Mortality in Brazilian federal highway police officers: time series from 2001 to 2020 / Mortalidade em agentes da polícia rodoviária federal: série temporal entre 2001 e 2020

ABSTRACT OBJECTIVE To analyze the mortality trend from all causes in Brazilian federal highway police officers from 2001 to 2020. METHODS This is an ecological time-series study based on mortality official data from the Brazilian federal highway police registry system and death certificates from the federal registry system. Deaths of active police officers from 2001 to 2020 were assessed. We performed a descriptive analysis reporting proportions and incidence rates per 1,000 police officers. The chi-square test was used for bivariate analyzes and Prais-Winsten regression was used for trend analysis. RESULTS Among 346 deaths, 146 were from natural and 189 from unnatural causes (11 were from undefined causes). Most deaths occurred among police officers who were men (n = 333; 96.3%), over 35 years old (n = 265; 76.6%), whose service time was up to 15 years (n = 185; 53.5%), living in Northeast Brazil, and from unnatural causes (n = 189; 56.4%). The absolute number of deaths presented a decreasing trend throughout the series (p = -0.78; 95%CI: -1.03 to -0.5). Traffic accidents (n = 96; 28.7%), cardiovascular diseases (n = 58; 17.3%), interpersonal violence (n = 51; 15.2%), suicides (n = 35; 10.5%), and malignant neoplasms (n = 35; 10.4%) were the main causes of death. Most natural deaths occurred among police officers who were 51-73 years old (68.3%; 95%CI: 58.6 to 76.7) and worked more than 26 years (64.7%; 95%CI: 52.7 to 75.1), while most unnatural deaths occurred among officers who were 19-35 years old (87.3%; 95%CI: 78.0 to 93.1) and worked up to 15 years (70.2%; 95%CI: 63.1 to 76.4). CONCLUSION The mortality trend in Brazilian federal highway police officers decreased within the period studied. Understanding mortality causes may help to develop policies for disease prevention and health protection of police officers.

RESUMO OBJETIVO Descrever e analisar a tendência de mortalidade, por todas as causas, em agentes da polícia rodoviária federal, entre os anos de 2001 e 2020. MÉTODOS Trata-se de um estudo ecológico de séries temporais, baseado em dados oficiais sobre mortalidade registrados no sistema de cadastro nacional da polícia rodoviária federal e de certidões de óbitos do sistema de cadastro federal. Foram coletados os óbitos de agentes que estavam em efetivo exercício entre 2001 e 2020. Realizou-se análise descritiva, calcularam-se proporções e taxas de incidência por 1.000 policiais. Utilizou-se qui-quadrado para análises bivariadas e regressão de Prais-Winsten para análise de tendência. RESULTADOS Ocorreram 346 óbitos (11 por causas indeterminadas), dos quais 146 foram por mortes naturais e 189 não naturais. A maioria das mortes ocorreu em policiais do sexo masculino (n = 333; 96,3%), acima de 35 anos (n = 265; 76,6%), tempo de serviço até 15 anos (n = 185; 53,5%), da região Nordeste e por causas não naturais (n = 189; 56,4%). O número absoluto de óbitos de agentes apresentou tendência decrescente ao longo da série (p = -0,78; IC95% -1,03 - -0,5). Entre as principais causas de morte estão acidentes de trânsito (n = 96; 28,7%), doenças cardiovasculares (n = 58; 17,3%), violência interpessoal (n = 51; 15,2%), suicídio (n = 35; 10,5%) e neoplasias malignas (n = 35; 10,4%). As mortes naturais predominaram entre os agentes com idade entre 51-73 anos (68,3%; IC95% 58,6-76,7) e mais de 26 anos de serviço (64,7%; IC95% 52,7-75,1), já as não naturais, entre a faixa etária de 19-35 anos (87,3%; IC95% 78,0-93,1) e de até 15 anos de serviço (70,2%; IC95% 63,1-76,4). CONCLUSÕES Conclui-se que a tendência das mortes de agentes da polícia rodoviária federal foi decrescente no período. O conhecimento das causas de mortalidade pode auxiliar no desenvolvimento de políticas de prevenção de doenças e proteção à saúde desses policiais.

