Are heart attacks deadlier on weekends? Evidence of weekend effect in Brazil / Os ataques cardíacos são mais letais nos fins de semana? Evidência do "efeito final de semana" no Brasil

Abstract This article aims to examine the effects of weekend admission on in-hospital mortality for patients with acute myocardial infarction (AMI) in Brazil. Information from the Hospital Information System of the Unified Health System (SIH/SUS) of urgently admitted patients diagnosed with acute myocardial infarction (AMI) between 2008 and 2018 was used, made available through the Hospital Admission Authorization (AIH). Multivariable logistic regression models, controlling for observable patient characteristics, hospital characteristics and year and hospital-fixed effects, were used. The results were consistent with the existence of the weekend effect. For the model adjusted with the inclusion of all controls, the chance of death observed for individuals hospitalized on the weekend is 14% higher. Our results indicated that there is probably an important variation in the quality of hospital care depending on the day the patient is hospitalized. Weekend admissions were associated with in-hospital AMI mortality in Brazil. Future research should analyze the possible channels behind the weekend effect to support public policies that can effectively make healthcare equitable.

Resumo O objetivo deste artigo é examinar os efeitos da internação no final de semana na mortalidade hospitalar de pacientes com infarto agudo do miocárdio (IAM) no Brasil. Foram utilizadas informações do Sistema de Informação Hospitalar do Sistema Único de Saúde (SIH/SUS) de pacientes internados em urgência com diagnóstico de infarto agudo do miocárdio (IAM) entre 2008 e 2018, disponibilizados por meio da Autorização de Internação Hospitalar (AIH). Foram usados modelos de regressão logística multivariada, controlando as características observáveis ​​do paciente, características do hospital e efeitos fixos de ano e hospital. Os resultados foram consistentes com a existência do efeito fim de semana. Para o modelo ajustado com a inclusão de todos os controles, a chance de óbito observada para indivíduos internados no final de semana é 14% maior. Nossos resultados indicaram que provavelmente existe uma variação importante na qualidade da assistência hospitalar dependendo do dia em que o paciente fica internado. Internações em finais de semana foram associadas à mortalidade por IAM intra-hospitalar no Brasil. Pesquisas futuras devem analisar os possíveis canais por trás do weekend effect para subsidiar políticas públicas que possam efetivamente tornar o atendimento equitativo.

Curva de Aprendizagem da Mortalidade Hospitalar da Substituição da Válvula Aórtica Transcateter: Insights do Registro Nacional Brasileiro / Learning Curve for In-Hospital Mortality of Transcatheter Aortic Valve Replacement: Insights from the Brazilian National Registry

Resumo Fundamento Dados robustos sobre a curva de aprendizagem (LC) da substituição da válvula aórtica transcateter (TAVR) são escassos nos países em desenvolvimento. Objetivo Avaliar a LC da TAVR no Brasil ao longo do tempo. Métodos Analisamos dados do registro brasileiro de TAVR de 2008 a 2023. Pacientes de cada centro foram numerados cronologicamente em número sequencial de caso (NSC). A LC foi realizada usando um spline cúbico restrito ajustado para o EuroSCORE-II e o uso de próteses de nova geração. Ainda, os desfechos hospitalares foram comparados entre grupos definidos de acordo com o nível de experiência, com base no NSC: 1º ao 40º caso (experiência inicial), 41º ao 80º caso (experiência básica), 81º ao 120º caso (experiência intermediária) e 121º caso em diante (experiência alta). Análises adicionais foram conduzidas de acordo com o número de casos tratados antes de 2014 (>40 e ≤40 procedimentos). O nível de significância adotado foi p <0,05. Resultados Foram incluídos 3194 pacientes de 25 centros. A idade média foi 80,7±8,1 anos e o EuroSCORE II médio foi 7±7,1. A análise da LC demonstrou uma queda na mortalidade hospitalar ajustada após o tratamento de 40 pacientes. Um patamar de nivelamento na curva foi observado após o caso 118. A mortalidade hospitalar entre os grupos foi 8,6%, 7,7%, 5,9%, e 3,7% para experiência inicial, básica, intermediária e alta, respectivamente (p<0,001). A experiência alta foi preditora independente de mortalidade mais baixa (OR 0,57, p=0,013 vs. experiência inicial). Centros com baixo volume de casos antes de 2014 não mostraram uma redução significativa na probabilidade de morte com o ganho de experiência, enquanto centros com alto volume de casos antes de 2014 apresentaram uma melhora contínua após o caso de número 10. Conclusão Observou-se um fenômeno de LC para a mortalidade hospitalar do TAVR no Brasil. Esse efeito foi mais pronunciado em centros que trataram seus 40 primeiros casos antes de 2014 que naqueles que o fizeram após 2014.

Abstract Background Robust data on the learning curve (LC) of transcatheter aortic valve replacement (TAVR) are lacking in developing countries. Objective To assess TAVR's LC in Brazil over time. Methods We analyzed data from the Brazilian TAVR registry from 2008 to 2023. Patients from each center were numbered chronologically in case sequence numbers (CSNs). LC was performed using restricted cubic splines adjusted for EuroSCORE-II and the use of new-generation prostheses. Also, in-hospital outcomes were compared between groups defined according to the level of experience based on the CSN: 1st to 40th (initial-experience), 41st to 80th (early-experience), 81st to 120th (intermediate-experience), and over 121st (high-experience). Additional analysis was performed grouping hospitals according to the number of cases treated before 2014 (>40 and ≤40 procedures). The level of significance adopted was <0.05. Results A total of 3,194 patients from 25 centers were included. Mean age and EuroSCORE II were 80.7±8.1 years and 7±7.1, respectively. LC analysis demonstrated a drop in adjusted in-hospital mortality after treating 40 patients. A leveling off of the curve was observed after case #118. In-hospital mortality across the groups was 8.6%, 7.7%, 5.9%, and 3.7% for initial-, early-, intermediate-, and high-experience, respectively (p<0.001). High experience independently predicted lower mortality (OR 0.57, p=0.013 vs. initial experience). Low-volume centers before 2014 showed no significant decrease in the likelihood of death with gained experience, whereas high-volume centers had a continuous improvement after case #10. Conclusion A TAVR LC phenomenon was observed for in-hospital mortality in Brazil. This effect was more pronounced in centers that treated their first 40 cases before 2014 than those that reached this milestone after 2014.

O Índice de Imuno Inflamação Sistêmica Prevê Mortalidade Hospitalar em Pacientes Submetidos à Cirurgia Cardíaca com Circulação Extracorpórea / The Systemic Immune-Inflammation Index Predicts In-Hospital Mortality in Patients Who Underwent On-Pump Cardiac Surgery

Resumo Fundamento: O índice de imuno-inflamação sistêmica (SII), um novo índice inflamatório calculado usando contagens de plaquetas, neutrófilos e linfócitos, demonstrou ser um fator de risco independente para a identificação de doença arterial coronariana de alto risco em pacientes submetidos a intervenção coronária percutânea e cardiovascular e cirurgia com circulação extracorpórea (CEC). A relação entre as taxas de mortalidade relacionadas ao SII e à CEC permanece obscura. Objetivo: Esta pesquisa foi desenhada para investigar o uso do SII para prever mortalidade hospitalar em pacientes submetidos à cirurgia cardíaca com CEC. Métodos: Quatrocentos e oitenta pacientes submetidos a procedimento cardíaco envolvendo CEC durante 3 anos foram coletados do banco de dados do hospital. Foram comparados os dados demográficos, comorbidades, perfis hematológicos e bioquímico e dados operatórios dos grupos. Análises múltiplas de regressão logística foram feitas para determinar preditores independentes de mortalidade. Os fatores prognósticos foram avaliados por análise multivariada e os valores preditivos de SII, relação neutrófilo-linfócito (NLR) e razão plaqueta-linfócito (PLR) para mortalidade foram comparados. Um valor de p <0,05 foi considerado significativo. Resultados: Dos 480 pacientes, 78 desenvolveram mortalidade hospitalar após cirurgia cardíaca. O SII foi um preditor independente de mortalidade hospitalar (odds ratio: 1,003, intervalo de confiança de 95%: 1,001-1,005, p<0,001). O valor de corte do SII foi >811,93 com sensibilidade de 65% e especificidade de 65% (área sob a curva: 0,690). Os valores preditivos de SII, PLR e NLR foram próximos entre si. Conclusão: Altos escores pré-operatórios do SII podem ser usados para determinação precoce de tratamentos apropriados, o que pode melhorar os resultados cirúrgicos de cirurgia cardíaca no futuro.

