Telemedicine Rounding Support for Public Health System Pediatric Intensive Care Units in Brazil can Improve Outcomes.

There are discrepancies in resources and expertise available between pediatric intensive care units (PICUs) in Brazil that likely significantly impact the clinical outcomes of patients. The goal of this study was to evaluate the impact of telemedicine rounding support in two public PICUs located in the North and Northeast regions of Brazil. Our intervention involves telehealth rounds connecting two "level II" PICUs with specialist doctors from a hospital of recognized excellence. A before-and-after study was carried out to evaluate telemedicine's impact on PICUs between December 2018 and July 2019. Nine hundred and forty patients were evaluated during this period (426 pre-telemedicine, 514 post-telemedicine). The intervention occurred through telerounds between the command center and the ICUs assisted by telemedicine. In unit A, the implementation of telemedicine reduced the mortality rate from 18.86% to 9.29%, while in unit B, it decreased from 10.76% to 9.72%. There was no change in the median length of stay in unit A, but in unit B, it increased from 6 to 8 days. Logistic regression analysis confirmed a significant reduction in mortality in unit A (odds ratio (OR) 0.50; 95% confidence interval (CI) 0.29-0.86). The study found a positive correlation between adherence to telemedicine recommendations and mortality reduction across both units. This suggests that telemedicine can effectively improve outcomes in PICUs, particularly in regions with limited health-care resources.

Endovascular Repair in Patients with Axillary-Subclavian Arterial Trauma.

BACKGROUND: Arterial trauma of the axillary subclavian segment carries considerable morbidity and mortality risks. Surgical approaches are challenging given the hidden trajectory of these vessels, which has made the endovascular approach a valid and potentially better alternative for managing these injuries. We describe the incidence of relevant outcomes for patients with traumatic axillary and/or subclavian artery injury who underwent endovascular therapy at a tertiary care university hospital over a 15-year period in Cali, Colombia. METHODS: We conducted an incidence study based on clinical records that included patients aged 15 years or older with traumatic axillary subclavian arterial injury treated with endovascular therapy between 2008 and 2022. Vascular injuries caused by intra-arterial dialysis catheter insertion (iatrogenic) were excluded. We described clinical and imaging characteristics upon admission, perioperative findings, and the incidence of complications and in-hospital mortality, with accompanying 95% confidence intervals (CIs). RESULTS: We included 32 patients, 93.8% of whom were male, with a median (interquartile range) age of 30 (21-42) years. The type of trauma was penetrating in 75% of patients (62.5% corresponding to gunshot wounds) and blunt in 25%. Upon admission, 12 patients (37.5%) exhibited hard signs of vascular injury, and 20 patients (62.5%) exhibited soft signs. Fourteen patients (47%) had an Injury Severity Score greater than 15, and 12 (37.5%) had hemodynamic instability. All but 3 patients (90.6%) suffered subclavian artery injury (right 48.3%, left 51.7%), while 12.9% had axillary artery injury (one patient with both vessels affected). Intraoperative complications happened in one patient (3.1%, 95% CI: 0.2-18%). Pseudoaneurysms were identified in 11 patients (34.4%), thrombosis in 6 (18.8%), and dissection in 6 (18.8%). Three (9.4%) patients required hybrid management (endovascular therapy following conventional surgery). No cases of ischemia or amputation occurred. The length of hospital stay was 6 (3, 11.5) days. No cases of in-hospital mortality were reported (0%, 95% CI: 0.0-13.4%). CONCLUSIONS: Endovascular treatment in trauma is a minimally invasive technique with favorable clinical outcomes in patients with arterial trauma in the axillary-subclavian segment. This should be a viable therapeutic option for selected cases.

The Impact of Hospital Delivery Volumes of Newborns Born Very Preterm on Mortality and Morbidity.

OBJECTIVE: To examine if the annual patient volume of infants born very preterm (VPT, gestational age <32 weeks) at a hospital is associated with neonatal mortality and morbidity. STUDY DESIGN: We performed an observational, secondary data analysis using a 20-year panel of birth certificates linked to hospital discharge abstracts, including transfers in California, Michigan, Missouri, Oregon, Pennsylvania, and South Carolina from 1996 through 2015. The study included all in-hospital VPT deliveries (n = 208 261). Study outcomes were in-hospital mortality or serious morbidity (intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, or bronchopulmonary dysplasia), attributed to the hospital of birth. Poisson regression models estimated the risk-adjusted relative risk (RR) for mortality and serious morbidity across different patient volume categories within a given hospital using hospital fixed effects. RESULTS: The risk of mortality and serious morbidity for VPT infants increased as the number of infants born VPT at a hospital decreased. Compared with VPT delivery volumes >100 infants per year, the risk of mortality increased when a given hospital had VPT delivery volumes < 60 per year, ranging from a RR of 1.13 (95% C.I. 1.02-1.25) for volumes between 50 to 59 and 1.39 (1.19-1.62) for VPT volumes <10, and the risk of mortality or serious morbidity increased when a given hospital had VPT volumes <100, ranging from a RR of 1.05 (1.02-1.08) for volumes between 90 to 99 and 1.27 (1.19-1.36) for VPT volumes <10. CONCLUSIONS: These results suggest that, for VPT infants, the risk of both mortality and mortality or serious morbidity is increased as the VPT volume within a given hospital declines.

