Palliative care for patients with HIV/AIDS admitted to intensive care units. / Cuidados paliativos no paciente com HIV/AIDS internado na unidade de terapia intensiva.

OBJECTIVE: To describe the characteristics of patients with HIV/AIDS and to compare the therapeutic interventions and end-of-life care before and after evaluation by the palliative care team. METHODS: This retrospective cohort study included all patients with HIV/AIDS admitted to the intensive care unit of the Instituto de Infectologia Emílio Ribas who were evaluated by a palliative care team between January 2006 and December 2012. RESULTS: Of the 109 patients evaluated, 89% acquired opportunistic infections, 70% had CD4 counts lower than 100 cells/mm3, and only 19% adhered to treatment. The overall mortality rate was 88%. Among patients predicted with a terminally ill (68%), the use of highly active antiretroviral therapy decreased from 50.0% to 23.1% (p = 0.02), the use of antibiotics decreased from 100% to 63.6% (p < 0.001), the use of vasoactive drugs decreased from 62.1% to 37.8% (p = 0.009), the use of renal replacement therapy decreased from 34.8% to 23.0% (p < 0.0001), and the number of blood product transfusions decreased from 74.2% to 19.7% (p < 0.0001). Meetings with the family were held in 48 cases, and 23% of the terminally ill patients were discharged from the intensive care unit. CONCLUSION: Palliative care was required in patients with severe illnesses and high mortality. The number of potentially inappropriate interventions in terminally ill patients monitored by the palliative care team significantly decreased, and 26% of the patients were discharged from the intensive care unit.

Susceptibility to antibiotics in urinary tract infections in a secondary care setting from 2005-2006 and 2010-2011, in São Paulo, Brazil: data from 11,943 urine cultures.

INTRODUCTION: Urinary tract infection (UTI) has a high incidence and recurrence, therefore, treatment is empirical in the majority of cases. OBJECTIVES: The aim of this study was to analyze the urine cultures performed at a secondary hospital, during two periods, 2005-2006 and 2010-2011, and to estimate the microbial resistance. PATIENTS AND METHODS: We analyzed 11,943 aerobic urine cultures according to basic demographic data and susceptibility to antibiotics in accordance with the Clinical and Laboratory Standards Institute (CLSI) for Vitek 1 and 2. RESULTS: Most of our cohort consisted of young adult females that were seen at the Emergency Department. E. coli was the most frequent (70.2%) among the 75 species isolated. Resistance of all isolates was ≥ 20% for trimethoprim/sulfamethoxazole (TMP/SMX), norfloxacin, nitrofurantoin, cefazolin and nalidixic acid. Although E. coli was more susceptible (resistance ≥ 20% for TMP/SMX and nalidixic acid) among all of the isolates, when classified by the number and percentage of antibiotic resistance. Global resistance to fluoroquinolones was approximately 12%. Risk factors for E. coli were female gender and an age less than 65 years. Men and patients older than 65 years of age, presented more resistant isolates. Extended spectrum beta-lactamases (ESBL) were identified in 173 out of 5,722 Gram-negative isolates (3.0%) between 2010 and 2011. CONCLUSION: E. coli was the most frequent microbe isolated in the urine cultures analyzed in this study. There was a significant evolution of bacterial resistance between the two periods studied. In particular, the rise of bacterial resistance to fluoroquinolones was concerning.

High rate of virologic suppression with darunavir/ritonavir plus optimized background therapy among highly antiretroviral-experienced HIV-infected patients: results of a prospective cohort study in São Paulo, Brazil.

OBJECTIVES: To assess the virologic and immunological response of darunavir/ritonavir plus optimized background therapy in highly antiretroviral-experienced HIV-infected patients in Brazil. METHODS: Prospective cohort study carried out in a tertiary center in Sao Paulo, Brazil. Three-class antiretroviral-experienced patients with confirmed virologic failure began darunavir/ritonavir plus optimized background therapy (nucleoside/tide reverse transcriptase inhibitors ± raltegravir ± enfuvirtide ± maraviroc) after performing a genotypic resistance assay. Clinical evaluation and laboratory tests were collected at baseline and at weeks 12, 24, and 48. Multivariate analysis was performed to identify predictors of virologic response at 48 weeks. RESULTS: Ninety-two patients were included. The median of darunavir resistant mutation was 1 (range 0-6). The median genotypic sensitivity score in the optimized background therapy was 2 (interquartile range 1-2). At week 48, 83% (95% CI: 75-90%) had an HIV RNA level <50 copies/mL and the median CD4 cell count was 301 (interquartile range 224-445) cells/mm(3). Baseline HIV RNA >100000 copies/mL was inversely associated with virologic success at week 48 (HR: 0.22, 95% CI: 0.06-0.85, p=0.028). CONCLUSIONS: Darunavir/ritonavir plus optimized background therapy was a highly effective salvage regimen under clinical routine conditions in a referral center in Brazil, which is similar to the reported in high-income countries.

