Trends in Health-Care Utilization at the End of Life Among Patients With Hematologic Malignancies in a Middle-Income Country: Challenges and Opportunities in Brazil.

Patients with hematologic malignancies (HMs) often receive poor-quality end-of-life care. This study aimed to identify trends in end-of-life care among patients with HM in Brazil. We conducted a retrospective cohort study (2015-2018) of patients who died with HM, using electronic medical records linked to health insurance databank, to evaluate outcomes consistent with health-care resource utilization at the end of life. Among 111 patients with HM, in the last 30 days of life, we found high rates of emergency department visits (67%, n = 75), intensive care unit admissions (56%, n = 62), acute renal replacement therapy (10%, n = 11), blood transfusions (45%, n = 50), and medical imaging utilization (59%, n = 66). Patients received an average of 13 days of inpatient care and the majority of them died in the hospital (53%, n = 58). We also found that almost 40% of patients (38%, n = 42) used chemotherapy in the last 14 days of life. These patients were more likely to be male (64% vs 22%; P < .001), to receive blood transfusions (57% vs 38%; P = .05), and to die in the hospital (76% vs 39%; P = .009) than patients who did not use chemotherapy in the last 14 days of life. This study suggests that patients with HM have high rates of health-care utilization at the end of life in Brazil. Patients who used chemotherapy in the last 14 days of life were more likely to receive blood transfusions and to die in the hospital.

Quality in intensive care units: proposal of an assessment instrument.

BACKGROUND: There is an increasing need for standardized instruments for quality assessment that are able to reflect the actual conditions of the intensive care practices, especially in low and middle-income countries. The aim of this article is to describe the preparation of an instrument for quality assessment of adult intensive care services adapted to the actual conditions of intensive care in a middle-income country and comprising indicators validated in the literature. METHODS: The study consisted of five steps: (1) a literature survey; (2) a discussion with specialists by consensus method; (3) a pilot field test; (4) a description of indicators; and (5) an elaboration of the final version of the instrument. Each generated indicator was attributed a score ("out of standard" = 0; "below standard" = 1; "standard" = 2) that allowed calculation of the total score for each service assessed. RESULTS: A total of 62 indicators were constructed, distributed as follows: 38 structure indicators (physical structure: 4; human resources: 14; continued education and training: 2; protocols and routines: 12; material resources: 6); 17 process indicators (safety: 7; work: 10); and seven outcome indicators. The maximum possible total score was 124. CONCLUSIONS: Possible future applications of the instrument for the assessment of intensive care units that was constructed in the present study include benchmarking, multicenter studies, self-assessment of intensive care units, and evaluation of changes resulting from interventions.

A first postoperative day predictive score of mortality for cardiac surgery.

PURPOSE: Several prognostic scores for cardiac surgery based on preoperative variables are available. We propose a new one based on pre-and intraoperative and first postoperative day variables for cardiac surgery patients admitted to a surgical intensive care unit. MATERIALS AND METHODS: Classical cohort of data consecutively collected from June 2000 to March 2003 (1,458 patients). Forty-six risk variables were identified. The statistical study comprised univariate analysis followed by logistic regression with receiver operating characteristics (ROC) curve. RESULTS: After logistic regression, the selected variables and respective odds ratios were: age >65 and <75 years (2.05); age >/=75 years (4.79); left atrial diameter >45 mm (2.58); preoperative creatinine >2 mg/dL (4.84); and cardiopulmonary bypass time >/=180 min (4.93+/-2). The first postoperative day variables were as follows: the worst PaO(2)/FiO(2) <100 (9.47); epinephrine or norepinephrine dose >/=0.1 microg/kg/min (6.78); and mechanical ventilation time >12 h (2.24). The area under the ROC curve was 0.84. CONCLUSION: The score shows the strength of first postoperative day variables, probably related to intraoperative conditions. It also evidences the importance of left atrial diameter as a new marker of preoperative risk.

Predictive factors for pneumonia onset after cardiac surgery in Rio de Janeiro, Brazil.