Eighteen-year trends in the rates of intra-operative cardiac arrest and associated mortality at a public university hospital in Brazil.

BACKGROUND: Intra-operative cardiac arrest is a rare but life-threatening event. Over the past two decades, various initiatives have improved the care of patients undergoing surgery at our quaternary teaching hospital in Brazil. We aimed to evaluate the epidemiology of intra-operative cardiac arrest and associated 30-day mortality over an 18-year period. A secondary aim was to identify associated risk factors. METHODS: We conducted a retrospective observational study using data collected from 1 January 2005 to 31 December 2022. Factors associated with cardiac arrest and mortality were identified using multivariable logistic regression analysis. RESULTS: Among the 154,178 cases, the overall rates of intra-operative cardiac arrest (n = 297) and associated 30-day mortality (n = 248) were 19.3 (95%CI (16.6-21.9)) and 16.1 (95% CI 13.9-18.3) per 10,000 anaesthetics, respectively. These decreased over time (2005-2010 vs. 2017-2022) from 26.3 (95%CI 21.0-31.6) to 15.4 (95%CI 12.0-18.7) per 10,000 anaesthetics, and from 23.4 (95%CI 18.8-28.1) to 13.7 (95%CI 10.8-16.7) per 10,000 anaesthetics, respectively. Factors associated with intra-operative cardiac arrest included children aged < 1 year (adjusted OR (95%CI) 3.51 (1.87-6.57)); ASA physical status 3-5 (adjusted OR (95%CI) 13.85 (8.86-21.65)); emergency surgery (adjusted OR (95%CI) 10.06 (7.85-12.89)); general anaesthesia (adjusted OR (95%CI) 8.79 (4.60-19.64)); surgical procedure involving multiple specialities (adjusted OR (95%CI) 9.13 (4.24-19.64)); cardiac surgery (adjusted OR (95%CI) 7.69 (5.05-11.71)); vascular surgery (adjusted OR (95%CI) 6.21 (4.05-9.51)); and gastrointestinal surgery (adjusted OR (95%CI) 2.98 (1.91-4.65)). DISCUSSION: We have shown an important reduction in intra-operative cardiac arrest and associated 30-day mortality over an 18-year period. Identification of relative risk factors associated with intra-operative cardiac arrest can be used to improve the safety and quality of patient care, especially in a resource-limited setting.

Effect of Early Multiprofessional Mobilization on Quality Indicators of Intensive Care in a Less Economically Developed Country: An Action on "Rehabilitation 2030" in Brazil.

OBJECTIVE: To investigate the effects of implementing early multiprofessional mobilization on quality indicators of intensive care in Brazil. DESIGN: This is a retrospective cohort study. SETTING: A Brazilian educational and research-intensive care unit (ICU). PARTICIPANTS: A total of 1047 patients were hospitalized from May 2016 to April 2018. INTERVENTIONS: Implementation of early multiprofessional mobilization using the MobilizAÇÃO Program (MAP). MAIN OUTCOME MEASURES: Clinical, ventilation and safety quality indicators, and physical function before (preprogram period) and after (postprogram period) the MAP. RESULTS: There was a reduction in sedation time (4 vs 1d), hospital stay (21 vs 14d) and ICU stay (14 vs 7d), mechanical ventilation (8 vs 4d), hospital death rate (46% vs 26%) (P<.001), and ICU readmission (21% vs 16%; P=.030) from pre to post MAP. Successful weaning (42% vs 55%) and discharge rate (50% vs 71%) (P<.001) increased after MAP. No differences were found to safety quality indicators between periods. After MAP, complex physical functions assessed using the Manchester Mobility Score (MMS) were more frequent. The in-bed intervention was a predictor for readmission (P=.009; R²=0.689) and death (P=.035; R²=0.217), while walking was a predictor for successful weaning (P=.030; R²=0.907) and discharge (P=.033; R²=0.373). The postprogram period was associated with the MMS at ICU discharge (P<.001; R²=0.40). CONCLUSIONS: Early mobilization implementation through changes in low mobility culture and multiprofessional actions improved quality indicators, including clinical, ventilation, and physical functional quality, without compromising patient safety in the ICU.

Long-lasting effects of control measures on trends in incidence in neonatal late-onset sepsis due to multiresistant bacteria in a Brazilian neonatal unit.

