The financial impact of neonatal sepsis on the Brazilian Unified Health System.

OBJECTIVE: To evaluate the hospital cost of newborn infants diagnosed with sepsis from the perspective of the Brazilian Public Health System over 11 years. METHOD: Cross-sectional study that analyzed secondary data from the databases of the Hospital Information System of the Brazilian Public Health System. Infants hospitalized between 0‒29 days after birth with a diagnosis of sepsis from 2008 to 2018 were included. The diagnosis used in the study was the one that the hospital considered the main diagnosis at admission. Costs were analyzed in US dollars and reflected the amount paid by the Brazilian Public Health System to the hospitals for the informed diagnosis upon admission. The costs were evaluated as the total per admission, and they were compared among Brazilian geographic regions, among etiologic agents, and between neonates with the diagnosis of sepsis that survived or died. RESULTS: From 2008 to 2018, 47,554 newborns were hospitalized with sepsis (148.04 cases per 100,000 live births), with an average cost of US$ 3345.59 per hospitalization, ranging from US$ 2970.60 in the North region to US$ 4305.03 in the Midwest. Among sepsis with identified agents, the highest mean cost was related to Gram-negative agents, and the lowest to Streptococcus agalactiae sepsis. Patients with sepsis who died had a higher cost than the survivors (t-test; p = 0.046). CONCLUSIONS: The evaluation of costs related to neonatal sepsis in the country during an 11-year period shows the economic impact of morbidity that may be avoided by improving the quality of neonatal care.

Mirabegron and Anticholinergics in the Treatment of Overactive Bladder Syndrome: A Meta-analysis.

OBJECTIVE: To compare the use of mirabegron with anticholinergics drugs for the treatment of overactive bladder (OB). DATA SOURCE: Systematic searches were conducted in EMBASE, PUBMED, Cochrane, and LILACS databases from inception to September 2021. We included RCTs, women with clinically proven OB symptoms, studies that compared mirabegron to antimuscarinic drugs, and that evaluated the efficacy, safety or adherence. DATA COLLECTION: RevMan 5.4 was used to combine results across studies. We derived risk ratios (RRs) and mean differences with 95% CIs using a random-effects meta-analytic model. Cochrane Collaboration Tool and GRADE was applied for risk of bias and quality of the evidence. DATA SYNTHESIS: We included 14 studies with a total of 10,774 patients. Fewer total adverse events was reported in mirabegron group than in antimuscarinics group [RR 0.93 (0.89-0.98)]. The risk of gastrointestinal tract disorders and dry mouth were lower with mirabegron [RR 0,58 (0.48-0.68); 9375 patients; RR 0.44 (0.35-0.56), 9375 patients, respectively]. No difference was reported between mirabegron and antimuscarinics drugs for efficacy. The adherence to treatment was 87.7% in both groups [RR 0.99 (0.98-1.00)]. CONCLUSION: Mirabegron and antimuscarinics have comparable efficacy and adherence rates; however, mirabegron showed fewer total and isolated adverse events.

OBJETIVO: Comparar o uso de mirabegrom com anticolinérgicos para o tratamento da bexiga hiperativa (BH). FONTE DE DADOS: Buscas sistemáticas foram realizadas nas bases de dados EMBASE, PUBMED, Cochrane e LILACS desde o início até setembro de 2021. Incluímos ECR, mulheres com sintomas de BH clinicamente comprovados, estudos que compararam mirabegrom a medicamentos antimuscarínicos e avaliaram a eficácia, segurança ou adesão. COLETA DE DADOS: RevMan 5.4 foi usado para combinar os resultados entre os estudos. Derivamos razões de risco (RRs) e diferenças médias com intervalo de confiança (IC) de 95% usando um modelo meta-analítico de efeitos aleatórios. Cochrane Collaboration Tool e GRADE foi aplicado para risco de viés e qualidade da evidência. SíNTESE DOS DADOS: Foram incluídos 14 estudos com um total de 10.774 pacientes. Menos eventos adversos totais foram relatados no grupo mirabegrom do que no grupo antimuscarínicos [RR: 0,93 (0,89­0,98)]. O risco de distúrbios do trato gastrointestinal e boca seca foram menores com mirabegrom [RR: 0,58 (0,48­0,68); 9.375 pacientes; RR: 0,44 (0,35­0,56), 9.375 pacientes, respectivamente]. Nenhuma diferença foi relatada entre mirabegrom e drogas antimuscarínicos para eficácia. A adesão ao tratamento foi de 87,7% em ambos os grupos [RR: 0,99 (0,98­1,00)]. CONCLUSãO: Mirabegrom e antimuscarínicos têm eficácia e taxas de adesão comparáveis, porém o mirabegrom apresentou menos eventos adversos totais e isolados.

