The decline in mortality due to acute complications of diabetes mellitus in Brazil, 1991-2010.

BACKGROUND: Mortality from acute complications of diabetes, a predominantly preventable condition, although controlled in high income countries, remains a major challenge for low/middle income countries. The aim of this study is to describe trends in mortality from acute complications of diabetes between 1991 and 2010 in Brazil, a period during which a national health system was implemented offering broad access to diabetes treatment. METHODS: We obtained the number of deaths listed in the Brazilian Mortality Information System between 1991 and 2010 as due to acute complications of diabetes (ICD-9 250.1, .2, or .3 and ICD-10 E10-14.0 or 1), corrected this number for ill-defined causes of death and incompleteness in mortality reporting, and calculated mortality rates standardized to the world's population. We describe mortality trends with Joinpoint regressions. RESULTS: Over this 20 year period, mortality due to the acute complications of diabetes fell 70.9 % (95 % CI 67.2 to 74.5 %), from 8.42 (95 % CI 8.27 to 8.57) deaths per 100000 inhabitants in 1991 to 2.45 (95 % CI 2.38 to 2.52) per 100000 in 2010. The reduction occurred in men and women, in all age groups, and in all regions of Brazil. CONCLUSIONS: Mortality from acute complications of diabetes in Brazil has declined markedly in parallel with the implementation of a national health system providing access to insulin and organization of health care. Further decline is possible and necessary.

Advanced triage protocols in the emergency department: A systematic review and meta-analysis. / Protocolos de triagem avançada no serviço de emergência: revisão sistemática e metanálise.

OBJECTIVE: To evaluate the effectiveness of using advanced triage protocols on the length of stay, safety and satisfaction of the patients and professionals in the emergency department. METHOD: A systematic review with meta-analysis of randomized clinical trials included in the Embase, BVS, PubMed, CINAHL, Cochrane Library databases and in the gray literature, using Review Manager 5.4. Studies that analyzed length of stay in their outcomes were included and the studies excluded were those that considered other triage protocols. RESULTS: 26,672 peer-reviewed studies were found and ten were included in the meta-analysis. For the patients' length of stay, seven studies were included in the meta-analysis (n=8,229), showing a 36-minute reduction (-0.36[-0.55;-0.17] p=0.002), a result with low certainty of evidence, favorable to the intervention, varying between -0.53 (-0.81;- 0.25) and -0.29 (-0.50;-0.07) in the analysis of the subgroups. Regarding the exams requested, five studies were included (n=2,270), indicating that there is no significant difference between the groups (odds ratio 0.94 [0.64;1.38]). Four studies (n=6,094) analyzed the patients' and the professionals' satisfaction, indicating a favorable result to the intervention. CONCLUSION: The advanced triage protocol reduced length of stay in the emergency room without compromising care safety and quality, although more randomized clinical studies on the theme are needed. Registered in PROSPERO (CRD42019142640).

Adult patients admitted to a tertiary hospital for COVID-19 and risk factors associated with severity: a retrospective cohort study.

COVID-19 is a disease whose knowledge is still under construction, high transmissibility, with no consensual treatment available to everyone. Therefore, the identification of patients at higher risk of evolving to the critical form of the disease is fundamental. The study aimed to determine risk factors associated with the severity of COVID-19 in adults patients. This is an observational, retrospective study from a cohort of adult patients with COVID-19 admitted to a public hospital from March to August 2020, whose medical records were evaluated. For the association of possible severity predictors, a Poisson regression was used. The primary outcome was the critical form of the disease (need for admission to the Intensive Care Unit and/or invasive mechanical ventilation). We included 565 patients: mostly men; 55.5% of those who progressed to the critical form of the disease were over sixty years old. Hypertension, diabetes mellitus and obesity were the most frequent comorbidities. There were 39.8% of patients who progressed to the critical form of the disease. The hospital mortality rate was 22.1%, and that of critical patients was 46.7%. The independent factors associated with the severity of the disease were obesity [RR = 1.33 (95% CI 1.07 to 1.66; p = 0.011)], SpO2/FiO2 ratio ≤ 315 [RR = 2.20 (95% CI 1.79 to 2.71; p = 0.000)], C-reactive protein > 100 mg/L [RR = 1.65 (95% CI 1.33 to 2.06; p = 0.000)], and lymphocytes < 1,000/µL [RR = 1.44 (95% CI 1.18 to 1.75; p = 0.000)]. Advanced age and comorbidities were dependent factors strongly associated with the critical form of the disease.