BACKGROUND: In response to a 1995 outbreak of sepsis caused by multidrug-resistant (MR) Gram-negative bacteria (GNB), a Brazilian level III neonatal unit established a series of control and prevention measures. This study evaluated the long-term effects of these measures on late-onset neonatal sepsis (LONS) caused by MR bacteria from 2000 to 2020 and examined their impact on in-hospital mortality. METHODS: Newborns with LONS and positive cultures for Staphylococcus aureus, GNB, and Enterococcus sp were selected, adhering to Center for Desease Control and Prevention and local criteria. Joinpoint regression analysis was used to assess annual trends. RESULTS: Over the 21-year period, the overall LONS rate was 4.6%, showing a significant decline from 2000 to 2016 (P < .0001, slope -0.36). However, from 2016 to 2020, there was a non-significant increase in sepsis rates (slope +0.92, P = .08). MR sepsis were in 15.8% of sepsis cases and displayed a non-significant upward trend (slope +0.50, P = .08) with no major shifts. In-hospital mortality rates for MR and non-MR LONS showed no significant differences (P = .413). DISCUSSION: The study indicates a low prevalence of MR sepsis due to effective antimicrobial use and educational interventions. CONCLUSIONS: MR sepsis prevalence remained low and stable, not increasing in-hospital mortality.

The burden of pre-operative anaemia and postoperative outcomes in 15 166 surgical patients from a public hospital in Brazil: A retrospective cohort study.

BACKGROUND: Preoperative anaemia is associated with poor postoperative outcomes; however, few studies have reported its prevalence in developing countries and its association with significant postoperative outcomes. OBJECTIVE: We aimed to identify the prevalence of anaemia and its association with postoperative outcomes in a major public hospital in Brazil. DESIGN: Retrospective cohort study. SETTING: Single-centre, 860-bed, quaternary university-affiliated teaching hospital in Southern Brazil. PATIENTS: We included adult patients who had undergone surgery between 2015 and 2019. Main outcome measures: The main outcome was the in-hospital 30-day postoperative mortality. According to the World Health Organisation, we defined anaemia and its sub-classification (mild, moderate, and severe). We developed Poisson regression models to examine the association between preoperative anaemia and outcomes. RESULTS: We included 15 166 patients, of whom 6387 (42.1%) were anaemic. After adjustment for confounding factors, patients with anaemia had an increased risk of in-hospital 30-day postoperative mortality (relative risk (RR) 1.69, 95% confidence interval (CI) 1.44 to 1.99, P  < 0.001). Mild [relative risk (RR) 1.38, 95% CI 1.12 to 1.71, P  = 0.003], moderate (RR 1.73, 95% CI 1.43 to 2.10, P  < 0.001), and severe anaemia (RR 2.43, 95% CI 1.92 to 3.07, P  < 0.001) were associated with the primary outcome. Anaemia increased the transfusion risk (RR 4.44, 95% CI 3.90 to 5.06, P  < 0.001) and postoperative intensive care unit (ICU) admission (RR 1.09, 95% CI 1.04 to 1.16, P  = 0.001). CONCLUSIONS: Four out of 10 patients had anaemia. These patients had an increased risk of adverse postoperative outcomes. Comprehension of the magnitude and impact of anaemia is essential to establish interventions in low-resource scenarios to optimise the patient's journey. STUDY REGISTRATION: Institutional Review Board Registration number 40522820000005327 (Brazilian CEP/CONEP System, available in https://plataformabrasil.saude.gov.br/ ).

Clinical impact of sex differences and procedural setting in transcatheter aortic valve implantation

BACKGROUND Transcatheter aortic valve implantation (TAVR) is a well-established treatment for symptomatic patients with aortic ste nosis. Yet the impact of sex differences and public vs private proce dural setting on TAVR outcomes remain uncertain. METHODS The RIBAC-NT (Brazilian Registry for Evaluation of Transcatheter Aortic Valve Replacement Outcomes) dataset included 3,194 TAVR patients from 2009 to 2021. This retrospective analysis explored disparities in baseline characteristics and procedural and in hospital outcomes, stratifying patients by sex and procedural setting. Temporal trends were also investigated. RESULTS We included 1,551 (49%) female and 1,643 (51%) male pa tients. Women were older (83 years (78-87 years) vs 81 years [75-85 years); P<0.01) but had a lower prevalence of diabetes mellitus (30.2% vs 36.3%; P<0.01) and coronary artery disease (39.0% vs 52.2%; P < 0.01). However, women had a 3-fold higher tisk of life- threatening bleeding (6.1% vs 2.4% P < 0.01). Women presented higher procedural and in-hospital mortality rates (4.4% vs 2.5% and 7.7% vs 4.5%; all P < 0.01, respectively). Over time, mortality rates decreased more in women than in men in both public and private centers. Public hospitals presented -2-fold higher procedural mor- tality rate compared with private settings (5.0% vs 2.7%; P<0.01). CONCLUSION Women had higher procedural and in-hospital mortal- ity rates after TAVR as compared with men, while facing higher life. threatening bleeding and adverse events rates. Public hospitals exhibited higher mortality rates than private centers. In recent years, women experienced more significant reductions in mortality rates in both settings.

Short- and long-term outcomes in critically ill patients with primary glomerular disease: a case‒control study.

