Risk of SARS-CoV-2 infection among front-line healthcare workers in Northeast Brazil: a respondent-driven sampling approach.

OBJECTIVES: We assessed the prevalence of SARS-CoV-2 infection, personal protective equipment (PPE) shortages and occurrence of biological accidents among front-line healthcare workers (HCW). DESIGN, SETTING AND PARTICIPANTS: Using respondent-driven sampling, the study recruited distinct categories of HCW attending suspected or confirmed patients with COVID-19 from May 2020 to February 2021, in the Recife metropolitan area, Northeast Brazil. OUTCOME MEASURES: The criterion to assess SARS-CoV-2 infection among HCW was a positive self-reported PCR test. RESULTS: We analysed 1525 HCW: 527 physicians, 471 registered nurses, 263 nursing assistants and 264 physical therapists. Women predominated in all categories (81.1%; 95% CI: 77.8% to 84.1%). Nurses were older with more comorbidities (hypertension and overweight/obesity) than the other staff. The overall prevalence of SARS-CoV-2 infection was 61.8% (95% CI: 55.7% to 67.5%) after adjustment for the cluster random effect, weighted by network, and the reference population size. Risk factors for a positive RT-PCR test were being a nursing assistant (OR adjusted: 2.56; 95% CI: 1.42 to 4.61), not always using all recommended PPE while assisting patients with COVID-19 (OR adj: 2.15; 95% CI: 1.02 to 4.53) and reporting a splash of biological fluid/respiratory secretion in the eyes (OR adj: 3.37; 95% CI: 1.10 to 10.34). CONCLUSIONS: This study shows the high frequency of SARS-CoV2 infection among HCW presumably due to workplace exposures. In our setting, nursing assistant comprised the most vulnerable category. Our findings highlight the need for improving healthcare facility environments, specific training and supervision to cope with public health emergencies.

Interventions to improve professional adherence to guidelines for prevention of device-related infections.

BACKGROUND: Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections. OBJECTIVES: To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence. SEARCH METHODS: We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews. SELECTION CRITERIA: We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information. MAIN RESULTS: We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times. AUTHORS' CONCLUSIONS: The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

[Survival and prognostic factors in systolic heart failure with recent symptom onset]. / Sobrevida e fatores prognósticos na insuficiência cardíaca sistólica com início recente dos sintomas.

OBJECTIVE: To study survival and prognostic factors associated with mortality in patients with systolic heart failure followed up since symptom onset. METHODS: We carried out a study with a cohort of 204 consecutive patients with systolic heart failure, whose symptom onset occurred within the 6 weeks preceding the first medical visit. They were followed up for 46 months. The prognostic variables analyzed were collected when the patients were included in the study and were correlated with cardiovascular mortality. An EF < or =40% on echocardiography characterized systolic ventricular dysfunction. RESULTS: The overall survival rates according to the Kaplan-Meier technique were 98.0%, 90.6%, and 70.2% at 3, 12, and 48 months of follow-up, respectively. The multivariate analysis identified the independent effect of 6 variables on the risk of cardiovascular death. Functional classes III and IV increased risk 2.7 times as compared with class II; 10-mmHg increments in systolic blood pressure reduced the risk of death by 25%; each 10-bpm increase in heart rate increased the risk of death 1.6 times; and each 0.25-mg/dL increment in serum creatinine caused a 60% increase in risk. The presence of the third cardiac sound caused a 3-fold increase in the risk of death, and chagasic etiology was also associated with cardiovascular mortality (P<0.0001). CONCLUSION: Evidence shows that mortality in the initial phase is not elevated, and that etiology, advanced functional class, arterial hypotension, tachycardia, presence of the third cardiac sound, and elevated serum creatinine lead to a worse prognosis.