Protocolos de triagem avançada no serviço de emergência: revisão sistemática e metanálise / Advanced triage protocols in the emergency department: A systematic review and meta-analysis / Protocolos de triage avanzado en el servicio de emergencia: revisión sistemática y metaanálisis

Resumo Objetivo Avaliar a efetividade do uso de protocolos de triagem avançada no tempo de permanência, segurança e satisfação dos pacientes e profissionais no serviço de emergência. Método Revisão sistemática com metanálise de ensaios clínicos randomizados das bases de dados Embase, BVS, PubMed, CINAHL, Cochrane Library e literatura cinza, utilizando o Review Manager 5.4. Foram incluídos estudos que analisaram tempo de permanência em seus desfechos e excluídos estudos que consideraram outros protocolos de triagem. Resultados Foram encontrados 26.672 estudos, revisados por pares, e dez foram incluídos na metanálise. Para tempo de permanência dos pacientes, sete estudos foram incluídos na metanálise (n=8.229), mostrando uma redução de 36 minutos (-0,36[-0,55; -0,17] p=0,002), resultado com baixa certeza de evidências, favorável à intervenção, variando entre -0,53(-0,81; - 0,25) e -0,29(-0,50; -0,07) na análise dos subgrupos. Quanto aos exames solicitados, cinco estudos foram incluídos (n=2270), indicando que não há diferença significativa entre os grupos (odds ratio 0,94 [0,64;1,38]). Quatro estudos (n=6094) analisaram a satisfação dos pacientes e profissionais, apontando um resultado favorável à intervenção. Conclusão O protocolo de triagem avançada reduziu o tempo de permanência na emergência sem comprometer a segurança e a qualidade do atendimento, embora sejam necessários mais estudos clínicos randomizados sobre o tema. Registrado na PROSPERO (CRD42019142640).

Abstract Objective To evaluate the effectiveness of using advanced triage protocols on the length of stay, safety and satisfaction of the patients and professionals in the emergency department. Method A systematic review with meta-analysis of randomized clinical trials included in the Embase, BVS, PubMed, CINAHL, Cochrane Library databases and in the gray literature, using Review Manager 5.4. Studies that analyzed length of stay in their outcomes were included and the studies excluded were those that considered other triage protocols. Results 26,672 peer-reviewed studies were found and ten were included in the meta-analysis. For the patients' length of stay, seven studies were included in the meta-analysis (n=8,229), showing a 36-minute reduction (-0.36[-0.55;-0.17] p=0.002), a result with low certainty of evidence, favorable to the intervention, varying between -0.53 (-0.81;- 0.25) and -0.29 (-0.50;-0.07) in the analysis of the subgroups. Regarding the exams requested, five studies were included (n=2,270), indicating that there is no significant difference between the groups (odds ratio 0.94 [0.64;1.38]). Four studies (n=6,094) analyzed the patients' and the professionals' satisfaction, indicating a favorable result to the intervention. Conclusion The advanced triage protocol reduced length of stay in the emergency room without compromising care safety and quality, although more randomized clinical studies on the theme are needed. Registered in PROSPERO (CRD42019142640).