INTRODUCTION: Glomerular diseases, encompassing primary and secondary forms, pose significant morbidity and mortality risks. Despite their impact, little is known about critically ill patients with primary glomerulopathy admitted to the intensive care unit (ICU). METHODS: We conducted a case‒control study of patients with primary glomerulopathy using the Medical Information Mart for Intensive Care IV database. Demographic, clinical, and outcome data were collected. Logistic regression and mediation analysis were performed to identify predictors of hospital and long-term mortality. RESULTS: Among 50,920 patients, 307 with primary glomerulopathy were included. Infectious and cardiovascular-related causes were the main reasons for ICU admission, with sepsis being diagnosed in more than half of the patients during their ICU stay. The hospital mortality rate was similar to that of the control group, with a long-term mortality rate of 29.0% three years post-ICU discharge. Reduced urine output and serum albumin were identified as independent predictors of hospital mortality, while serum albumin and the Charlson comorbidity index were significantly associated with long-term mortality. Notably, although acute kidney injury was frequent, it was not significantly associated with mortality. Additionally, reduced urine output mediates nearly 25% of the association between serum albumin and hospital mortality. CONCLUSION: Critically ill patients with primary glomerulopathy exhibit unique characteristics and outcomes. Although hospital mortality was comparable to that of the control group, long-term mortality remained high. The serum albumin concentration and Charlson Comorbidity Index score emerged as robust predictors of long-term mortality, highlighting the importance of comprehensive risk assessment in this population. The lack of an association between acute kidney injury and mortality suggests the need for further research to understand the complex interplay of factors influencing outcomes in this patient population.

[Critical patients in general hospitalization wards: a descriptive analysis of factors inherent to the transfer to a closed unit] / El paciente crítico en sala de internación general.

Introduction: Unplanned transfers from the General Ward to Critical Care Units occur due to a deterioration in the patient's clinical status. They are of great interest because of their negative impact, associated with longer hospital stays and higher mortality. Objectives: To report the frequency at which these transfers occur, characteristics of these patients and causes of the transfer. Identify shortcomings in the care process that may allow improvement strategies. Methodology: cross-sectional study. Cases were considered those who, during the first 24 hours of hospitalization in the General Ward, required transfer to the ICU between January - December 2022 in a high-complexity hospital in Buenos Aires. Results: Of 8317 admissions, 124 were transferred to the ICU, with a rate of 14 per 1000 and an average of 70 years. The most frequent comorbidities were high blood pressure, heart failure, cancer and overweight-obesity. The main causes of hospitalization were respiratory and gastrointestinal symptoms. 67% had non-alarming results in the NEWS score prior to transfer to the ICU. The most frequent causes were respiratory failure, hemodynamic instability and requirement for monitoring. Average hospital stay was 10 days and in-hospital mortality was 26%. Conclusions: Respiratory decompensation in elderly male patients was the most common cause of transfer to a Closed Unit. One of the shortcomings of the care process seems to be the NEWS score, where in 67% of cases it did not warn about the high requirement of patient monitoring.

Introducción: Los traslados no programados, de Sala General a Unidades de Cuidados Críticos, se producen debido a un deterioro en el estado clínico del paciente. Son de gran interés debido a su impacto negativo, asociado con estadías hospitalarias más largas y mayor mortalidad. Objetivos: Reportar la frecuencia en la que ocurren estos traslados, las características de estos pacientes y las causas del pase. Identificar falencias del proceso asistencial que permitan generar estrategias de mejora. Metodología: estudio de corte transversal. Se consideraron casos quienes durante las primeras 24 horas de internación en Sala General requirieron traslado a UCI entre Enero - Diciembre 2022 en un hospital de alta complejidad en Buenos Aires. Resultados: De 8317 ingresos 124 fueron trasladados a UCI, con una tasa de 14 por 1000 y una media de 70 años. Las comorbilidades más frecuentes fueron hipertensión arterial, insuficiencia cardíaca, cáncer y sobrepeso-obesidad. Las principales causas de internación fueron cuadros respiratorios y gastrointestinales. Un 67% tuvieron resultados no alarmantes en el score NEWS previo al pase a UCI. Las causas más frecuentes fueron insuficiencia respiratoria, inestabilidad hemodinámica y requerimiento de monitoreo. La estadía hospitalaria media fue de 10 días y la mortalidad intrahospitalaria 26%. Conclusión: Los descompensación respiratoria en pacientes añosos de sexo masculino fue la causa más común de pase a Unidad Cerrada.Una de las falencias del proceso asistencial pareciera ser el score NEWS, donde en un 67% de los casos no alertó sobre el alto requerimiento de monitoreo del paciente.

Serum glucose-potassium ratio predicts inhospital mortality in patients admitted to coronary care unit.

