Prevalência e fatores de risco para disfagia orofaríngea em idosos frágeis com fraturas traumato-ortopédicas / Prevalence and risk factors for oropharyngeal dysphagia in fragile older adults with orthopedic fractures

RESUMO Objetivo Estimar a prevalência e fatores de risco para disfagia orofaríngea em indivíduos idosos hospitalizados por fraturas traumato-ortopédicas. Métodos Foram coletados dados sociodemográficos, incluindo comorbidades clínicas, autopercepção do desempenho de deglutição (Eating Assessment Tool) e identificação de risco nutricional (Mini Avaliação Nutricional). Para avaliar o sistema estomatognático e a deglutição, foram utilizados os protocolos Avaliação Miofuncional para Pessoas Idosas e o Volume Viscosity Swallow Test, compilados para composição do desfecho a partir da Functional Oral Intake Scale (FOIS). Resultados O estudo evidenciou que 58% dos indivíduos apresentaram restrições de consistências alimentares devido à disfagia orofaríngea (FOIS ≤ 6). Observou-se, também, risco de diminuição funcional entre aqueles com idade maior ou igual a 70 anos, com piores condições dentárias, diminuição da funcionalidade global, doenças neurológicas associadas e com percepção de alterações na deglutição. Conclusão Houve prevalência de disfagia orofaríngea em seis a cada dez indivíduos, sendo a fragilidade, idade avançada, múltiplas doenças e condições orais deficitárias os fatores de risco para a alteração, fatores estes que devem ser identificados para a prevenção de aspiração alimentar.

ABSTRACT Purpose To estimate the prevalence of and risk factors for oropharyngeal dysphagia in older adults hospitalized for orthopedic trauma fractures. Methods Sociodemographic data, clinical comorbidities, auto-perception of swallowing performance (Eating Assessment Tool) and identification of nutritional risk (Mini Nutritional Assessment) were collected. In order to evaluate the stomatognathic system and swallowing, the Orofacial Myofunctional Evaluation Protocol for older people and the Volume Viscosity Swallow Test protocols were used to assess the outcome through the Functional Oral Intake Scale (FOIS). Results 58% individuals presented dietary consistency restrictions due to oropharyngeal dysphagia (FOIS ≤ 6). A risk for functional decrease was observed among patients 70 years or older, with worse dental conditions, global functionality decreased, neurologic disorders and self-perception of swallowing changes. Conclusion The study observed a prevalence of oropharyngeal dysphagia in six out of ten individuals. Frailty, advanced age, multiple comorbidities and deficient oral conditions are risk factors that should be identified in order to prevent food aspiration.

Critical illness polyneuromyopathy in septic patients: Is it possible to diagnose it in a bedside clinical examination? / Polineuromiopatia do doente crítico em pacientes sépticos: É possível diagnosticar em um exame clínico à beira do leito?

ABSTRACT Objective: To determine the sensitivity and specificity of peripheral and respiratory muscle strength tests in diagnosing critical illness polyneuromyopathy (CIPNM), compared with an electrophysiological examination. Methods: Fifty septic patients who required mechanical ventilation for at least five days, and without a previous history of muscle weakness, were included. Peripheral muscle strength was assessed using the Medical Research Council (MRC) score, handgrip strength by dynamometry, and respiratory muscle strength with maximum respiratory pressures. Diagnosis of CIPNM was either confirmed or rejected by an electrophysiological examination. Receiver operating characteristic curve analysis was performed to determine the cut-off values with the best sensitivity (SN) and specificity (SP) of the studied variables in the presence or absence of CIPNM. Results: Patients with CIPNM were older, more critical (APACHE IV/SAPS 3), had a longer hospitalization, required mechanical ventilation for longer, and had a higher rate of intensive care unit readmission. Cutoff values identified CIPNM patients using MRC scores, dynamometry according to sex, maximal expiratory and inspiratory pressures, as well as being confirmed by the electrophysiological examination, with good sensitivity and specificity: < 40 (SN: 0.893; SP: 0.955); < 7 kg (SN: 1; SP: 0.909) for men, < 4 kg (SN: 0.882; SP: 1) for women; < 34 cmH2O (SN: 0.808; SP: 0.909) and > −40 cmH2O (SN: 0.846; SP: 0.909), respectively. Conclusion: The MRC score, dynamometry or maximum respiratory pressures can be used to identify patients with CIPNM at the intensive care bedside assessment. The healthcare professional can choose any of the methods studied to evaluate the patient, based on his experience and the resource available.