Resumen Objetivo Evaluar la efectividad del uso de protocolos de triage avanzado en la duración de la estancia, seguridad y satisfacción de los pacientes y profesionales en el servicio de emergencia. Método Revisión sistemática con metaanálisis de ensayos clínicos aleatorizados de las bases de datos Embase, BVS, PubMed, CINAHL, Cochrane Library y de la literatura gris, utilizando Review Manager 5.4. Se incluyeron los estudios que analizaron la duración de la estancia en sus resultados y se excluyeron los estudios que consideraron otros protocolos de triage. Resultados Se encontraron 26.672 estudios, fueron revisados por pares y diez se incluyeron en el metaanálisis. Para la duración de la estancia de los pacientes, se incluyeron siete estudios en el metaanálisis (n=8.229), que muestran una reducción de 36 minutos (-0,36 [-0,55; -0,17] p=0,002), un resultado con baja certeza de la evidencia, favorable a la intervención, que osciló entre -0,53(-0,81;-0,25) y -0,29(-0,50;-0,07) en el análisis de los subgrupos. En cuanto a las pruebas solicitadas, se incluyeron cinco estudios (n=2270) que indican que no hay diferencia significativa entre los grupos (odds ratio 0,94 [0,64; 1,38]). Cuatro estudios (n=6094) analizaron la satisfacción de los pacientes y profesionales e indican que la intervención tuvo un resultado favorable. Conclusión El protocolo de triage avanzado redujo la estancia en el servicio de emergencia sin comprometer la seguridad y la calidad de la atención, aunque es necesario que se realicen más ensayos clínicos aleatorizados sobre el tema. Registrado en PROSPERO (CRD42019142640).

Factors associated with mortality in critically ill patients with COVID-19 / Fatores associados à mortalidade em pacientes críticos com COVID-19 / Factores asociados a la mortalidad en pacientes críticos con COVID-19

Background and objectives: COVID-19 is a life-threatening disease. Recognizing the main characteristics of the disease and its main complications will help future interventions, care, and management of health services since territorial and population diversities directly influence health outcomes. Our main objective is to describe the clinical characteristics, outcomes, and factors associated with mortality of patients with COVID-19 admitted to the intensive care unit of a public and tertiary hospital. Methods: Cohort study, conducted from March 1 to September 30, 2020. Poisson regression was performed to investigate the variables of hospital treatment as potential risk factors for in-hospital mortality. Results: Of the 283 eligible patients in this study, the hospital mortality rate was of 41.7% (n=118). The most common outcomes were acute respiratory distress syndrome, nosocomial infection, and septic shock. Factors independently associated with increased risk of death were age greater than 51 years old (RR=1.7, 95%CI=1.0-2.8), especially over 70 years old (RR=2.9, 95%CI=1.7-2.8), current smoker (RR=1.8, 95%CI=1.1-2.9), requiring the use of inotrope (RR=1.4, 95%CI=1.0-2.0), and presenting potassium greater than 5.0 mEq/l on admission (RR=1.3, 95%CI=1.0-1.7). Conclusion: Mortality was associated with older age, being a current smoker, inotrope use, and presenting potassium greater than 5.0 on hospital admission.(AU)

Justificativa e objetivos: A COVID-19 é uma doença ameaçadora à vida. Reconhecer as características da doença e suas principais complicações nesta população auxiliará em futuras intervenções, cuidados e gestão dos serviços de saúde, uma vez que a diversidade territorial e populacional influencia diretamente nos resultados de saúde. O objetivo principal do presente estudo é descrever as características clínicas, desfechos e fatores associados à mortalidade de pacientes com COVID-19 internados na unidade de terapia intensiva de um hospital público e terciário. Métodos: Estudo de coorte, realizado de 1º de março a 30 de setembro de 2020. Foi realizada regressão de Poisson para investigar variáveis de apresentação hospitalar como potenciais fatores de risco para mortalidade intra-hospitalar. Resultados: Dos 283 pacientes elegíveis neste estudo, o dado de mortalidade hospitalar foi de 41,7% (n=118). Os desfechos mais comuns foram síndrome do desconforto respiratório agudo, infecção hospitalar e choque séptico. Os fatores independentemente associados ao aumento do risco de morte foram idade superior a 51 anos (RR=1,7, IC 95%=1,0-2,8), principalmente acima de 70 anos (RR=2,9, IC 95%=1,7-2,8), tabagismo atual (RR=1,8, IC 95%=1,1-2,9), necessidade de inotrópico (RR=1,4, IC 95%=1,0-2,0) e potássio maior que 5,0 mEq/l (RR=1,3, IC 95%=1,0- 1.7) na admissão. Conclusão: A mortalidade esteve associada à idade avançada, tabagismo atual, uso de inotrópicos e potássio maior que 5,0 na admissão hospitalar.(AU)