Mirabegron and Anticholinergics in the Treatment of Overactive Bladder Syndrome: A Meta-analysis / Mirabegron e anticolinérgicos no tratamento da síndrome da bexiga hiperativa: metanálise

Abstract Objective To compare the use of mirabegron with anticholinergics drugs for the treatment of overactive bladder (OB). Data Source Systematic searches were conducted in EMBASE, PUBMED, Cochrane, and LILACS databases from inception to September 2021. We included RCTs, women with clinically proven OB symptoms, studies that compared mirabegron to antimuscarinic drugs, and that evaluated the efficacy, safety or adherence. Data Collection RevMan 5.4 was used to combine results across studies. We derived risk ratios (RRs) and mean differences with 95% CIs using a random-effects meta-analytic model. Cochrane Collaboration Tool and GRADE was applied for risk of bias and quality of the evidence. Data Synthesis We included 14 studies with a total of 10,774 patients. Fewer total adverse events was reported in mirabegron group than in antimuscarinics group [RR 0.93 (0.89-0.98)]. The risk of gastrointestinal tract disorders and dry mouth were lower with mirabegron [RR 0,58 (0.48-0.68); 9375 patients; RR 0.44 (0.35-0.56), 9375 patients, respectively]. No difference was reported between mirabegron and antimuscarinics drugs for efficacy. The adherence to treatment was 87.7% in both groups [RR 0.99 (0.98-1.00)]. Conclusion Mirabegron and antimuscarinics have comparable efficacy and adherence rates; however, mirabegron showed fewer total and isolated adverse events.

Resumo Objetivo Comparar o uso de mirabegrom com anticolinérgicos para o tratamento da bexiga hiperativa (BH). Fonte de Dados Buscas sistemáticas foram realizadas nas bases de dados EMBASE, PUBMED, Cochrane e LILACS desde o início até setembro de 2021. Incluímos ECR, mulheres com sintomas de BH clinicamente comprovados, estudos que compararam mirabegrom a medicamentos antimuscarínicos e avaliaram a eficácia, segurança ou adesão. Coleta de Dados RevMan 5.4 foi usado para combinar os resultados entre os estudos. Derivamos razões de risco (RRs) e diferenças médias com intervalo de confiança (IC) de 95% usando um modelo meta-analítico de efeitos aleatórios. Cochrane Collaboration Tool e GRADE foi aplicado para risco de viés e qualidade da evidência. Síntese dos Dados Foram incluídos 14 estudos com um total de 10.774 pacientes. Menos eventos adversos totais foram relatados no grupo mirabegrom do que no grupo antimuscarínicos [RR: 0,93 (0,89-0,98)]. O risco de distúrbios do trato gastrointestinal e boca seca foram menores com mirabegrom [RR: 0,58 (0,48-0,68); 9.375 pacientes; RR: 0,44 (0,35-0,56), 9.375 pacientes, respectivamente]. Nenhuma diferença foi relatada entre mirabegrom e drogas antimuscarínicos para eficácia. A adesão ao tratamento foi de 87,7% em ambos os grupos [RR: 0,99 (0,98-1,00)]. Conclusão Mirabegrom e antimuscarínicos têm eficácia e taxas de adesão comparáveis, porém o mirabegrom apresentou menos eventos adversos totais e isolados.

The financial impact of neonatal sepsis on the Brazilian Unified Health System

Abstract Objective To evaluate the hospital cost of newborn infants diagnosed with sepsis from the perspective of the Brazilian Public Health System over 11 years. Method Cross-sectional study that analyzed secondary data from the databases of the Hospital Information System of the Brazilian Public Health System. Infants hospitalized between 0‒29 days after birth with a diagnosis of sepsis from 2008 to 2018 were included. The diagnosis used in the study was the one that the hospital considered the main diagnosis at admission. Costs were analyzed in US dollars and reflected the amount paid by the Brazilian Public Health System to the hospitals for the informed diagnosis upon admission. The costs were evaluated as the total per admission, and they were compared among Brazilian geographic regions, among etiologic agents, and between neonates with the diagnosis of sepsis that survived or died. Results From 2008 to 2018, 47,554 newborns were hospitalized with sepsis (148.04 cases per 100,000 live births), with an average cost of US$ 3345.59 per hospitalization, ranging from US$ 2970.60 in the North region to US$ 4305.03 in the Midwest. Among sepsis with identified agents, the highest mean cost was related to Gram-negative agents, and the lowest to Streptococcus agalactiae sepsis. Patients with sepsis who died had a higher cost than the survivors (t-test; p= 0.046). Conclusions The evaluation of costs related to neonatal sepsis in the country during an 11-year period shows the economic impact of morbidity that may be avoided by improving the quality of neonatal care.