Abstract Background: Systemic immune-inflammation index (SII), a new inflammatory index calculated using platelet, neutrophil, and lymphocyte counts, has been demonstrated to be an independent risk factor for the identification of high-risk coronary artery disease in patients undergoing percutaneous coronary intervention and cardiovascular surgery with cardiopulmonary bypass (CPB). The relationship between SII and CPB-related mortality rates remains unclear. Objective: This research was designed to investigate the use of SII to predict in-hospital mortality in patients undergoing cardiac surgery with CPB. Methods: Four hundred eighty patients who underwent a cardiac procedure involving CPB over 3 years, were obtained from the hospital's database. The demographic data, comorbidities, hematological and biochemical profiles, and operative data of the groups were compared. Multiple logistic regression analyses were done to determine independent predictors of mortality. Prognostic factors were assessed by multivariate analysis, and the predictive values of SII, neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) for mortality were compared. A p-value <0.05 was considered significant. Results: Of 480 patients, 78 developed in-hospital mortality after cardiac surgery. SII was an independent predictor of in-hospital mortality (Odds ratio: 1.003, 95% confidence interval: 1.001-1.005, p<0.001). The cut-off value of the SII was >811.93 with 65% sensitivity and 65% specificity (area under the curve: 0.690). The predictive values of SII, PLR, and NLR were close to each other. Conclusion: High preoperative SII scores can be used for early determination of appropriate treatments, which may improve surgical outcomes of cardiac surgery in the future.

Evaluation of Pan-Immuno-Inflammation Value for In-Hospital Mortality in Acute Pulmonary Embolism Patients

ABSTRACT Background: Pan-immuno-inflammation value is a new and comprehensive index that reflects both the immune response and systemic inflammation in the body. Objective: The aim of this study was to investigate the prognostic relevance of pan-immuno-inflammation value in predicting in-hospital mortality in acute pulmonary embolism patients and to compare it with the well-known risk scoring system, pulmonay embolism severity index, which is commonly used for a short-term mortality prediction in such patients. Methods: In total, 373 acute pulmonary embolism patients diagnosed with contrast-enhanced computed tomography were included in the study. Detailed cardiac evaluation of each patient was performed and pulmonary embolism severity index and pan-immuno-inflammation value were calculated. Results: In total, 60 patients died during their hospital stay. The multivariable logistic regression analysis revealed that baseline heart rate, N-terminal pro-B-type natriuretic peptide, lactate dehydrogenase, pan-immuno-inflammation value, and pulmonary embolism severity index were independent risk factors for in-hospital mortality in acute pulmonay embolism patients. When comparing with pulmonary embolism severity index, pan-immuno-inflammation value was non-inferior in terms of predicting the survival status in patients with acute pulmonay embolism. Conclusion: In our study, we found that the PIV was statistically significant in predicting in-hospital mortality in acute pulmonay embolism patients and was non-inferior to the pulmonary embolism severity index. (Rev Invest Clin. 2024;76(2):97-102)

Caracterización clínico-epidemiológica de pacientes con un primer evento de fibrilación auricular

Fundamento: Pese a la importancia del primer evento de fibrilación auricular como una de las urgencias médicas más tratadas, en Cienfuegos, son insuficientes los estudios en los que se describan las características clínico-epidemiológicas de estos pacientes. Objetivo: Caracterizar clínica y epidemiológicamente los pacientes con primer evento de fibrilación auricular en Cienfuegos entre los años 2020-2022. Método: Se realizó un estudio descriptivo y transversal. El universo estuvo conformado por 54 pacientes con diagnóstico de primer evento de fibrilación auricular ingresados en el Servicio de Cardiología del Hospital General Universitario Dr. Gustavo Aldereguía Lima de Cienfuegos entre los años 2020-2022. Las variables estudiadas fueron: edad, sexo, color de la piel, hábitos tóxicos, antecedentes patológicos personales, manifestaciones clínicas, parámetros ecocardiográficos y tratamiento. Se calcularon la frecuencia absoluta y relativa de las variables. Los resultados se presentaron en tablas. Resultados: Predominó el sexo masculino, el grupo etáreo de 36-55 años, el color de piel blanca, y el tabaquismo. Los antecedentes patológicos personales más frecuentes fueron: la hipertensión arterial (74,1 %), la diabetes mellitus tipo 2 (16,7 %) y las valvulopatías (11,1 %). Las manifestaciones clínicas más frecuentes fueron: las palpitaciones (77,8 %), seguidas de la disnea (12,9 %). Los parámetros ecocardiográficos estuvieron en el rango de la normalidad. El tratamiento farmacológico se aplicó al 68,5 % seguido de cardioversión farmacológica y eléctrica en el 16,7 %. Conclusiones: El mayor número de pacientes con primer evento de fibrilación auricular, tienen un corazón estructuralmente sano, por lo que se considera de vital importancia la prevención de recurrencias, esto evitará la creación de condiciones eléctricas y anatómicas que perpetúen la arritmia.

Foundation: Despite the importance of the first event of atrial fibrillation as one of the most treated medical emergencies, in Cienfuegos, there are insufficient studies describing the clinical-epidemiological characteristics of these patients. Objective: To clinically and epidemiologically characterize patients with the first event of atrial fibrillation in Cienfuegos between the years 2020-2022. Method: A descriptive and cross-sectional study was carried out. The universe was made up of 54 patients diagnosed with a first event of atrial fibrillation admitted to the Cardiology Service of the Dr. Gustavo Aldereguía Lima General University Hospital in Cienfuegos between the years 2020-2022. The variables studied were: age, sex, skin color, toxic habits, personal pathological history, clinical manifestations, echocardiographic parameters and treatment. The absolute and relative frequencies of the variables were calculated. The results were presented in tables. Results: The male sex, the age group of 36-55 years, white skin color, and smoking predominated. The most common personal pathological history was: high blood pressure (74.1%), type 2 diabetes mellitus (16.7%) and valvular heart disease (11.1%). The most frequent clinical manifestations were: palpitations (77.8%), followed by dyspnea (12.9%). Echocardiographic parameters were within the normal range. Pharmacological treatment was applied to 68.5% followed by pharmacological and electrical cardioversion in 16.7%. Conclusions: The largest number of patients with a first event of atrial fibrillation have a structurally healthy heart, so the prevention of recurrences is considered of vital importance, this will avoid the creation of electrical and anatomical conditions that perpetuate the arrhythmia.

