Aggressive intraoperative warming versus routine thermal management during non-cardiac surgery (PROTECT): a multicentre, parallel group, superiority trial.

BACKGROUND: Moderate intraoperative hypothermia promotes myocardial injury, surgical site infections, and blood loss. Whether aggressive warming to a truly normothermic temperature near 37°C improves outcomes remains unknown. We aimed to test the hypothesis that aggressive intraoperative warming reduces major perioperative complications. METHODS: In this multicentre, parallel group, superiority trial, patients at 12 sites in China and at the Cleveland Clinic in the USA were randomly assigned (1:1) to receive either aggressive warming to a target core temperature of 37°C (aggressively warmed group) or routine thermal management to a target of 35·5°C (routine thermal management group) during non-cardiac surgery. Randomisation was stratified by site, with computer-generated, randomly sized blocks. Eligible patients (aged ≥45 years) had at least one cardiovascular risk factor, were scheduled for inpatient non-cardiac surgery expected to last 2-6 h with general anaesthesia, and were expected to have at least half of the anterior skin surface available for warming. Patients requiring dialysis and those with a body-mass index exceeding 30 kg/m2 were excluded. The primary outcome was a composite of myocardial injury (troponin elevation, apparently of ischaemic origin), non-fatal cardiac arrest, and all-cause mortality within 30 days of surgery, as assessed in the modified intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT03111875. FINDINGS: Between March 27, 2017, and March 16, 2021, 5056 participants were enrolled, of whom 5013 were included in the intention-to-treat population (2507 in the aggressively warmed group and 2506 in the routine thermal management group). Patients assigned to aggressive warming had a mean final intraoperative core temperature of 37·1°C (SD 0·3) whereas the routine thermal management group averaged 35·6°C (SD 0·3). At least one of the primary outcome components (myocardial injury after non-cardiac surgery, cardiac arrest, or mortality) occurred in 246 (9·9%) of 2497 patients in the aggressively warmed group and in 239 (9·6%) of 2490 patients in the routine thermal management group. The common effect relative risk of aggressive versus routine thermal management was an estimated 1·04 (95% CI 0·87-1·24, p=0·69). There were 39 adverse events in patients assigned to aggressive warming (17 of which were serious) and 54 in those assigned to routine thermal management (30 of which were serious). One serious adverse event, in an aggressively warmed patient, was deemed to be possibly related to thermal management. INTERPRETATION: The incidence of a 30-day composite of major cardiovascular outcomes did not differ significantly in patients randomised to 35·5°C and to 37°C. At least over a 1·5°C range from very mild hypothermia to full normothermia, there was no evidence that any substantive outcome varied. Keeping core temperature at least 35·5°C in surgical patients appears sufficient. FUNDING: 3M and the Health and Medical Research Fund, Food and Health Bureau, Hong Kong. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Sugammadex, neostigmine and postoperative pulmonary complications: an international randomised feasibility and pilot trial.

BACKGROUND: Sugammadex reduces residual neuromuscular blockade after anaesthesia, potentially preventing postoperative pulmonary complications. However, definitive evidence is lacking. We therefore conducted a feasibility and pilot trial for a large randomised controlled trial of sugammadex, neostigmine, and postoperative pulmonary complications. METHODS: Patients aged ≥40 years having elective or expedited abdominal or intrathoracic surgery were recruited in Australia and Hong Kong. Perioperative care was at the discretion of clinicians, except for the use of rocuronium and/or vecuronium for neuromuscular blockade and the randomised intervention (sugammadex or neostigmine) for reversal. Feasibility measurements included recruitment, crossover, acceptability, completeness, and workload. Trial coordinator feedback was systematically sought. Patient-reported quality of life was measured using the EQ-5D-5L score. The primary pilot outcome was the incidence of new pulmonary complications up to hospital discharge (or postoperative day 7 if still in hospital). RESULTS: Among 150 eligible patients, 120 consented to participate (recruitment rate 80%, 95% confidence interval [CI] 73 to 86%). The randomised intervention was administered without crossover to 115 of 117 patients who received reversal (98%, 95% CI 94 to 100%). The protocol was acceptable or highly acceptable to the anaesthetist in 108 of 116 cases (93%, 95% CI 87 to 97%; missing = 4). Four patients of the 120 patients were lost to follow-up at 3 months (3.3%, 95% CI 0.9 to 8.3%). Case report forms were complete at 3 months for all remaining patients. The median time to complete trial processes was 3.5 h (range 2.5-4.5 h). Trial coordinators reported no barriers to trial processes. Patients were aged 64 (standard deviation 11) years, 70 (58%) were male and 50 (42%) were female, and planned surgeries were thoracic (23 [19%]), upper abdominal (41 [34%]), and lower abdominal (56 [47%]). The primary outcome was observed in 5 (8.5%) of the 59 sugammadex patients and 5 (8.2%) of the 61 neostigmine patients (odds ratio 1.02, 95% CI 0.28 to 3.67). CONCLUSIONS: A large international randomised controlled trial of sugammadex, neostigmine and postoperative pulmonary complications in adult patients having abdominal and intrathoracic surgery, including collection of cost-effectiveness evidence for Health Technology Appraisal, is feasible. TRIAL REGISTRATION: Prospectively registered at the Australian and New Zealand Clinical Trials Registry ( ACTRN12620001313921 ) on December 7, 2020. www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380645&isReview=true .