A Cost Effectiveness Model of Long-Acting Reversible Contraceptive Methods in the Brazilian National Health System.

INTRODUCTION: The use of long-acting reversible contraceptives is low among adolescents owing to the high up-front cost. In this study, a 5-year cost-effectiveness model and budget impact analysis were used to compare the use of long-acting reversible contraceptives with the use of combined oral contraceptives among Brazilian adolescents. METHODS: A Markov model was developed to mirror the clinical and economic effects of long-acting reversible contraceptives among sexually active Brazilian adolescents in the public health system for a 5-year duration, starting from 2018. The costs were expressed in U.S.$, and a 5% discount rate was applied for both costs and benefits. Model inputs included costs of the contraceptive methods, contraceptive discontinuation and adherence rates, abortion, and birth costs associated with unintended pregnancies. The model outcomes were avoided pregnancies, abortions, and births. Univariate and probabilistic sensitivity analyses were conducted. RESULTS: Copper intrauterine device use was dominant 100% of the time for all outcomes, and a budget impact analysis revealed a cost savings of $422,431,269.10 in the 5-year period. Levonorgestrel intrauterine system and subdermal implant use were cost effective for all outcomes. The budget impact analyses revealed costs of $65,645,417.54 for levonorgestrel intrauterine system and $302,852,972.12 for subdermal implant use during the 5-year study period. CONCLUSIONS: According to this Brazilian model, copper intrauterine device use is dominant, and levonorgestrel intrauterine systems and subdermal implants are more cost effective than combined oral contraceptives.

Pooled incidence of continuation and pregnancy rates of four contraceptive methods in young women: a meta-analysis.

BACKGROUND: Continuation rates of contraceptive methods in young women vary among studies, and there is scarce data regarding the pregnancy rate in this population. METHODS: Four independently systematic searches were performed in PUBMED, EMBASE, LILACS, and Cochrane databases from inception until January 2021 for oral contraceptive pill (OCP), copper IUD, levonorgestrel intrauterine system (LNG-IUS), and subdermal implant. Inclusion criteria were observational or RCT studies that reported continuation for at least 12 months and/or pregnancy rate of these contraceptives methods in girls aged 22 years old or younger. Two authors extracted data from the study design and the outcomes. Pooled proportions of each method were applied using the inverse variance in all calculations with LOGIT transformation, using the random-effects model. Cochrane collaboration tool and New Castle-Ottawa were used to assess the quality and bias of all included studies. GRADE criteria evaluated the quality of evidence. RESULTS: Continuation rate for OCP was 51% (95%CI 34%-68%), while for cooper IUD was 77% (95%CI 74%-80%), LNG-IUS 84% (95%CI 80%-87%), and implant 85% (95%CI 81%-88%). The pooled estimated pregnancy rate for OCP was 11% (95%CI 6%-20%), while for cooper IUD was 5% (95%CI 3%-7%), LNG-IUS 1.6% (95%CI 1.2%-2.3%), and implant 1.8% (95%CI 0.4%-8.4%). CONCLUSION: Long-acting contraceptive methods presented higher continuation rates and lower pregnancy rates when compared to OCPs.

Care bundles to reduce unplanned extubation in critically ill children: a systematic review, critical appraisal and meta-analysis.