Justificación y objetivos: La COVID-19 es una enfermedad potencialmente mortal. Reconocer las características de la enfermedad y sus principales complicaciones en esta población ayudará a futuras intervenciones, atención y gestión de los servicios de salud, ya que las diversidades territoriales y poblacionales influyen directamente en los resultados de salud. El objetivo principal de este estudio es describir las características clínicas, los resultados y los factores asociados a la mortalidad de los pacientes con COVID-19 ingresados en la unidad de cuidados intensivos de un hospital público y de tercer nivel. Métodos: Estudio de cohorte, realizado del 1 de marzo al 30 de septiembre de 2020. Se realizó regresión de Poisson para investigar variables en la presentación hospitalaria como potenciales factores de riesgo para la mortalidad intrahospitalaria. Resultados: De los 283 pacientes elegibles en este estudio, el 41,7% (n=118) tuvo mortalidad hospitalaria. Los desenlaces más comunes fueron síndrome de dificultad respiratoria aguda, infección nosocomial y shock séptico. Los factores independientemente asociados a mayor riesgo de muerte fueron edad mayor de 51 años (RR=1,7, IC95%=1,0-2,8), especialmente mayores de 70 años (RR=2,9, IC95%=1,7-2,8), tabaquismo actual (RR=1,8, IC95%=1,1-2,9), necesidad de inotrópico (RR=1,4, IC95%=1,0-2,0) y potasio mayor que 5,0 mEq/l (RR=1,3, IC95%=1,0-1,7). Conclusión: La mortalidad estuvo asociada a la edad avanzada, tabaquismo actual, uso de inotrópico y potasio mayor a 5,0 en la admisión hospitalaria.(AU)

Adult patients admitted to a tertiary hospital for COVID-19 and risk factors associated with severity: a retrospective cohort study

ABSTRACT COVID-19 is a disease whose knowledge is still under construction, high transmissibility, with no consensual treatment available to everyone. Therefore, the identification of patients at higher risk of evolving to the critical form of the disease is fundamental. The study aimed to determine risk factors associated with the severity of COVID-19 in adults patients. This is an observational, retrospective study from a cohort of adult patients with COVID-19 admitted to a public hospital from March to August 2020, whose medical records were evaluated. For the association of possible severity predictors, a Poisson regression was used. The primary outcome was the critical form of the disease (need for admission to the Intensive Care Unit and/or invasive mechanical ventilation). We included 565 patients: mostly men; 55.5% of those who progressed to the critical form of the disease were over sixty years old. Hypertension, diabetes mellitus and obesity were the most frequent comorbidities. There were 39.8% of patients who progressed to the critical form of the disease. The hospital mortality rate was 22.1%, and that of critical patients was 46.7%. The independent factors associated with the severity of the disease were obesity [RR = 1.33 (95% CI 1.07 to 1.66; p = 0.011)], SpO2/FiO2 ratio ≤ 315 [RR = 2.20 (95% CI 1.79 to 2.71; p = 0.000)], C-reactive protein > 100 mg/L [RR = 1.65 (95% CI 1.33 to 2.06; p = 0.000)], and lymphocytes < 1,000/µL [RR = 1.44 (95% CI 1.18 to 1.75; p = 0.000)]. Advanced age and comorbidities were dependent factors strongly associated with the critical form of the disease.

