In-hospital mortality in patients with acute limb ischemia over a 12-year period in the Brazilian public health-care system / Mortalidade hospitalar na saúde pública brasileira em pacientes com isquemia aguda dos membros em um período de 12 anos

Abstract Background Arterial diseases represent a severe public health problem in the 21st century. Although men have a higher overall prevalence, reports have suggested that women may exhibit atypical manifestations, be asymptomatic, and have hormonal peculiarities, resulting in worse outcomes and severe emergencies, such as acute limb ischemia (ALI). Objectives To analyze the morbidity and mortality profile of ALI emergencies in Brazil between 2008 and 2019. Methods An ecological study was carried out with secondary data from SIH/SUS, using ICD-10 code I.74 The proportions of emergency hospital admissions and in-hospital mortality rates (HMR) by gender, ethnicity, and age were extracted from the overall figures. P<0.05 was considered significant. Results From 2008 to 2019, there were 195,567 urgent hospitalizations due to ALI in Brazil, 111,145 (56.8%) of which were of men. Women had a higher HMR (112:1,000 hospitalizations) than men (85:1,000 hospitalizations) (p<0.05), and a higher chance of death (OR=1.36; p<0.05). Furthermore, mean survival was significantly higher among men (8,483/year versus 6,254/year; p<0.05). Stratified by ethnicity, women who self-identified as white (OR=1.44; p<0.05), black (OR=1.33; p<0.05), and brown (RR=1.25; p <0.05) had greater chances of death than men in the same ethnicity categories. Moreover, women over the age of 50 years had a higher chance of death, with a progressive increment in risk as age increased. Conclusions There was a trend to worse prognosis in ALI emergencies associated with women, especially in older groups. The literature shows that the reasons for these differences are still poorly investigated and more robust studies of this relevant disease in the area of vascular surgery are encouraged.

Resumo Contexto Doenças arteriais representam um grave problema de saúde pública no século XXI. Apesar de homens apresentarem maior prevalência geral, estudos sugerem que mulheres podem cursar com quadros assintomáticos, clínica atípica e particularidades hormonais, que resultam em desfechos desfavoráveis e urgências graves, como oclusões arteriais aguda (OAA). Objetivos Analisar o perfil de morbimortalidade das urgências em OAA no Brasil entre 2008 e 2019. Métodos Realizou-se estudo ecológico com dados secundários do Sistema de Informações Hospitalares/Sistema Único de Saúde, utilizando-se o código I.74 do Código Internacional de Doenças-10. Dos números absolutos, obteve-se proporções de internamentos de urgência e taxa de mortalidade intra-hospitalar (TMH) por gênero, etnia e idade. Considerou-se p < 0,05 significativo. Resultados Entre 2008 e 2019, houve 195.567 internamentos de urgência por OAA no Brasil, dos quais 111.145 (56,8%) eram homens. Mulheres tiveram maior TMH (112:1.000 hospitalizações) em comparação a homens (85:1.000 hospitalizações) (p < 0,05), assim como maior chance de morte (odds ratio [OR] = 1,36; p < 0,05). Ademais, a média de sobrevida anual foi maior entre homens do que entre mulheres (8.483/ano vs. 6.254/ano, respectivamente; p < 0,05). Estratificando por etnia, mulheres apresentaram maior chance de óbitos entre brancas (OR = 1,44; p < 0,05), pretas (OR = 1,33; p < 0,05) e pardas (razão de risco [RR] = 1,25; p < 0,05), comparadas a homens das mesmas etnias. Nas análises etárias, mulheres com mais de 50 anos apresentaram maior chance de óbito, com aumento progressivo do risco com o envelhecimento. Conclusões Nossas análises comparativas evidenciaram tendência de pior prognóstico nas urgências em OAA associadas a mulheres, sobretudo em grupos de idade avançada. A literatura evidencia que as razões para essas diferenças ainda são pouco estudadas, estimulando investigações mais robustas sobre essa importante casuística da cirurgia vascular.

