Long-term survival and cause-specific mortality of patients newly diagnosed with tuberculosis in São Paulo state, Brazil, 2010­15: a population-based, longitudinal study

Background Long-term survival and cause-specific mortality of patients who start tuberculosis treatment is rarely described. We aimed to assess the long-term survival of these patients and evaluate the association between vulnerable conditions (social, health behaviours, and comorbidities) and cause-specific mortality in a country with a high burden of tuberculosis. Methods In this population-based, longitudinal study in São Paulo state, Brazil, we described the 5-year survival of patients who were newly diagnosed with tuberculosis in 2010. We included patients with newly-diagnosed tuberculosis, aged 15 years or older, and notified to the São Paulo State Tuberculosis Program in 2010. We excluded patients whose diagnosis had changed during follow-up (ie, they did not have tuberculosis) and patients who had multidrug-resistant (MDR) tuberculosis. We selected our population with tuberculosis from the dedicated electronic system TBweb. Our primary objective was to estimate the excess mortality over 5 years and within the group who survived the first year, compared with the general São Paulo state population. We also estimated the association between social vulnerability (imprisonment and homelessness), health behaviours (alcohol and drug use), and comorbidities (diabetes and mental disorders) with all-cause and cause-specific mortality. We used the competing risk analysis framework, estimating cause-specific hazard ratios (HRs) adjusted for potential confounding factors. Findings In 2010, there were 19 252 notifications of tuberculosis cases. We excluded 550 cases as patients were younger than 15 years, 556 cases that were not tuberculosis, 2597 retreatments, and 48 cases of MDR tuberculosis, resulting in a final cohort of 15 501 patients with tuberculosis. Over a period of 5 years from tuberculosis diagnosis, 2660 (17%) of 15 501 patients died. Compared with the source population, matched by age, sex, and calendar year, the standardised mortality ratio was 6·47 (95% CI 6·22­6·73) over 5 years and 3·93 (3·71­4·17) among those who survived the first year. 1197 (45%) of 2660 deaths were due to infection. Homelessness and alcohol and drug use were associated with death from infection (adjusted cause-specific HR 1·60, 95% CI 1·39­1·85), cardiovascular (1·43, 1·06­1·95), and external or ill-defined causes of death (1·80, 1·37­2·36). Diabetes was associated with deaths from cardiovascular causes (1·70, 1·23­2·35). Interpretation Patients newly diagnosed with tuberculosis were at a higher risk of death than were the source population, even after tuberculosis treatment. Post-tuberculosis sequelae and vulnerability are associated with excess mortality and must be addressed to mitigate the tuberculosis burden worldwide.

Avaliação de custo-efetividade da passagem de cateter venoso central guiada por ultrassonografia comparada com a técnica convencional sob perspectiva da fonte pagadora / Evaluation of cost-effectiveness from the funding body's point of view of ultrasound-guided central venous catheter insertion compared with the conventional technique

RESUMO Objetivo: Avaliar o custo-efetividade da inserção de cateter venoso central guiada por ultrassonografia em tempo real, em comparação com a técnica tradicional, que é baseada na técnica de reparos anatômicos externos, sob a perspectiva da fonte pagadora. Métodos: Uma simulação teórica, baseada em dados de literatura internacional foi aplicada ao contexto brasileiro, ou seja, ao Sistema Único de Saúde (SUS). Foi estruturada uma árvore de decisão, que apresentava as duas técnicas para inserção de cateter venoso central: ultrassonografia em tempo real versus reparos anatômicos externos. As probabilidades de falha e complicações foram extraídas de uma busca nas bases PubMed e Embase, e os valores associados ao procedimento e às complicações foram extraídos de pesquisa de mercado e do Departamento de Informática do Sistema Único de Saúde (DATASUS). Cada alternativa de passagem do cateter venoso central teve um custo calculado por meio do seguimento de cada um dos possíveis caminhos da árvore de decisão. A razão de custo-efetividade incremental foi calculada considerando-se a divisão do custo incremental médio da técnica de ultrassonografia em tempo real comparada à técnica de reparos anatômicos externos pelo benefício incremental médio, em termos de complicações evitadas. Resultados: O custo final médio avaliado pela árvore de decisão, considerando a incorporação da ultrassonografia em tempo real e a redução de custo por diminuição de complicações, para a técnica de reparos anatômicos externos foi de R$262,27 e, para ultrassonografia em tempo real, de R$187,94. O custo incremental final foi de -R$74,33 por cateter venoso central. A razão de custo-efetividade incremental foi -R$2.494,34 por pneumotórax evitado. Conclusão: A inserção de cateter venoso central com auxílio de ultrassonografia em tempo real esteve associada à diminuição da taxa de falhas e complicações, além de hipoteticamente reduzir custos na perspectiva da fonte pagadora, no caso o SUS.