Equidade intraurbana na utilização de medicamentos especializados para esquizofrenia: marcas do nível socioeconômico nos itinerários da rede de atenção à saúde / Intra-urban equity in the use of specialized medicines for schizophrenia:socioeconomic status in the health care network itineraries

Avaliar relações da utilização de medicamentos especializados para esquizofrenia em Porto Alegre com desigualdades sociais e itinerário do usuário na rede de atenção à saúde. (AU)

Equidade na utilização de medicamentos especializados para tratamento de esquizofrenia / Equity in the use of specialised medicines for the treatment of schizophrenia

Avaliação da influência de desigualdades sociais e cobertura com saúde suplementar na utilização de medicamentos especializados do Protocolo Clínico de Esquizofrenia no Sistema Único de Saúde (SUS) em Porto Alegre. (AU)

Efeito do vínculo com um médico de família no controle da pressão arterial em hipertensos / Effect of family doctor relationship on blood pressure control in hypertensive patients / Efecto del vínculo con un médico de familia en el control de la presión arterial en hipertensos

Objetivo: Avaliar a associação entre vínculo com um médico de família e controle da pressão arterial em hipertensos de duas unidades de saúde de Porto Alegre, RS. Métodos: Estudo transversal com uma amostra aleatória de 128 hipertensos de 18 anos ou mais de duas unidades de saúde, nos quais foi aplicado um questionário para avaliar suas características e a presença ou não de vínculo com um médico de família, e aferidos pressão arterial, peso e altura, entre março e setembro de 2016. Foi realizada regressão de Poisson para controle de possíveis fatores de confusão entre vínculo e controle da pressão. Resultados: A população estudada era acompanhada pelas unidades em média há 15 anos, era predominantemente idosa, do sexo feminino, branca, com sobrepeso, não tabagista, sedentária, aderente ao tratamento, 68,0% possuíam vínculo com um médico e 61,7% estavam com a pressão controlada. A presença de vínculo com um médico foi associada a um controle da pressão arterial 48% maior, controlado para possíveis fatores de confusão. Conclusão: O vínculo com um médico é uma ferramenta de baixo custo que permite melhorar o controle pressórico em pacientes hipertensos ­ controle este importante para a redução das complicações cardiovasculares.

Objective: To evaluate the relation between a family doctor-patient relationship and blood pressure control in hypertensive patients from two health units in Porto Alegre, Rio Grande do Sul. Methods: A cross-sectional study with a random sample of 128 hypertensive 18 years of age and older patients from two health units, in which a questionnaire was applied to evaluate their characteristics and the presence or absence of a link with a family doctor, while blood pressure, weight and height were measured between March and September 2016. Poisson regression was performed to control possible confounding factors between family doctor-patient relationship and blood pressure control. Results: The population studied was monitored by the health units during 15 years on average and was predominantly elderly, female, white, overweight, non-smoker, sedentary, adherent to treatment, while 68.0% had a relationship with a family doctor and 61.7% had controlled blood pressure. The presence of a relationship with a doctor was associated with a blood pressure control 48% higher, controlled for possible confounding factors. Conclusion: Doctor-patient relationship is a low cost tool in medical practice that allows better blood pressure control in hypertensive patients ­ a control which is important in reducing cardiovascular complications.