Association of Obstructive Sleep Apnea With Difficult Intubation: Prospective Multicenter Observational Cohort Study.

BACKGROUND: Obstructive sleep apnea (OSA) has been found to be associated with difficult airway, although there is a paucity of prospective studies investigating thresholds of OSA severity with difficult airway outcomes. The aim of this study was to examine the association between OSA and difficult intubation or difficult mask ventilation. We also explored the utility of the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender (STOP-Bang) score for difficult airway prediction. METHODS: The Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) trial was an international prospective cohort study of surgical patients 45 years or older with one or more cardiac risk factor presenting for noncardiac surgery, with planned secondary analyses of difficult airway outcomes. Multivariable logistic regression analyses tested associations between OSA severity and predictors of difficult airway with difficult intubation or difficult mask ventilation. Overall, 869 patients without prior diagnosis of OSA were screened for OSA risk with the STOP-Bang tool, underwent preoperative sleep study, and had routine perioperative care, including general anesthesia with tracheal intubation. The primary outcome analyzed was difficult intubation, and the secondary outcome was difficult mask ventilation. RESULTS: Based on the sleep studies, 287 (33%), 324 (37%), 169 (20%), and 89 (10%) of the 869 patients had no, mild, moderate, and severe OSA, respectively. One hundred and seventy-two (20%) had a STOP-Bang score of 0-2 (low risk), 483 (55%) had a STOP-Bang score of 3-4 (intermediate risk), and 214 (25%) had a STOP-Bang score 5-8 (high risk). The incidence of difficult intubation was 6.7% (58 of 869), and difficult mask ventilation was 3.7% (32 of 869). Multivariable logistic regression demonstrated that moderate OSA (odds ratio [OR] = 3.26 [95% confidence interval {CI}, 1.37-8.38], adjusted P = .010) and severe OSA (OR = 4.05 [95% CI, 1.51-11.36], adjusted P = .006) but not mild OSA were independently associated with difficult intubation compared to patients without OSA. Relative to scores of 0-2, STOP-Bang scores of 3-4 and 5-8 were associated with increased odds of difficult intubation (OR = 3.01 [95% CI, 1.13-10.40, adjusted P = .046] and 4.38 [95% CI, 1.46-16.36, adjusted P = .014]), respectively. OSA was not associated with difficult mask ventilation, and only increasing neck circumference was found to be associated (adjusted P = .002). CONCLUSIONS: Moderate and severe OSA were associated with difficult intubation, and increasing neck circumference was associated with difficult mask ventilation. A higher STOP-Bang score of 3 or more may be associated with difficult intubation versus STOP-Bang score of 0-2. Anesthesiologists should be vigilant for difficult intubation when managing patients suspected or diagnosed with OSA.

Diagnostic performance of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea in different ethnic groups.