OBJECTIVE: To assess the current evidence for the efficacy of care bundles in reducing unplanned extubations (UEs) in critically ill children. DESIGN: Systematic review according to the Cochrane guidelines and meta-analysis using random-effects modelling. METHODS: We searched MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, Cochrane and SciELO databases from inception until April 2021. We conducted a quality appraisal for each study using the Newcastle-Ottawa Scale and Standards for Quality Improvement Reporting Excellence (SQUIRE) V.2.0 checklist. MAIN OUTCOME: The primary outcome measure was UE rates per 100 intubation days. RESULTS: We screened 10 091 records and finally included 11 studies. Six studies were pre/post-intervention studies, and five were interrupted time-series studies. The methodological quality was 'good' in 70%, and the remaining as 'fair' (30%). The most frequently used implementation strategies were staff education (100%), root cause analysis (100%), and audit and feedback (82%). Key bundle care components comprised identification of high-risk patients, endotracheal tube care and sedation protocol. Not all studies fully completed the SQUIRE V.2.0 checklist. Meta-analysis revealed a reduction in UE rate following the introduction of care bundles (rate ratio: 0.40 (95% CI: 0.19 to 0.84); p=0.02), which equates to a 60% reduction in UE rates. CONCLUSIONS: We found that identifying high-risk patients, endotracheal tube care and protocol-directed sedation are core elements in care bundles for preventing UEs. However, there are several methodological gaps in the literature, including poor evaluation of adherence to bundle components. Future studies should address these gaps to strengthen their validity.

Willingness to pay for short- and long-acting contraceptives among female adolescents and their parents in Brazil:a pilot study.

OBJECTIVE: To evaluate willingness to pay for short- and long-acting reversible contraceptive methods among female Brazilian adolescents and their parents, as well as their perspective on using such methods. METHODS: This is a cross-sectional study of female adolescents aged 13 to 19 years and their parents. We surveyed to estimate their willingness to pay for contraceptive methods. The values are expressed as mean±standard deviation in Brazilian reals (R$). Spearman correlation was employed for socioeconomic status of parents, age of adolescents and their standpoints. The methods types and adolescent and parent perspectives were analyzed by the test χ2. To determine an agreement between pairs and their willingness to pay, we used the Bland-Altman plot. RESULTS: A total of 165 surveys were collected. Short-acting method was significantly more acceptable to pay than the long-action method, by both parents and their daughters. Parents and their daughters are willing to pay out-of-pocket R$ 52,25±22,48 and R$ 51,63±21,24 for short-acting reversible contraception method, and R$ 176,83±130,34 and R$ 174,83±143,64, for long-acting method, respectively. Bland-Altman analysis indicated an agreement on both perspectives and the price they are willing to pay for each contraceptive method. CONCLUSION: Parents and adolescent daughters are more willing to pay for short-acting methods. We showed an agreement between the parent and the daughter for the values paid for each method.

Who is going to turn on the ventilators?

OBJECTIVE: To analyze the COVID-19 pandemic in Brazil, a continental-sized country, considered as an emerging economy but with several regional nuances, focusing on the availability of human resources, especially for intensive care units. METHODS: The database of the National Registry of Health Facilities was accessed. Healthcare professionals in the care of COVID-19 were georeferenced. We correlated the number of professionals with the parameters used by the World Health Organization. According to the Brazilian Intensive Care Medicine Association, we correlated the data for adult intensive care unit beds in each state with the number of professionals for each ten intensive care unit beds. The number of professionals, beds, and cases were then organized by state. RESULTS: The number of physicians per 100 thousand inhabitants followed the World Health Organization recommendations; however, the number of nurses did not. The number of intensivists, registered nurses, nurse technicians specialized in intensive care, and respiratory therapists, necessary for every ten intensive care beds, was not enough for any of these professional categories. A complete team of critical care specialists was available for 10% of intensive care unit beds in Brazil. CONCLUSION: There is a shortage of professionals for intensive care unit, as we demonstrated for Brazil. Intensive care physical resources to be efficiently used require extremely specialized human resources; therefore, planning human resources is just as crucial as planning physical and structural resources.

Antibody indexes in COVID-19 convalescent plasma donors: Unanswered questions.

OBJECTIVE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is characterized by high contagiousness, as well as variable clinical manifestations and immune responses. The antibody response to SARS-CoV-2 is directly related to viral clearance and the antibodies' ability to neutralize the virus and confer long-term immunity. Nevertheless, the response can also be associated with disease severity and evolution. This study correlated the clinical characteristics of convalescent COVID-19 patients with immunoglobulin A (IgA) and IgG anti-SARS-CoV-2 antibodies. METHODS: This study included 51 COVID-19 health care professionals who were candidates for convalescent plasma donation from April to June 2020. The subjects had symptomatic COVID-19 with a polymerase chain reaction-confirmed diagnosis. We measured anti-SARS-CoV-2 IgA and IgG antibodies after symptom recovery, and the subjects were classified as having mild, moderate, or severe symptoms. RESULTS: Anti-SARS-CoV-2 antibodies were positive in most patients (90.2%). The antibody indexes for IgA and IgG did not differ significantly between patients presenting with mild or moderate symptoms. However, they were significantly higher in patients with severe symptoms. CONCLUSIONS: Our study showed an association between higher antibody indexes and severe COVID-19 cases, and several hypotheses regarding the association of the antibody dynamics and severity of the disease in SARS-CoV-2 infection have been raised, although many questions remain unanswered.