Objetivo: Evaluar la asociación entre el vínculo con un médico de familia y el control de la presión arterial en hipertensos de dos unidades de salud de Porto Alegre, Rio Grande do Sul. Métodos: Estudio transversal con una muestra aleatoria de 128 hipertensos mayores de 18 años de dos unidades de salud, en los cuales fue aplicado un cuestionario para evaluar sus características y la presencia o no de un vínculo con un médico de familia y la medida de la presión arterial, peso y altura entre marzo y septiembre de 2016. Fue realizada una regresión de Poisson para el control de los posibles factores de confusión entre el vínculo y el control de la presión. Resultados: La población estudiada era acompañada por las unidades en una media de 15 años, predominantemente de edad avanzada, de sexo femenino, blanca, con sobrepeso, no fumadora, sedentaria, con adhesión al tratamiento, y el 68,0% tenía vínculo con un médico y 61,7% estaba con la presión controlada. La presencia del vínculo con un médico fue asociada a un control de la presión arterial 48% mayor, controlada para posibles factores de confusión. Conclusión: El vínculo con un médico de familia es una herramienta de bajo costo, que permite mejorar el control tensional en pacientes hipertensos, el cual es importante para la reducción de las complicaciones cardiovasculares.

Mortalidade por complicações agudas do diabetes melito no Brasil, 2006-2010 / Mortality from acute complications of diabetes mellitus in Brazil, 2006-2010 / Mortalidad por complicaciones agudas de la diabetes mellitus en Brasil, 2006-2010

Objetivo: descrever a mortalidade por complicações agudas do diabetes melito no Brasil segundo faixa etária, sexo, regiões e unidades federativas. Métodos: estudo descritivo com dados de óbitos registrados no Sistema de Informações sobre Mortalidade (SIM), corrigidos para sub-registro e causas mal definidas, para 2010 ou o período 2006-2010; as taxas foram padronizadas por idade e sexo. Resultados: a mortalidade por complicações agudas no Brasil foi de 2,45/100 mil habitantes e de 0,29/100 mil hab. entre menores de 40 anos de idade, correspondendo a 6,8 por cento e 22,9 por cento dos óbitos pelo diabetes como causa básica, respectivamente; a taxa de mortalidade foi maior nas regiões Norte (4,33/100 mil) e Nordeste (3,46/100 mil), aumentando com a idade. Conclusões: a taxa de mortalidade por complicações agudas do diabetes foi elevada, especialmente no Norte e Nordeste, considerando-se sua potencial evitabilidade; este indicador mostrou-se importante para avaliação de ações preventivas e de iniquidades regionais em saúde.

Objective: to describe mortality from acute complications of diabetes in Brazil according to geographical region, age and sex. Methods: deaths registered on the Brazilian Mortality System due to these complications (ICD-10 E10-14.0 or 1) in 2006-2010 were corrected for under-reporting and ill-defined causes. Mortality rates were standardized by age and sex. Results: annual mortality in Brazil was 2.45 deaths per 100,000 inhabitants, and 0.29 deaths/100,000 inhabitants among those <40 years old, accounting for 6.8 percent and 22.9 percent of deaths registering diabetes as the underlying cause, respectively. Mortality was higher in the North and Northeast regions and increased with age. Conclusion: given its potential avoidability, mortality due to acute complications of diabetes was high, especially in the Northeast and the North regions. As such, it is an important indicator for evaluating preventive actions and regional health inequalities.

Objetivo: describir la mortalidad por complicaciones agudas de la diabetes mellitus en Brasil según franja de edad, sexo, regiones y unidades federativas. Métodos: estudio descriptivo con datos de óbitos registrados en el Sistema de Informaciones sobre Mortalidad (SIM), corregidos para subregistro y causas mal definidas, para 2010 o el período 2006-2010; las tasas fueron estandarizadas por edad y sexo. Resultados: la mortalidad por complicaciones agudas en Brasil fue de 2,45/100 mil habitantes y de 0,29/100 mil habitantes entre menores de 40 años de edad, correspondiendo a 6,8% y 22,9% de los óbitos causados por la diabetes como causa básica, respectivamente; la tasa de mortalidad fue mayor en las regiones Norte (4,33/100 mil) y Nordeste (3,46/100 mil), aumentando con la edad. Conclusiones: la tasa de mortalidad por complicaciones agudas de la diabetes fue elevada, especialmente en el Norte y el Nordeste, considerando la posibilidad potencial de evitarla; este indicador se mostró importante para evaluación de acciones preventivas y de inequidades regionales en salud.