Immune reconstitution inflammatory syndrome associated with pulmonary sarcoidosis in an HIV-infected patient: an immunohistochemical study.

Sarcoidosis has been rarely described in literature as a cause of interstitial pulmonary disease associated with AIDS. This study reports a case of immune reconstitution inflammatory syndrome associated with pulmonary sarcoidosis in a patient with a history of previous pulmonary tuberculosis concomitant with HIV infection. Results of the immunohistochemical study of samples from the resected right lower lobe are described. Pathological findings suggest a role of Th1, Th2 and Th17 response in IRIS associated sarcoidosis.

Cuidados paliativos no paciente com HIV/AIDS internado na unidade de terapia intensiva / Palliative care for patients with HIV/AIDS admitted to intensive care units

RESUMO Objetivo: Descrever as características de pacientes com HIV/AIDS e comparar as medidas terapêuticas e cuidados de fim de vida, antes e após a avaliação da equipe de cuidados paliativos. Métodos: Trata-se de uma coorte retrospectiva, que incluiu todos os pacientes com HIV/AIDS internados na unidade de terapia intensiva do Instituto de Infectologia Emílio Ribas e avaliados pela equipe de cuidados paliativos no período de janeiro de 2006 a dezembro de 2012. Resultados: Dos 109 pacientes avaliados, 89% tinham relato de doenças oportunistas, 70% apresentavam CD4 menor que 100cels/mm3 e apenas 19% aderiram ao tratamento. A mortalidade geral foi de 88%. Dentre os pacientes considerados em provável terminalidade (68%), observaram-se redução do uso da terapia antirretroviral altamente ativa (50,0% para 23,1%; p = 0,02), antibioticoterapia (100% para 63,6%; p < 0,001), drogas vasoativas (62,1% para 37,8%, p = 0,009), terapia de substituição renal (34,8% para 23%; p < 0,0001) e transfusão de hemoderivados (74,2% para 19,7%; p < 0,0001). Foi realizada reunião com a família em 48% dos casos, e 23% dos pacientes em provável terminalidade receberam alta da unidade de terapia intensiva. Conclusão: A equipe de cuidados paliativos foi acionada para pacientes com perfil de elevadas gravidade e mortalidade. Os pacientes acompanhados pela equipe de cuidados paliativos avaliados como provável terminalidade tiveram significativa redução de intervenções potencialmente inapropriadas, e 26% desses pacientes conseguiram receber alta da unidade de terapia intensiva.

ABSTRACT Objective: To describe the characteristics of patients with HIV/AIDS and to compare the therapeutic interventions and end-of-life care before and after evaluation by the palliative care team. Methods: This retrospective cohort study included all patients with HIV/AIDS admitted to the intensive care unit of the Instituto de Infectologia Emílio Ribas who were evaluated by a palliative care team between January 2006 and December 2012. Results: Of the 109 patients evaluated, 89% acquired opportunistic infections, 70% had CD4 counts lower than 100 cells/mm3, and only 19% adhered to treatment. The overall mortality rate was 88%. Among patients predicted with a terminally ill (68%), the use of highly active antiretroviral therapy decreased from 50.0% to 23.1% (p = 0.02), the use of antibiotics decreased from 100% to 63.6% (p < 0.001), the use of vasoactive drugs decreased from 62.1% to 37.8% (p = 0.009), the use of renal replacement therapy decreased from 34.8% to 23.0% (p < 0.0001), and the number of blood product transfusions decreased from 74.2% to 19.7% (p < 0.0001). Meetings with the family were held in 48 cases, and 23% of the terminally ill patients were discharged from the intensive care unit. Conclusion: Palliative care was required in patients with severe illnesses and high mortality. The number of potentially inappropriate interventions in terminally ill patients monitored by the palliative care team significantly decreased, and 26% of the patients were discharged from the intensive care unit.

