We examined the efficacy and safety of three different dosages of venlafaxine hydrochloride (75, 225, and 375 mg/day) in a multicenter, randomized, double-blind, placebo-controlled, four-group study. METHOD: Outpatients, 18 to 65 years old, who met DSM-III criteria for major depression were included (N = 358 randomized; 194 completed). Of the total patients completing the trial, 59%, 56%, 51%, and 51% were in the placebo, 75-mg, 225-mg, and 375-mg groups, respectively. The primary outcome measures were the Hamilton Rating Scale for Depression (HAM-D21) total, HAM-D21 depression item, Montgomery-Asberg Depression Rating Scale total, and Clinical Global Impressions scale. RESULTS: Each dosage of venlafaxine was associated with statistically significant improvement as compared with placebo, based on the intent-to-treat sample. The two higher dosages were associated with a modestly greater antidepressant response than was the 75-mg dosage. Nausea, dizziness, somnolence, and anorexia were the most common adverse events attributable to venlafaxine. Since headache occurred at a similar frequency in both the drug and placebo groups, we did not consider it to be attributable to venlafaxine use. Withdrawal from the study due to adverse events occurred in 5%, 17%, 24%, and 30% of the patients in the placebo, 75-mg, 225-mg, and 375-mg groups, respectively. CONCLUSION: Venlafaxine, at dosages of 75-375 mg/day, is an effective and well-tolerated antidepressant. With increasing dosage, greater efficacy and possibly more adverse effects will occur.

Gepirone and 1-(2-pyrimidinyl)-piperazine in vitro: human cytochromes mediating transformation and cytochrome inhibitory effects.

Biotransformation of gepirone to its principal metabolite, 1-(2-pyrimidinyl)-piperazine (1-PP), was studied in human liver microsomes and in microsomes from cDNA-transfected human lymphoblastoid cells. Formation of 1-PP from gepirone in liver microsomes proceeded with a mean apparent Km ranging from 335 to 677 microM. Coincubation with 1 microM ketoconazole reduced reaction velocity to less than 5% of control values at a gepirone concentration of 250 microM. Three other metabolites, presumed to be hydroxylated products, were also formed from gepirone. Formation of all three products was reduced to approximately 20% of control values by 1 microM ketoconazole; quinidine at 1 microM produced a small reduction in formation (91-94% of control) of two of the metabolites. 1-PP was formed from gepirone exclusively by pure P450-3A4 with a Km of 849 microM; Km values for the other metabolites were 245, 240, and 415 microM. Two of the products were also formed by P450-2D6. The results indicate that 3A4 is the principal cytochrome mediating 1-PP formation, as well as formation of the other metabolites. The properties of gepirone and 1-PP themselves as cytochrome inhibitors were tested in human liver microsomes using index reactions representing activity of P450-1A2, -2C9, -2C19, -2D6, -2E1 and -3A. Gepirone and 1-PP produced negligible inhibition of all these reactions. Thus gepirone at therapeutic doses in humans has a low likelihood of inhibiting P450-mediated drug metabolism involving these cytochromes.

A comparison of fluvoxamine and fluoxetine in the treatment of major depression.

This randomized, double-blind, parallel-group design study of 100 outpatients with major depressive disorder is the first study in the United States to compare the efficacy and tolerability of fluvoxamine (100-150 mg/day) and fluoxetine (20-80 mg/day). After a variable, single-blind, washout period, patients were randomized to receive either fluvoxamine (51 patients) of fluoxetine (49 patients) for 7 weeks. Efficacy was assessed with the 21-item Hamilton Rating Scale for Depression (HAM-D), and Clinical Global Impressions scale for severity and improvement. Eighty-four percent of each treatment group completed the study with each group having a mean score at end point of less than 10. Both groups demonstrated a 60% improvement in HAM-D scores over the 7-week trial. There were no statistically significant differences observed between the two groups on any efficacy parameter. The medications were well tolerated, with only two patients in each group who were terminated because of side effects. There were differences in the side-effect profiles, with fluvoxamine being associated with less nausea than fluoxetine. In summary, fluvoxamine and fluoxetine were equally effective in reducing depressive symptoms, but the two drugs displayed slightly different side-effect profiles.

Fluvoxamine versus imipramine and placebo: a double-blind comparison in depressed patients.