STUDY OBJECTIVES: The STOP-Bang questionnaire is a concise and easy screening tool for obstructive sleep apnea (OSA). Using modified body mass index (BMI), we assessed the diagnostic performance of the STOP-Bang questionnaire in predicting OSA in ethnically different groups of patients undergoing surgery. METHODS: This was a multicenter prospective cohort study involving patients with cardiovascular risk factors who were undergoing major noncardiac surgery. Patients underwent home sleep apnea testing. All patients completed the STOP-Bang questionnaire. The predictive parameters of STOP-Bang scores were calculated against the apnea-hypopnea index. RESULTS: From 4 ethnic groups 1,205 patients (666 Chinese, 161 Indian, 195 Malay, and 183 Caucasian) were included in the study. The mean BMI ranged from 25 ± 4 to 30 ± 6 kg/m² and mean age ranged from 64 ± 8 to 71 ± 10 years. For the Chinese and Indian patients, diagnostic parameters are presented using BMI threshold of 27.5 kg/m² with the area under curve to predict moderate-to-severe OSA being 0.709 (0.665-0.753) and 0.722 (0.635-0.808), respectively. For the Malay and Caucasian, diagnostic parameters are presented using BMI threshold of 35 kg/m² with the area under curve for predicting moderate-to-severe OSA being 0.645 (0.572-0.720) and 0.657 (0.578-0.736), respectively. Balancing the sensitivity and specificity, the optimal STOP-Bang thresholds for the Chinese, Indian, Malay, and Caucasian groups were determined to be 4 or greater. CONCLUSIONS: For predicting moderate-to-severe OSA, we recommend BMI threshold of 27.5 kg/m² for Chinese and Indian patients and 35 kg/m² for Malay and Caucasian patients. The optimal STOP-Bang threshold for the Chinese, Indian, Malay and Caucasian groups is 4 or greater. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Postoperative Vascular Events in Unrecognized Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/study/NCT01494181; Identifier: NCT01494181.

Impact of Locally Adopted Simulation-Based Crew Resource Management Training on Patient Safety Culture: Comparison Between Operating Room Personnel and General Health Care Populations Pre and Post Course.

Crew resource management (CRM) was introduced to enhance patient safety and reduce medical errors through multidisciplinary learning experience. This study investigates the impact of locally adopted simulation-based CRM training on participants' perceptions and knowledge. A 32-item web-based questionnaire was administered pre course, 1 month, and 1 year post course to assess changes in perceptions and knowledge. Another 12-item paper-based questionnaire was administered immediately post course to assess reactions. Among 712 participants analyzed, 165 were operating room staff. The majority agreed that the training is useful and relevant in daily practice. All participants showed significant improvements in perception and knowledge 1 month post course; however, these improvements declined 1 year post course. The CRM course is associated with satisfactory reaction (Kirkpatrick level 1) and improvement in attitude and knowledge (level 2) toward patient safety. However, the effect may be short-lived and regular refresher courses should be mandatory to sustain momentum of ongoing change.

Superior Vena Cava Duplication: The Red Herring of Central Line Placement.

5 million central venous access lines are placed every year in the United States, and it is a common surgical bedside procedure. We present a case of a central venous catheter placement with port for chemotherapy use, during which a duplication of a superior vena cava was discovered on CTA chest after fluoroscopy could not confirm placement of the guidewire. Due to its potential clinical implications, superior vena cava duplication must be recognized when it occurs.

Association of Unrecognized Obstructive Sleep Apnea With Postoperative Cardiovascular Events in Patients Undergoing Major Noncardiac Surgery.