Susceptibility oo antibiotics in urinary tract nfections in a secondary care ssetting from 2005-2006 and 2010-2011, in são paulo, Brazil: data from 11,943 urine cultures / Suscetibilidade a antibióticos em infecções de trato urinário em um hospital secundário, 2005-2006 e 2010-2011, em São Paulo, Brasil: dados de 11.943 uroculturas

Introduction: Urinary tract infection (UTI) has a high incidence and recurrence, therefore, treatment is empirical in the majority of cases. Objectives: The aim of this study was to analyze the urine cultures performed at a secondary hospital, during two periods, 2005-2006 and 2010-2011, and to estimate the microbial resistance. Patients and methods: We analyzed 11,943 aerobic urine cultures according to basic demographic data and susceptibility to antibiotics in accordance with the Clinical and Laboratory Standards Institute (CLSI) for Vitek 1 and 2. Results: Most of our cohort consisted of young adult females that were seen at the Emergency Department. E. coli was the most frequent (70.2%) among the 75 species isolated. Resistance of all isolates was ≥ 20% for trimethoprim/sulfamethoxazole (TMP/SMX), norfloxacin, nitrofurantoin, cefazolin and nalidixic acid. Although E. coli was more susceptible (resistance ≥ 20% for TMP/SMX and nalidixic acid) among all of the isolates, when classified by the number and percentage of antibiotic resistance. Global resistance to fluoroquinolones was approximately 12%. Risk factors for E. coli were female gender and an age less than 65 years. Men and patients older than 65 years of age, presented more resistant isolates. Extended spectrum beta-lactamases (ESBL) were identified in 173 out of 5,722 Gram-negative isolates (3.0%) between 2010 and 2011. Conclusion: E. coli was the most frequent microbe isolated in the urine cultures analyzed in this study. There was a significant evolution of bacterial resistance between the two periods studied. In particular, the rise of bacterial resistance to fluoroquinolones was concerning.

Introdução: A infecção do trato urinário (ITU) tem alta incidência e recorrência, e o tratamento é empírico na maioria dos casos. Objetivos: O objetivo deste estudo foi analisar as culturas de urina realizadas em um hospital secundário, durante dois períodos: 2005-2006 e 2010-2011, para estimar a resistência microbiana. Pacientes e métodos: Foram analisadas 11.943 culturas aeróbicas de urina de acordo com um conjunto de dados demográficos básicos e susceptibilidade aos antibióticos, obedecendo às normas do Clinical and Laboratory Standards Institute (CLSI) para Vitek 1 e 2. Resultados: A maioria dos participantes era adulta e jovem atendida no Serviço de Emergência. E. coli foi a mais freqüente (70,2%) entre as 75 espécies isoladas. Resistência de todos os isolados foi ≥ 20% para sulfametoxazol/trimetoprim (SMX/TMP), norfloxacina, nitrofurantoína, cefazolina e ácido nalidíxico, apesar de E. coli ter sido mais suscetível (resistência ≥ 20% apenas para SMX/TMP e ácido nalidíxico) entre todos os isolados, levando em conta a porcentagem de resistência e o número de antibióticos testados. Resistência às fluoroquinolonas foi de 12%. Fatores de risco para E. coli: sexo feminino e idade < 65 anos. Homens e pacientes com mais de 65 anos apresentaram isolados mais resistentes. Beta-lactamases de espectro estendido (ESBL) foram identificadas em 173 de 5.722 isolados Gram-negativos (3,0%), 2010-2011. Conclusões: E. coli foi o isolado mais sensível a antibióticos. Houve uma evolução significativa da resistência antimicrobiana entre os dois períodos. Foi preocupante o aumento da resistência às fluoroquinolonas.

[Risks to health of intensive care unity nursing staff: proposal of integral approach of health]. / Riscos à saúde de equipe de enfermagem em unidade de terapia intensiva: proposta de abordagem integral da saúde.

BACKGROUND AND OBJECTIVES: In this study we discuss about risks to health of intensive care unity staff and suggest a proposal of integral approach of health. CONTENTS: Literature review, from 1997 to 2007, at Bireme database about "health education", "intensive care unity", "nursing" and "occupational health", regardless of design of study. CONCLUSIONS: All studies show that the environment of intensive care unity is unhealthy, which is also due to habits and attitudes of ICU health professionals. An approach to health education would be beneficial to minimize the problem. Strategies for continuing education are appropriate both in the prevention of occupational and environmental risks in intensive care units.

High rate of virologic suppression with darunavir/ritonavir plus optimized background therapy among highly antiretroviral-experienced HIV-infected patients: results of a prospective cohort study in São Paulo, Brazil

OBJECTIVES: To assess the virologic and immunological response of darunavir/ritonavir plus optimized background therapy in highly antiretroviral-experienced HIV-infected patients in Brazil. METHODS: Prospective cohort study carried out in a tertiary center in Sao Paulo, Brazil. Three-class antiretroviral-experienced patients with confirmed virologic failure began darunavir/ritonavir plus optimized background therapy (nucleoside/tide reverse transcriptase inhibitors ± raltegravir ± enfuvirtide ± maraviroc) after performing a genotypic resistance assay. Clinical evaluation and laboratory tests were collected at baseline and at weeks 12, 24, and 48. Multivariate analysis was performed to identify predictors of virologic response at 48 weeks. RESULTS: Ninety-two patients were included. The median of darunavir resistant mutation was 1 (range 0-6). The median genotypic sensitivity score in the optimized background therapy was 2 (interquartile range 1-2). At week 48, 83% (95% CI: 75-90%) had an HIV RNA level <50 copies/mL and the median CD4 cell count was 301 (interquartile range 224-445) cells/mm³. Baseline HIV RNA >100 000 copies/mL was inversely associated with virologic success at week 48 (HR: 0.22, 95% CI: 0.06-0.85, p = 0.028). CONCLUSIONS: Darunavir/ritonavir plus optimized background therapy was a highly effective salvage regimen under clinical routine conditions in a referral center in Brazil, which is similar to the reported in high-income countries.

