Late-Onset Psychogenic Chronic Phonic-Tics.

BACKGROUND: Tics beginning in late adulthood often have an identifiable etiology. Psychogenic tics with onset around 60 years of age are rarely described in the literature. CASE REPORT: A 67-year-old female had experienced phonic tics for 8 years. Episodes occurred without premonitory sensations and precipitant factors, and she could not suppress them. She had no history of childhood tic disorder, and secondary causes of tics were excluded. She was diagnosed with psychogenic tics and treated with quetiapine with mild improvement. DISCUSSION: When physicians are faced with no identifiable cause of tics combined with certain clinical clues, a psychogenic disorder must be suspected.

Clonic Perseveration after Acute Ischemic Stroke: An Insight into the Pathophysiological Mechanisms.

Poststroke movement disorders may manifest as parkinsonism, dystonia, chorea, ballism, athetosis, tremor, myoclonus, stereotypies, and akathisia. In this article, we describe a patient with clonic perseveration 2 days after an acute ischemic stroke. We discuss the phenomenology and provide insights on possible pathophysiological mechanisms involved.

Indicações de dispositivos mecânicos de suporte na insuficiência cardíaca refratár / Indications of mechanical support devices in refractory heart failur

A insuficiência cardíaca refratária e o choque cardiogênico estão relacionados aelevadas taxas de mortalidade e a baixa qualidade de vida. As estratégias de tratamento para esses pacientes foram limitadas, nos últimos anos, às terapias farmacológicas que pouco modificaram a evolução da doença. Entretanto, com o desenvolvimento tecnológico em dispositivos mecânicos de suporte circulatório, diversas modalidades terapêuticas utilizando diferentes tipos de tecnologia proporcionam melhor suporte hemodinâmico, diminuição e reversão de disfunções orgânicas causadas pela insuficiência cardíaca.Esses dispositivos quando indicados corretamente melhoram os desfechos clínicos de pacientes que aguardam transplante cardíaco e dos que não são candidatos a transplante. Atualmente, observam-se indicações cada vez mais precoces de dispositivos de suporte circulatório, tornando-os uma terapia essencial no manejo de pacientes cominsuficiência cardíaca refratária ou choque cardiogênico. Esta revisão abordará os principais tipos de dispositivos disponíveis em nosso país e suas indicações...

The refractory heart failure and cardiogenic shock are related to high rates of mortality and poor quality of life. Treatment strategies for these patients have been limited in the last yearsto pharmacological therapies that change only slightly the evolution of the disease. However, with technological advances in mechanical devices for circulatory assistance, various therapeutic modalities using different types of technology provide better hemodynamic support, reduction and reversal of organic dysfunction caused by heart failure. When properly indicated,these devices can provide better clinical outcomes of patients on heart transplantation waiting list and those who are not candidates for transplantation. Contemporarily, indications for mechanical support devices are occurring increasingly earlier, making them an essential therapy in the management of patients with refractory heart failure or cardiogenic shock.This review covers the different types of devices available in our country and its indications...

Use of demonstrably effective therapies in the treatment of acute coronary syndromes: comparison between different Brazilian regions. Analysis of the Brazilian Registry on Acute Coronary Syndromes (BRACE).

BACKGROUND: Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE: To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS: A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS: In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION: The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.

Utilização de terapêuticas comprovadamente úteis no tratamento da coronariopatia aguda: comparação entre diferentes regiões brasileiras. Análise do Registro Brasileiro de Síndromes Coronarianas Agudas (BRACE - Brazilian Registry on Acute Coronary Syndromes) / Use of demonstrably effective therapies in the treatment of acute coronary syndromes: comparison between different brazilian regions. Analysis of the Brazilian Registry on Acute Coronary Syndromes (BRACE) / Utilización de terapéuticas comprobadamente útiles en el tratamiento de la coronariopatía aguda: comparación entre diferentes regiones brasileñas. Análisis del Registro Brasileño de Síndromes Coronarios Agudos (BRACE - Brazilian Registry on Acute Coronary Syndromes)