OBJECTIVE: The aim of our study was to determine the role of serum glucose-potassium ratio in predicting inhospital mortality in coronary care unit patients. METHODS: This study used data from the MORtality in CORonary Care Units in Turkey study, a national, observational, multicenter study that included all patients admitted to coronary care units between September 1, 2022, and September 30, 2022. Statistical analyses assessed the independent predictors of mortality. Two models were created. Model 1 included age, history of heart failure, chronic kidney disease, hypertension, diabetes mellitus, and coronary artery disease. Model 2 included glucose-potassium ratio in addition to these variables. Multivariate regression and receiver operating characteristic analysis were performed to compare Model 1 and Model 2 to identify if the glucose-potassium ratio is an independent predictor of inhospital mortality. RESULTS: In a study of 3,157 patients, the mortality rate was 4.3% (n=137). Age (p=0.002), female gender (p=0.004), mean blood pressure (p<0.001), serum creatinine (p<0.001), C-reactive protein (p=0.002), white blood cell (p=0.002), and glucose-potassium ratio (p<0.001) were identified as independent predictors of mortality through multivariate regression analysis. The receiver operating characteristic analysis indicated that Model 2 had a statistically higher area under the curve than Model 1 (area under the curve 0.842 vs area under the curve 0.835; p<0.001). A statistically significant correlation was found between the inhospital mortality and glucose-potassium ratio (OR 1.015, 95%CI 1.006-1.024, p<0.001). CONCLUSION: Our study showed that the glucose-potassium ratio may be a significant predictor of inhospital mortality in coronary care unit patients.

Hospitalizations in the public health system and mining disasters in Mariana and Brumadinho, Brazil.

BACKGROUND: Mining occupies a prominent place in Brazil, which, if observed, means that one must work with the contingencies that arise from its activity. Mining disasters, such as those in Mariana and Brumadinho, exemplify the impact on the health system and are models for similar situations, so the study sought to investigate the impact of these disasters on hospital admissions in the Brazilian public health system. METHODS: Through segmented regression, we sought to assess possible changes in the variables HAA (authorized hospital admissions), total admission value, and mortality rate in Mariana and Brumadinho. This measurement method allows the researcher to identify changes during the study period. RESULTS: The​​​​​​​ study observed significant changes in the variable mortality rate in the city of Brumadinho. Although the other variables, both in Mariana and Brumadinho, do not present a level of significance compatible with possible effects, we can still say that they present a trend that can be inferred as an effect of the disaster. CONCLUSIONS: The mining disaster significantly changed the mortality profile in the city of Brumadinho, with implications for the health system. In Mariana, there have been no objective changes, but there is evidence of potential impacts.

Effect of Tele-ICU on Clinical Outcomes of Critically Ill Patients: The TELESCOPE Randomized Clinical Trial.

Importance: Despite its implementation in several countries, there has not been a randomized clinical trial to assess whether telemedicine in intensive care units (ICUs) could improve clinical outcomes of critically ill patients. Objective: To determine whether an intervention comprising daily multidisciplinary rounds and monthly audit and feedback meetings performed by a remote board-certified intensivist reduces ICU length of stay (LOS) compared with usual care. Design, Setting, and Participants: A parallel cluster randomized clinical trial with a baseline period in 30 general ICUs in Brazil in which daily multidisciplinary rounds performed by board-certified intensivists were not routinely available. All consecutive adult patients (aged ≥18 years) admitted to the participating ICUs, excluding those admitted due to justice-related issues, were enrolled between June 1, 2019, and April 7, 2021, with last follow-up on July 6, 2021. Intervention: Remote daily multidisciplinary rounds led by a board-certified intensivist through telemedicine, monthly audit and feedback meetings for discussion of ICU performance indicators, and provision of evidence-based clinical protocols. Main Outcomes and Measures: The primary outcome was ICU LOS at the patient level. Secondary outcomes included ICU efficiency, in-hospital mortality, incidence of central line-associated bloodstream infections, ventilator-associated events, catheter-associated urinary tract infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation, and rate of patients with oxygen saturation values under that of normoxemia, assessed using generalized linear mixed models. Results: Among 17 024 patients (1794 in the baseline period and 15 230 in the intervention period), the mean (SD) age was 61 (18) years, 44.7% were female, the median (IQR) Sequential Organ Failure Assessment score was 6 (2-9), and 45.5% were invasively mechanically ventilated at admission. The median (IQR) time under intervention was 20 (16-21) months. Mean (SD) ICU LOS, adjusted for baseline assessment, did not differ significantly between the tele-critical care and usual care groups (8.1 [10.0] and 7.1 [9.0] days; percentage change, 8.2% [95% CI, -5.4% to 23.8%]; P = .24). Results were similar in sensitivity analyses and prespecified subgroups. There were no statistically significant differences in any other secondary or exploratory outcomes. Conclusions and Relevance: Daily multidisciplinary rounds conducted by a board-certified intensivist through telemedicine did not reduce ICU LOS in critically ill adult patients. Trial Registration: ClinicalTrials.gov Identifier: NCT03920501.

Coinfections and In-Hospital Mortality in a Group of Patients With HIV/AIDS: A Longitudinal Study.