Sobrevida e fatores prognósticos na insuficiência cardíaca sistólica com início recente dos sintomas / Survival and prognostic factors in systolic heart failure with recent symptom onset

OBJETIVO: Analisar a sobrevida e fatores prognósticos associados à mortalidade em pacientes com insuficiência cardíaca sistólica acompanhados desde o início de seus sintomas. MÉTODOS: Coorte de 204 pacientes consecutivos com insuficiência cardíaca sistólica, identificada com início dos sintomas até seis semanas do primeiro atendimento e seguida por 46 meses. As variáveis prognósticas analisadas foram coletadas à inclusão e correlacionadas com a mortalidade cardiovascular. A Fração de Ejeção (FE) < 40 por cento ao ecocardiograma caracterizava a disfunção sistólica ventricular. RESULTADOS: A taxa geral de sobrevida pela técnica de Kaplan-Meier foi de 98,0 por cento, 90,6 por cento e de 70,2 por cento aos três, 12 e 48 meses de seguimento, respectivamente. A análise multivariada identificou o efeito independente de seis variáveis sobre o risco de morte cardiovascular. As classes funcionais III e IV aumentou em 2,7 vezes o risco em relação à classe II; incrementos de 10 mmHg na pressão arterial sistólica reduziram em 25 por cento o risco de morte; cada aumento de 10 bpm na freqüência cardíaca elevava o risco de morte em 1,6 vezes e cada incremento de 0,25 mg/dL na creatinina sérica acarretava um aumento de risco de 60 por cento. A presença de 3ª bulha aumentou em 3,0 vezes o risco de morte e a etiologia chagásica também se associou à mortalidade cardiovascular (P<0,0001). CONCLUSÃO: Estas evidências mostram que a mortalidade na fase inicial não é elevada e que a etiologia, classe funcional avançada, hipotensão arterial, taquicardia, presença de 3ª bulha e creatinina sérica elevada, conferem um pior prognóstico.

Ethical aspects in the management of the terminally ill patient in the pediatric intensive care unit.

OBJECTIVE: To identify the prevalence of management plans and decision-making processes for terminal care patients in pediatric intensive care units. METHODOLOGY: Evidence-based medicine was done by a systematic review using an electronic data base (LILACS, 1982 through 2000) and (MEDLINE, 1966 through 2000). The key words used are listed and age limits (0 to 18 years) were used. RESULTS: One hundred and eighty two articles were found and after selection according to the exclusion/inclusion criteria and objectives 17 relevant papers were identified. The most common decisions found were do-not-resuscitation orders and withdrawal or withholding life support care. The justifications for these were "imminent death" and "unsatisfatory quality of life". CONCLUSION: Care management was based on ethical principles aiming at improving benefits, avoiding harm, and when possible, respecting the autonomy of the terminally ill patient.

Ethical aspects in the management of the terminally ill patient in the pediatric intensive care unit

OBJETIVO: Identificar a prevalência das condutas e o processo de decisão na abordagem do paciente terminal na UTI pediátrica. METODOLOGIA: Revisão sistemática da literatura. seguindo os critérios da medicina baseada em evidências. nas seguintes bases de dados: LILACS (1982-2000) e MEDLINE (1966-2000). usando os descritores abaixos limitados para a idade (0 a 18 anos). RESULTADOS: Foram selecionados 183 artigos e após análise dos critérios de exclusão / inclusão e os objetivos restaram 17 artigos. As condutas mais prevalentes foram: ordem de não ressuscitar. omissão e/ou suspensão de suporte de vida. As justificativas mais encontradas para tais condutas foram: "morte iminente" e "qualidade de vida insatisfatória". CONCLUSAO: A abordagem tem base nos princípios éticos e visa maximizar o benefício e evitar a distanásia. se possível. respeitando a autonomia do paciente terminal.

Comparison of US and non-US central venous catheter infection rates: evaluation of processes and indicators in infection control study.