Epidemiologia e desfecho dos pacientes de alto risco cirúrgico admitidos em unidades de terapia intensiva no Brasil / Epidemiology and outcome of high-surgical-risk patients admitted to an intensive care unit in Brazil

RESUMO Objetivo: Definir o perfil epidemiológico e os principais determinantes de morbimortalidade dos pacientes cirúrgicos não cardíacos de alto risco no Brasil. Métodos: Estudo prospectivo, observacional e multicêntrico. Todos os pacientes cirúrgicos não cardíacos admitidos nas unidades de terapia intensiva, ou seja, considerados de alto risco, no período de 1 mês, foram avaliados e acompanhados diariamente por, no máximo, 7 dias na unidade de terapia intensiva, para determinação de complicações. As taxas de mortalidade em 28 dias de pós-operatório, na unidade de terapia intensiva e hospitalar foram avaliadas. Resultados: Participaram 29 unidades de terapia intensiva onde foram realizadas cirurgias em 25.500 pacientes, dos quais 904 (3,5%) de alto risco (intervalo de confiança de 95% - IC95% 3,3% - 3,8%), tendo sido incluídos no estudo. Dos pacientes envolvidos, 48,3% eram de unidades de terapia intensiva privadas e 51,7% de públicas. O tempo de internação na unidade de terapia intensiva foi de 2,0 (1,0 - 4,0) dias e hospitalar de 9,5 (5,4 - 18,6) dias. As taxas de complicações foram 29,9% (IC95% 26,4 - 33,7) e mortalidade em 28 dias pós-cirurgia 9,6% (IC95% 7,4 - 12,1). Os fatores independentes de risco para complicações foram Simplified Acute Physiology Score 3 (SAPS 3; razão de chance − RC = 1,02; IC95% 1,01 - 1,03) e Sequential Organ Failure Assessment Score (SOFA) da admissão na unidade de terapia intensiva (RC =1,17; IC95% 1,09 - 1,25), tempo de cirurgia (RC = 1,001; IC95% 1,000 - 1,002) e cirurgias de emergências (RC = 1,93; IC95% 1,10 - 3,38). Em adição, foram associados com mortalidade em 28 dias idade (RC = 1,032; IC95% 1,011 - 1,052) SAPS 3 (RC = 1,041; IC95% 1,107 - 1,279), SOFA (RC = 1,175; IC95% 1,069 - 1,292) e cirurgias emergenciais (RC = 2,509; IC95% 1,040 - 6,051). Conclusão: Pacientes com escores prognósticos mais elevados, idosos, tempo cirúrgico e cirurgias emergenciais estiveram fortemente associados a maior mortalidade em 28 dias e mais complicações durante permanência em unidade de terapia intensiva.

ABSTRACT Objective: To define the epidemiological profile and the main determinants of morbidity and mortality in noncardiac high surgical risk patients in Brazil. Methods: This was a prospective, observational and multicenter study. All noncardiac surgical patients admitted to intensive care units, i.e., those considered high risk, within a 1-month period were evaluated and monitored daily for a maximum of 7 days in the intensive care unit to determine complications. The 28-day postoperative, intensive care unit and hospital mortality rates were evaluated. Results: Twenty-nine intensive care units participated in the study. Surgeries were performed in 25,500 patients, of whom 904 (3.5%) were high-risk (95% confidence interval - 95%CI 3.3% - 3.8%) and were included in the study. Of the participating patients, 48.3% were from private intensive care units, and 51.7% were from public intensive care units. The length of stay in the intensive care unit was 2.0 (1.0 - 4.0) days, and the length of hospital stay was 9.5 (5.4 - 18.6) days. The complication rate was 29.9% (95%CI 26.4 - 33.7), and the 28-day postoperative mortality rate was 9.6% (95%CI 7.4 - 12.1). The independent risk factors for complications were the Simplified Acute Physiology Score 3 (SAPS 3; odds ratio - OR = 1.02; 95%CI 1.01 - 1.03) and Sequential Organ Failure Assessment Score (SOFA) on admission to the intensive care unit (OR = 1.17; 95%CI 1.09 - 1.25), surgical time (OR = 1.001, 95%CI 1.000 - 1.002) and emergency surgeries (OR = 1.93, 95%CI, 1.10 - 3.38). In addition, there were associations with 28-day mortality (OR = 1.032; 95%CI 1.011 - 1.052), SAPS 3 (OR = 1.041; 95%CI 1.107 - 1.279), SOFA (OR = 1.175, 95%CI 1.069 - 1.292) and emergency surgeries (OR = 2.509; 95%CI 1.040 - 6.051). Conclusion: Higher prognostic scores, elderly patients, longer surgical times and emergency surgeries were strongly associated with higher 28-day mortality and more complications during the intensive care unit stay.