FUNDAMENTO: Pouco se sabe, em nosso meio, sobre diferenças regionais no tratamento da coronariopatia aguda. OBJETIVO: Analisar o comportamento regional relativamente à utilização de terapêuticas comprovadamente úteis na coronariopatia aguda. MÉTODOS: Foram selecionados aleatoriamente 71 hospitais, respeitando-se a proporcionalidade do país em relação à localização geográfica, entre outros critérios. Na população global, foi analisada regionalmente a utilização de AAS, clopidogrel, inibidor da ECA/bloqueador de AT1, betabloqueador e estatina, isoladamente e agrupados por escore individual que variou de 0 (nenhum medicamento utilizado) a 100 (todos utilizados). No infarto com supradesnivelamento de ST (IAMCSST) foram analisadas diferenças regionais sobre utilização de terapêuticas de recanalização (fibrinolíticos e angioplastia primária). RESULTADOS: No global da população, nas primeiras 24 horas de hospitalização, a média de escore na região Norte-Nordeste (70,5 ± 22,1) foi menor (p < 0,05) do que nas regiões Sudeste (77,7 ± 29,5), Centro-Oeste (82 ± 22,1) e Sul (82,4 ± 21). Por ocasião da alta, o escore da região Norte-Nordeste (61,4 ± 32,9) foi menor (p < 0,05) do que nas regiões Sudeste (69,2 ± 31,6), Centro-Oeste (65,3 ± 33,6), e Sul (73,7 ± 28,1); adicionalmente, o escore do Centro-Oeste foi menor (p < 0,05) do que o do Sul. No IAMCSST, o uso de terapêuticas de recanalização foi maior no Sudeste (75,4%, p = 0,001 em relação ao restante do país), e menor no Norte-Nordeste (52,5%, p < 0,001 em relação ao restante do país). CONCLUSÃO: O uso de terapêuticas comprovadamente úteis no tratamento da coronariopatia aguda está aquém do desejável no país, com importantes diferenças regionais.

BACKGROUND: Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE: To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS: A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS: In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION: The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.

FUNDAMENTO: Se conocen muy poco en nuestro medio las diferencias regionales en el tratamiento de la coronariopatía aguda. OBJETIVO: Analizar el comportamiento regional relativo a la utilización de terapéuticas comprobadamente útiles en la coronariopatía aguda. MÉTODOS: Fueron seleccionados aleatoriamente 71 hospitales, respetando la proporción del país con relación a la ubicación geográfica, entre otros criterios. En la población global, fue analizada regionalmente la utilización de AAS, clopidogrel, inhibidor de la ECA/bloqueante de AT1, betabloqueante y estatina, aisladamente y agrupados por una puntuación individual que varió de 0 (ningún medicamento utilizado) a 100 (todos utilizados). En el infarto con supradesnivelación de ST (IAMCSST), se analizaron las diferencias regionales sobre la utilización de terapéuticas de re-canalización (fibrinolíticos y angioplastia primaria). RESULTADOS: En términos generales, en las primeras 24 horas de ingreso, la población obtuvo un promedio de puntuación en la región Norte-Nordeste de (70,5 ± 22,1) siendo menor (p < 0,05) que en las regiones Sudeste (77,7 ± 29,5), Centro-Oeste (82 ± 22,1) y Sur (82,4 ± 21). En razón del alta, la puntuación de la región Norte-Nordeste (61,4 ± 32,9) fue menor (p < 0,05) que en las regiones Sudeste (69,2 ± 31,6), Centro-Oeste (65,3 ± 33,6), y Sur (73,7 ± 28,1). Por añadidura, la puntuación del Centro-Oeste fue menor (P<0,05) que la del Sur. En el IAMCSST, el uso de terapéuticas de re-canalización fue mayor en el Sudeste (75,4%, P=0,001 con relación al resto del país), y menor en el Norte-Nordeste (52,5%, P<0,001 con relación al resto del país). CONCLUSIONES: El uso de las terapéuticas comprobadamente útiles en el tratamiento de la coronariopatía aguda, todavía no llega a los niveles deseados en el país existiendo importantes diferencias regionales.