Importance: Unrecognized obstructive sleep apnea increases cardiovascular risks in the general population, but whether obstructive sleep apnea poses a similar risk in the perioperative period remains uncertain. Objectives: To determine the association between obstructive sleep apnea and 30-day risk of cardiovascular complications after major noncardiac surgery. Design, Setting, and Participants: Prospective cohort study involving adult at-risk patients without prior diagnosis of sleep apnea and undergoing major noncardiac surgery from 8 hospitals in 5 countries between January 2012 and July 2017, with follow-up until August 2017. Postoperative monitoring included nocturnal pulse oximetry and measurement of cardiac troponin concentrations. Exposures: Obstructive sleep apnea was classified as mild (respiratory event index [REI] 5-14.9 events/h), moderate (REI 15-30), and severe (REI >30), based on preoperative portable sleep monitoring. Main Outcomes and Measures: The primary outcome was a composite of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, and stroke within 30 days of surgery. Proportional-hazards analysis was used to determine the association between obstructive sleep apnea and postoperative cardiovascular complications. Results: Among a total of 1364 patients recruited for the study, 1218 patients (mean age, 67 [SD, 9] years; 40.2% women) were included in the analyses. At 30 days after surgery, rates of the primary outcome were 30.1% (41/136) for patients with severe OSA, 22.1% (52/235) for patients with moderate OSA, 19.0% (86/452) for patients with mild OSA, and 14.2% (56/395) for patients with no OSA. OSA was associated with higher risk for the primary outcome (adjusted hazard ratio [HR], 1.49 [95% CI, 1.19-2.01]; P = .01); however, the association was significant only among patients with severe OSA (adjusted HR, 2.23 [95% CI, 1.49-3.34]; P = .001) and not among those with moderate OSA (adjusted HR, 1.47 [95% CI, 0.98-2.09]; P = .07) or mild OSA (adjusted HR, 1.36 [95% CI, 0.97-1.91]; P = .08) (P = .01 for interaction). The mean cumulative duration of oxyhemoglobin desaturation less than 80% during the first 3 postoperative nights in patients with cardiovascular complications (23.1 [95% CI, 15.5-27.7] minutes) was longer than in those without (10.2 [95% CI, 7.8-10.9] minutes) (P < .001). No significant interaction effects on perioperative outcomes were observed with type of anesthesia, use of postoperative opioids, and supplemental oxygen therapy. Conclusions and Relevance: Among at-risk adults undergoing major noncardiac surgery, unrecognized severe obstructive sleep apnea was significantly associated with increased risk of 30-day postoperative cardiovascular complications. Further research would be needed to assess whether interventions can modify this risk.

Targeted Genotyping Identifies Susceptibility Locus in Brain-derived Neurotrophic Factor Gene for Chronic Postsurgical Pain.

BACKGROUND: The purpose of this study was to evaluate the association between single-nucleotide polymorphisms and chronic postsurgical pain. METHODS: Using GoldenGate genotyping assays, we genotyped 638 polymorphisms within 54 pain-related genes in 1,152 surgical patients who were enrolled in our Persistent Pain after Surgery Study. Patients were contacted by phone to determine whether they had chronic postsurgical pain at 12 months. Polymorphisms identified were validated in a matched cohort of 103 patients with chronic postsurgical pain and 103 patients who were pain free. The functions of targeted polymorphisms were tested in an experimental plantar incisional nociception model using knock-in mice. RESULTS: At 12 months after surgery, 246 (21.4%) patients reported chronic postsurgical pain. Forty-two polymorphisms were found to be associated with chronic postsurgical pain, 19 decreased the risk of pain, and 23 increased the risk of pain. Patients carrying allele A of rs6265 polymorphism in brain-derived neurotrophic factor (BDNF) had a lower risk of chronic postsurgical pain in the discovery and validation cohorts, with an adjusted odds ratio (95% CI) of 0.62 (0.43 to 0.90) and 0.57 (0.39 to 0.85), respectively. Age less than 65 yr, male sex, and prior history of pain syndrome were associated with an increased risk of pain. Genetic polymorphisms had higher population attributable risk (7.36 to 11.7%) compared with clinical risk factors (2.90 to 5.93%). Importantly, rs6265 is a substitution of valine by methionine at amino acid residue 66 (Val66Met) and was associated with less mechanical allodynia in BDNF mice compared with BDNF group after plantar incision. CONCLUSIONS: This study demonstrated that genetic variant of BDNF rs6265G>A is associated with decreased risk of chronic postsurgical pain.

Botulinum toxin in migraine: Role of transport in trigemino-somatic and trigemino-vascular afferents.

Migraine secondary to meningeal input is referred to extracranial regions innervated by somatic afferents that project to homologous regions in the trigeminal nucleus caudalis (TNC). Reported efficacy of extracranial botulinum toxin (BoNT) in treating migraine is surprising since a local extracranial effect of BoNT cannot account for its effect upon meningeal input. We hypothesize that intradermal BoNT acts through central transport in somatic afferents. Anesthetized C57Bl/6 mice (male) received unilateral supraorbital (SO) injections of BoNT-B (1.5 U/40 µl) or saline. 3 days later, mice received ipsilateral (ipsi)-SO capsaicin (20 µl of 0.5mM solution) or meningeal capsaicin (4 µl of 0.35 µM). Pre-treatment with ipsi-SO BoNT-B i) decreased nocicsponsive ipsilateral wiping behavior following ipsi-SO capsaicin; ii) produced cleavage of VAMP in the V1 region of ipsi-TG and in TG neurons showing WGA after SO injection; iii) reduced expression of c-fos in ipsi-TNC following ipsi-SO capsaicin; iv) reduced c-fos activation and NK-1 internalization in ipsi-TNC secondary to ipsi-meningeal capsaicin; and vi) SO WGA did not label dural afferents. We conclude that BoNT-B is taken up by peripheral afferents and transported to central terminals where it inhibits transmitter release resulting in decreased activation of second order neurons. Further, this study supports the hypothesis that SO BoNT exerts a trans-synaptic action on either the second order neuron (which receives convergent input from the meningeal afferent) or the terminal/TG of the converging meningeal afferent.