T helper type cytokines in sepsis: time-shared variance and correlation with organ dysfunction and hospital mortality

ABSTRACT Objective: We evaluated the kinetics of cytokines belonging to the T helper1 (Th1), Th2, and Th17 profiles in septic patients, and their correlations with organ dysfunction and hospital mortality. Methods: This was a prospective observational study in a cohort of septic patients admitted to the intensive care units (ICU) of three Brazilian general hospitals. A total of 104 septic patients and 53 health volunteers (controls) were included. Plasma samples were collected within the first 48 h of organ dysfunction or septic shock (0D), after seven (D7) and 14 days (D14) of follow-up. The following cytokines were measured by flow cytometry: Interleukin-1β (IL-1β), IL-2, IL-6, IL-8, IL-10, IL-12/23p40, IL-17, IL-21, tumor necrosis factor-α (TNF-α), granulocyte-macrophage colony stimulating factor (GM-CSF), granulocyte colony-stimulating factor (G-CSF). Results: IL-6, IL-8, G-CSF and IL-10 concentrations were higher in septic patients than in controls (p < 0.001), while IL-12/23p40 presented higher levels in the controls (p = 0.003). IL-6, IL-8 and IL-17 correlated with Sequential [Sepsis-related] Organ Failure Assessment (SOFA) D0, D1 and D3 (except for IL-6 at D0). IL-8 was associated with renal and cardiovascular dysfunction. In a mixed model analysis, IL-10 estimated means were lower in survivors than in deceased (p = 0.014), while IL-21 had an estimated mean of 195.8 pg/mL for survivors and 98.5 for deceased (p = 0.03). Cytokines were grouped in four factors according to their kinetics over the three dosages (D0, D7, D14). Group 1 encompassed IL-6, IL-8, IL-10, IL-1β, and G-CSF while Group 3 encompassed IL-17 and IL-12/23p40. Both correlated with SOFA (D0) (p = 0.039 and p = 0.003, respectively). IL-21 (Group 4) was higher in those who survived. IL-2, TNF-α and GM-CSF (Group 2) showed no correlation with outcomes. Conclusion: Inflammatory and anti-inflammatory cytokines shared co-variance in septic patients and were related to organ dysfunctions and hospital mortality.

Factors associated with hospital mortality in renal transplant patients admitted to the intensive care unit with acute respiratory failure / Fatores associados à mortalidade hospitalar em pacientes com transplante renal admitidos na unidade de terapia intensiva com insuficiência respiratória aguda