Gestão em terapia intensiva: conceitos e inovações / Management in intensive care: concepts and innovations

JUSTIFICATIVA E OBJETIVOS: Atualmente, várias propostas são feitas com o objetivo de resolver ou pelo menos, controlar o grande problema da gestão na área da saúde: reduzir ou conter custos ao mesmo tempo em que a melhoria contínua da qualidade é promovida. A Unidade de Terapia Intensiva (UTI) é um dos setores mais importantes do hospital, local onde mudanças são essenciais. A procura por modelos em que medicina baseada em evidênciase utilização de rotinas e protocolos em UTI convivam como conceito de gestão ocorre em velocidade nunca vista antes. Cabe ao líder da UTI, tornar o setor modelo de unidade de negócios,preocupando-se com aspectos financeiros, segurança, qualidade, educação e inovação no atendimento ao cliente interno e externo. CONTEÚDO: Revisão da literatura incluindo modelos estudados e aplicados em outras áreas de conhecimento humano, bem como a proposta inovadora da utilização do instrumento Product Lifecycle Management (PLM) como opção de implementação de serviços médicos em UTI. CONCLUSÃO: O conhecimento de conceitos fundamentais e aplicação de modelos de gestão que priorizam a redução de margem de erro, segurança e aplicação da medicina baseada em evidência para o paciente crítico, podem estar relacionados a melhor utilização de recursos em Medicina Intensiva, colaborando na solução do dilema da área da saúde, manter qualidade e conter ou reduzir custos.

BACKGROUND AND OBJECTIVES: As each day passes, various proposals are made to resolve or at least control the major problem of health care: to reduce or contain costs at the same time as continuous quality improvement is promoted. One of the most important sectors of a hospital, where changes are essential,is the Intensive Care Unit (ICU). The search for models in which evidence-based medicine and the use of routines and protocols in ICU mingle with the concept of management occurs at a rate never seen before. It is for the leader of ICU, making the sector a business model unit, concerned with financial aspects, safety, quality, education and innovation in customer service. CONTENTS: Review of literature including models studied and applied in other areas of human knowledge and a innovative approach,using the tool Product Lifecycle Management (PLM), asan option for implementation of medical services in Intensive Care Units. CONCLUSION: Knowledge of fundamental concepts and application of management models that emphasize the reduction of error, security and implementation of evidence-based medicine for the critically ill patient, may be related to better utilization of resources in intensive care, collaborating in the solution of health care dilemma, maintain quality and contain or reduce costs.

Cardiogenic shock due to cytomegalovirus myocarditis: successful clinical treatment.

OBJECTIVE: Cytomegalovirus (CMV) systemic disease and myocarditis in healthy persons is infrequently reported in the literature, although in increasing numbers in recent years. The importance of the recognition of the syndrome that usually has an initial picture of a mononucleosis like infection in an otherwise healthy person, is the available therapeutic agent, ganciclovir, that can cure the infectious disease. METHODS: We analyzed the clinical result of pulsotherapy with steroids in a patient with CMV myocarditis after 7 days of etiological treatment, with ganciclovir, intravenous vasodilators, and the conventional treatment for congestive heart failure. RESULTS: The clinical condition of the patient improved accordingly to the better function of the left ventricle, and the ganciclovir was kept for 21 days, most of it in an out patient basis. The patient was dismissed from the hospital, with normal myocardial function. CONCLUSION: Potentially curable forms of myocarditis, like M pneumoniae and CMV, for example, can have an initial disproportionate aggression to the myocardium, by the acute inflammatory reaction, that can by itself make worse the damage to the LV function. In our opinion, the blockade of this process by pulsotherapy with steroids can help in the treatment of these patients. We understand that the different scenario of immunosuppressive treatments for the possible auto immunity of the more chronic forms of the presumably post viral cardiomyopathy has been in dispute in the literature, and has stolen the focus from the truly acute cases.