Uma análise de custo-efetividade de propofol versus midazolam para sedação de pacientes adultos admitidos à unidade de terapia intensiva / A cost-effectiveness analysis of propofol versus midazolam for the sedation of adult patients admitted to the intensive care unit

RESUMO Objetivo: Construir um modelo de custo-efetividade para comparar o uso de propofol com o de midazolam em pacientes críticos adultos sob uso de ventilação mecânica. Métodos: Foi construído um modelo de árvore decisória para pacientes críticos submetidos à ventilação mecânica, o qual foi analisado sob a perspectiva do sistema privado de saúde no Brasil. O horizonte temporal foi o da internação na unidade de terapia intensiva. Os desfechos foram custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e custo-efetividade por hora de ventilação mecânica evitada. Foram obtidos os dados do modelo a partir de metanálise prévia. Assumiu-se que o custo da medicação estava incluído nos custos da unidade de terapia intensiva. Conduziram-se análises univariada e de sensibilidade probabilística. Resultados: Pacientes mecanicamente ventilados em uso de propofol tiveram diminuição de sua permanência na unidade de terapia intensiva e na duração da ventilação mecânica, respectivamente, em 47,97 horas e 21,65 horas. Com o uso de propofol, ocorreu redução média do custo de U$2.998,971 em comparação ao uso do midazolam. A custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e por hora de ventilação mecânica evitada foi dominante, respectivamente, em 94,40% e 80,8% do tempo. Conclusão: Ocorreu diminuição significante do custo associado ao uso de propofol, no que se refere à permanência na unidade de terapia intensiva e à duração da ventilação mecânica para pacientes críticos adultos.

ABSTRACT Objective: To build a cost-effectiveness model to compare the use of propofol versus midazolam in critically ill adult patients under mechanical ventilation. Methods: We built a decision tree model for critically ill patients submitted to mechanical ventilation and analyzed it from the Brazilian private health care system perspective. The time horizon was that of intensive care unit hospitalization. The outcomes were cost-effectiveness per hour of intensive care unit stay avoided and cost-effectiveness per hour of mechanical ventilation avoided. We retrieved data for the model from a previous meta-analysis. We assumed that the cost of medication was embedded in the intensive care unit cost. We conducted univariate and probabilistic sensitivity analyses. Results: Mechanically ventilated patients using propofol had their intensive care unit stay and the duration of mechanical ventilation decreased by 47.97 hours and 21.65 hours, respectively. There was an average cost reduction of US$ 2,998.971 for propofol when compared to midazolam. The cost-effectiveness per hour of intensive care unit stay and mechanical ventilation avoided were dominant 94.40% and 80.8% of the time, respectively. Conclusion: There was a significant reduction in costs associated with propofol use related to intensive care unit stay and duration of mechanical ventilation for critically ill adult patients.

Does admission time matter in a paediatric intensive care unit? A prospective cohort study.

AIM: Studies assessing the association between admission time to paediatric intensive care unit (PICU) and mortality are sparse with conflicting results. We aimed to evaluate the impact of time of admission on PICU mortality within 48 h after admission. METHODS: This was a single-centre prospective cohort. We collected data from all consecutive children aged 1 month to 16 years over 10 years. RESULTS: We included a total of 1368 admissions, with a PICU mortality of 6.6%. Compared with daytime admissions, the overall mortality rate (5.3% vs. 8.5%, P = 0.026) and the mortality within 48 h after admission were higher for those admitted during night-time (2% vs. 4.2%, P = 0.021). There were no differences between mortality rates and the day of admission (weekend admissions vs. weekday admissions). The adjusted odds of death within 48 h after admission was 2.5 (95% confidence interval = 1.22-5.24, P = 0.012) for patients admitted at night-time. A secondary analysis assessing trends in mortality rates during admission showed that the last 5 years of study were more responsible for the chances of death within 48 h (odds ratio = 7.6, 95% confidence interval = 1.91-30.17, P = 0.0039). CONCLUSION: Admission to the PICU during night shifts was strongly associated with death compared to daytime admissions. A time analysis of the moment of admission is necessary as a metric of quality of care to identify the interruption or improvement in the continuity of care. Further studies are needed to assess the modified contributing factors.