Abstract Introduction: The lungs are often involved in a variety of complications after kidney transplantation. Acute respiratory failure (ARF) is one of the most serious manifestations of pulmonary involvement. Objective: To describe the main causes of ARF in kidney transplant patients who require intensive care and identify the factors associated with mortality. Methods: This retrospective study evaluated adult patients with ARF admitted to the intensive care unit of a center with high volume of transplants from August 2013 to August 2015. Demographic, clinical, and transplant characteristics were analyzed. Multivariate logistic regression analysis was performed to identify factors associated with hospital mortality. Results: 183 patients were included with age of 55.32 ± 13.56 years. 126 (68.8%) were deceased-donor transplant, and 37 (20.2%) patients had previous history of rejection. The ICU admission SAPS3 and SOFA score were 54.39 ± 10.32 and 4.81 ± 2.32, respectively. The main cause of hospitalization was community-acquired pneumonia (18.6%), followed by acute pulmonary edema (15.3%). Opportunistic infections were common: PCP (9.3%), tuberculosis (2.7%), and cytomegalovirus (2.2%). Factors associated with mortality were requirement for vasopressor (OD 8.13, CI 2.83 to 23.35, p < 0.001), invasive mechanical ventilation (OD 3.87, CI: 1.29 to 11.66, p = 0.016), and SAPS3 (OD 1.04, CI 1.0 to 1.08, p = 0.045). Conclusion: Bacterial pneumonia is the leading cause of ARF requiring intensive care, followed by acute pulmonary edema. Requirement for vasopressor, invasive mechanical ventilation and SAP3 were associated with hospital mortality.

Resumo Introdução: Os pulmões são frequentemente envolvidos em uma variedade de complicações após o transplante renal. A insuficiência respiratória aguda (IRA) é uma das manifestações mais graves do envolvimento pulmonar. Objetivo: Descrever as principais causas de IRA em pacientes transplantados de rim que necessitaram de cuidados intensivos e identificar os fatores associados à mortalidade. Métodos: Estudo retrospectivo que avaliou pacientes adultos com diagnóstico de insuficiência respiratória aguda internados na unidade de terapia intensiva (UTI) de um centro com alto volume de transplantes, no período de agosto de 2013 a agosto de 2015. Dados demográficos, clínicos e características do transplante foram analisados. Análise de regressão logística multivariada foi realizada para identificar os fatores associados a mortalidade hospitalar. Resultados: Foram incluídos 183 pacientes com idade de 55,32 ± 13,56 anos. 126 (68,8%) receberam rim de doador falecido e 37 (20,2%) tiveram histórico prévio de rejeição. O SAPS3 de admissão na UTI foi de 54,39 ± 10,32 e o SOFA de 4,81 ± 2,32. A principal causa de internação foi pneumonia comunitária (18,6%), seguida de edema agudo de pulmão (15,3%). Infecções oportunistas foram comuns, como pneumocistose (9,3%), tuberculose (2,7%) e citomegalovírus (2,2%). Os fatores associados a mortalidade foram necessidade de vasopressor (OD 8,13, IC 2,83-23,35, p < 0,001), ventilação mecânica invasiva (OD 3,87, IC: 1,29-11,66, p = 0,016) e SAPS3 (OD 1,04, IC 1,0-1,08, p = 0,045). Conclusão: Pneumonia bacteriana foi a principal causa de insuficiência respiratória aguda com necessidade de cuidados intensivos, seguida por edema agudo de pulmão. Necessidade de vasopressor, ventilação mecânica invasiva e SAP3 foram associados a mortalidade.

Fatores de risco para desenvolvimento de agitação em pacientes críticos / Risk factors for agitation in critically ill patients

RESUMO Objetivo: Avaliar a incidência de agitação nos primeiros 7 dias após admissão à unidade de terapia intensiva, seus fatores de risco e associação com desfechos clínicos. Métodos: Estudo de coorte unicêntrico prospectivo que incluiu maiores 18 anos, admitidos à unidade de terapia intensiva há menos de 24 horas e com previsão de permanência superior a 48 horas. Agitação psicomotora foi definida como pontuação igual ou superior a +2 na Escala de Agitação e Sedação de Richmond ou episódio de agitação, ou registro de uso de medicação específica na ficha clínica. Resultados: Ocorreu agitação em 31,8% dos 113 pacientes incluídos. Na análise multivariada, delirium (OR = 24,14; IC95% 5,15 - 113,14; p < 0,001), dor moderada ou intensa (OR = 5,74; IC95% 1,73 - 19,10; p = 0,004), ventilação mecânica (OR = 10,14; IC95% 2,93 - 35,10; p < 0,001) e tabagismo (OR = 4,49; IC95% 1,33 - 15,17; p = 0,015) foram independentemente associados a maior risco de desenvolver de agitação. Por outro lado, hiperlactatemia associou-se a um menor risco de ocorrência de agitação (OR = 0,169; IC95% 0,04 - 0,77; p = 0,021). Pacientes agitados tiveram menor tempo livre de ventilação mecânica em 7 dias (p = 0,003). Conclusão: A incidência de agitação nos 7 primeiros dias de internação em unidade de terapia intensiva foi elevada. Delirium, dor moderada ou intensa, ventilação mecânica e tabagismo foram fatores de risco independentes para o desenvolvimento de agitação. Pacientes agitados tiveram menor tempo livre de ventilação mecânica nos 7 primeiros dias.