Cardiogenic shock due to citomegalovirus myocarditis: successful clinical treatment / Choque cardiogênico devido à miocardite por citomegalovírus: terapêutica clínica com sucesso

OBJECTIVE: Cytomegalovirus (CMV) systemic disease and myocarditis in healthy persons is infrequently reported in the literature, although in increasing numbers in recent years. The importance of the recognition of the syndrome that usually has an initial picture of a mononucleosis like infection in an otherwise healthy person, is the available therapeutic agent, ganciclovir, that can cure the infectious disease. METHODS: We analyzed the clinical result of pulsotherapy with steroids in a patient with CMV myocarditis after 7 days of etiological treatment, with ganciclovir, intravenous vasodilators, and the conventional treatment for congestive heart failure. RESULTS: The clinical condition of the patient improved accordingly to the better function of the left ventricle, and the ganciclovir was kept for 21 days, most of it in an out patient basis. The patient was dismissed from the hospital, with normal myocardial function. CONCLUSION: Potentially curable forms of myocarditis, like M pneumoniae and CMV, for example, can have an initial disproportionate aggression to the myocardium, by the acute inflammatory reaction, that can by itself make worse the damage to the LV function. In our opinion, the blockade of this process by pulsotherapy with steroids can help in the treatment of these patients. We understand that the different scenario of immunosuppressive treatments for the possible auto immunity of the more chronic forms of the presumably post viral cardiomyopathy has been in dispute in the literature, and has stolen the focus from the truly acute cases.

OBJETIVO: Doença sistêmica por citomegalovírus (CMV) com miocardite em pessoas saudáveis é raramente referida na literatura, apesar de em maior número em anos recentes. A importância do reconhecimento da síndrome, que usualmente tem um quadro inicial "mononucleosis like" em uma pessoa sadia é a disponibilidade do agente terapêutico ganciclovir, que pode curar a infecção. MÉTODOS: Nós analisamos o resultado da pulsoterapia com esteróides em um paciente com miocardite por CMV, após 7 dias de tratamento etiológico com ganciclovir, vasodilatadores intravenosos e o tratamento convencional para insuficiência cardíaca congestiva. RESULTADOS: A condição clínica do paciente melhorou com a melhor função do ventrículo esquerdo e o ganciclovir foi mantido por 21 dias após alta hospitalar.A função miocárdica retornou ao normal. CONCLUSÃO: Formas curáveis de miocardites como M pneumonia e CMV, por exemplo, podem ter uma agressão grave ao miocárdio por uma ação inflamatória que pode piorar a função cardíaca. Em nossa opinião, o bloqueio deste processo pela pulsoterapia com esteróides pode auxiliar no tratamento destes pacientes. Entendemos que existe um cenário diferente de tratamento com imunossupressores para possível agressão auto-imune das formas mais crônicas de cardiomiopatias dilatadas e isso está em disputa na literatura, talvez mudando o foco dos casos realmente agudos.

Low compliance with alcohol gel compared with chlorhexidine for hand hygiene in ICU patients: results of an alcohol gel implementation program

Although the introduction of alcohol based products have increased compliance with hand hygiene in intensive care units (ICU), no comparative studies with other products in the same unit and in the same period have been conducted. We performed a two-month-observational prospective study comparing three units in an adult ICU, according to hand hygiene practices (chlorhexidine alone-unit A, both chlorhexidine and alcohol gel-unit B, and alcohol gel alone-unit C, respectively). Opportunities for hand hygiene were considered according to an institutional guideline. Patients were randomly allocated in the 3 units and data on hand hygiene compliance was collected without the knowledge of the health care staff. TISS score (used for measuring patient complexity) was similar between the three different units. Overall compliance with hand hygiene was 46.7 percent (659/1410). Compliance was significantly higher after patient care in unit A when compared to units B and C. On the other hand, compliance was significantly higher only between units A (32.1 percent) and C (23.1 percent) before patient care (p=0.02). Higher compliance rates were observed for general opportunities for hand hygiene (patient bathing, vital sign controls, etc), while very low compliance rates were observed for opportunities related to skin and gastroenteral care. One of the reasons for not using alcohol gel according to health care workers was the necessity for water contact (35.3 percent, 12/20). Although the use of alcohol based products is now the standard practice for hand hygiene the abrupt abolition of hand hygiene with traditional products may not be recommended for specific services.