Approximately 20 million patients suffer from major depressive disorder each year, indicating a need for antidepressant agents that are synonymous with effectiveness, tolerability and patient compliance. The authors examined the effects of fluvoxamine, a selective serotonin reuptake inhibitor, in the treatment of outpatients meeting DSM-III-R criteria for major depressive disorder. A randomized, double-blind, parallel group, placebo- and imipramine-controlled single center study was conducted in 150 outpatients. Patients were randomized to receive up to 150 mg/day of fluvoxamine as a single bedtime dose, 240 mg/day of imipramine on a twice-daily (BID) schedule, or placebo for six weeks. Efficacy measurements included HAM-D, MADRS, CGI, Raskin-Covi and SCL-56 scales. The HAM-D total score indicated that both active treatment groups showed significantly (p < or = 0.05) greater therapeutic benefit than did placebo. Severely depressed patients (HAM-D > or = 30) responded better to fluvoxamine in five of six measures. Side-effects from fluvoxamine were similar to those reported for other selective serotonin reuptake inhibitors (nausea, somnolence) and were well tolerated. Imipramine was associated with anticholinergic effects such as dry mouth and dizziness. The pharmacokinetic properties of fluvoxamine which allow the drug to be administered as a single daily dose should aid in the maintenance of patient compliance, while offering significant clinical benefit in the improvement of depressive symptoms.

A comparison of Culture-Free Self-Esteem Scale means from different child and adolescent groups.

The Culture-Free Self-Esteem Inventory (CFSEI-2) was administered to 7 groups of children: 84 White Catholic school students from a New Orleans suburb, 78 White rural public school students from Virginia, 62 Hispanic Migrant student from Florida, 90 Aboriginal and White students from an isolated Canadian community, 199 African American students attending an inner city school, 60 Hispanic and White international students from Venezuela, and 61 Innuit students from isolated community in Labrador. The four elder groups also wrote three words to describe themselves (the Adjective Generation Technique [AGT]). Significant differences in responding between groups were found on all CFSEI-2 scales and for AGT favorability means. Although several possible reasons for these results are discussed, we conclude that the CFSEI-2 is not culture-free. Recommendations are: change the title of the test to avoid misrepresentation, limit test usage to elementary school children, develop an adolescent version with age appropriate language, and construct local norms before using the CFSEI-2 to make decisions about a child's self-esteem. To determine relevance of scores, a team of professionals and lay persons should review items from this or any test given to children who may be different from the normative or standardization group.

Sertraline safety and efficacy in major depression: a double-blind fixed-dose comparison with placebo.

In a 6-week, randomized, double-blind, multicenter trial, sertraline 50 mg, 100 mg, or 200 mg, or placebo, was administered once daily to 369 patients with DSM-III-defined major depression. Efficacy variables included changes from baseline scores for total Hamilton Rating Scale for Depression (HAMD), HAMD Bech Depression Cluster, Clinical Global Impressions (CGI) Severity, CGI Improvement, and Profile of Mood States Depression/Dejection Factor. For the evaluable-patients analysis, all sertraline groups showed significantly (p < 0.05 or better) greater improvements in all efficacy variables except one when compared with the placebo group. For the all-patients analysis, all efficacy variables in the 50 mg group were statistically significantly (p < 0.05) better than placebo. Side effects increased with increasing dosage but were usually mild and well tolerated. The results of this study show that sertraline 50 mg once daily is as effective as higher dosages for the treatment of major depression with fewer side effects and therapy discontinuations.

ICI 204,636, a novel, atypical antipsychotic: early indication of safety and efficacy in patients with chronic and subchronic schizophrenia.

We evaluated the effects of ICI 204,636 in 12 hospitalized patients with schizophrenia in a double-blind, placebo-controlled, parallel-group, rising-dose study. Patients met the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised criteria for chronic or subchronic schizophrenia and had a total score > or = 30 on the 18-item Brief Psychiatric Rating Scale (BPRS) and a score > or = 3 on the Clinical Global Impression (CGI) Severity of Illness item. Patients received 21 days of double-blind treatment with increasing doses of ICI 204,636 (25 to 250 mg/d) or placebo. Efficacy was assessed using the BPRS and CGI. Response to treatment was defined as a > or = 30% decrease in the BPRS total score from baseline. Extrapyramidal symptoms and abnormal involuntary movements were assessed using the Simpson Scale and Abnormal Involuntary Movement Scale. Changes from baseline in the BPRS and CGI were significantly greater at end point for patients who received ICI 204,636 versus placebo (BPRS, -20.9 vs -4.8; CGI, -2.9 vs -1.0; P < 0.05, analysis of covariance; P < or = 0.06, Wilcoxon rank sum test). All patients in the ICI 204,636 group responded to treatment (P < 0.10) versus only two patients in the placebo group. Mild somnolence occurred in 50% of ICI 204,636-treated patients. No treatment-emergent extrapyramidal symptoms or dystonic reactions were observed. ICI 204,636 showed efficacy in the positive and negative symptoms of schizophrenia and was well tolerated.