Human immunodeficiency virus (HIV) is a global public health problem. Coinfections in HIV patients are frequent complications that increase their mortality. The aim of this study was to assess coinfections and in-hospital mortality in a group of patients infected with HIV in Colombia. A retrospective longitudinal study was carried out. Patients treated in 4 highly complex clinics in Colombia between 2015 and 2023 were included. The cases were identified from International Classification of Diseases codes related to HIV. Sociodemographic, clinical, laboratory and pharmacological variables were collected. Descriptive, bivariate, and multivariable analyses were performed. Of the 249 patients identified, 79.1% were men, and the median age was 38.0 years. Approximately 81.1% had a diagnosis of acquired immune deficiency syndrome (AIDS). Coinfections caused by Mycobacterium tuberculosis (24.1%) and Treponema pallidum (20.5%) were the most frequent. A total of 20.5% of the patients had sepsis, 12.4% had septic shock, and the fatality rate was 15.7%. Antibiotics and antifungals were used in 88.8% and 53.8%, respectively, of the patients. Patients with a diagnosis of HIV before admission, those infected with M. tuberculosis, and those who presented with sepsis were more likely to die, whereas patients who received antiretroviral agent treatment before admission presented a lower risk. In this study, most HIV patients were in an advanced stage of the disease. Coinfection with M. tuberculosis was common and was associated with an increased risk of death. Previous HIV diagnosis and sepsis also increased the risk. Approximately half of the patients with a previous HIV diagnosis were receiving antiretroviral therapy and had a better prognosis.

Acute kidney injury and mortality in patients with critical COVID-19 in Mexico: case-control study.

OBJECTIVE: We aimed to test the association between acute kidney injury (AKI) and mortality in critically ill patients with Coronavirus disease 2019 (COVID-19). METHOD: We conducted a single-center case-control study at the intensive care unit (ICU) of a second-level hospital in Mexico. We included 100 patients with critical COVID-19 from January to December 2021, and collected demographic characteristics, comorbidities, APACHE II, SOFA, NEWS2, and CO-RADS scores at admission, incidence of intrahospital complications, length of hospital and ICU stay, and duration of mechanical ventilation, among others. RESULTS: The median survival of deceased patients was 20 days. After multivariable logistic regression, the following variables were significantly associated to mortality: AKI (adjusted odds ratio [AOR] 6.64, 95% confidence intervals [CI] = 2.1-20.6, p = 0.001), age > 55 years (AOR 5.3, 95% CI = 1.5-18.1, p = 0.007), and arrhythmias (AOR 5.15, 95% CI = 1.3-19.2, p = 0.015). Median survival was shorter in patients with AKI (15 vs. 22 days, p = 0.043), as well as in patients with overweight/obesity (15 vs. 25 days, p = 0.026). CONCLUSION: Our findings show that the development of AKI was the main risk factor associated with mortality in critical COVID-19 patients, while other factors such as older age and cardiac arrhythmias were also associated with this outcome. The management of patients with COVID-19 should include renal function screening and staging on admission to the Emergency Department.

OBJETIVO: Probar la asociación entre lesión renal aguda y mortalidad en pacientes con COVID-19 grave. MÉTODO: Realizamos un estudio de casos y controles unicéntrico en la unidad de cuidados intensivos (UCI) de un hospital de segundo nivel en México. Incluimos 100 pacientes con COVID-19 grave de enero a diciembre 2021, recolectando características demográficas, comorbilidad, APACHE II, SOFA, NEWS2 y CO-RADS al ingreso, incidencia de complicaciones intrahospitalarias, duración de la estancia hospitalaria y en la UCI, duración de ventilación mecánica, etc. RESULTADOS: La mediana de supervivencia de los pacientes que fallecieron fue de 20 días. Al realizar el análisis de regresión logística multivariable, las siguientes variables se asociaron significativamente con la mortalidad: lesión renal aguda (odds ratio ajustada [ORa]: 6.64; intervalo de confianza del 95% [IC95%]: 2.1-20.6; p = 0.001), edad > 55 años (ORa: 5.3; IC95%: 1.5-18.1; p = 0.007) y arritmias (ORa: 5.15; IC95%: 1.3-19.2; p = 0.015). La supervivencia fue menor en pacientes con lesión renal aguda (15 vs. 22 días; p = 0,043), así como en pacientes con sobrepeso u obesidad (15 vs. 25 días; p = 0.026). CONCLUSIONES: Nuestros resultados muestran que el desarrollo de lesión renal aguda es el principal factor de riesgo asociado a mortalidad en pacientes con COVID-19 grave, mientras que otros factores, como la edad > 55 años y la presencia de arritmias cardiacas, también se asocian a mortalidad por COVID-19. El manejo de pacientes con COVID-19 debe incluir el tamizaje y la estadificación de la función renal al ingreso a urgencias.

Time to death from cervical cancer and its predictors in hospitalized patients: a survival approach study in Mato Grosso, Brazil.