RESUMO Objetivo: Determinar a sensibilidade (SN) e especificidade (SP) dos testes de força muscular periférica e respiratória no diagnóstico da Polineuromiopatia do Doente Crítico (PNDC) em comparação com o estudo eletrofisiológico. Métodos: Foram incluídos 50 pacientes sépticos, em ventilação mecânica (VM) durante pelo menos cinco dias e sem história prévia de fraqueza muscular. A força muscular foi avaliada utilizando o escore Medical Research Council (MRC), a força de preensão palmar e as pressões respiratórias máximas. O diagnóstico de PNDC foi confirmado ou excluído pelo estudo eletrofisiológico. A análise da curva ROC foi realizada para determinar os valores de corte com a melhor SN e SP. Resultados: Os pacientes com PNDC eram mais velhos, mais graves, tiveram hospitalização mais longa, necessitaram de VM por mais tempo e apresentaram maior taxa de readmissão na Unidade de Terapia Intensiva. Os valores de corte identificaram os pacientes com PNDC usando o MRC, a dinamometria de acordo com o sexo, as pressões expiratórias e inspiratórias máximas, também confirmado pelo estudo eletrofisiológico, com boa sensibilidade e especificidade: < 40 (SN: 0.893; SP: 0.955), < 7 kg (SN: 1; SP: 0,909) para homens, < 4 kg (SN: 0,882; SP: 1) para mulheres, <34 cmH2O (SN: 0,808; SP: 0,909) e > −40 cmH2O (SN: 0,846; SP: 0,909), respectivamente. Conclusão: Tanto o MRC, a dinamometria quanto as pressões respiratórias máximas podem ser usadas para identificar pacientes com PNDC na avaliação à beira do leito, podendo o profissional de saúde escolher qualquer um dos métodos baseado em sua experiência e no recurso disponível.

Impact of an inpatient multidisciplinary glucose control management program

ABSTRACT Objective: Glycemic control has been increasingly recognized as a critical element in inpatient care, but optimal management of blood glucose in the hospital setting remains challenging. The aims of this study were to describe and evaluate the impact of the implementation of an inpatient multidisciplinary glucose control management program on glucose control in hospitalized patients. Materials and methods: Retrospective analysis of medical records and glucose monitoring data obtained by point- of-care testing (POCT) in hospitalized patients before (May 2014) and after (June 2015 and May 2017) the implementation of the program. Results: We analyzed 6888, 7290, and 7669 POCTs from 389, 545, and 475 patients in May 2014, June 2015, and May 2017, respectively. Hyperglycemia (≥ 180 mg/ dL) occurred in 23.5%, 19.6%, and 19.3% POCTs in May 2014, June 2015, and May/2017, respectively (p < 0.001), while severe hyperglycemia (≥ 300 mg/dL) was observed in 2.5%, 2.2%, and 1.8% of them, respectively (p = 0.003). Hyperglycemia (≥ 180 mg/dL) reduced significantly from May 2014 to June 2015 (16.3%, p < 0.001) and from May 2014 to May 2017 (178%, p < 0.001). No significant changes occurred in hypoglycemic parameters. Conclusions: The implementation of an inpatient multidisciplinary glucose control management program led to significant reductions in hyperglycemic events. The key elements for this achievement were the development of institutional inpatient glycemic control protocols, establishment of a multidisciplinary team, and continuing educational programs for hospital personnel. Altogether, these actions resulted in improvements in care processes, patient safety, and clinical outcomes of hospitalized patients.

Detection of schistosomiasis in an area directly affected by the São Francisco River large-scale water transposition project in the Northeast of Brazil

Abstract INTRODUCTION: The development of the São Francisco River Integration Project [Projeto de Integração do Rio São Francisco (PISF)] in the State of Ceará, Brazil, has resulted in environmental and socioeconomic changes with potential risks to public health. We aimed to determine the presence of Schistosoma mansoni infections in schoolchildren (aged 7-14 years) and workers from the construction site in an area under the direct influence of the PISF in the municipality of Brejo Santo-CE, to aid in the prevention and control of schistosomiasis. METHODS: We conducted a cross-sectional study using two S. mansoni-detection methods: detection of S. mansoni eggs by the Kato-Katz parasitological method in stool samples (assessed in triplicate for each sample) and S. mansoni circulating cathodic antigen by the point-of-care immunochromatographic rapid test (POC-CCA) in urine. RESULTS In general, the positivity rates for S. mansoni detection were 1.9% (2/106) among schoolchildren and 2.9% (4/138) among workers. No child had evidence of S. mansoni eggs in their stools; 1.9% tested positive by the POC-CCA method. Among workers, two (1.4%) tested positive by the Kato-Katz test and three (2.2%) by the POC-CCA test. If the POC-CCA test results that were scored as traces were considered negative, then the positivity rates dropped to 0.9% and 0.7% for schoolchildren and workers, respectively. CONCLUSIONS: The active transmission of schistosomiasis in a region covered by the PISF was recognized, reinforcing the necessity to consolidate surveillance and control actions, as well as structural sanitation measures to reverse the social determinants of the disease.