Immune reconstitution inflammatory syndrome associated with pulmonary sarcoidosis in an HIV-infected patient: an immunohistochemical study

Sarcoidosis has been rarely described in literature as a cause of interstitial pulmonary disease associated with AIDS. This study reports a case of immune reconstitution inflammatory syndrome associated with pulmonary sarcoidosis in a patient with a history of previous pulmonary tuberculosis concomitant with HIV infection. Results of the immunohistochemical study of samples from the resected right lower lobe are described. Pathological findings suggest a role of Th1, Th2 and Th17 response in IRIS associated sarcoidosis.

Riscos à saúde de equipe de enfermagem em unidade de terapia intensiva: proposta de abordagem integral da saúde: [revisão] / Risks to health of intensive care unity nursing staff: proposal of integral approach of health: [review]

JUSTIFICATIVA E OBJETIVOS: O objetivo deste estudo foi rever a saúde ocupacional em unidade de terapia intensiva (UTI), bem como avaliar os aspectos para abordagem educacional da equipe multidisciplinar de forma integral. CONTEÚDO: Revisão da literatura realizada no período de 1997-2007, acerca de questões relevantes da saúde de profissionais da equipe multidisciplinar de UTI, na base de dados da Biblioteca Regional de Medicina (Bireme). Foram utilizados os termos "UTI", "educação em saúde" e "saúde ocupacional", sem haver seleção por desenho de estudo. CONCLUSÕES: Todos os estudos observados demonstraram que o ambiente de UTI é insalubre. Contudo entre os fatores que contribuem para tal insalubridade estão atitudes e hábitos dos profissionais de saúde da UTI, os quais são perfeitamente passíveis de mudança, razões pela qual uma abordagem de educação em saúde seria benéfica para diminuir o problema. As estratégias de educação continuada são adequadas na prevenção, tanto de riscos ocupacionais quanto ambientais nas UTI.

BACKGROUND AND OBJECTIVES: In this study we discuss about risks to health of intensive care unity staff and suggest a proposal of integral approach of health. CONTENTS: Literature review, from 1997 to 2007, at Bireme database about "health education", "intensive care unity", "nursing" and "occupational health", regardless of design of study. CONCLUSIONS: All studies show that the environment of intensive care unity is unhealthy, which is also due to habits and attitudes of ICU health professionals. An approach to health education would be beneficial to minimize the problem. Strategies for continuing education are appropriate both in the prevention of occupational and environmental risks in intensive care units.

Sistematização da abordagem da saúde dos trabalhadores do Hospital das Clínicas da Unicamp / Systematization of the approach of the health of workers of the Unicamp’s Hospital

O Hospital das Clínicas da Unicamp (HC-Unicamp) é uma instituição de saúde pública terciária e quaternária do Estado de SãoPaulo que emprega 3.100 funcionários, atende cerca de 500 mil pacientes por ano e em consonância com o PlanejamentoEstratégico da instituição, este trabalho visa a elaborar um questionário estruturado para estudo transversal acerca da saúdedos funcionários do HC-Unicamp a fim de avaliar inicialmente a saúde e o conhecimento destes, em relação a si próprio, arespeito dos seguintes temas: vacinação, diabetes mellitus, hipertensão arterial, obesidade, sedentarismo, dislipidemia,dependência química, tuberculose, doenças sexualmente transmissíveis e comportamento sexual de risco, trauma eviolência, epilepsia, saúde bucal, saúde mental e acidentes pérfuro-cortantes. Após esse estudo inicial, cujos dados serãotrabalhados de maneira descritiva, ter-se-á em mãos um instrumento para guiar um programa de intervenção, em uma feirade saúde, cujo um evento será de utilidade pública e sem fins lucrativos, realizado nas dependências do HC-Unicamp, quepoderá englobar, conforme a disponibilidade de verbas e recursos, comunidades adjacentes. O evento será o passo inicial deum trabalho de sensibilização dos funcionários que deverá ser realizado continuamente, por meio de vigilância em saúderealizada no HC-Unicamp.