BACKGROUND: Cervical cancer (CC) is a serious public health concern, being the fourth most common cancer among women and a leading cause of cancer mortality. In Brazil, many women are diagnosed late, and in Mato Grosso, with its geographical diversity, there are specific challenges. This study analyzed hospital survival and its predictors using data from the Hospital Information System (SIH) of the Unified Health System (SUS) in Mato Grosso from 2011 to 2023. METHODS: Cox regression and Kaplan-Meier models were applied to determine survival time and identify mortality predictors. The adjusted Hazard Ratio (AHR) with a 95% Confidence Interval (CI) was used to measure the association between the factors analyzed. RESULTS: The hospital mortality rate was 9.88%. The median duration of hospitalization was 33 days (interquartile range [IQR]: 12-36), with a median survival of 43.7%. Patients were followed up for up to 70 days. In the multivariable Cox model, after adjusting for potential confounders, the risk of death during hospitalization was higher in patients aged 40-59 years (AHR = 1.39, p = 0.027) and 60-74 years (AHR = 1.54, p = 0.007), in the absence of surgical procedures (AHR = 4.48, p < 0.001), in patients with medium service complexity (AHR = 2.40, p = 0.037), and in the use of ICU (AHR = 4.97, p < 0.001). On the other hand, patients with hospital expenses above the median (152.971 USD) showed a reduced risk of death (AHR = 0.21, p < 0.001). CONCLUSION: This study highlights that hospitalized CC patients have reduced survival, underscoring the need for interventions to improve care, including strategies for early diagnosis and expanded access to adequately resourced health services.

Acute kidney injury developed in the intensive care unit: a population-based prospective cohort study in the Brazilian Amazon.

The Brazilian Amazon is a vast area with limited health care resources. To assess the epidemiology of critically ill acute kidney injury (AKI) patients in this area, a prospective cohort study of 1029 adult patients of the three intensive care units (ICUs) of Rio Branco city, the capital of Acre state, were evaluated from February 2014 to February 2016. The incidence of AKI was 53.3%. Risk factors for AKI included higher age, nonsurgical patients, admission to the ICU from the ward, higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores at ICU admission, and positive fluid balance > 1500 ml/24 hours in the days before AKI development in the ICU, with aOR of 1.3 (95% CI 1.03-1.23), 1.47 (95% CI 1.07-2.03), 1.96 (95% CI 1.40-2.74), 1.05 (95% CI 1.03-1.08) for each unit increase, and 1.62 (95% CI 1.16-2.26), respectively. AKI was associated with higher ICU mortality (aOR 2.03, 95% CI 1.29-3.18). AKI mortality was independently associated with higher age, nonsurgical patients, sepsis at ICU admission, presence of shock or use of vasoactive drugs, mechanical ventilation and mean positive fluid balance in the ICU > 1500 ml/24 hours, both during ICU follow-up, with aOR 1.27 (95% CI 1.14-1.43) for each 10-year increase, 1.64 (95% CI 1.07-2.52), 2.35 (95% CI 1.14-4.83), 1.88 (95% CI 1.03-3.44), 6.73 (95% CI 4.08-11.09), 2.31 (95% CI 1.52-3.53), respectively. Adjusted hazard ratios for AKI mortality 30 and 31-180 days after ICU discharge were 3.13 (95% CI 1.84-5.31) and 1.69 (95% CI 0.99-2.90), respectively. AKI incidence was strikingly high among critically ill patients in the Brazilian Amazon. The AKI etiology, risk factors and outcomes were similar to those described in high-income countries, but mortality rates were higher.

Revascularização do vaso culpado antes da angiografia completa como estratégia para minimizar atrasos na intervenção coronariana percutânea primária em pacientes com IAMCSST: uma meta-análise / Culprit vessel revascularization before complete angiography as a strategy to minimize delays in primary percutaneous coronary intervention in patients with STEMI: a meta-analysis

INTRODUÇÃO: A rápida restauração do fluxo sanguíneo em pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST) através da intervenção coronariana percutânea (ICP) é crucial para a sobrevivência desta população. As tentativas de diminuir o tempo desde o diagnóstico do IAMCSST até a chegada ao laboratório de cateterismo têm sido extensivamente investigadas. Contudo, faltam estratégias que visem reduzir o tempo intraprocedimento. OBJETIVO: Portanto, realizamos uma meta-análise para avaliar a revascularização do vaso culpado antes da angiografia completa como estratégia para minimizar atrasos na ICP primária em pacientes com IAMCSST. MÉTODOS: Pesquisamos na PubMed, Embase e Cochrane Central. Os desfechos de interesse foram: tempo acesso vascular-balão, tempo porta-balão, tempo primeiro contato médico-balão, mortalidade hospitalar, mortalidade em 30 dias, mortalidade em 1 ano, mortalidade cardíaca em 30 dias, reinfarto em 30 dias, sangramento BARC ≥ tipo 3, encaminhamento para cirurgia de revascularização do miocárdio e FEVE %. A análise estatística foi realizada no programa R (versão 4.3.2). A heterogeneidade foi avaliada com estatística I2. RESULTADOS: Incluímos 2.050 pacientes de 6 estudos, dos quais 2 eram ECRs e 4 estudos observacionais. A mediana de acompanhamento variou de 17 a 65 meses. A revascularização do vaso culpado antes da angiografia completa foi associada a uma diminuição estatisticamente significativa dos tempos: acesso vascular-balão (MD -6,79; IC 95% [- 8,00, - 5,58]; p<0,01; I2 = 82%) e porta-balão (MD -9,02; IC 95% [− 12,83, − 5,22]; p<0,01; I2 =93%). Além disso, a abordagem inicial da artéria culpada com a ICP foi associada ao aumento da FEVE (MD 1,90; IC95% 0,77 − 3,04]; p<0,01; I2 =82%). Não houve diferença significativa entre os grupos em termos de mortalidade hospitalar (RR 1,15; IC 95% 0,34 - 3,87; p=0,823; I2 =0%), mortalidade em 1 ano (RR 0,83; IC 95% 0,59 - 1,17; p =0,282; I2 =0%), mortalidade cardíaca em 30 dias (RR 0,77; IC 95% 0,38 - 1,57; p=0,472; I2 =0%) e reinfarto em 30 dias (RR 1,02; IC 95% 0,29 - 3,58; p=0,980; CONCLUSÃO: Nesta meta-análise abrangente de pacientes que apresentaram IAMCSST, a realização da ICP na lesão culpada antes da angiografia coronária completa levou a tempos de reperfusão significativamente mais curtos, sem diferenças discerníveis nas taxas de complicações.