Assessment of a glycated hemoglobin point-of-care analyzer (A1CNow+) in comparison with an immunoturbidimetric method: a diagnostic accuracy study / Avaliação de um aparelho de diagnóstico local para hemoglobina glicada (A1CNow+) comparado com um método imunoturbidimétrico: estudo de acurácia de teste diagnóstico

CONTEXT AND OBJECTIVE: To monitor glycemic control in diabetic patients, regular measurement of glycated hemoglobin (HbA1c) is recommended, but this can be difficult in remote places without access to laboratories. Portable point-of-care testing devices can prove a useful alternative. Our study aimed to assess the performance of one of them: A1CNow+, from Bayer. DESIGN AND SETTING: Cross-sectional accuracy study conducted at a university hospital in Brazil. METHODS: We made three successive measurements of capillary HbA1c using the A1CNow+ in 55 diabetic volunteers, while the same measurement was made on venous blood using the hospital reference method (Vitros 5,1 FS). We used the Bland-Altman graphical method to assess the A1CNow+ in relation to the Vitros 5,1 FS method. We also evaluated clinical usefulness by calculating the sensitivity and specificity of A1CNow+ for detecting patients with HbA1c lower than 7%, which is the usual limit for good glycemic control. RESULTS: The coefficient of variation between repeat testing for the A1CNow+ was 3.6%. The mean difference between A1CNow+ and Vitros 5,1 FS was +0.67% (95% confidence interval, CI: +0.52 to +0.81). The agreement limits of our Bland-Altman graph were -0.45 (95% CI: -0.71 to -0.19) and +1.82 (95% CI: +1.52 to +2.05). The sensitivity and specificity in relation to the 7% limit were respectively 100% and 67.7%. CONCLUSIONS: Although the A1CNow+ had good sensitivity, its accuracy was insufficient for use as a replacement for laboratory measurements of HbA1c, for glycemic control monitoring in diabetic patients.

CONTEXTO E OBJETIVO: Para monitorar o controle glicêmico dos diabéticos, é recomendado medir regularmente a hemoglobina glicada (HbA1c). Isso pode ser difícil em locais distantes sem acesso a laboratórios. Uma alternativa é usar aparelhos portáteis à beira do leito do paciente. Nosso estudo visou avaliar o desempenho de um deles: A1CNow+, da Bayer. TIPO DE ESTUDO E LOCAL: Estudo transversal de acurácia realizado em hospital universitário no Brasil. MÉTODOS: Medimos, com o A1CNow+, três vezes seguidas, a HbA1c capilar de 55 diabéticos voluntários, enquanto a mesma medida era feita em sangue venoso pelo método de referência do hospital (Vitros 5,1 FS). Usamos a análise gráfica de Bland-Altman para avaliar o A1CNow+ em relação ao Vitros 5,1 FS. Verificamos a utilidade clínica através do cálculo da sensibilidade e da especificidade do A1CNow+ para detectar pacientes com HbA1c abaixo de 7%, limite usual indicando glicemia controlada. RESULTADOS: O coeficiente de variação entre testes repetidos do A1CNow+ foi de 3,6%. A diferença média entre o A1CNow+ e o Vitros 5,1 FS foi de +0,67% (95% intervalo de confiança, IC: +0,52 para +0,81). Os limites de concordância do gráfico de Bland-Altman foram -0,45 (95% IC: -0,71 para -0,19) and +1,82 (95% IC: +1,52 para +2,05). A sensibilidade e a especificidade em relação ao limite de 7% foram 100% e 67,7%, respectivamente. CONCLUSÃO: Apesar da boa sensibilidade, o A1CNow+ não tem acurácia suficiente para ser utilizado no monitoramento do controle glicêmico de pacientes diabéticos em substituição das medidas da HbA1c em laboratório.