Telemonitoring of Children with COVID-19: Experience Report of the First 100 Cases.

Introduction: The first case of coronavirus disease 2019 (COVID-19) in Brazil was diagnosed in February 2020. On March 20, the Ministry of Health issued Ordinance no. 467, regulating the use of telemedicine during the pandemic period. One of the various modalities of telemedicine is telemonitoring. Objective: To report our experience with telemonitoring and evaluate its applicability in the follow-up of the first 100 children who received the diagnosis of COVID-19 after visiting the emergency department of Sabará Hospital Infantil ("Hospital Sabará") and who had no indications for hospitalization. Methods: The care records of the children were retrospectively analyzed, and telephone contact with the families of patients who did not complete the proposed telemonitoring protocol was initiated. Results: The average age of the children was 5.5 years, and a slight male predominance (54/100) was observed. Comorbidities were present in 24/100. The source of infection was family members living in the same household in 88/100 and other sources in 12/100. In the first telemonitoring, 44% of the evaluated patients were asymptomatic. In the second telemonitoring, 81% of the patients were asymptomatic. Telemonitoring was completed by 70% of the children. A total of 14 children returned to the emergency department, 11 of whom spontaneously (2/11 were admitted) and 3 under the indication of telemedicine (3/3 were admitted). Conclusions: Telemonitoring proved to be a clinically valuable resource in the follow-up of children with COVID-19, as it allowed continuity of care and identified patients with indications to return to the emergency department of Hospital Sabará and for hospitalization, thus avoiding unnecessary emergency department visits.

The Role of Echocardiography Doppler in Pulmonary Embolism.

The purpose of this review is to make a critical analysis of selected literature about the role of echo-Doppler in suspected or proved venous thromboembolism and to address some issues about the potential use of echo-Doppler in specific situations in patients with pulmonary embolism (PE). Echo-Doppler is of great value in patients with suspected PE because many conditions that may be clinically mistaken for PE will be diagnosed. Echo-Doppler should not be used alone to rule out the diagnosis of PE because the ability of the technique in proving the diagnosis of PE in a nonselected population is limited. Echo-Doppler may be of value for diagnosis in selected subgroups of PE patients, mostly in scenarios like the emergency department or intensive care unit. Echo-Doppler is valuable in the hemodynamic assessment of patients with PE, making possible a strategy for risk stratification of in-hospital death in relation to the degree of right ventricle dysfunction at the time of diagnosis of acute PE. Echo-Doppler is useful for serial assessment of patients with established diagnosis of chronic thromboembolic pulmonary hypertension. Echo-Doppler may be useful in follow-up of patients after a diagnosis of acute PE to enable early identification of patients with persistent pulmonary hypertension/right ventricle dysfunction.

[Evidence of healthcare quality improvement in acute myocardial infarction].

BACKGROUND: The monitoring of healthcare quality indicators (HCQI) is a process of utmost importance in patient healthcare services. OBJECTIVE: To evaluate whether the monitoring of HCQI and the root-cause analysis improve the healthcare quality in acute myocardial infarction (AMI). METHODS: A cross-sectional and comparative analysis of HCQI was performed in patients with AMI in the years 2006 and 2007. Of the 1,461 patients admitted with chest pain, 172 (11.7%) had a diagnosis of AMI and were included in the analysis. RESULTS: The rate of primary angioplasty was 8.47% higher in 2007 (97.3%) when compared to that in 2006 (89.7%), but this difference was not statistically significant (p = 0.35). Moreover, there was no difference regarding the time of hospitalization (4 vs 5 days, p = 0.15) and the in-hospital mortality (7.8% vs 5.1%, p = 0.67) between 2007 and 2006, respectively. However, the time to the first troponin level was 27% shorter in 2007 (69 min.; 95%CI = 44-94 min.) when compared to 2006 (95 min.; 53-136 min.) (p = 0.025). The door-to-balloon time was 12% shorter (72 +/- 29 min. vs 109 +/- 85 min.; p = 0.03), the rate of ASA prescription at hospital discharge was 35% higher (94.7% vs 70.3%; p = 0.002) and the rate of PCA shorter than 90 minutes was 52% higher (78.3 vs 51.4%; p = 0.03) in 2007, when compared to 2006. CONCLUSION: Our results suggest that the strategy of monitoring the HCQI and the implementation of the root-cause analysis methodology can improve the healthcare process in patients with AMI.