A cost-effectiveness analysis of propofol versus midazolam for the sedation of adult patients admitted to the intensive care unit. / Uma análise de custo-efetividade de propofol versus midazolam para sedação de pacientes adultos admitidos à unidade de terapia intensiva.

OBJECTIVE: To build a cost-effectiveness model to compare the use of propofol versus midazolam in critically ill adult patients under mechanical ventilation. METHODS: We built a decision tree model for critically ill patients submitted to mechanical ventilation and analyzed it from the Brazilian private health care system perspective. The time horizon was that of intensive care unit hospitalization. The outcomes were cost-effectiveness per hour of intensive care unit stay avoided and cost-effectiveness per hour of mechanical ventilation avoided. We retrieved data for the model from a previous meta-analysis. We assumed that the cost of medication was embedded in the intensive care unit cost. We conducted univariate and probabilistic sensitivity analyses. RESULTS: Mechanically ventilated patients using propofol had their intensive care unit stay and the duration of mechanical ventilation decreased by 47.97 hours and 21.65 hours, respectively. There was an average cost reduction of US$ 2,998.971 for propofol when compared to midazolam. The cost-effectiveness per hour of intensive care unit stay and mechanical ventilation avoided were dominant 94.40% and 80.8% of the time, respectively. CONCLUSION: There was a significant reduction in costs associated with propofol use related to intensive care unit stay and duration of mechanical ventilation for critically ill adult patients.

OBJETIVO: Construir um modelo de custo-efetividade para comparar o uso de propofol com o de midazolam em pacientes críticos adultos sob uso de ventilação mecânica. MÉTODOS: Foi construído um modelo de árvore decisória para pacientes críticos submetidos à ventilação mecânica, o qual foi analisado sob a perspectiva do sistema privado de saúde no Brasil. O horizonte temporal foi o da internação na unidade de terapia intensiva. Os desfechos foram custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e custo-efetividade por hora de ventilação mecânica evitada. Foram obtidos os dados do modelo a partir de metanálise prévia. Assumiu-se que o custo da medicação estava incluído nos custos da unidade de terapia intensiva. Conduziram-se análises univariada e de sensibilidade probabilística. RESULTADOS: Pacientes mecanicamente ventilados em uso de propofol tiveram diminuição de sua permanência na unidade de terapia intensiva e na duração da ventilação mecânica, respectivamente, em 47,97 horas e 21,65 horas. Com o uso de propofol, ocorreu redução média do custo de U$2.998,971 em comparação ao uso do midazolam. A custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e por hora de ventilação mecânica evitada foi dominante, respectivamente, em 94,40% e 80,8% do tempo. CONCLUSÃO: Ocorreu diminuição significante do custo associado ao uso de propofol, no que se refere à permanência na unidade de terapia intensiva e à duração da ventilação mecânica para pacientes críticos adultos.

Nutrition Therapy Cost-Effectiveness Model Indicating How Nutrition May Contribute to the Efficiency and Financial Sustainability of the Health Systems.

BACKGROUND: Malnutrition is highly prevalent in hospitalized patients but seldom recognized and treated. Malnutrition poses several adverse events, such as increased infection rates, length of hospital stay, and mortality, as well as costs. Early nutrition interventions have been shown to decrease the associated malnutrition burdens, leading to relevant savings. Thus, this study aims to evaluate the cost-effectiveness of nutrition therapy, including oral supplements to at-risk or malnourished adult inpatients admitted to the Brazilian Public System (SUS) hospitals. METHOD: A cost-effectiveness model, encompassing a 1-year period and regarding total costs, length of hospital stay, readmissions, and mortality related to malnutrition, was developed, having the provision of early nutrition therapy as the intervention variable. The number of avoided hospitalization days, prevented hospital readmissions, and prevented deaths defined the effectiveness of the model. All the costs were estimated based on the SUS database. RESULTS: Early nutrition therapy provided to all at-risk or malnourished patients would represent cost-effectiveness of US $92.24, US $544.59, US $1848.12, and US $3698.92, for each day of hospitalization avoided, for additional patients having access to hospitalization, for preventing readmission, and for prevented death, respectively. The highest impact on savings was represented by the mean reduction in the length of hospital stay. CONCLUSION: Early oral nutrition intervention for patients malnourished or at risk of malnutrition resulted in overall reduced hospital costs. These findings provide a rationale to tackle the implementation of educational programs focusing on the care of inpatients with malnutrition or its risk.