ABSTRACT Objective: To evaluate the cost-effectiveness, from the funding body's point of view, of real-time ultrasound-guided central venous catheter insertion compared to the traditional method, which is based on the external anatomical landmark technique. Methods: A theoretical simulation based on international literature data was applied to the Brazilian context, i.e., the Unified Health System (Sistema Único de Saúde - SUS). A decision tree was constructed that showed the two central venous catheter insertion techniques: real-time ultrasonography versus external anatomical landmarks. The probabilities of failure and complications were extracted from a search on the PubMed and Embase databases, and values associated with the procedure and with complications were taken from market research and the Department of Information Technology of the Unified Health System (DATASUS). Each central venous catheter insertion alternative had a cost that could be calculated by following each of the possible paths on the decision tree. The incremental cost-effectiveness ratio was calculated by dividing the mean incremental cost of real-time ultrasound compared to the external anatomical landmark technique by the mean incremental benefit, in terms of avoided complications. Results: When considering the incorporation of real-time ultrasound and the concomitant lower cost due to the reduced number of complications, the decision tree revealed a final mean cost for the external anatomical landmark technique of 262.27 Brazilian reals (R$) and for real-time ultrasound of R$187.94. The final incremental cost of the real-time ultrasound-guided technique was -R$74.33 per central venous catheter. The incremental cost-effectiveness ratio was -R$2,494.34 due to the pneumothorax avoided. Conclusion: Real-time ultrasound-guided central venous catheter insertion was associated with decreased failure and complication rates and hypothetically reduced costs from the view of the funding body, which in this case was the SUS.

Effect of intraoperative HES 6% 130/0.4 on the need for blood transfusion after major oncologic surgery: a propensity-matched analysis

OBJECTIVES: To evaluate the effect of the intraoperative use of hydroxyethyl starch on the need for blood products in the perioperative period of oncologic surgery. The secondary end-points included the need for other blood products, the clotting profile, the intensive care unit mortality and length of stay. METHODS: Retrospective observational analysis in a tertiary oncologic ICU in Brazil including 894 patients submitted to oncologic surgery for a two-year period from September 2007. Patients were grouped according to whether hydroxyethyl starch was used during surgery (hydroxyethyl starch and No-hydroxyethyl starch groups) and compared using a propensity score analysis. A total of 385 propensity-matched patients remained in the analysis (97 in the No-hydroxyethyl starch group and 288 in the hydroxyethyl starch group). RESULTS: A higher percentage of patients in the hydroxyethyl starch group required red blood cell transfusion during surgery (26% vs. 14%; p = 0.016) and in the first 24 hours after surgery (5% vs. 0%; p = 0.015) but not in the 24- to 48-hour period after the procedure. There was no difference regarding the transfusion of other blood products, intensive care unit mortality or length of stay. CONCLUSION: Hydroxyethyl starch use in the intraoperative period of major oncologic surgery is associated with an increase in red blood cell transfusions. There are no differences in the need for other blood products, intensive care unit length of stay or mortality. .

Videotoracoscopia como uma opção no tratamento cirúrgico do quilotórax após cirurgia cardíaca pediátrica / Video-assisted thoracoscopy as an option in the surgical treatment of chylothorax after cardiac surgery in children

OBJETIVO: Avaliar o uso de videotoracoscopia no tratamento cirúrgico do quilotórax após cirurgia para correção de cardiopatias congênitas em crianças. MÉTODOS: Revisamos os prontuários médicos de 3.092 crianças operadas para a correção de cardiopatias congênitas no Instituto do Coração/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (SP) entre fevereiro de 2002 e fevereiro de 2007. RESULTADOS: Das 3.092 crianças, 64 (2,2 por cento) apresentaram quilotórax como complicação pós-operatória. Em 50 (78,1 por cento) dessas, o tratamento clínico foi bem-sucedido, enquanto esse falhou em 14 (21,9 por cento), as quais foram submetidas à ligação do ducto torácico por videotoracoscopia. A ligação do ducto torácico obteve sucesso em 12 pacientes (86 por cento) e falhou em 2 casos, os quais foram resolvidos com medidas clínicas adicionais, como dieta pobre em gorduras e nutrição parenteral. Não houve morbidade ou mortalidade relacionada à operação. Dos 14 pacientes, 5 (35 por cento) faleceram em decorrência de complicações cardíacas ou infecciosas. CONCLUSÕES: A ligadura videoassistida do ducto torácico pode ser realizada com segurança em pacientes gravemente enfermos e com doença cardíaca grave, com resultados favoráveis.

OBJECTIVE: To evaluate the use of video-assisted thoracoscopy in the surgical treatment of chylothorax developed after the surgical correction of congenital heart disease in children. METHODS: We reviewed the medical charts of 3,092 children who underwent surgery for congenital heart disease between February of 2002 and February of 2007 at the Heart Institute of the University of São Paulo School of Medicine Hospital das Clínicas, in São Paulo, Brazil. RESULTS: Of the 3,092 children, 64 (2.2 percent) presented with chylothorax as a postoperative complication. In 50 (78.1 percent) of those patients, the clinical management was successful, whereas it failed in 14 (21.9 percent), all of whom were then submitted to thoracic duct ligation by video-assisted thoracoscopy. The thoracic duct ligation was successful in 12 patients (86 percent) but failed in 2. In the postoperative period, additional clinical measures, such as a low-fat diet and parenteral nutrition, were required in order to resolve those 2 cases. There was no surgical morbidity or mortality. Of the 14 patients who underwent thoracic duct ligation, 5 (35 percent) died due to cardiac or infectious complications. CONCLUSIONS: Video-assisted thoracic duct ligation can be safely performed in patients with severe heart disease, and the outcomes are favorable.