Choque cardiogênico: disfunção mecânica e inflamatória / Cardiogenic shock: a mechanical and inflammatory dysfunction

O choque cardiogênico é caracterizado como um estado de hipoperfusão sistêmica secundária a disfunção cardíaca grave. Clinicamente é definido como pressão sistólica abaixo de 90mmHg ou queda da pressão arterial média de 30 mmHg em relação ao basal. Em termos hemodinâmicos, é definido como índice cardíaco menor que 1,8 1/min/m2 sem suporte ou entre 2,0 1/min/m2 e 2,2 1/min/m2 com suporte, além de pressão capilar pulmonar elevada em, pelo menos, 15 mmHg. Sua principal etiologia é o infarto agudo do miocárdio com supradesnivelamento de ST. Estudos recentes tem demonstrado que cerca de 20 por cento dos pacientes com choque cardiogênico evoluem com características clínicas e hemodinâmicas de resposta inflamatória sistêmica caracterizada por febre, leucocitose e diminuição da resistência vascular sistêmica. Neste artigo discutiremos esses aspectos e as implicações dessa apresentação.

Estratificação de risco e tratamento da embolia pulmonar / Pulmonary embolism: risk stratification and treatment

O tromboembolismo pulmonar é uma doença potencialmente fatal, consequente à fragmentação e à embolização de trombos oriundos do sistema venoso profundo para o território arterial pulmonar. Nos pacientes não tratados, a mortalidade é de aproximadamente 30 por cento. O diagnóstico precoce e o rápido tratamento melhoram a qualidade de vida e reduzem o risco de suas complicações: a hipertensão pulmonar e a síndrome pós-trombose venosa profunda. O tratamento convencional baseia-se na anticoagulação sistêmica com heparina não-fracionda ou de baixo peso molecular associada à anticoagulação oral. Quando contraindicada, pode-se utilizar o filtro de veia cava inferior ou embolectomia cirúrgica ou percutânea. Os pacientes com instabilidade hemodinâmica são candidatos à terapia fibrinolítica. Algoritmos diagnósticos e estratificação de risco são estratégias que auxiliam na orientação terapêutica.

Gastric tonometry versus cardiac index as resuscitation goals in septic shock: a multicenter, randomized, controlled trial.

INTRODUCTION: Resuscitation goals for septic shock remain controversial. Despite the normalization of systemic hemodynamic variables, tissue hypoperfusion can still persist. Indeed, lactate or oxygen venous saturation may be difficult to interpret. Our hypothesis was that a gastric intramucosal pH-guided resuscitation protocol might improve the outcome of septic shock compared with a standard approach aimed at normalizing systemic parameters such as cardiac index (CI). METHODS: The 130 septic-shock patients were randomized to two different resuscitation goals: CI >or= 3.0 L/min/m2 (CI group: 66 patients) or intramucosal pH (pHi) >or= 7.32 (pHi group: 64 patients). After correcting basic physiologic parameters, additional resuscitation consisting of more fluids and dobutamine was started if specific goals for each group had not been reached. Several clinical data were registered at baseline and during evolution. Hemodynamic data and pHi values were registered every 6 hours during the protocol. Primary end point was 28 days' mortality. RESULTS: Both groups were comparable at baseline. The most frequent sources of infection were abdominal sepsis and pneumonia. Twenty-eight day mortality (30.3 vs. 28.1%), peak Therapeutic Intervention Scoring System scores (32.6 +/- 6.5 vs. 33.2 +/- 4.7) and ICU length of stay (12.6 +/- 8.2 vs. 16 +/- 12.4 days) were comparable. A higher proportion of patients exhibited values below the specific target at baseline in the pHi group compared with the CI group (50% vs. 10.9%; P < 0.001). Of 32 patients with a pHi < 7.32 at baseline, only 7 (22%) normalized this parameter after resuscitation. Areas under the receiver operator characteristic curves to predict mortality at baseline, and at 24 and 48 hours were 0.55, 0.61, and 0.47, and 0.70, 0.90, and 0.75, for CI and pHi, respectively. CONCLUSIONS: Our study failed to demonstrate any survival benefit of using pHi compared with CI as resuscitation goal in septic-shock patients. Nevertheless, a normalization of pHi within 24 hours of resuscitation is a strong signal of therapeutic success, and in contrast, a persistent low pHi despite treatment is associated with a very bad prognosis in septic-shock patients.