Utilidad de la puntuación qSOFA para predecir mortalidad hospitalaria en pacientes con cáncer / Usefulness of the qSOFA score for predicting hospital mortality in cancer patients

Resumen Antecedentes: El quick Sequential Sepsis-related Organ Failure Assessment (qSOFA) es una puntuación propuesta para identificar de forma rápida a pacientes con mayor probabilidad de morir. Objetivo: Describir la utilidad de la puntuación qSOFA para predecir mortalidad hospitalaria en pacientes con cáncer. Material y métodos: Estudio transversal realizado entre enero de 2021 y diciembre de 2022. La mortalidad hospitalaria fue la variable dependiente. Se calculó el área bajo la curva ROC (ABC) para determinar la capacidad discriminativa de qSOFA para predecir mortalidad hospitalaria. Resultados: Se incluyeron 587 pacientes con cáncer. La puntuación qSOFA < 1 obtuvo una sensibilidad de 57.2 %, una especificidad de 78.5 %, un valor predictivo positivo de 55.4 % y un valor predictivo negativo de 79.7 %. El ABC de qSOFA para predecir mortalidad hospitalaria fue de 0.70. La mortalidad hospitalaria de los pacientes con qSOFA de 2 y 3 puntos fue de 52.7 y 64.4 %, respectivamente. La mortalidad hospitalaria fue de 31.9 % (187/587). Conclusión: qSOFA mostró capacidad discriminativa aceptable para predecir mortalidad hospitalaria en pacientes con cáncer.

Abstract Background: The quick Sequential Sepsis-related Organ Failure Assessment (qSOFA) is a score that has been proposed to quickly identify patients at higher risk of death. Objective: To describe the usefulness of the qSOFA score to predict in-hospital mortality in cancer patients. Material and methods: Cross-sectional study carried out between January 2021 and December 2022. Hospital mortality was the dependent variable. The area under the ROC curve (AUC) was calculated to determine the discriminative ability of qSOFA to predict in-hospital mortality. Results: A total of 587 cancer patients were included. A qSOFA score higher than 1 obtained a sensitivity of 57.2 %, specificity of 78.5 %, a positive predictive value of 55.4 % and negative predictive value of 79.7 %. The AUC of qSOFA for predicting in-hospital mortality was 0.70. In-hospital mortality of patients with qSOFA scores of 2 and 3 points was 52.7 and 64.4 %, respectively. In-hospital mortality was 31.9 % (187/587). Conclusions: qSOFA showed acceptable discriminative ability for predicting in-hospital mortality in cancer patients.

Hiperglicemia como factor de riesgo de mortalidad hospitalaria en infarto de miocardio / Hiperglicemia como factor de riesgo de mortalidad hospitalaria en infarto de miocardio

RESUMEN Introducción: El infarto de miocardio continúa con altas tasas de mortalidad, desde 4.6 % hasta 13.1 %. Existen modelos predictivos de estratificación de riesgo, como el Score Grace, que no incluye la glicemia como variable. Los pacientes hospitalizados por infarto de miocardio con hiperglicemia al ingreso pueden tener mayor mortalidad, en infarto ST elevado y no elevado. Objetivo: Identificar y sistematizar la evidencia sobre hiperglicemia al ingreso como biomarcador de mortalidad y de insuficiencia cardiaca en infarto de miocardio. Materiales y Métodos: La búsqueda se realizó en la base de datos Medline, se incluyeron los términos MeSH hiperglicemia y mortalidad hospitalaria o insuficiencia cardiaca en infarto de miocardio y se seleccionaron 12 artículos. Resultados: La mortalidad hospitalaria se calculó en 11 artículos; en 9 de ellos se encontró asociación significativa entre hiperglicemia y mortalidad hospitalaria; en el análisis bivariado y en el multivariado y en dos artículos, no se demostró dicha asociación. En 11, se determinó la frecuencia de aparición de insuficiencia cardiaca y se encontró mayor frecuencia en nueve de ellos. Para mortalidad hospitalaria, se sintetizaron y analizaron los resultados de 11 artículos incluidos en esta revisión; en ocho, se realizó el análisis en no diabéticos y se obtuvo OR: 4,15, IC 95 % (2,853-6,035); en tres, para diabéticos, OR 2,365 IC 95 % (1,778-3,146) y en 6, para población total, OR 3,314 (2,910-3,774). Conclusiones: Hiperglicemia al ingreso está asociada a mayor mortalidad y frecuencia de aparición de insuficiencia cardiaca durante la hospitalización por infarto de miocardio con evidencia de moderada calidad.

ABSTRACT Introduction: Myocardial infarction continues with high mortality rates, from 4.6% to 13.1%. There are predictive risk stratification models, such as the Grace Score, which does not include glycemia as a variable. Patients hospitalized for myocardial infarction with hyperglycemia on admission may have higher mortality, in ST elevated and non-elevated infarcts. Objectives: The objective of this review is to identify and systematize the evidence on hyperglycemia on admission as a biomarker of mortality and heart failure in acute myocardial infarction. Materials and Methods: The search was carried out in the MEDLINE database including the MeSH terms hyperglycemia and hospital mortality or heart failure in myocardial infarction, selecting 12 articles. Results: Hospital mortality was calculated in 11 articles, in 9 of them a significant association was found between hyperglycemia and hospital mortality, both in the bivariate and multivariate analysis, and in 2 articles this association was not demonstrated. For in-hospital mortality, the results of 11 articles included in this review were synthesized. The frequency of occurrence of heart failure was determined in 11 articles, finding a higher frequency in 9 of them. For in-hospital mortality, the results of 11 articles included in this review were synthesized and analyzed, in 8 the analysis was performed in non-diabetics, obtaining OR: 4.15, IC 95% (2.853-6.035), in 3 for diabetics obtaining OR 2.365 IC 95% (1.778- 3,146) and in 6 for the total population finding OR 3,314 (2,910-3,774). Conclusions: Hyperglycemia on admission is associated with increased mortality and frequency of occurrence of heart failure during hospitalization for myocardial infarction, with evidence of moderate quality.

Mortalidad intrahospitalaria de pacientes con COVID-19 complicados con neumonías bacterianas en asistencia respiratoria mecánica en Cuidados Intensivos de Adultos en un Hospital del Paraguay / In-hospital mortality of patients with COVID-19 complicated by bacterial pneumonia on mechanical ventilation in Adult Intensive Care in a Hospital in Paraguay

Introducción: los pacientes con COVID-19 ingresan en mayor proporción a asistencia respiratoria mecánica, aumentando: el riesgo de neumonía asociada a ventilador (NAV) las tasas de mortalidad, los días de permanencia en las unidades de terapia intensiva (UCI) y los costos sanitarios. Objetivo: determinar la Mortalidad intrahospitalaria de pacientes con COVID-19 complicados con neumonías bacterianas en asistencia respiratoria mecánica en Cuidados Intensivos de Adultos en un Hospital del Paraguay durante los años 2020 a 2021. Metodología: estudio analítico de tipo cohorte retrospectiva. Se registraron variables demográficas, comorbilidades, puntajes en scores de gravedad como el APACHE II al ingreso, la cifra más baja de oxigenación durante la internación expresado por la PaO2 / FIO2, días de ventilación, colocación en decúbito prono, traqueotomía, medidas terapéuticas farmacológicas y no farmacológicas, días de internación, así como las complicaciones y la mortalidad. Resultados: fueron incluidos 214 pacientes, 135 ingresaron a asistencia respiratoria mecánica (ARM) de los cuales 58 (42,9 %) desarrollaron NAV, con edad mediana de 52 años (40-60). Los microorganismos de NAV fueron cocos Gram negativos en 98,3 %, incluyendo Acinetobacter baumanii en 46,5 %, Klebsiella pneumoniae en 22,8 %, Pseudomona aeruginosa en 15,5 % y 5,2 % Stenotrophomona maltofilia. La mortalidad intrahospitalaria fue del 44,8 %. Los menores de 50 años tienen una sobrevida mayor que los mayores (34 días vs 22 días, con p de 0,026). Conclusión: la mortalidad intrahospitalaria fue del 44,8 %. La edad fue un factor de riesgo independiente para la mortalidad en pacientes con NAV, por lo que los profesionales de la salud deben estar atentos a la posibilidad de NAV en pacientes que requieren asistencia respiratoria mecánica, especialmente en pacientes mayores de 50 años.