Mortalidad intrahospitalaria en adultos mayores chilenos con fractura de cadera: incidencia, causas y otros elementos de interés / Early in-hospital Mortality in Chilean Older People with Hip Fracture

INTRODUCCIÓN: Las fracturas de cadera (FC) presentan alta mortalidad. Existen escasos estudios que profundizan en la mortalidad intrahospitalaria (MIH) asociada. OBJETIVO: Describir MIH en pacientes ≥ 60 años con FC. MATERIALES Y MÉTODOS: Corte transversal, descriptivo y analítico, monocéntrico, de colección completa. Fueron evaluados 647 sujetos, de ambos géneros, ingresados con FC entre 01.01.2010 y 31.12.2012, agrupándolos en fallecidos y egresados vivos. Se registró fallecimientos, género, edad, ubicación anatómica, tipo de traumatismo, lugar de ocurrencia de FC, tiempo fractura-fallecimiento, tiempo de estancia hospitalaria, porcentaje de operados, diagnósticos asociados a FC, diagnóstico de fallecimiento, comorbilidad asociada al diagnóstico de fallecimiento y lugar de fallecimiento. Datos en planilla ortogeriátrica, análisis descriptivo. RESULTADOS: MIH = 3,09%. Edad promedio 84 años. Los diagnósticos de fallecimiento más importantes fueron infecciones (40%) y enfermedad tromboembólica (15%). El 80% presentó comorbilidad crónica relacionada con la causa de fallecimiento. Sin diferencias significativas según edad, género, ubicación anatómica de la FC, lugar de ocurrencia de la FC, tiempo de estancia hospitalaria. Hubo diferencias significativas en cantidad de no operados, mayor en el grupo con MIH (p < 0.000), esperable por sesgo de selección. Es deseable identificar precozmente los sujetos con FC que presentan alto riesgo de MIH. Esto, para definir manejo conservador, optimizar calidad de vida y recursos hospitalarios.

INTRODUCTION: Hip fractures (HIF), have high rates of early mortality. However, there are few studies that deepen in in-hospital mortality (IHM). OBJETIVE: To describe IHM in patients with ≥ 60 years with HIF. MATERIALS AND METHODS: Cross-sectional, descriptive and analytical, monocentric, full collection. 647 subjects, both genders, admitted with HIF between 01.01.2010 and 12.31.2012, separating them in inhospital deceased and discharged alive. Registered deaths, gender, age, anatomic location, type of trauma, place of occurrence of HIF, time fracture-death, length of hospital stay, percentage of operated, diagnosis associated with HIF, diagnosis of death, comorbidity associated with the diagnosis of death and place of death. Data in orthogeriatric chart, descriptive analysis. RESULTS: IHM = 3.09%. Average age 84 years. The most important diagnoses of death were infections (40%) and thromboembolic disease (15%). 80% presented chronic comorbidity related to the cause of death. There were no significant differences according to age, gender, HIF anatomical location, place of occurrence of the HIF, length of hospital stay. There were significant differences in the number of non-operated, higher in the IHM group (p < 0.000), expected for selection bias. It is desirable to identify early those subjects with HIF who are at high risk for IHM. This, to define conservative management, optimize quality of life and hospital resources.

Características clínico epidemiológicas de la insuficiencia cardíaca aguda en un hospital terciario de lima, Perú / Epidemiological Clinical Characteristics of Acute Cardiac Insufficiency in a Tertiary Hospital in Lima, Peru

RESUMEN Con el objetivo de describir las características clínicas y epidemiológicas de la insuficiencia cardiaca aguda (ICA), se realizó un estudio descriptivo en 1075 pacientes de un hospital de Lima. La edad promedio fue 74 años y el 55% fueron de sexo masculino. El 39% tuvo ICA con fracción de eyección reducida, el 15% con fracción de eyección de rango medio y el 46% con fracción de eyección preservada. Las comorbilidades más frecuentes fueron la hipertensión arterial (52,6%) y la enfermedad coronaria (51%). El 29,2% de los pacientes tuvo hospitalizaciones previas por ICA. La mediana de la estancia hospitalaria fue de 3 días. La mortalidad intrahospitalaria por todas las causas fue 7,2%. La hospitalización ocurre, predominantemente, en pacientes de edad avanzada y con múltiples comorbilidades. El bajo uso de fármacos recomendados, conjuntamente con la alta frecuencia de hospitalizaciones previas, probablemente, inciden en la alta tasa de mortalidad registrada en el presente estudio.

ABSTRACT The objective of this study was to describe the clinical and epidemiological characteristics of acute heart failure (AHF) in 1,075 patients from a hospital in Lima, Peru. The average patient age was 74 years and 55% of study subjects were men. Moreover, 39% of patients in the sample had AHF with low ejection fraction, 15% had intermediate ejection fraction, and 46% had preserved ejection fraction. The most common comorbidities were hypertension (52.6%) and coronary disease (51%). Moreover, 29.2% of patients had previous hospitalizations due to AHF. The median hospital stay was 3 days. The rate of in- hospital mortality from all causes was 7.2%. Hospitalization was more common in elderly patients with multiple comorbidities. The low use of prescription drugs together with the high rate of previous hospitalizations may explain the high mortality rate reported in this study.