Indicators of healthcare quality in isolated coronary artery bypass graft surgery performed at a tertiary cardiology center.

BACKGROUND: Quality indicators (QI) for cardiac surgery are important instruments for measuring healthcare quality in hospital centers and allow comparison with high-quality healthcare centers. OBJECTIVE: To evaluate QIs in isolated myocardial revascularization procedures (CABG) performed at a tertiary cardiology center. METHODS: One hundred and forty-four consecutive patients who had undergone isolated CABG were evaluated between October 2005 and March 2007. One hundred and eight patients were men (75%), the mean age was 65+/-11, and the EuroSCORE was 4+/-3. The following QIs were measured: time elapsed between the surgery date-setting appointment and the actual day of the CABG (TDC); surgery cancellation rate (SCR) due to problems in hospital infrastructure; length of hospital stay (LOS); operative mortality (OM) and rate of readmission (RHR) for infection in the surgical wound. RESULTS: The TDC (n=98) was 4+/-3 days (median: 4 days) and the SCR was zero. The OM recorded of 4.9% (95% confidence interval [CI] = 2.2 - 9.87%) was lower than the expected OM of 5.1% (95% CI = 1.4% to 14.37%), but with no statistical significance (p=0.65). The area under the ROC curve of the EuroSCORE for the OM was 0.702 (95% CI = 0.485 - 0.919). LOS was 11+/-9 days. The area under the ROC curve of the EuroSCORE for the LOS was 0.764 (95% CI = 0.675 - 0.852). The RHR recorded was 2.1%. CONCLUSION: The measurement of the QIs showed that, in a medical center with a low annual volume of CABG, the results were compatible with the risk profile of the population involved.

Evidência de melhora na qualidade do cuidado assistencial no infarto agudo do miocárdio / Evidence of healthcare quality improvement in acute myocardial infarction

FUNDAMENTO: A monitoração dos indicadores de qualidade no cuidado com a saúde (IQS) é um processo de fundamental importância na atenção à saúde dos pacientes. OBJETIVO: Avaliar se a monitoração dos IQS e a análise da causa-raiz melhoram a qualidade do cuidado no infarto agudo do miocárdio (IAM). MÉTODOS: Foi realizada uma análise transversal e comparativa dos IQS em pacientes com IAM nos anos de 2006 e 2007. Dos 1.461 pacientes admitidos com dor torácica, 172 (11,7 por cento) tiveram o diagnóstico de IAM e foram incluídos na análise. RESULTADOS: A taxa de angioplastia primária foi 8,47 por cento maior em 2007 (97,3 por cento) do que em 2006 (89,7 por cento), mas esta diferença não alcançou significado estatístico (p = 0,35). Também não houve diferença estatística no tempo de hospitalização (4 vs 5 dias, p = 0,15) e na mortalidade intra-hospitalar (7,8 por cento vs 5,1 por cento, p = 0,67) entre 2007 e 2006, respectivamente. No entanto, o tempo até o resultado da primeira troponina foi 27 por cento menor em 2007 (69 min.; IC 95 por cento = 44-94 min.) do que em 2006 (95 min.; 53-136 min.) (p = 0,025). O tempo porta-balão foi 12 por cento menor (72 ± 29 min. vs 109 ± 85 min.; p = 0,03), a taxa de prescrição de aspirina na alta foi 35 por cento maior (94,7 por cento vs 70,3 por cento; p = 0,002) e a taxa de APCP, menor do que 90 minutos, foi 52 por cento maior (78,3 vs 51,4 por cento; p = 0,03) em 2007, quando comparada a 2006. CONCLUSÃO: Nossos resultados sugerem que a estratégia de monitorar os IQS e a de implementação da metodologia de análise da causa-raiz melhora o processo de cuidado com a saúde no IAM.