Introduction: patients with COVID-19 are more likely to require mechanical ventilation, which increases the risk of ventilator-associated pneumonia (VAP), mortality rates, length of stay in intensive care units (ICUs), and healthcare costs. Objective: to determine the in-hospital mortality of patients with COVID-19 complicated by bacterial pneumonia on mechanical ventilation in Adult Intensive Care in a Hospital in Paraguay during the years 2020 to 2021. Methodology: this is a retrospective cohort analytical study. Demographic variables, comorbidities, severity scores such as APACHE II on admission, the worst oxygenation during hospitalization expressed by PaO2/FiO2, days of ventilation, prone position, tracheostomy, pharmacological and non-pharmacological therapeutic measures, days of hospitalization, as well as complications and mortality were recorded. Results: a total of 214 patients were included, 135 were admitted to mechanical ventilation (MRA), of which 58 (42.9%) developed VAP, with a median age of 52 years (40-60). VAP microorganisms were Gram-negative cocci in 98.3%, including Acinetobacter baumanii in 46.5%, Klebsiella pneumoniae in 22.8%, Pseudomona aeruginosa in 15.5%, and Stenotrophomona maltophilia in 5.2%. In-hospital mortality was 44.8%. Those under 50 years of age have a longer survival than those older (34 days vs. 22 days, with p of 0.026). Conclusion: the overall mortality rate was 44.8%. Age was an independent risk factor for mortality in patients with VAP, so healthcare professionals should be aware of the possibility of VAP in patients who require mechanical ventilation, especially in patients over 50 years of age.

Uso de la tomografía corporal total en pacientes con heridas de arma de fuego y hemodinámicamente inestables: ¿Rompiendo paradigmas de atención inicial? / Whole-body computed tomography in hemodynamically unstable patients with gunshot wounds: A paradigm shift in trauma management?

Introducción. El objetivo del estudio fue analizar el impacto del uso de la tomografía corporal total en la evaluación de los pacientes con trauma penetrante por proyectil de arma de fuego y hemodinámicamente inestables atendidos en un centro de referencia de trauma. Métodos. Se realizó un estudio analítico, retrospectivo, con base en un subanálisis del registro de la Sociedad Panamericana de Trauma ­ Fundación Valle del Lili. Se incluyeron los pacientes con trauma penetrante por proyectil de arma de fuego atendidos entre 2018 y 2021. Se excluyeron los pacientes con trauma craneoencefálico severo, trauma leve y en condición in extremis. Resultados. Doscientos pacientes cumplieron los criterios de elegibilidad, 115 fueron estudiados con tomografía corporal total y se compararon con 85 controles. La mortalidad intrahospitalaria en el grupo de tomografía fue de 4/115 (3,5 %) vs 10/85 (12 %) en el grupo control. En el análisis multivariado se identificó que la tomografía no tenía asociación significativa con la mortalidad (aOR=0,46; IC95% 0,10-1,94). El grupo de tomografía tuvo una reducción relativa del 39 % en la frecuencia de cirugías mayores, con un efecto asociado en la disminución de la necesidad de cirugía (aOR=0,47; IC95% 0,22-0,98). Conclusiones. La tomografía corporal total fue empleada en el abordaje inicial de los pacientes con trauma penetrante por proyectil de arma de fuego y hemodinámicamente inestables. Su uso no se asoció con una mayor mortalidad, pero sí con una menor frecuencia de cirugías mayores.

Introduction. This study aims to assess the impact of whole-body computed tomography (WBCT) in the evaluation of patients with penetrating gunshot wounds (GSW) who are hemodynamically unstable and treated at a trauma referral center. Methods. An analytical, retrospective study was conducted based on a subanalysis of the Panamerican Trauma Society-FVL registry. Patients with GSW treated between 2018 and 2021 were included. Patients with severe cranioencephalic trauma, minor trauma, and those in extremis were excluded. Patients with and without WBCT were compared. The primary outcome was in-hospital mortality, and the secondary outcome was the frequency of major surgeries (thoracotomy, sternotomy, cervicotomy, and/or laparotomy) during initial care. Results. Two hundred eligible patients were included, with 115 undergoing WBCT and compared to 85 controls. In-hospital mortality in the WBCT group was 4/115 (3.5%) compared to 10/85 (12%) in the control group. Multivariate analysis showed that WBCT was not significantly associated to mortality (aOR: 0.46; 95% CI 0.10-1.94). The WBCT group had a relative reduction of 39% in the frequency of major surgeries, with an associated effect on reducing the need for surgery (aOR: 0.47; 95% CI 0.22-0.98). Conclusions. Whole-body computed tomography was employed in the initial management of patients with penetrating firearm projectile injuries and hemodynamic instability. The use of WBCT was not associated with mortality but rather with a reduction in the frequency of major surgery.

Early stratification of in-hospital mortality risk in adult septic shock patients and development of a simplified scoring system / 重庆医学

Objective To analyze the independent factors impacting the in-hospital prognosis of patients with septic shock,and to construct a simplified scoring system and evaluate its predictive value.Methods A retrospective analysis was carried out on 247 patients with septic shock admitted to the People's Hospital of Xinjiang Uygur Autonomous Region from January 2021 to July 2022,among whom 122 patients survived and 125 died.Univariate analysis and multivariate Cox proportional hazard regression model were used to screen the independent factors affecting in-hospital mortality of septic shock patients.The best cut-off value was ob-tained by using the receiver operating characteristics(ROC)curve,and the continuous variables were conver-ted into binary variables and assigned.Finally,a simplified scoring system was established,and its predictive efficacy for hospital death in septic shock patients was verified.Results The results of multivariate Cox pro-portional hazard regression model showed that the Glasgow coma scale(GCS)score(HR=0.929,95%CI:0.875-0.985,P=0.014),quick sequential organ failure assessment(qSOFA)score(HR=1.475,95%CI:1.094-1.989,P=0.011),lactate level(HR=1.096,95%CI:1.049-1.145,P<0.001),procalcitonin level(HR=1.009,95%CI:1.000-1.018,P=0.048),and albumin level(HR=0.958,95%CI:0.922-0.996,P=0.029)were identified as independent influencing factors for in-hospital mortality in patients with septic shock.The ROC curve showed that the simplified scoring system,based on GCS score,qSOFA score,lactate,procalcitonin,and albumin levels,exhibited an area under the curve and 95%CI of 0.866(0.822-0.910),with an optimal cutoff value of 2.5.The sensitivity and specificity were 80.0%and 78.7%,respectively.Con-clusion The simplified scoring system,based on early assessments of GCS score,qSOFA score,lactate,pro-calcitonin,and albumin levels,demonstrates substantial predictive value for in-hospital mortality in patients with septic shock.