OBJECTIVE: To develop a predictive system for the occurrence of nosocomial pneumonia in patients who had cardiac surgery performed. DESIGN: Retrospective cohort study.Setting. Two cardiologic tertiary care hospitals in Rio de Janeiro, Brazil. PATIENTS: Between June 2000 and August 2002, there were 1,158 consecutive patients who had complex heart surgery performed. Patients older than 18 years who survived the first 48 postoperative hours were included in the study. The occurrence of pneumonia was diagnosed through active surveillance by an infectious diseases specialist according to the following criteria: the presence of new infiltrate on a radiograph in association with purulent sputum and either fever or leukocytosis until day 10 after cardiac surgery. Predictive models were built on the basis of logistic regression analysis and classification and regression tree (CART) analysis. The original data set was divided randomly into 2 parts, one used to construct the models (ie, "test sample") and the other used for validation (ie, "validation sample"). RESULTS: The area under the receiver-operating characteristic (ROC) curve was 69% for the logistic regression model and 76% for the CART model. Considering a probability greater than 7% to be predictive of pneumonia for both models, sensitivity was higher for the logistic regression models, compared with the CART models (64% vs 56%). However, the CART models had a higher specificity (92% vs 70%) and global accuracy (90% vs 70%) than the logistic regression models. Both models showed good performance, based on the 2-graph ROC, considering that 84.6% and 84.3% of the predictions obtained by regression and CART analyses were regarded as valid. CONCLUSION: Although our findings are preliminary, the predictive models we created showed fairly good specificity and fair sensitivity.

Rioescore: escore preditivo de mortalidade para pacientes submetidos à cirurgia cardíaca baseado em variáveis de pré, per e primeiro dia de pós-operatório / Rioescore: a predictive score of mortality for patients undergoing cardiac surgery based on pre, intra and first postoperative day variables

Objetivo: Criar um escore preditivo de mortalidade hospitalar em pacientes submetidos à cirurgia carddíaca e admitidos em duas Unidades de Terapia Intensiva Cirúrgica, analisando variáveis pré, per e de primeiro dia de pós-operatório.Métodos: Coorte clássica de 1458 pacientes internados consecutivamente no período de junho 2000 até março de 2003, com 46 variáveis previamente definidas. a análise estatística consistiu em análise univariada, seguida de regressão logística (RL), com teste de tendência linear e curva ROC.Resultados:Após, as variáveis selecionadas com os respectivos OR foram: idade entre 65 e 75 anos (2,05);idade maior ou igual 75 anos (4,79); diâmetro do átrio esquerdo maior 45mm (2,58)...

Circulating levels of macrophage migration inhibitory factor are associated with mild pulmonary dysfunction after cardiopulmonary bypass.

Macrophage migration inhibitory factor (MIF) is a central mediator of inflammatory response and acute lung injury that is secreted in response to corticosteroids. A rise in systemic MIF levels was described after cardiac surgery in steroid-treated patients. This study aimed to investigate the circulating levels of MIF and the possible relationship of this cytokine to pulmonary dysfunction after cardiopulmonary bypass (CPB). We included 74 patients without previous organ dysfunction undergoing elective coronary artery bypass surgery (CABS). The same team performed all CABS via a standard technique adding methylprednisolone (15 mg/kg) to the CPB priming solution (Group MP, n = 37). In the remaining patients (Group NS, n = 37), methylprednisolone was withdrawn from the CPB priming. MIF, C-reactive protein (CRP), and total C3 were assayed in peripheral blood sampled immediately before anesthesia induction and 3, 6, and 24 h post-CPB. Preoperative risk scores and peri- and postoperative variables were documented. Postoperative kinetics of MIF and C3 were similar for both groups. Levels of CRP 24 h post-CPB were higher in Group MP (P = 0.003). Higher MIF levels were detected 6 h post-CPB, and returned to preoperative levels 24 h after CPB. MIF levels 6 h post-CPB were inversely related to the postoperative PaO2/FiO2 ratio (P = 0.0021) and were directly related to the duration of mechanical ventilation (P = 0.014). Perioperative use of methylprednisolone did not modify the MIF response to CPB, but it was related to an enhanced acute phase response. Higher circulating MIF levels 6 h post-CPB were associated with worse postoperative pulmonary short-course outcome.