BACKGROUND: The monitoring of healthcare quality indicators (HCQI) is a process of utmost importance in patient healthcare services. OBJECTIVE: To evaluate whether the monitoring of HCQI and the root-cause analysis improve the healthcare quality in acute myocardial infarction (AMI). METHODS: A cross-sectional and comparative analysis of HCQI was performed in patients with AMI in the years 2006 and 2007. Of the 1,461 patients admitted with chest pain, 172 (11.7 percent) had a diagnosis of AMI and were included in the analysis. RESULTS: The rate of primary angioplasty was 8.47 percent higher in 2007 (97.3 percent) when compared to that in 2006 (89.7 percent), but this difference was not statistically significant (p = 0.35). Moreover, there was no difference regarding the time of hospitalization (4 vs 5 days, p = 0.15) and the in-hospital mortality (7.8 percent vs 5.1 percent, p = 0.67) between 2007 and 2006, respectively. However, the time to the first troponin level was 27 percent shorter in 2007 (69 min.; 95 percentCI = 44-94 min.) when compared to 2006 (95 min.; 53-136 min.) (p = 0.025). The door-to-balloon time was 12 percent shorter (72 ± 29 min. vs 109 ± 85 min.; p = 0.03), the rate of ASA prescription at hospital discharge was 35 percent higher (94.7 percent vs 70.3 percent; p = 0.002) and the rate of PCA shorter than 90 minutes was 52 percent higher (78.3 vs 51.4 percent; p = 0.03) in 2007, when compared to 2006. CONCLUSION: Our results suggest that the strategy of monitoring the HCQI and the implementation of the root-cause analysis methodology can improve the healthcare process in patients with AMI.

Indicadores de qualidade assistencial na cirurgia de revascularização miocárdica isolada em centro cardiológico terciário / Indicators of healthcare quality in isolated coronary artery bypass graft surgery performed at a tertiary cardiology center

FUNDAMENTO: Indicadores de qualidade (IQ) em cirurgia cardíaca são importantes instrumentos de avaliação da assistência médica em centros hospitalares. OBJETIVO: Avaliar os IQ da cirurgia de revascularização miocárdica (CRVM) isolada em centro terciário cardiológico. MÉTODOS: Foram avaliados 144 pacientes consecutivos submetidos a CRVM isolada entre outubro de 2005 e março de 2007: 108 pacientes eram do sexo masculino (75 por cento), com média de idade de 65±11 anos e EuroSCORE de 4±3. Os IQ avaliados foram: intervalo de tempo entre a marcação e a realização da cirurgia (TMC); taxa de cancelamento (TxC) decorrentes de problemas ligados à infra-estrutura hospitalar; tempo de permanência hospitalar (TPH); mortalidade operatória (MO) e taxa de reinternação hospitalar por infecção em ferida cirúrgica (TxRH). RESULTADOS: O TMC (n=98) foi de 4±3 dias (mediana de 4 dias) e a TxC foi zero. A MO observada de 4,9 por cento (Intervalo de Confiança [IC] 95 por cento = 2,2 - 9,87 por cento) foi menor do que a MO esperada de 5,1 por cento (IC 95 por cento = 1,4 por cento a 14,37 por cento), mas sem significância estatística (p=0,65). A área sob a curva ROC do EuroSCORE para MO observada foi de 0,702 (IC 95 por cento = 0,485 - 0,919). O TPH foi de 11±9 dias. A área sob a curva ROC do EuroSCORE para TPH foi de 0,764 (IC 95 por cento = 0,675 - 0,852). A TxRH observada foi de 2,1 por cento. CONCLUSÃO: A avaliação dos IQ demonstrou que, em um centro com baixo número anual de CRVM, os resultados alcançados foram compatíveis com o perfil de risco da população envolvida.

BACKGROUND: Quality indicators (QI) for cardiac surgery are important instruments for measuring healthcare quality in hospital centers and allow comparison with high-quality healthcare centers. OBJECTIVE: To evaluate QIs in isolated myocardial revascularization procedures (CABG) performed at a tertiary cardiology center. METHODS: One hundred and forty-four consecutive patients who had undergone isolated CABG were evaluated between October 2005 and March 2007. One hundred and eight patients were men (75 percent), the mean age was 65±11, and the EuroSCORE was 4±3. The following QIs were measured: time elapsed between the surgery date-setting appointment and the actual day of the CABG (TDC); surgery cancellation rate (SCR) due to problems in hospital infrastructure; length of hospital stay (LOS); operative mortality (OM) and rate of readmission (RHR) for infection in the surgical wound. RESULTS: The TDC (n=98) was 4±3 days (median: 4 days) and the SCR was zero. The OM recorded of 4.9 percent (95 percent confidence interval [CI] = 2.2 - 9.87 percent) was lower than the expected OM of 5.1 percent (95 percent CI = 1.4 percent to 14.37 percent), but with no statistical significance (p=0.65). The area under the ROC curve of the EuroSCORE for the OM was 0.702 (95 percent CI = 0.485 - 0.919). LOS was 11±9 days. The area under the ROC curve of the EuroSCORE for the LOS was 0.764 (95 percent CI = 0.675 - 0.852). The RHR recorded was 2.1 percent. CONCLUSION: The measurement of the QIs showed that, in a medical center with a low annual volume of CABG, the results were compatible with the risk profile of the population involved.