Correlation between dynamic high-density lipoprotein trajectories and clinical outcomes in critically ill children / 中华实用儿科临床杂志

Objective:To characterize the longitudinal and dynamic high-density lipoprotein (HDL) trajectories in critically ill children and explore their correlation with clinical outcomes.Methods:Retrospective cohort study.All critically ill children admitted to the Pediatric Intensive Care Unit (PICU) of West China Hospital, Sichuan University from January 1, 2015 to October 1, 2020 were included in this retrospective study.Group-based trajectory modeling (GBTM) was applied to characterize the HDL trajectories in days 0-6 post-PICU admission and develop HDL trajectory groups.The in-hospital mortality rate was reported as frequency (%) and then compared by the Chi-square test or Fisher′s exact test between HDL trajectory groups.The length of stay (LOS) in the PICU was described by M( Q1, Q3), and its difference between HDL trajectory groups was evaluated by the Kruskal Wallis test.Logistic regression and multiple linear regression were used to determine the correlation between HDL trajectories and clinical outcomes.The primary outcome was in-hospital mortality rate, and the secondary outcome was LOS in the PICU. Results:A total of 4 384 critically ill children were ultimately enrolled in the study, and 6 HDL trajectory groups were developed based on GBTM analyses: group 1 (758 cases), the lowest HDL group; group 2 (1 413 cases), the low HDL group; group 3 (74 cases), the low-to-high HDL group; group 4 (621 cases), the medium HDL group; group 5 (1 371 cases), the high HDL group; and group 6 (147 cases), the highest HDL group.Logistic regression analysis showed that compared with critically ill children in group 1, those belonging to groups 2, 3, 4, 5, and 6 were at lower risks of in-hospital mortality with odds ratio ( OR): 0.475, 95%confidence interval ( CI): 0.352-0.641, P<0.001; OR: 0.093, 95% CI: 0.013-0.679, P=0.019; OR: 0.322, 95% CI: 0.208-0.479, P<0.001; OR: 0.263, 95% CI: 0.185-0.374, P<0.001, and OR: 0.142, 95% CI: 0.044-0.454, P=0.001, respectively.Multiple linear regression analysis revealed that compared with critically ill children in group 1, those belonging to groups 4, 5, and 6 had the trend of shorter LOS in PICU, and the β value and 95% CI were β: -4.332, 95% CI: -5.238- -3.426, P<0.001; β: -3.053, 95% CI: -3.809--2.297, P<0.001; β: -6.281, 95% CI: -7.842--4.721, P<0.001, respectively. Conclusions:The dynamic HDL trajectories during 0-6 days after PICU admission are associated with in-hospital mortality rate of critically ill children.The HDL trajectory at a persistently low level is associated with higher mortality, while the HDL trajectory at a persistently high level or with the trend from a low level rising to a high level shows a lower risk of mortality.It is suggested that the HDL trajectory model may become an indicator to predict the condition and prognosis of critically ill children.

Congenital esophageal atresia:clinical report of 553 cases / 中国新生儿科杂志

Objective:To study the clinical characteristics of congenital esophageal atresia (CEA) and risk factors of mortality associated with esophageal repair (ER) surgery.Methods:From January 2010 to December 2022, patients diagnosed of CEA using chest and abdomen X-ray and esophagography in our hospital were retrospectively reviewed. The patients were assigned into ER group and non-ER group according to the treatments. The ER group was subgrouped into survival group and death group according to the prognosis. Clinical data and outcomes were collected and compared between the groups.Results:A total of 553 cases were enrolled. According to Gross classification, 29 patients (5.2%) were type A, 2 patients (0.4%) were type B, 504 patients (91.1%) were type C, 6 patients (1.1%) were type D and 11 patients (2.0%) were type E. One patient had simple transluminal septal atresia of the esophagus. 406 patients were in ER group and 147 in non-ER group. Compared with ER group, non-ER group had significantly higher incidences of preterm birth, low birth weight and overall malformations (all P<0.05). In ER group, 152 patients (37.4%) received open thoracic surgery (OTS), 243 (59.9%) had video-assisted thoracoscopic surgery (VATS) and 11 (2.7%) were VATS converted to OTS. Postoperative anastomotic leakage (PAL) occurred in 92 patients (22.7%) and 15 patients (3.7%) died after surgery. The median length of hospital stay was 23 (17, 36) d. Compared with the survival group, the death group had higher incidences of preterm birth, low birth weight, VATS converted to OTS, mechanical ventilation after ER, and shorter length of hospital stay (all P<0.05). After adjusted for birth weight, VATS converted to OTS ( OR=9.585, 95% CI 1.899-48.374) and mechanical ventilation after ER ( OR=7.821, 95% CI 1.002-61.057) were risk factors of mortality in ER patients. Conclusions:Non-ER patients have higher incidences of preterm birth, low birth weight and overall malformations than ER patients. VATS is the method of choice for CEA. Preterm birth, low birth weight, VATS converted to OTS and mechanical ventilation after ER are risk factors of mortality in ER patients.

Impact of the age-adjusted Charlson comorbidity index on in-hospital mortality in long-living people with community-acquired pneumonia and a predictive mortality model / 中华老年医学杂志

Objective:To investigate the relationship between the age-adjusted Charlson comorbidity index(aCCI)and the risk of in-hospital death for people aged ≥ 90 years with community-acquired pneumonia(CAP), and to construct a novel scoring model for predicting in-hospital mortality.Methods:Basic personal and medical data about sex, age, hospitalization days, hospitalization expenses, in-hospital outcomes and discharge/admitting diagnosis of CAP patients aged ≥ 90 years hospitalized in Peking University Third Hospital between 2010 and 2019 were collected retrospectively.Multivariate Logistic regression analysis was conducted to examine the association between aCCI or other complications and in-hospital death.The receiver operating characteristic curve(ROC)was used to assess the value of aCCI and a new scoring model in predicting in-hospital death of CAP in people aged ≥ 90 years.Results:A total of 274 CAP patients aged ≥ 90 years were included in this study, of whom 85 died in hospital.Multivariate Logistic regression analysis showed that malnutrition( OR=2.21, 95% CI: 1.05-4.67, P<0.05), respiratory failure( OR=18.91, 95% CI: 9.34-38.25, P<0.001)and aCCI( OR=1.51, 95% CI: 1.23-1.85, P<0.001)were prognostic factors for in-hospital death in CAP patients aged ≥ 90 years.Based on the above results, a novel scoring model, MRC(malnutrition, respiratory failure, aCCI)was established.The area under the ROC curve of the aCCI score for predicting the risk of in-hospital death in CAP patients aged ≥ 90 years was 0.743(95% CI: 0.684-0.802). The area under the ROC curve of the MRC score was 0.891(95% CI: 0.848-0.933), indicating a higher predictive value than that of the aCCI score alone( Z=6.337, P<0.001). Conclusions:The MRC score model can be used to evaluate and predict the risk of in-hospital death in long-living CAP patients.

Hyperglycémie de stress: prévalence et impact sur la mortalité intra hospitalière au cours des accidents vasculaires cérébraux ischémiques à la phase aigue au Centre Hospitalier Universitaire Yalgado Ouédraogo, Burkina Faso / Stress hyperglycemia: Prevalence and impact on intra-hospital mortality during ischemic strokes in the acute phase at the Yalgado Ouédraogo University Hospital, Burkina Faso

Contexte et objectif. L'hyperglycémie de stress est fréquente et délétère à la phase aigüe de l'accident vasculaire cérébral ischémique. L'objectif de la présente étude était de déterminer la prévalence de l'hyperglycémie de stress à la phase aigüe de l'AVCI et d'analyser son impact sur la mortalité intra hospitalière Méthodes. Il s'est agi d'une série retrospective de cas qui s'est déroulée du 1er janvier 2021 au 31 Décembre 2022 dans les services des urgences médicales et de Neurologie du Centre hospitalier Yalgado Ouédraogo. Les patients non diabétiques de plus de 15 ans hospitalisés pour un AVCI confirmé par une imagerie cérébrale et ayant une hyperglycémie avec une hémoglobine glyquée normale ont été inclus. Résultats. La prévalence de l'hyperglycémie de stress était de 37,8 %. L'âge moyen était de 59,98 ± 15,9 ans avec des extrêmes de 20 et 98 ans. Le sex-ratio M/F était de 1,12/1. Les facteurs de risque vasculaire les plus fréquents étaient l'hypertension artérielle (54,1 %), la sédentarité (20,3 %) et l'antécédent personnel d'AVC (11 %). Le taux moyen de l'hyperglycémie était de 8,8 ± 2,2mmol/l avec des extrêmes de 7,0 à 15,3 mmol/l. La mortalité intra hospitalière était de 13,37 %. L'hyperglycémie à l'admission ≥ 7mmol/l (p= 0,0027) la température ≥ 38,5° à l'admission (p= 0,0107) et l'insuffisance cardiaque (p= 0,0045) ont émergé comme prédicteurs indépendants de la mortalité intra-hospitalière. Conclusion. L'hyperglycémie de stress est associée à un mauvais pronostic au cours de la phase aigüe des AVCI d'où la nécessité d'un monitorage de la glycémie et d'une prise en charge adaptée