Hospitalization rates, length of stay and in-hospital mortality in a cohort of HIV infected patients from Rio de Janeiro, Brazil

Abstract In this study, we evaluated trends in hospitalization rates, length of stay and in-hospital mortality in a cohort of HIV-infected patients in Rio de Janeiro, Brazil, from 2007 through 2013. Among the 3991 included patients, 1861 hospitalizations occurred (hospitalization rate of 10.44/100 person-years, 95% confidence interval 9.98-10.93/100 person-years). Hospitalization rates decreased annually (per year incidence rate ratio 0.92, 95% confidence interval 0.89-0.95) as well as length of stay (median of 15 days in 2007 vs. 11 days in 2013, p-value for trend < 0.001), and in-hospital mortality (13.4% in 2007 to 8.1% in 2013, p-value for trend = 0.053). Our results show that, in a middle-income setting, hospitalization rates are decreasing over time and non-AIDS hospitalizations are currently more frequent than those related to AIDS. Notwithstanding, compared with high-income settings, our patients had longer length of stay and higher in-hospital mortality. Further studies addressing these outcomes are needed to provide information that may guide protocols and interventions to further reduce health-care costs and in-hospital mortality.

In-hospital mortality risk factors in community acquired pneumonia: evaluation of immunocompetent adult patients without comorbidities / Fatores de risco para mortalidade intra-hospitalar em pneumonia adquirida em comunidade: avaliação de pacientes imunocompetentes sem comorbidades

Summary Objective: several scores were developed in order to improve the determination of community acquired pneumonia (CAP) severity and its management, mainly CURB-65 and SACP score. However, none of them were evaluated for risk assessment of in-hospital mortality, particularly in individuals who were non-immunosuppressed and/or without any comorbidity. In this regard, the present study was carried out. Methods: we performed a cross-sectional study in 272 immunocompetent patients without comorbidities and with a diagnosis of CAP. Performance of CURB- 65 and SCAP scores in predicting in-hospital mortality was evaluated. Also, variables related to death were assessed. Furthermore, in order to design a model of in-hospital mortality prediction, sampled individuals were randomly divided in two groups. The association of the variables with mortality was weighed and, by multiple binary regression, a model was constructed in one of the subgroups. Then, it was validated in the other subgroup. Results: both scores yielded a fair strength of agreement, and CURB-65 showed a better performance in predicting in-hospital mortality. In our casuistry, age, white blood cell counts, serum urea and diastolic blood pressure were related to death. The model constructed with these variables showed a good performance in predicting in-hospital mortality; moreover, only one patient with fatal outcome was not correctly classified in the group where the model was constructed and in the group where it was validated. Conclusion: our findings suggest that a simple model that uses only 4 variables, which are easily accessible and interpretable, can identify seriously ill patients with CAP .

Resumo Objetivo: diversos escores de gravidade da pneumonia adquirida em comunidade (PAC) foram desenvolvidos com o intuito de melhorar o manejo clínico, em especial os escores CURB-65 e SCAP. Contudo, nenhum dos dois foi avaliado para determinar o risco de morte intra- hospitalar, principalmente em pacientes imunocompetentes e/ou sem comorbidades. Diante disso, propusemo- nos a analisar a utilidade dos escores para prever a mortalidade intra-hospitalar e estudar as variáveis associadas ao desfecho fatal. Métodos: desenvolvemos um trabalho transversal com 272 pacientes imunocompetentes, sem comorbidades e com diagnóstico de PAC. Foi avaliada a eficácia dos escores CURB-65 e SCAP em prever a mortalidade durante a internação. Foram estudadas as variáveis relacionadas a este desfecho. Por fim, a amostra foi dividida em dois subgrupos com o objetivo de desenvolver um modelo de avaliação do risco de morte em um subgrupo, validando-o no outro. Resultados: ambos os escores apresentaram pobre concordância de classificação da gravidade para PAC. O escore CURB-65 mostrou melhor desempenho na avaliação do risco de morte. Em nossa amostra, idade, contagem de glóbulos brancos, ureia sérica e pressão arterial diastólica foram as variáveis que se associaram à mortalidade. O modelo desenvolvido com essas variáveis mostrou eficácia muito boa para prever o desfecho fatal. Inclusive, somente um paciente no grupo de desenvolvimento do modelo e outro no grupo de validação foram classificados de modo incorreto. Conclusão: nossos resultados sugerem que com um modelo de quatro variáveis, de fácil acesso e interpretação, foi possível identificar pacientes gravemente enfermos com PAC. .