ABSTRACT Objective: To evaluate the incidence of agitation in the first 7 days after intensive care unit admission, its risk factors and its associations with clinical outcomes. Methods: This single-center prospective cohort study included all patients older than 18 years with a predicted stay > 48 hours within the first 24 hours of intensive care unit admission. Agitation was defined as a Richmond Agitation Sedation Scale score ≥ +2, an episode of agitation or the use of a specific medication recorded in patient charts. Results: Agitation occurred in 31.8% of the 113 patients. Multivariate analysis showed that delirium [OR = 24.14; CI95% 5.15 - 113.14; p < 0.001], moderate or severe pain [OR = 5.74; CI95% 1.73 - 19.10; p = 0.004], mechanical ventilation [OR = 10.14; CI95% 2.93 - 35.10; p < 0.001], and smoking habits [OR = 4.49; CI95% 1.33 - 15.17; p = 0.015] were independent factors for agitation, while hyperlactatemia was associated with a lower risk [OR = 0.169; CI95% 0.04 - 0.77; p = 0.021]. Agitated patients had fewer mechanical ventilation-free days at day 7 (p = 0.003). Conclusion: The incidence of agitation in the first 7 days after admission to the intensive care unit was high. Delirium, moderate/severe pain, mechanical ventilation, and smoking habits were independent risk factors. Agitated patients had fewer ventilator-free days in the first 7 days.

The impact of duration of organ dysfunction on the outcome of patients with severe sepsis and septic shock

OBJECTIVES: This study aimed to assess the impact of the duration of organ dysfunction on the outcome of patients with severe sepsis or septic shock. METHODS: Clinical data were collected from hospital charts of patients with severe sepsis and septic shock admitted to a mixed intensive care unit from November 2003 to February 2004. The duration of organ dysfunction prior to diagnosis was correlated with mortality. Results were considered significant if p<0.05. RESULTS: Fifty-six patients were enrolled. Mean age was 55.6 ± 20.7 years, mean APACHE II score was 20.6 ± 6.9, and mean SOFA score was 7.9 ± 3.7. Thirty-six patients (64.3 percent) had septic shock. The mean duration of organ dysfunction was 1.9 ± 1.9 days. Within the univariate analysis, the variables correlated with hospital mortality were: age (p=0.015), APACHE II (p=0.008), onset outside the intensive care unit (p=0.05), blood glucose control (p=0.05) and duration of organ dysfunction (p=0.0004). In the multivariate analysis, only a duration of organ dysfunction persisting longer than 48 hours correlated with mortality (p=0.004, OR: 8.73 (2.37-32.14)), whereas the APACHE II score remained only a slightly significant factor (p=0.049, OR: 1.11 (1.00-1.23)). Patients who received therapeutic interventions within the first 48 hours after the onset of organ dysfunction exhibited lower mortality (32.1 percent vs. 82.1 percent, p=0.0001). CONCLUSIONS: These findings suggest that the diagnosis of organ dysfunction is not being made in a timely manner. The time elapsed between the onset of organ dysfunction and initiation of therapeutic intervention can be quite long, and this represents an important determinant of survival in cases of severe sepsis and septic shock.