Balloon-expandable versus self-expanding valves for transcatheter aortic valve replacement using new generation devices: An analysis of the Brazilian RIBAC-NT registry

BACKGROUND Conflicting data yet exists regarding the clinical outcomes of transcatheter aortic valve replacement (TAVR) using balloon-expandable (BEV) and self-expanding valves (SEV). AIM To compare the in-hospital outcomes of TAVR performed with new-generation BEV vs. SEV in a real-world population. METHODS Retrospective study using data from the Brazilian TAVR registry. All consecutive native tricuspid TAVR procedures using new-generation valves were included. Transapical procedures were excluded. Patients were analyzed according to the type of prosthesis implanted (BEV vs. SEV). Unadjusted and propensity-score matching comparisons were made. Primary outcome was in-hospital mortality. Secondary outcomes included major vascular complication, major or life-threatening bleeding, any stroke, and new pacemaker implantation. RESULTS A total of 1706 patients from 25 centers were included in the analysis, 887 in the BEV and 819 in the SEV groups. Mean age was 80.7 ± 7.2 years and 48.9% were women. The SEV group had a higher proportion of female patients (53.5% vs. 44.6%, p ≤ 0.001) and more comorbidities, yielding a higher EuroSCORE-2 (3.4 [2­6.4] vs. 4.5 [2.5­8.2], p < 0.001). The Sapien 3/Ultra (Edwards Lifescience, Irvine, CA, USA) and the Evolut R/PRO (Medtronic, Minneapolis, MN, USA) accounted for 97.8% and 72.6% of BEV and SEV cases, respectively. Pre- and postdilatation was more common for SEV (both p < 0.001). Valve embolization, the need for a second valve, and coronary occlusion were rare but more frequent for SEV. There was no difference in the unadjusted in-hospital mortality (BEV = 3.6% vs. SEV = 4.8%, p = 0.27) and after propensity-score matching (3.5% vs. 5.0%, p = 0.16). There were also no significant differences between groups in vascular complications, bleeding, stroke, and the need for a new pacemaker. Logistic regression adjusted for sex, EuroSCORE-2, and vascular access also indicated similar mortality between both valves (OR 1.22, p = 0.4). Sensitivity analysis, including only Sapien 3 and Evolut cases, showed consistent results with the primary analysis. CONCLUSION In real-world all-comers TAVR patients, from Brazil procedures performed with newer generation BEV and SEV devices had comparable in-hospital outcomes.

Assistance time and peripheral oxygen saturation in prehospital emergency data as predictors of COVID19 hospital outcomes.

To verify if data obtained in the prehospital evaluation of patients with severe acute respiratory syndrome (SARS) during the initial response to the COVID-19 pandemic is associated with clinical outcomes: mechanical ventilation, hospital discharge, and death. This is a retrospective analysis involving secondary data from the Emergency Medical Service (EMS) records and the Health Surveillance Information System of patients assisted by the EMS in Manaus, from January to June 2020, the period of the first peak of COVID-19 cases. The combination of the two databases yielded a total of 1.190 patients, who received a first EMS response and were later admitted to hospital with SARS and had data on clinical outcomes of interest available. Patients were predominantly male (754, 63.4%), with a median age of 66 (IQR: 54.0-78.0) years. SARS illness before medical assistance was associated to need for invasive mechanical ventilation (IMV, p < 0.001). Lower pre-hospital SpO2 was associated to death (p = 0.025). Death was more common among patients with respiratory support needs, especially in the invasive ventilation group (262/287; 91.3%) (p < 0.001). In addition, IMV was more common among elderly individuals (p < 0.001). Patients admitted to ICU had a greater chance of dying when compared to non-ICU admitted patients (p < 0.001), and closely related to IMV (p < 0.001). Patients in ICU were also older (p = 0.003) and had longer hospital stay (p < 0.001). Mortality was associated with mechanical ventilation (p < 0.001), ICU admission (p < 0.001), and older age (p < 0.001). Patients who died had a shorter length of both ICU and total hospital stay (p < 0.001). Prehospital EMS may provide feasible and early recognition of critical patients with SARS in strained healthcare systems, such as in low-resource settings and pandemics.