Mortalidad hospitalaria en pacientes con infección por VIH: a diez años del acceso universal a TARAA en México / In-hospital mortality in HIV-infected patients: 10 years after the implementation of universal access to HAART in Mexico

Objetivo. Establecer las características y causas de muerte de pacientes VIH positivos que fallecen al estar hospitalizados. Material y métodos. Se incluyeron pacientes VIH positivos que fallecieron durante la hospitalización entre 2010 y 2013. Se recabaron datos sociodemográficos y clínicos, causas de muerte y muertes prevenibles. Se consideraron prevenibles aquellas muertes en pacientes con menos de seis meses de terapia antirretroviral altamente activa (TARAA) o sin tratamiento y con menos de 350 CD4+ al momento del diagnóstico o del internamiento, con o sin enfermedades oportunistas. Resultados. Se identificaron 128 muertes. La mediana de CD4+ fue 47 cels/mm³; 18% llegó al internamiento sin diagnóstico de VIH, 51% tenía menos de seis meses de haber sido diagnosticado y 40.5% no había recibido TARAA. Las principales causas de muerte fueron eventos definitorios de sida (65.6%). Se identificaron 70 muertes prevenibles (57%). Conclusión. A pesar del acceso universal a TARAA, en México los pacientes VIH positivos siguen falleciendo por eventos relacionados con sida, que es un indicador de diagnóstico tardío del VIH. Es urgente implementar programas de detección temprana para hacer accesible el beneficio de la TARAA.

Objective. To establish the characteristics and causes of death of HIV patients who die while hospitalized. Materials and methods. We included HIV+ patients who died during hospitalization, in three hospitals in Mexico City between 2010 and 2013. Sociodemographic and clinical data were collected as well as causes of death. We identified preventable deaths (defined as deaths that occurred in patients with less than six months of HAART, or without HAART, with less than 350 CD4 at diagnosis and/or opportunistic events as the cause of hospitalization). Results. 128 deaths were analyzed. The median of CD4 count was 47 cells/mm³; 18% of the patients ignored their HIV status at the time of hospitalization, 51% had less than six months of HAART, 40.5% had never received HAART before. The main causes of death were AIDS defining events, with 65.6%. We identified 70 preventable deaths (57%). Conclusions. Despite universal access to HAART, HIV patients in Mexico are still dying of AIDS defining illnesses, an indicator of late diagnosis. It is urgent to implement HIV testing programs to allow earlier diagnosis and make HAART benefit accessible to all.

Mortalidad intrahospitalaria por accidente cerebrovascular / In-hospital mortality due to stroke

La mortalidad global por accidente cerebrovascular (ACV) ha disminuido en las últimas tres décadas, probablemente debido a un mejor control de los factores de riesgo vascular. La mortalidad hospitalaria por ACV ha sido tradicionalmente estimada entre 6 y 14% en la mayoría de las series comunicadas. Sin embargo, los datos de ensayos clínicos recientes sugieren que esta cifra sería sustancialmente menor. Se revisaron datos de pacientes internados con diagnóstico de ACV del Banco de Datos de Stroke de FLENI y los registros institucionales de mortalidad entre los años 2000 y 2010. Los subtipos de ACV isquémicos se clasificaron según criterios TOAST y los ACV hemorrágicos en hematomas intrapanquimatosos, hemorragias subaracnoideas aneurismáticas, malformaciones arteriovenosas y otros hematomas intraparenquimatosos. Se analizaron 1514 pacientes, 1079 (71%) con ACV isquémico (grandes vasos 39%, cardioembólicos 27%, lacunares 9%, etiología indeterminada 14%, otras etiologías 11%) y 435 (29%) con ACV hemorrágico (intraparenquimatosos 27%, hemorragia subaracnoidea 30%, malformaciones arteriovenosas 25% y otros hematomas espontáneos 18%). Se registraron 38 muertes intrahospitalarias (17 ACV isquémicos y 21 ACV hemorrágicos), representando una mortalidad global del 2.5% (1.7% en ACV isquémicos y 4.8% en ACV hemorrágicos). No se registraron muertes asociadas al uso de fibrinolíticos endovenosos. La mortalidad intrahospitalaria en pacientes con ACV isquémico y hemorrágico en nuestro centro fue baja. El manejo en un centro dedicado a las enfermedades neurológicas y el enfoque multidisciplinario por personal médico y no médico entrenado en el cuidado de la enfermedad cerebrovascular podrían explicar, al menos en parte, estos resultados.