MRI predicts remission at 1 year in first-episode schizophrenia in females with larger striato-thalamic volumes.

BACKGROUND/AIMS: The Remission in Schizophrenia Working Group has defined remission as 'a low-mild symptom intensity level, maintained for a minimum of 6 months, where such symptoms do not affect an individual's behaviour' [Andreasen et al.: Am J Psychiatry 2005;162:441-449]. Since brain morphology relates to symptomatology, treatment and illness progression, MRI may assist in predicting remission. METHODS: Thirty-nine patients newly diagnosed with DSM-IV schizophrenia underwent MRI brain scan prior to antipsychotic exposure. The Global Assessment of Functioning (GAF) score was entered into a voxel-based analysis to evaluate its relationship with cerebral grey matter volume from the baseline MRI. We entered age, total intracranial volume and intake GAF score as co-variates. Males and females were analysed separately because gender is a potent determinant of outcome. RESULTS: Males had lower GAF scores than females, both at intake and at 1 year. Males comprised only 40% (12 out of 39) of the early remission group. For females only, early remission was strongly and positively correlated with bilateral lentiform and striatal volumes. For males, there was no such relationship. CONCLUSION: Larger striato-thalamic volume correlated with early remission in females only. These baseline MRI findings were unlikely to be confounded by antipsychotic treatment and chronicity. These brain morphological markers show gender dimorphism and may assist in the prediction of early remission in newly diagnosed schizophrenia.

Factores asociados a mortalidad por neumonía nosocomial en un hospital público de Perú: 2006- 2010 / Factors associated with nosocomial pneumonia mortality in a public hospital in Peru: 2006-2010

Objetivos: determinar los factores asociados a mortalidad en pacientes con neumonía nosocomial en el Hospital Dos de Mayo, Lima - Perú entre el período enero 2006-diciembre 2010. Materiales y Métodos: estudio de cohorte retrospectivo de pacientes con diagnóstico de neumonía nosocomial. Los pacientes elegibles para el estudio fueron mayores de 18 años, tiempo de enfermedad, y condición de egreso conocido (alta o fallecido). Para el análisis de supervivencia se utilizó el método de Kaplan-Meier y regresión de Cox. Resultados: se identificaron 658 pacientes con diagnóstico de neumonía nosocomial, el agente causal fue identificado en 173 (26,75%) casos. La edad media fue 58,4 ± 19,6 años, fallecieron 238 (36,2%) pacientes, la mediana de supervivencia fue de 16 días. El sexo masculino presentó un Hazard Ratio (HR) de 1,15 (IC 95%: 0,89 a 1,49). A las 10 y 20 días la tasa de supervivencia fue de 70% y 40% en aquellos pacientes con Klebsiella, 85% y 75% en aquellos con Pseudomonas, y el 70% y 65% en aquellos con Staphylococcus aureus. En el análisis multivariado, se identificaron la exposición a ventilación mecánica (HR 1,98 (95% IC 1,35- 2,89), el uso de una sonda nasogástrica (HR 1,33 (95% IC 1,01- 1,76) y la edad mayor de 65 años (HR 1,96:95% IC 1,51-2,55). La resistencia a ceftazidima y amikacina (95% HR 1.45 (0.74- 2.84). Conclusiones: en la neumonía nosocomial, la exposición a ventilación mecánica, sonda nasogástrica y edad mayor de 65 años, se asoció con una menor supervivencia. Esto sugiere la instauración de medidas preventivas en este grupo de riesgo