Context and objective. Neonatal jaundice is a common symptom. The objective of the present study was to update the epidemiological profile and identify the factors associated with neonatal jaundice in sick newborns. Methods. A descriptive cross-sectional study was conducted from June 2022 to April 2023 at the Kinshasa University Hospital. The study included sick newborns who presented with mucocutaneous jaundice. Sociodemographic, perinatal, clinical and paraclinical variables were sought. Results. Out of 152 sick newborns, 102 (67.1 %) cases of jaundice were identified. Fullterm newborns (72.5 %), born vaginally (67.6 %) and whose mothers had presented with urogenital infections (98 %) and blood group O (53 %) rhesus positive (97.1 %) were the most represented. Jaundice appeared in the first week of life (85.3 %). Baseline total serum bilirubin was between 10 and 15 mmol/L (57.8 %). The infectious origin was noted in 85 % of cases (Klebsiella pneumoniae in 50 % of cases). Conventional phototherapy was used in 74.5 %. Vaginal delivery was the only associated factor (p=0.001). Conclusion. Neonatal jaundice is common in sick newborns. The infectious etiology must be systematically sought. Appropriate management helps reduce the occurrence of neurosensory after effects.

Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis / Pronação consciente em pacientes com COVID-19 não intubados e com síndrome do desconforto respiratório agudo: revisão sistemática e metanálise

ABSTRACT Objective: To systematically review the effect of the prone position on endotracheal intubation and mortality in nonintubated COVID-19 patients with acute respiratory distress syndrome. Methods: We registered the protocol (CRD42021286711) and searched for four databases and gray literature from inception to December 31, 2022. We included observational studies and clinical trials. There was no limit by date or the language of publication. We excluded case reports, case series, studies not available in full text, and those studies that included children < 18-years-old. Results: We included ten observational studies, eight clinical trials, 3,969 patients, 1,120 endotracheal intubation events, and 843 deaths. All of the studies had a low risk of bias (Newcastle-Ottawa Scale and Risk of Bias 2 tools). We found that the conscious prone position decreased the odds of endotracheal intubation by 44% (OR 0.56; 95%CI 0.40 - 0.78) and mortality by 43% (OR 0.57; 95%CI 0.39 - 0.84) in nonintubated COVID-19 patients with acute respiratory distress syndrome. This protective effect on endotracheal intubation and mortality was more robust in those who spent > 8 hours/day in the conscious prone position (OR 0.43; 95%CI 0.26 - 0.72 and OR 0.38; 95%CI 0.24 - 0.60, respectively). The certainty of the evidence according to the GRADE criteria was moderate. Conclusion: The conscious prone position decreased the odds of endotracheal intubation and mortality, especially when patients spent over 8 hours/day in the conscious prone position and treatment in the intensive care unit. However, our results should be cautiously interpreted due to limitations in evaluating randomized clinical trials, nonrandomized clinical trials and observational studies. However, despite systematic reviews with meta-analyses of randomized clinical trials, we must keep in mind that these studies remain heterogeneous from a clinical and methodological point of view.

RESUMO Objetivo: Revisar sistematicamente o efeito da posição prona na intubação endotraqueal e na mortalidade em pacientes com COVID-19 não intubados com síndrome do desconforto respiratório agudo. Métodos: Registramos o protocolo (CRD42021286711) e pesquisamos quatro bancos de dados e literatura cinzenta desde o início até 31 de dezembro de 2022. Incluímos estudos observacionais e ensaios clínicos. Não houve limite de data ou idioma de publicação. Excluímos relatos de casos, séries de casos, estudos não disponíveis em texto completo e estudos que incluíram pacientes < 18 anos de idade. Resultados: Incluímos 10 estudos observacionais, 8 ensaios clínicos, 3.969 pacientes, 1.120 eventos de intubação endotraqueal e 843 mortes. Todos os estudos tinham baixo risco de viés (ferramentas Newcastle-Ottawa Scale e Risk of Bias 2). Observamos que a pronação consciente reduziu as chances de intubação endotraqueal em 44% (RC 0,56; IC95% 0,40 - 0,78) e a mortalidade em 43% (RC 0,57; IC95% 0,39 - 0,84) em pacientes com COVID-19 não intubados com síndrome do desconforto respiratório agudo. Esse efeito protetor sobre a intubação endotraqueal e a mortalidade foi mais robusto naqueles que passaram > 8 horas por dia na pronação consciente (RC 0,43; IC95% 0,26 - 0,72 e OR 0,38; IC95% 0,24 - 0,60, respectivamente). A certeza da evidência, de acordo com os critérios GRADE, foi moderada. Conclusão: A pronação consciente diminuiu as chances de intubação endotraqueal e mortalidade, especialmente quando os pacientes passaram > 8 horas por dia na pronação consciente e tratamento na unidade de terapia intensiva. Contudo, nossos resultados devem ser interpretados com cautela devido às limitações na avaliação de ensaios clínicos randomizados, ensaios clínicos não randomizados e estudos observacionais. Não obstante, apesar das revisões sistemáticas com metanálises de ensaios clínicos randomizados, devemos ter em mente que esses estudos permanecem heterogêneos do ponto de vista clínico e metodológico.

Comparative Analysis of Modified BT Shunt and Central Shunt in Pediatric Patients

ABSTRACT Introduction: Cyanotic congenital heart diseases constitute 40-45% of all congenital heart diseases. In patients who are not suitable for primary repair, modified BT (MBT) shunt and central shunt (CS) procedures are still frequently used. Methods: This study included 62 pediatric patients who underwent MBT shunt or CS via median sternotomy. Patients' demographic, echocardiographic, operative, and postoperative data were collected retrospectively. The patients were classified as single ventricle and bi-ventricle according to their cardiac anatomy, and the presence of prematurity and heterotaxy was noted. Procedure details of the patients who underwent endovascular intervention prior to the surgery were investigated, and operation data were accessed from the surgery notes. Data regarding postoperative follow-ups were obtained and comparatively analyzed. Results: Of the total 62 patients, 32 (51.6%) were newborns and 16 (25.8%) had a body weight < 3 kg. MBT shunt was applied to 48 patients (77.4%), while CS was applied to 14 patients (22.6%). There was no significant difference between the two surgical procedures in terms of requirement for urgent shunt or cardiopulmonary bypass, additional simultaneous surgical intervention, need for high postoperative inotropes, and in-hospital mortality (P>0.05). The rate of congestive heart failure in patients with in-hospital mortality was determined as 66.7% and it was significantly higher than in patients without heart failure (P<0.001). Conclusion: MBT shunt and CS are still frequently used in cyanotic patients. The use of small-diameter shunts, particularly when centrally located, can prevent the onset of congestive heart failure and lower mortality.