Tratamento cirúrgico da endocardite infecciosa na fase ativa / Surgical treatment of infective endocarditis in the active phase

Foram estudados 20 pacientes submetidos à cirurgia cardíaca no HSE-RJ, de julho de 82 a junho de 86, portadores de endocardite infecciosa (EI) com infecçäo ativa. O critério diagnóstico utilizado foi a presença de pelo menos dois dos seguintes parámetros: a) quadro clínico típico; b) duas hemoculturas positivas para o mesmo germe; c) presença de vegetaçäo no ecocardiograma. Além disto foi critério obrigatório e excludente, a presença de vegetaçöes e demais evidências histopatológicas de infecçäo ativa na peça operatória. A doença cardíaca prévia mais freqüente foi a febre reumática em 35% dos pacientes. Apenas 15% dos pacientes näo exibiam doença cardíaca prévia, enquanto em 10% a EI assestou-se em próteses mecânicas. Outras patologias encontradas foram a cardiopatia congênita em 20% dos casos, a degeneraçäo mixomatosa em 10% e miocardiopatia hipertrófica em 5%. A indicaçäo cirúrgica baseou-se em insuficiência cardíaca grave, progressiva e refratária ao tratamento em 90% dos pacientes, enquanto nos 10% restantes foi a infecçäo incontrolável. O comprometimento da válvula aórtica em 70% dos nossos pacientes, parece indicar uma evoluçäo mais grave nesta localizaçäo da endocardite. A mortalidade (30%) se aproxima dos resultados obtidos nos grandes centros médicos internacionais. O tratamento cirúrgico na fase ativa da endocardite infecciosa em pacientes de alto risco proporciona uma sobrevida muito maior do que o tratamento clínico isolado. Todos os pacientes sobreviventes estudados apresentaram cura bacteriológica, grande melhora da funçäo cardíaca, bem como da qualidade de vida

Resultados imediatos e tardios da dupla troca valvar mitro-aórtica por prótese mecânica / Early and late results in combined mitral and aortic replacement by mechanical prosthesis

Quarenta pacientes foram submetidos a dupla troca valvar mitral e aórtica por prótese mecânica e em 4 deles também foi realizada a plastia tricuspídea. A mortalidade precoce foi de 10% (4 pacientes). Dos 36 sobreviventes conseguimos acompanhar 33 num período total de 6 anos. Durante este follow-up" a letalidade foi de 12% (4 pacientes). Foram observadas as seguintes complicaçöes; 2 acidentes hemorrágicos (sem óbito) e 2 endocardites infecciosas que foram ao óbito. Houve melhora significativa da classe funcional após a cirurgia, com retorno da grande maioria dos pacientes a suas atividades habituais. No pré-operatório havia igual número de pacientes (42,5%) nas classes funcionais III e IV e no pós-operatório 85% dos pacientes estavam em classe funcional. Os autores salientam a baixa mortalidade cirúrgica em grupo de pacientes de alto risco, submetidos a cirurgia cardíaca de grande porte e os excelentes resultados a longo prazo da dupla troca mitro-aórtica por prótese mecânica. É importante assinalar a ausência de episódios tromboembólicos e o baixo índice de acidentes hemorrágicos na nossa casuística

Estudo ecocardiográfico em esclerose sistêmica progressiva e lúpus eritematoso sistêmico / Echocardiographic study in progressive systemic sclerosis and systemic lupus erithematosus

Os autores estudam, pela ecocardiografia, 44 pacientes 18 com LES e 26 com esclerose sistêmicas progressiva. Mostram a importância deste método näo invasivo em detectar alteraçöes pericárdicas miocárdicas e endocárdicas, mesmo em pacientes sem quaisquer manfestaçöes aparentes para o lado do aparelho cardiovascular. Acham que o ecocardiograma é um importante método para detectar a cardiopatia esclerodérmica e lúpica, além de sua utilidade no seguimento evolutivo destas colagenoses