Objectives: to determine factors associated with mortality in patients with nosocomial pneumonia in the Hospital Dos de Mayo, Lima - Peru during the period January 2006-December 2010. Materials and Methods: retrospective cohort study, patients eligible for the study were: age over 18 years of age, sick time record and known exit condition (discharge or deceased). For survival analysis we used the Kaplan- Meier and Cox regression. Results: we identified 658 patients diagnosed with nosocomial pneumonia, and the causative agent was identified in 173 (26,75%). The mean age was 58.4 ± 19.6 years, died 238 (36.2%); patients median survival time was 16 days. Male sex presented HR=1.15, IC95%: 0.89- 1.49. At 10 and 20 days the survival rate was 70% and 40% in those with Klebsiella, 85% and 75% in those with Pseudomonas, and 70% and 65% in those with Staphylococcus aureus. In the multivariate analysis, we identified exposure to mechanical ventilation (HR=1.98, IC95%:1.35-2.89, the use of a nasogastric tube (HR=1.33, IC95%:1.01-1,76) and age over 65 years (HR=1,96, IC95%:1.51-2.55). Resistance to ceftazidime and amikacin (HR=1.45, IC95%:0.74-2.84). Conclusions: in nosocomial pneumonia, the exposure to mechanical ventilation, nasogastric tube and age over 65 years, are associated with lower survival. This suggests the introduction of preventive measures in this risk group

Factores asociados a mortalidad por neumonía nosocomial en un hospital público de Perú / Factors associated with nosocomial pneumonia mortalityin a public hospital in Peru

Objetivo: Determinar los factores asociados a mortalidad en pacientes con neumon¡a nosocomial en el Hospital Dos de Mayo, Lima-Perú entre el per¡odo enero 2006-diciembre 2010. Métodos: Se realizó un estudio de cohorte única, retrospectivo, de pacientes con diagnóstico de neumon¡a nosocomial. Los pacientes elegibles para el estudio fueron mayores de 18 años, tiempo de enfermedad y condicón de egreso conocido (alta o fallecido). Para el análisis de supervivencia se utilizó el método de Kaplan-Meier y regresión de Cox. Resultados: Se identificaron 658 pacientes con diagnóstico de neumon¡a nosocomial, el agente causal fue identificado en 173 (26,75%) casos. La edad media fue 58,4ñ19,6 años, fallecieron 238 (36,2%) pacientes, la mediana de supervivencia fue de 16 d¡as. El sexo masculino presentó un hazard ratio (HR) de 1,15 (IC 95%: 0,89 a 1,49). A los 10 y 20 d¡as la tasa de supervivencia fue de 70% y 40% en aquellos pacientes con Klebsiella, 85% y 75% en aquellos con Pseudomonas, y el 70% y 65% en aquellos con Staphylococcus aureus. En el análisis multivariado, se identificaron a la exposición a ventilación mecánica (HR 1,98; IC95% 1,35-2,89), el uso de una sonda nasogástrica (HR 1,33; IC95% 1,01-1,76) y la edad mayor de 65 años (HR 1,96; IC95% 1,51-2,55) como factores asociados a mortalidad, mientras que la resistencia a ceftazidima y amikacina presentó HR 1,45 (IC95% 0,74-2,84). Conclusiones: En la neumon¡a nosocomial, la exposición a ventilación mecánica, sonda nasogástrica y edad mayor de 65 años, se asoció con una menor supervivencia. Esto sugiere la instauración de medidas preventivas en este grupo de riesgo.

Objective: To determine factors associated with mortality in patients with nosocomial pneumonia at the Hospital Dos de Mayo, Lima-Peru between January 2006 to December 2010. Methods: Retrospective cohort study, patients eligible for the study were over 18 years of age, sick time record and known exit condition (discharge or deceased). For survival analysis we used the Kaplan-Meier and Cox regression. Results: We identified 658 patients diagnosed with nosocomial pneumonia, and the causative agent was identified in 173 (26,75%). The mean age was 58,4ñ19,6 years, 238 patientes died (36,2%); median survival time was 16 days. Male sex presented HR=1,15, 95%CI 0.89-1.49. At 10 and 20 days the survival rate was 70% and 40% in those with Klebsiella, 85% and 75% in those with Pseudomonas, and 70% and 65% in those with Staphylococcus aureus. In the multivariate analysis, we identified exposure to mechanical ventilation (HR 1,98; 95%CI 1,35 to 2,89), use of a nasogastric tube (HR 1,33; 95%CI 1,01 to 1,76) and age over 65 years (HR 1,96; (95%CI 1,51 to 2,55) as factors associated with mortality, while resistance to ceftazidime and amikacin present HR 1,45 (95%CI 0,74 -2,84). Conclusions: In nosocomial pneumonia, the exposure to mechanical ventilation, nasogastric tube and age over 65 years, are associated with lower survival. This suggests the introduction of preventive measures in this risk group.