Association of elevated fasting glucose with increased short-term and 6-month mortality in ST-segment elevation and non-ST-segment elevation acute coronary syndromes: the Global Registry of Acute Coronary Events.

BACKGROUND: Elevated blood glucose level at admission is associated with worse outcome after a myocardial infarction. The impact of elevated glucose level, particularly fasting glucose, is less certain in non-ST-segment elevation acute coronary syndromes. We studied the relationship between elevated fasting blood glucose levels and outcome across the spectrum of ST-segment elevation and non-ST-segment elevation acute coronary syndromes in a large multicenter population broadly representative of clinical practice. METHODS: Fasting glucose levels were available for 13 526 patients in the Global Registry of Acute Coronary Events. A multivariate logistic regression analysis was used for assessing the association between admission or fasting glucose level and in-hospital or 6-month outcome, adjusted for the variables from the registry risk scores. RESULTS: Higher fasting glucose levels were associated with a graded increase in the risk of in-hospital death (odds ratios [95% confidence intervals] vs <100 mg/dL: 1.51 [1.12-2.04] for 100-125 mg/dL, 2.20 [1.64-2.60] for 126-199 mg/dL, 5.11 [3.52-7.43] for 200-299 mg/dL, and 8.00 [4.76-13.5] for > or =300 mg/dL). When taken as a continuous variable, higher fasting glucose level was related to a higher probability of in-hospital death, without detectable threshold and irrespective of whether patients had a history of diabetes mellitus. Higher fasting glucose levels were found to be associated with a higher risk of postdischarge death up to 6 months. The risk of postdischarge death at 6 months was significantly higher with fasting glucose levels between 126 and 199 mg/dL (1.71 [1.25-2.34]) and 300 mg/dL or greater (2.93 [1.33-6.43]), but not within the 200- to 299-mg/dL range (1.08 [0.60-1.95]). CONCLUSIONS: Short-term and 6-month mortality was increased significantly with higher fasting glucose levels in patients across the spectrum of acute coronary syndromes, thus extending this relation to patients with non-ST-segment elevation myocardial infarction. The relation between fasting glucose level and risk of adverse short-term outcomes is graded across different glucose levels with no detectable threshold for diabetic or nondiabetic patients.

Automatic versus manual pressure support reduction in the weaning of post-operative patients: a randomised controlled trial.

INTRODUCTION: Reduction of automatic pressure support based on a target respiratory frequency or mandatory rate ventilation (MRV) is available in the Taema-Horus ventilator for the weaning process in the intensive care unit (ICU) setting. We hypothesised that MRV is as effective as manual weaning in post-operative ICU patients. METHODS: There were 106 patients selected in the post-operative period in a prospective, randomised, controlled protocol. When the patients arrived at the ICU after surgery, they were randomly assigned to either: traditional weaning, consisting of the manual reduction of pressure support every 30 minutes, keeping the respiratory rate/tidal volume (RR/TV) below 80 L until 5 to 7 cmH2O of pressure support ventilation (PSV); or automatic weaning, referring to MRV set with a respiratory frequency target of 15 breaths per minute (the ventilator automatically decreased the PSV level by 1 cmH2O every four respiratory cycles, if the patient's RR was less than 15 per minute). The primary endpoint of the study was the duration of the weaning process. Secondary endpoints were levels of pressure support, RR, TV (mL), RR/TV, positive end expiratory pressure levels, FiO2 and SpO2 required during the weaning process, the need for reintubation and the need for non-invasive ventilation in the 48 hours after extubation. RESULTS: In the intention to treat analysis there were no statistically significant differences between the 53 patients selected for each group regarding gender (p = 0.541), age (p = 0.585) and type of surgery (p = 0.172). Nineteen patients presented complications during the trial (4 in the PSV manual group and 15 in the MRV automatic group, p < 0.05). Nine patients in the automatic group did not adapt to the MRV mode. The mean +/- sd (standard deviation) duration of the weaning process was 221 +/- 192 for the manual group, and 271 +/- 369 minutes for the automatic group (p = 0.375). PSV levels were significantly higher in MRV compared with that of the PSV manual reduction (p < 0.05). Reintubation was not required in either group. Non-invasive ventilation was necessary for two patients, in the manual group after cardiac surgery (p = 0.51). CONCLUSIONS: The duration of the automatic reduction of pressure support was similar to the manual one in the post-operative period in the ICU, but presented more complications, especially no adaptation to the MRV algorithm. TRIAL REGISTRATION NUMBER: ISRCTN37456640.