Noncardiac Surgery in Patients with Left Ventricular Assist Devices: A 11-Year Institutional Experience

ABSTRACT Introduction: Limited options in the end-stage treatment of heart failure have led to increased use of left ventricular assist devices. For this reason, the rate of non-cardiac surgeries in patients with left ventricular assist devices is also increasing. Our study aims to analyze surgical rate, anesthesia management, and results by reviewing our 11-year experience with patients who underwent non-cardiac surgery receiving left ventricular assist devices support. Methods: We retrospectively evaluated 57 patients who underwent non-cardiac surgery and 67 non-cardiac surgical procedures among 274 patients who applied between January 2011 and December 2022 and underwent left ventricular assist devices implantation with end-stage heart failure. Results: Fifty (74.6%) patients with left ventricular assist devices admitted to the hospital for non-cardiac surgery were emergency interventions. The most common reasons for admission were general surgery (52.2%), driveline wound revision (22.3%), and neurological surgery (14.9%). This patient group has the highest in-hospital mortality rate (12.8%) and the highest rate of neurological surgery (8.7%). While 70% of the patients who underwent neurosurgery were taken to surgery urgently, the International Normalized Ratio values of these patients were between 3.5 and 4.5 at the time of admission to the emergency department. Conclusion: With a perioperative multidisciplinary approach, higher morbidity and mortality risks can be reduced during emergencies and major surgical procedures.

Razão de mortalidade hospitalar padronizada: limites e potencialidades do indicador para a avaliação do desempenho hospitalar no Sistema Único de Saúde, Brasil / Hospital standardized mortality ratio: limits and potential of the indicator for assessing hospital performance in the Brazilian Unified National Health System / Razón de mortalidad hospitalaria estandarizada: límites y potencialidades del indicador para la evaluación del desempeño hospitalario en el Sistema Único de Salud, Brasil

Resumo: Análises comparativas, baseadas em indicadores de desempenho clínico, para monitorar a qualidade da assistência hospitalar vêm sendo realizadas há décadas em vários países, com destaque para a razão de mortalidade hospitalar padronizada (RMHP). No Brasil, ainda são escassos os estudos e a adoção de instrumentos metodológicos que permitam análises regulares do desempenho das instituições. O objetivo deste artigo foi explorar o uso da RMHP para a comparação do desempenho dos hospitais remunerados pelo Sistema Único de Saúde (SUS). O Sistema de Informações Hospitalares foi a fonte de dados sobre as internações de adultos realizadas no Brasil entre 2017 e 2019. A abordagem metodológica para estimar a RMHP foi adaptada aos dados disponíveis e incluiu as causas de internação (diagnóstico principal) responsáveis por 80% dos óbitos. O número de óbitos esperados foi estimado por um modelo de regressão logística que incluiu variáveis preditoras amplamente descritas na literatura. A análise foi realizada em duas etapas: (i) nível da internação e (ii) nível do hospital. O modelo final de ajuste de risco apresentou estatística C de 0,774, valor considerado adequado. Foi observada grande variação da RMHP, especialmente entre os hospitais com pior desempenho (1,54 a 6,77). Houve melhor desempenho dos hospitais privados em relação aos hospitais públicos. Apesar de limites nos dados disponíveis e desafios ainda vislumbrados para a sua utilização mais refinada, a RMHP é aplicável e tem potencial para se tornar um elemento importante na avaliação do desempenho hospitalar no SUS.

Abstract: Comparative analyses based on clinical performance indicators to monitor the quality of hospital care have been carried out for decades in several countries, most notably the hospital standardized mortality ratio (HSMR). In Brazil, studies and the adoption of methodological tools that allow regular analysis of the performance of institutions are still scarce. This study aimed to assess the use of HSMR to compare the performance of hospitals funded by the Brazilian Unified National Health System (SUS). The Hospital Information System was the source of data on adult hospitalizations in Brazil from 2017 to 2019. The methodological approach to estimate HSMR was adapted to the available data and included the causes of hospitalization (main diagnosis) responsible for 80% of deaths. The number of expected deaths was estimated using a logistic regression model that included predictor variables widely described in the literature. The analysis was conducted in two stages: (i) hospitalization level and (ii) hospital level. The final risk adjustment model showed a C-statistic of 0.774, which is considered adequate. The variation in HSMR was wide, especially among the worst-performing hospitals (1.54 to 6.77). Private hospitals performed better than public hospitals. Although the limits of the available data and the challenges still face its more refined use, HSMR is applicable and has the potential to become an important tool for assessing hospital performance in the SUS.

Resumen: Durante décadas se han realizado en varios países análisis comparativos basados en indicadores de desempeño clínico para monitorear la calidad de la atención hospitalaria, con énfasis en la razón de mortalidad hospitalaria estandarizada (RMHE). En Brasil, aún son escasos los estudios y la adopción de instrumentos metodológicos que permitan análisis regulares del desempeño de las instituciones. El objetivo fue explorar el uso de la RMHE para comparar el desempeño de los hospitales remunerados por el Sistema Único de Salud (SUS). El Sistema de Información Hospitalaria fue la fuente de datos sobre las hospitalizaciones de adultos realizadas en Brasil entre el 2017 y el 2019. El enfoque metodológico para estimar la RMHE se adaptó a los datos disponibles e incluyó las causas de hospitalización (diagnóstico principal) responsables del 80% de las muertes. El número de muertes esperadas se estimó mediante un modelo de regresión logística que incluyó variables predictoras ampliamente descritas en la literatura. El análisis se realizó en dos etapas: (i) nivel de la hospitalización y (ii) nivel del hospital. El modelo final de ajuste de riesgo presentó una estadística C de 0,774, valor considerado adecuado. Se observó una gran variación en la RMHE, especialmente entre los hospitales con peor desempeño (1,54 a 6,77). Hubo un mejor desempeño de los hospitales privados en comparación con los hospitales públicos. A pesar de las limitaciones de los datos disponibles y de los desafíos aún previstos para su uso más refinado, la RMHE es aplicable y tiene el potencial de convertirse en un elemento importante en la evaluación del desempeño hospitalario en el SUS.

Nationwide study of in-hospital maternal mortality in Ecuador, 2015-2022 / Estudio a nivel nacional de la mortalidad materna intrahospitalaria en Ecuador, 2015-2022 / Estudo nacional sobre mortalidade materna intra-hospitalar no Equador, 2015-2022

ABSTRACT Objective. This study aimed to analyze estimates of in-hospital delivery-related maternal mortality and sociodemographic factors influencing this mortality in Ecuador during 2015 to 2022. Methods. Data from publicly accessible registries from the Ecuadorian National Institute of Statistics and Censuses were analyzed. Maternal mortality ratios (MMRs) were calculated, and bivariate and multivariate logistic regression models were used to obtain unadjusted and adjusted odds ratios. Results. There was an increase in in-hospital delivery-related maternal deaths in Ecuador from 2015 to 2022: MMRs increased from 3.70 maternal deaths/100 000 live births in 2015 to 32.22 in 2020 and 18.94 in 2022. Manabí province had the highest rate, at 84.85 maternal deaths/100 000 live births between 2015 and 2022. Women from ethnic minorities had a higher probability of in-hospital delivery-related mortality, with an adjusted odds ratio (AOR) of 9.59 (95% confidence interval [95% CI]: 6.98 to 13.18). More maternal deaths were also observed in private health care facilities (AOR: 1.99, 95% CI: 1.4 to 2.84). Conclusions. Efforts to reduce maternal mortality have stagnated in recent years. During the COVID-19 pandemic in 2020, an increase in maternal deaths in hospital settings was observed in Ecuador. Although the pandemic might have contributed to the stagnation of maternal mortality estimates, socioeconomic, demographic and clinical factors play key roles in the complexity of trends in maternal mortality. The results from this study emphasize the importance of addressing not only the medical aspects of care but also the social determinants of health and disparities in the health care system.