Notificación de eventos adversos en un hospital nacional en Lima / No disponible

Objetivo: Establecer un sistema de notificación de eventos adversos (EA) en el Hospital Nacional Dos de Mayo (HNDM). Método: Investigación operativa, centrada en la puesta en funcionamiento de un sistema de notificación voluntario, confidencial y con vigilancia activa entre el 1 de octubre de 2005 y el 31 de marzo de2006. El modelo para el abordaje de los EA fue de carácter sistémico. Resultados: El total de egresos fue 8.964 y la cantidad de EA reportados,347. La tasa de EA fue del 3,9% y los EA potenciales, 12(0,13%). Los EA más detectados fueron las infecciones hospitalarias, con 241 (70%), y el servicio de neonatología es el que tiene elmayor número de casos: 47 (19,5%); entre éstos, la sepsis hospitalaria neonatal (19 casos) fue la más frecuente. La segunda causa de EA fue las reacciones adversas a medicamentos (RAM), con 49(14,2%) casos, de los cuales 39 (79,6%) ocurrieron durante el tratamiento antirretroviral. Casi todas las notificaciones fueron obtenidas por vigilancia activa y hubo sólo 5 reportes voluntarios. Encontramosinformación fragmentada de otros subsistemas, como el delcomité de infecciones hospitalarias, hemovigilancia, farmacovigilancia, sistema de quejas y auditorías. Se buscaron EA en las reintervencionesquirúrgicas no programadas, y se clasificaron los EA porfrecuencia e impacto. Conclusiones: La tasa general de EA estimada (3,9%) es menor que la de países desarrollados cuyas condiciones sanitarias son mejoresque las nuestras, lo que indica un probable subregistro. La vigilancia activa de EA e integración de subsistemas es la forma más adecuada en el momento para obtener información de EA

Objective: To establish a system for notifying adverse effects (AE) at the Dos de Mayo National Hospital.Method: We performed an operative investigation of the implementation of a confidential, voluntary reporting system with active surveillance from 1 October 2005 to 31 March 2006. A systems-based model was used for the management of AE. Results: Among a total of 8,964 hospital admissions, 347 AE were reported. The rate of AE was 3.9% and there were 12 near misses (0.13%). The most frequent AE were nosocomial infections241 (70%). The highest number of cases (47 [19.5%])occurred in the neonatology department and the most frequent condition was neonatal sepsis (19 cases). The second most frequent AE were adverse drug reactions, amounting to 49 cases (14.2%). Of these, 39 (79.6%) were caused by antiretroviral therapy.Almost all notifications were obtained by active surveillance and there were only five voluntary reports. We found additional informationin fragmented subsystems such as the nosocomial infections board, blood surveillance, pharmacology surveillance, the complaints system and audits. In addition, we searched for AE innon-elective surgical re-interventions. All AE were classified by frequency and impact. Conclusions: The estimated overall rate of AE (3.9%) was lowerthan that in developed countries with better health conditions, suggesting a possible under-reporting bias. We infer that active surveillance of AE coupled with integration of subsystems is currently themost appropriate way to obtain information on AE

Children with a regular FP - do they have better health behaviours and psychosocial health?

BACKGROUND: Adults who receive care from family physicians (FPs) are healthier than those who do not, but not much is known about the health behaviours and psychosocial health of children who have FPs. OBJECTIVE: This study aims to test the hypothesis that children who have a regular FP have better health behaviours and psychosocial health than children who do not have a regular FP. METHODS: The health behaviours and psychosocial wellbeing of 7057 children in Hong Kong were measured by the Youth Risk Behaviour Survey and the 'anxious/depressed', 'somatic complaints' and 'aggressive behaviours' domains of the Children Behaviour Checklist (CBCL). RESULTS: Good health and hygiene behaviours were significantly more prevalent in children who had a regular FP. Children who did not have a regular FP had statistically significant higher scores in all three main domains of the CBCL. Children with a regular FP had higher odds ratios for various hygiene and health behaviours after adjusting for socioeconomic status. DISCUSSION: The findings highlight the potential role of FPs in promoting health, hygiene, and wellbeing in children.