Who is going to turn on the ventilators? / Quem vai ligar os ventiladores?

ABSTRACT Objective To analyze the COVID-19 pandemic in Brazil, a continental-sized country, considered as an emerging economy but with several regional nuances, focusing on the availability of human resources, especially for intensive care units. Methods The database of the National Registry of Health Facilities was accessed. Healthcare professionals in the care of COVID-19 were georeferenced. We correlated the number of professionals with the parameters used by the World Health Organization. According to the Brazilian Intensive Care Medicine Association, we correlated the data for adult intensive care unit beds in each state with the number of professionals for each ten intensive care unit beds. The number of professionals, beds, and cases were then organized by state. Results The number of physicians per 100 thousand inhabitants followed the World Health Organization recommendations; however, the number of nurses did not. The number of intensivists, registered nurses, nurse technicians specialized in intensive care, and respiratory therapists, necessary for every ten intensive care beds, was not enough for any of these professional categories. A complete team of critical care specialists was available for 10% of intensive care unit beds in Brazil. Conclusion There is a shortage of professionals for intensive care unit, as we demonstrated for Brazil. Intensive care physical resources to be efficiently used require extremely specialized human resources; therefore, planning human resources is just as crucial as planning physical and structural resources.

RESUMO Objetivo Analisar a pandemia da COVID-19 no Brasil, um país de dimensões continentais, considerado uma economia emergente, mas com inúmeras diferenças regionais, abordando a disponibilidade de recursos humanos, especialmente para unidades de terapia intensiva. Métodos Foi acessado o banco de dados do Cadastro Nacional de Estabelecimentos de Saúde. Os profissionais de saúde que atuavam nos cuidados para COVID-19 foram georreferenciados. O número de profissionais foi correlacionado com os parâmetros utilizados pela Organização Mundial da Saúde. De acordo com a Associação de Medicina Intensiva Brasileira, correlacionaram-se os dados de leitos de terapia intensiva adulta em cada unidade federativa com o número de profissionais para cada dez leitos de terapia intensiva. Os números de profissionais, leitos e casos foram, então, organizados por unidade federativa. Resultados O número de médicos por 100 mil habitantes seguiu as recomendações da Organização Mundial da Saúde; mas não o número de enfermeiras. O número de intensivistas, enfermeiros, técnicos de enfermagem especializados em terapia intensiva e fisioterapeutas respiratórios, necessário a cada dez leitos de terapia intensiva, não foi suficiente para nenhuma dessas categorias profissionais. Uma equipe completa desses especialistas esteve disponível para 10% dos leitos de terapia intensiva do Brasil. Conclusão Há carência de profissionais para unidade de terapia intensiva, como demonstrado no Brasil. Os recursos físicos da terapia intensiva, para serem usados de forma eficiente, precisam de recursos humanos extremamente especializados; portanto, o planejamento de recursos humanos é tão crucial quanto o planejamento de recursos físicos e estruturais.

Antibody indexes in COVID-19 convalescent plasma donors: Unanswered questions

OBJECTIVE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is characterized by high contagiousness, as well as variable clinical manifestations and immune responses. The antibody response to SARS-CoV-2 is directly related to viral clearance and the antibodies' ability to neutralize the virus and confer long-term immunity. Nevertheless, the response can also be associated with disease severity and evolution. This study correlated the clinical characteristics of convalescent COVID-19 patients with immunoglobulin A (IgA) and IgG anti-SARS-CoV-2 antibodies. METHODS: This study included 51 COVID-19 health care professionals who were candidates for convalescent plasma donation from April to June 2020. The subjects had symptomatic COVID-19 with a polymerase chain reaction-confirmed diagnosis. We measured anti-SARS-CoV-2 IgA and IgG antibodies after symptom recovery, and the subjects were classified as having mild, moderate, or severe symptoms. RESULTS: Anti-SARS-CoV-2 antibodies were positive in most patients (90.2%). The antibody indexes for IgA and IgG did not differ significantly between patients presenting with mild or moderate symptoms. However, they were significantly higher in patients with severe symptoms. CONCLUSIONS: Our study showed an association between higher antibody indexes and severe COVID-19 cases, and several hypotheses regarding the association of the antibody dynamics and severity of the disease in SARS-CoV-2 infection have been raised, although many questions remain unanswered.