Overall mortality due to stroke has decreased in the last three decades probable due to a better control of vascular risk factors. In-hospital mortality of stroke patients has been estimated to be between 6 and 14% in most of the series reported. However, data from recent clinical trials suggest that these figures may be substantially lower. Data from FLENI Stroke Data Bank and institutional mortality records between 2000 and 2010 were reviewed. Ischemic stroke subtypes were classified according to TOAST criteria and hemorrhagic stroke subtypes were classified as intraparenchymal hematoma, aneurismatic subarachnoid hemorrhage, arterio-venous malformation, and other intraparenchymal hematomas. A total of 1514 patients were studied. Of these, 1079 (71%) were ischemic strokes,39% large vessels, 27% cardioembolic, 9% lacunar, 14% unknown etiology, and 11% others etiologies. There were 435 (29%) hemorrhagic strokes, 27% intraparenchymal hematomas, 30% aneurismatic subarachnoid hemorrhage, 25% arterio-venous malformation, and 18% other intraparenchymal hematomas. Moreover, 38 in-hospital deaths were recorded (17 ischemic strokes and 21 hemorrhagic strokes), accounting for 2.5% overall mortality (1.7% in ischemic strokes and 4.8% in hemorrhagic strokes). No deaths occurred associated with the use of intravenous fibrinolytics occurred. In our Centre in-hospital mortality in patients with stroke was low. Management of these patients in a Centre dedicated to neurological diseases along with a multidisciplinary approach from medical and non-medical staff trained in the care of cerebrovascular diseases could, at least in part, account for these results.

Preditores de mortalidade na cirurgia de revascularizção do miocárdio / Mortality predictors in coronary artery bypass grafting surgery

Fundamentos: A alta morbidade pós-operatória e os elevados índices de mortalidade dos pacientes submetidos à revascularização cirúrgica (RM) na fase aguda do infarto do miocárdio podem induzir o adiamento do procedimento. Objetivos: Identificar variáveis relacionadas à mortalidade, bem como os fatores de risco para o óbito de pacientes submetidos à cirurgia de revascularização do miocárdio. Métodos: A pesquisa foi realizada no período de setembro 2011 a maio 2012, no Hospital de Clínicas Gaspar Vianna, Belém, PA, Brasil. Foram utilizados prontuários de 240 pacientes, tendo sido aproveitados 223 (17 excluídos), referentes a pacientes internados no período de janeiro 2008 até dezembro 2011. Inicialmente foi calculada a frequência dos óbitos e, em seguida, a frequência das variáveis pré, intra e pós-operatórias e respectivos intervalos de confiança para caracterizar a população de estudo. Resultados: Dos 223 pacientes, 12 (5,4 %) foram a óbito. A variável no período pré-operatório mais significativa para o estudo foi a idade. No período intraoperatório, são os procedimentos cirúrgicos de urgência/emergência e, no pós-operatório, a transfusão sanguínea.Conclusão: No pós-operatório, as complicações cardiovasculares e as transfusões são fatores de risco, e a UTI se tornou um fator de proteção contra o óbito.

Background: High postoperative morbidity and mortality rates among patients undergoing coronary artery bypass surgery (CABG) during the acute phase of myocardial infarction may lead to the post ponement of these procedures.Objectives: To identify variables linked to o mortality and risk factors related to death among patients undergoing coronary artery bypass grafting surgery.Methods: The survey was conducted from September 2011 to May 2012 at the Hospital de Clinicas Gaspar Vianna in Belém, Pará State, Brazil, using the medical records of 240 patients (223 assessed and 17 excluded) admitted from January 2008 through December 2011. Initially, the death frequency was caculated, followed by the pre-, intra- and post-operative variable frequencies and their respective confidence intervals, in order to characterize the study population. Results: Among all 223 patients, 12 (5,4%) died, with age being the most significant varible in the pre-operative period. During the intra-operative stage, this was urgente or emergency surgical procedures, followed by post-operative blood transfusions. Conclusion: During the post-operative stage, cardiovascular complications and transfusions are risk factors, with the ICU constituting a protection fator against death.