Low compliance with alcohol gel compared with chlorhexidine for hand hygiene in ICU patients: results of an alcohol gel implementation program.

Although the introduction of alcohol based products have increased compliance with hand hygiene in intensive care units (ICU), no comparative studies with other products in the same unit and in the same period have been conducted. We performed a two-month-observational prospective study comparing three units in an adult ICU, according to hand hygiene practices (chlorhexidine alone-unit A, both chlorhexidine and alcohol gel-unit B, and alcohol gel alone-unit C, respectively). Opportunities for hand hygiene were considered according to an institutional guideline. Patients were randomly allocated in the 3 units and data on hand hygiene compliance was collected without the knowledge of the health care staff. TISS score (used for measuring patient complexity) was similar between the three different units. Overall compliance with hand hygiene was 46.7% (659/1410). Compliance was significantly higher after patient care in unit A when compared to units B and C. On the other hand, compliance was significantly higher only between units A (32.1%) and C (23.1%) before patient care (p=0.02). Higher compliance rates were observed for general opportunities for hand hygiene (patient bathing, vital sign controls, etc), while very low compliance rates were observed for opportunities related to skin and gastroenteral care. One of the reasons for not using alcohol gel according to health care workers was the necessity for water contact (35.3%, 12/20). Although the use of alcohol based products is now the standard practice for hand hygiene the abrupt abolition of hand hygiene with traditional products may not be recommended for specific services.

Association of Elevated Fasting GlucoseWith Increased Short-term and 6-Month Mortality in ST-Segment Elevation and Non–ST-Segment Elevation Acute Coronary Syndromes

Background: Elevated blood glucose level at admission is associated with worse outcome after a myocardial infarction. The impact of elevated glucose level, particularly fasting glucose, is less certain in non–ST-segment elevation acute coronary syndromes. We studied the relationshipbetween elevated fasting blood glucose levels and outcome across the spectrum of ST-segment elevation andnon–ST-segment elevation acute coronary syndromes in a large multicenter population broadly representative of clinical practice.Methods: Fasting glucose levels were available for 13 526 patients in the Global Registry of Acute Coronary Events. A multivariate logistic regression analysis was used forassessing the association between admission or fasting glucose level and in-hospital or 6-month outcome, adjustedfor the variables from the registry risk scores. Results: Higher fasting glucose levels were associated with a graded increase in the risk of in-hospital death (odds ratios [95% confidence intervals] vs 100 mg/dL: 1.51 [1.12-2.04] for 100-125 mg/dL, 2.20 [1.64-2.60] for 126-199 mg/ dL, 5.11 [3.52-7.43] for 200-299 mg/dL, and 8.00 [4.76-13.5] for 300 mg/dL). When taken as a continuous variable, higher fasting glucose level was related to a higherprobability of in-hospital death, without detectable threshold and irrespective of whether patients had a history ofdiabetes mellitus. Higher fasting glucose levels were found to be associated with a higher risk of postdischarge deathup to 6 months. The risk of postdischarge death at 6 monthswas significantly higher with fasting glucose levels between 126 and 199 mg/dL (1.71 [1.25-2.34]) and 300mg/dL or greater (2.93 [1.33-6.43]), but not within the 200- to 299-mg/dL range (1.08 [0.60-1.95])...