Current evidence of contraceptive uptake, pregnancy and continuation rates in young women: a systematic review and Meta-analysis.

OBJECTIVE: Half of all pregnancies worldwide are unintended, and the rate is even higher in women aged ≤25 years. We sought to identify which method of contraception was the most effective option to prevent unintended pregnancy in young women and adolescents. METHODS: Systematic searches, without language restrictions, were carried out of the PubMed, Embase, Lilacs and Cochrane databases from inception to July 2020. Abstracts and full-text articles of observational studies and randomised controlled trials comparing the use of multiple methods of long-acting reversible contraception (LARC) and short-acting reversible contraception (SARC) in young women and adolescents were screened and reviewed. Risk ratios (RRs) and mean differences with their 95% confidence interval (CI) were derived using a random-effects meta-analytical model. Meta-analyses provided pooled estimates for adverse events, continuation rates and efficacy of LARC methods in young women and adolescents. Nine of the 25 included studies compared LARC with SARC, and 16 compared LARC methods only. RESULTS: At 12 months, young women had better adherence with LARC compared with SARC (n = 1606; RR 1.60; 95% CI 1.21, 2.12; I 2 = 88%), which suggests a better unintended pregnancy prevention outcome for young women. However, more young women chose SARC (n = 2835; RR 0.37; 95% CI 0.17, 0.80; I 2 = 99%). Pregnancy during LARC use was rare. CONCLUSION: LARC methods are the most efficacious in preventing pregnancy, and women should be informed of this if pregnancy prevention is their priority. The evidence, however, is of low quality. PROSPERO REGISTRATION NUMBER: CRD42017055452.

High-Dose Vasopressor Therapy for Pediatric Septic Shock: When Is Too Much?

It is unknown if the requirement for high dose of vasopressor (HDV) represents a poor outcome in pediatric septic shock. This is a retrospective observational analysis with data obtained from a single center. We evaluated the association between the use of HDV and survival in these patients. A total of 62 children (38 survivors and 24 nonsurvivors) were assessed. The dose of vasopressor (hazard ratio 2.06) and oliguria (hazard ratio 3.17) was independently associated with mortality. The peak of vasopressor was the best prognostic predictor. A cutoff of 1.3 µg/kg/min was associated with mortality with a sensitivity of 75% and specificity of 89%. Vasopressor administration higher than 1.3 µg/kg/min was associated with increased mortality in children with septic shock.

Factors Associated With Unplanned Extubation in Children: A Case-Control Study.

PURPOSE: Although several studies assess unplanned extubation (UE) in children, few have addressed determinants of UE and factors associated with reintubation in a case-controlled manner. We aimed to identify the risk factors and outcomes associated with UE in a pediatric intensive care unit. METHODS: Cases of UE were randomly matched with control patients at a ratio of 1:4 for age, severity of illness, and admission diagnosis. For cases and controls, we also collected data associated with UE events, reintubation, and outcomes. RESULTS: We analyzed 94 UE patients (0.75 UE per 100 intubation days) and found no differences in demographics between the 2 groups. Logistic regression revealed that patient agitation (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.28-4.65), continuous sedation infusion (OR: 3.27; 95% CI: 1.70-6.29), night shifts (OR: 9.16; 95% CI: 4.25-19.72), in-charge nurse experience <2 years (OR: 2.38; 95% CI: 1.13-4.99), and oxygenation index (OI) >5 (OR: 76.9; 95% CI: 16.79-352.47) were associated with UE. Risk factors for reintubation after UE included prior level of sedation (COMFORT score < 27; OR: 7.93; 95% CI: 2.30-27.29), copious secretion (OR: 11.88; 95% CI: 2.20-64.05), and OI > 5 (OR: 9.32; 95% CI: 2.45-35.48). CONCLUSIONS: This case-control study showed that both patient- and nurse-associated risk factors were related to UE. Risk factors associated with reintubation included lower levels of consciousness, copious secretions, and higher OI. Further evidence-based studies, including a larger sample size, are warranted to identify predisposing factors in UEs.