OBJECTIVE: We sought to identify the presence or absence of international variation in central venous catheter-associated bloodstream infection (BSI) rates and to examine associated infection control practices that might underlie the differences. DESIGN: The Evaluation of Processes and Indicators in Infection Control (EPIC) study was conducted as a prospective surveillance study. SETTINGS: The study took place in intensive care units (ICUs) from 14 countries, which were from the Asian Pacific (3), Europe (7), Middle East (2), and South America (2), in addition to 41 US hospitals. METHODS: We compared the National Nosocomial Infections Surveillance catheter-associated BSI rate between the non-US and US units. We also compared the following organization factors between the 2 groups: hospital factors (ownership, average daily census of patients); ICU type (medical vs surgical); number of beds; and infection control-related factors (number of staff, number of hours spent on study ICU surveillance, years of experience, number of inservice sessions on line infection, number of blood cultures drawn/1000 patients). RESULTS: We found no significant difference in catheter-associated BSI rates between non-US and US hospitals (5.02 +/- 0.75 vs 3.82 +/- 0.42/1000 days, respectively; P =.27). Non-US hospitals were more likely to be government-owned (10/14 vs 7/41;P <.001) and to have larger daily patient census (795 +/- 84 vs 276 +/- 47 patients; P <.001). There was no difference in ICU type or number of beds. Infection control committees were present in all US and non-US hospitals. No significant differences were found in the number of staff involved in surveillance in the study ICU, years of experience, hours spent on surveillance, or the provision of inservices on line care. The use of barriers during line insertion also did not differ. CONCLUSIONS: Catheter-associated BSIs in patients in the ICU were not significantly different between non-US and US hospitals. All hospitals had infection control committees, and there were no significant differences in time spent and numbers of persons involved in ICU surveillance activities. These findings suggest that many aspects of the standards of care do not differ between the 2 groups.

Interferência entre as vacinas anti-sarampo e antipoliomielite / Interference between measles and polio vaccines

O objetivo da presente pesquisa foi avaliar se a administraçäo prévia de vacina oral antipoliomielite, tipo Sabin (VOP-Sabin), interfere na eficácia sorológica da vacina do sarampo. Com essa finalidade estudaram-se 117 crianças, de nove meses de idade, que receberam vacina de vírus vivo atenuado do sarampo (cep BIKEN CAM 70) no período de quatro semanas, ou menos, após terem recebido vacina oral antipoliomielite (VOP-Sabin), e 88 crianças, da mesma faixa etária mas sem vacinaçäo recente com a VOP-Sabin, como controle. Os anticorpos IgG para o sarampo foram pesquisados mediante a reaçäo de imunofluorescência indireta. A proporçäo de soroconversäo para a vacina do sarampo foi de 19/23 (82,6%) nas crianças que tinham recebido a VOP-Sabin 2 a 6 dias antes; 29/37 (78,4%), nas que receberam VOP-Sabin 9 a 13 dias antes; 32/42 (76,2%), nas vacinadas com a VOP-Sabin 16 a 20 dias antes; e 12/15 (80,0%), nas vacinadas com intervalos de 23 a 26 dias. A proporçäo de soroconversäo no grupo controle (vacinadas quatro semanas ou mais após a VOP-Sabin) foi de 68/88 (77,8%) e a comparaçäo destas proporçöes näo mostrou diferenças estatisticamente significativas. Os resultados obtidos näo demonstraram, portanto, uma menor eficácia sorológica para a vacina do sarampo em crianças previamente vacinadas contra a pólio que recebram a vacina Sabin durante as quatro semanas anteriores

Interferencia entre as vacinas anti-sarampo e antipoliomielite / Interference between measles and polio vaccines

The purpose of this study was to determine whether Sabin oral polio vaccine (OPV-Sabin) interferes with the serologic efficacy of measles vaccine administered subsequently. To this end, a study was made of 117 infants nine months old to whom attenuated live measles virus vaccine (BIKEN CAM 70 strain) was administered within a period of four weeks or less after receiving oral polio vaccine (OPV-Sabin), and of a control group of 88 infants of the same age to whom OPV-Sabin had not been recently administered.IgC antibodies to measles were studied by indirect inmunofluorescence. The proportion of seroconversion for measles vaccine was 19/23 (82.6 per cent) in the infants who had received OPV-Sabin two to six days before, 29/37(78.4 per cent) in those who had received OPV-Sabin nine to thirteen days before, 32/42 (76.2 per cent) in those in which OPV-sabin had been given 16 to 20 days before, and 12/15 (80.0 per cent) in the infants who had received the two vaccinations 23 to 26 days apart. The proportion of seroconversion in the control group (the infants vaccinated for weeks or longer after having received OPV-Sabin) was 68/88 (77.8 per cent). A comparison of these ratios brought out no statistically significant differences. Hence, the results obtained do no show reduced serologic efficacy of measles vaccine in infants