RESUMEN Objetivo. El objetivo de este estudio fue analizar las cifras estimadas de mortalidad materna intrahospitalaria asociada al parto y los factores sociodemográficos que influyen en ella en Ecuador en el período 2015-2022. Métodos. Se analizaron datos de los registros de acceso público del Instituto Nacional de Estadística y Censos de Ecuador. Se calcularon las razones de mortalidad materna (RMM) y se utilizaron modelos de regresión logística bivariados y multivariados para obtener los cocientes de posibilidades sin ajustar y ajustados. Resultados. Entre el 2015 y el 2022, se observó un aumento de las muertes maternas intrahospitalarias asociadas al parto en Ecuador: la RMM aumentó de 3,70 muertes maternas por 100 000 nacidos vivos en el 2015 a 32,22 en el 2020 y 18,94 en el 2022. En la provincia de Manabí se registró la cifra más alta, con 84,85 muertes maternas por 100 000 nacidos vivos entre el 2015 y el 2022. Las mujeres pertenecientes a minorías étnicas tuvieron una mayor probabilidad de muerte intrahospitalaria por causas relacionadas con el parto, con un cociente de posibilidades ajustado (aOR, por su sigla en inglés) de 9,59 (intervalo de confianza del 95% [IC del 95%]: 6,98 a 13,18). También se observó una mayor mortalidad materna en los establecimientos de salud privados (aOR: 1,99, IC del 95%: 1,4 a 2,84). Conclusiones. Los esfuerzos para reducir la mortalidad materna se han estancado en los últimos años. Durante la pandemia de COVID-19, se observó un aumento de las muertes maternas en el 2020 en entornos hospitalarios en Ecuador. Si bien la pandemia podría haber contribuido a que las cifras estimadas de mortalidad materna se estancaran, los factores socioeconómicos, demográficos y clínicos desempeñan un papel clave en la complejidad de las tendencias de la mortalidad materna. Los resultados de este estudio destacan la importancia de abordar no solo los aspectos médicos de la atención, sino también los determinantes sociales de la salud y las disparidades en el sistema de atención de salud.

RESUMO Objetivo. O objetivo deste estudo foi analisar estimativas de mortalidade materna relacionada ao parto intra-hospitalar e os fatores sociodemográficos que influenciaram esse tipo de mortalidade no período de 2015 a 2022 no Equador. Métodos. Foram analisados dados de registros de acesso público do Instituto Nacional de Estatísticas e Censos do Equador. Foram calculadas razões de mortalidade materna (RMM), com o uso de regressão logística bivariada e multivariada para obter razões de chance não ajustadas e ajustadas. Resultados. Houve um aumento nas mortes maternas relacionadas ao parto intra-hospitalar no Equador entre 2015 e 2022: as RMM aumentaram de 3,70 mortes maternas/100 mil nascidos vivos em 2015 para 32,22 em 2020 e 18,94 em 2022. A província de Manabí teve a taxa mais alta, com 84,85 mortes maternas/100 mil nascidos vivos entre 2015 e 2022. Mulheres de minorias étnicas tiveram maior probabilidade de mortalidade relacionada ao parto intra-hospitalar, com uma razão de chances ajustada (RCa) de 9,59 (intervalo de confiança de 95% [IC95%]: 6,98 a 13,18). Também foram observadas mais mortes maternas em estabelecimentos de saúde privados (RCa: 1,99, IC95%: 1,4 a 2,84). Conclusões. As inciativas para reduzir a mortalidade materna estagnaram nos últimos anos. Durante a pandemia de COVID-19 em 2020, foi observado um aumento nas mortes maternas em hospitais do Equador. Embora a pandemia possa ter contribuído para a estagnação das estimativas de mortalidade materna, fatores socioeconômicos, demográficos e clínicos desempenharam papéis fundamentais na complexidade das tendências de mortalidade materna. Os resultados deste estudo destacam a importância de abordar não apenas os aspectos clínicos da atenção, mas também os determinantes sociais da saúde e as disparidades do sistema de saúde.

Early vs. Standard Loop Ileostomy Closure: An Unmatched Case-Control Study / Cierre Temprano vs Estándar de Ileostomía en Asa. Estudio de Casos y Controles no Emparejado

SUMMARY: Early closure of a loop ileostomy (ECI) is a relatively new practice, for which there is insufficient evidence regarding its effectiveness in relation to closure at conventional times. The aim of this study was to report postoperative complications (POC) and hospital mortality in patients with loop ileostomy (LI) who underwent ECI, compared with patients with LI who underwent late closure. Un- matched case-control study. Patients with LI who underwent surgery at Clínica RedSalud Mayor Temuco (2010-2022) were included. Cases were defined as patients with LI who underwent early closure and controls as subjects who underwent closure at the usual times. No matching was performed, but a 1:1 relationship between cases and controls was considered. Outcome variables were postoperative complications and hospital mortality. Other variables of interest were surgical time and hospital stay. Descriptive statistics were applied with calculation of proportions and measures of central tendency. Subsequently, t-test and Pearson Chi2 for comparison of averages and proportions was applied, and odds ratios and their respective 95 % CI were calculated. In this study 39 patients with AI were operated on (18 cases and 21 controls). Age and BMI average of the studied subjects was 71.3±7.1 years and 27.3±19.8 kg/m2 respectively. Mean LI closure time, surgical time, and hospitalization were: 10.0±0.7 months; 62.5±10.6min; 3.8±0.1 days respectively. POC were only surgical site infections. Three in cases (16.7 %) and 3 in controls (14.3 %). No anastomotic dehiscence or hospital mortality was observed in either cases or controls. There were no differences in comorbidities or surgical site infection between cases and controls (OR of 0.6 and 1.2 respectively) In this experience, the results of performing the CTI were similar to the late closing in relation to the variables studied.

El cierre temprano de una ileostomía en asa (IA), es una práctica relativamente nueva, sobre la que no hay suficiente evidencia respecto de su efectividad en relación con el cierre en tiempos convencionales. El objetivo de este estudio fue verificar diferencias en la tasa de complicaciones postoperatorias (CPO) y de mortalidad hospitalaria en pacientes con IA sometidos a cierre temprano comparados con pacientes con IA sometidos a cierre tardío. Estudio de casos y controles sin emparejamiento. Se incluyeron pacientes con IA que fueron sometidos a cirugía en la Clínica RedSalud Mayor Temuco (2010-2022). Los casos se definieron como pacientes con IA sometidos a cierre temprano y los controles como sujetos con IA sometidos a cierre en tiempos habituales. No se realizó emparejamiento. Se consideró una relación 1:1 entre casos y controles. Las variables de resultado fueron CPO y mortalidad hospitalaria. Otras variables de interés fueron: tiempo quirúrgico y hospitalización. Se aplicó estadísticas descriptivas (cálculo de proporciones y medidas de tendencia central). Posteriormente, se aplicó prueba t-test y Chi2 para comparación de promedios y proporciones; y se calcularon odds ratios e intervalos de confianza del 95 %. Se operaron 39 pacientes con IA (18 casos y 21 controles). El promedio de edad e IMC fue 71,3±7,1 años y 27,3±19,8 kg/m2, respectivamente. El tiempo promedio de cierre de IA, tiempo quirúrgico y hospitalización fueron: 10,0±0,7 meses; 62,5±10,6 minutos; 3,8±0,1 días, respectivamente. Las CPO fueron infecciones del sitio quirúrgico (3 casos; 16,7 % y 3 controles; 14,3 %). No se observó dehiscencia anastomótica ni mortalidad hospitalaria en casos ni controles. No hubo diferencias en comorbilidades ni en infecciones del sitio quirúrgico entre casos y controles (OR de 0,6 y 1,2, respectivamente). No se evidenciaron diferencias entre realizar cierre temprano o tardío de IA, respecto de las variables CPO y de mortalidad hospitalaria.