Having chronic back pain did not impact COVID-19 outcome in a low-income population - a retrospective observational study

Abstract Introduction Chronic back pain (CBP) is a major cause of years lived with disability. Social inequalities increase the prevalence and burden of CBP. Management of CBP was affected by restricted access to non-pharmacological treatments and outdoor activities during COVID-19 pandemic. Objectives To determine the prevalence of CBP among patients with COVID-19 as well as the impact of having CBP in COVID-19 outcome in our low-income population. Methods Retrospective cohort of individuals with confirmed COVID diagnosis from May 2020 - March 2021, at Hospital Regional UNIMED (HRU) in Fortaleza, Ceará, Brazil. Data included comorbidities and household income. Results Among 1,487 patients, 600 (40.3%) were classified as having CBP. Mean age as well as income were similar in CBP and non-CBP groups, with more women in the CBP group. Hypertension and asthma, but not diabetes, were more prevalent in those with CBP. Need for emergency care, hospitalization, and admission to intensive care unit were similar regardless of having CBP. Dyspnea was more common in CBP vs. non-CBP groups, with 48.8% vs. 39.4% percentages, respectively (p = 0.0004). Conclusion Having CBP prior to COVID did not impact the acute clinical outcome of COVID individuals of a low- income population.

Ease in Emergency Hospital Visits Due to Covid-19 Following Implementation of a Telemedicine Service in Ceará, Brazil.

Background: We assessed the impact of implementing a virtual emergency room (VER) in easing emergency room (ER) visits in patients suspected of having COVID-19. Materials and Methods: Retrospective observational cohort study conducted in May 2020 and in March 2021, during the first and second waves in Brazil. Patients could choose to either visiting ER or using the VER (implemented in March 2021). Medical records were revised for demographic and clinical data. The primary outcome was the number of visits. Results: A total of 32,822 visits were evaluated. HR was more than three times less in the VER group with <10% VER clients going to ER. The trend and volume of use of the emergency sector in the periods did not show a statistically significant difference, despite the higher number of cases in the second period. Conclusion: This telemedicine strategy led to a reduction in visits to the ER. Also, our results suggest the safety of this intervention.

Dealing with the impact of the COVID-19 pandemic on a rapid response team operation in Brazil: Quality in practice.

QUALITY PROBLEM OR ISSUE: Up to 13 July 2020, >12 million laboratory-confirmed cases of coronavirus disease of 2019 (COVID-19) infection have been reported worldwide, 1 864 681 in Brazil. We aimed to assess an intervention to deal with the impact of the COVID-19 pandemic on the operations of a rapid response team (RRT). INITIAL ASSESSMENT: An observational study with medical record review was carried out at a large tertiary care hospital in Fortaleza, a 400-bed quaternary hospital, 96 of which are intensive care unit beds. All adult patients admitted to hospital wards, treated by the RRTs during the study period, were included, and a total of 15 461 RRT calls were analyzed. CHOICE OF SOLUTION: Adequacy of workforce sizing. IMPLEMENTATION: The hospital adjusted the size of its RRTs during the period, going from two to four simultaneous on-duty medical professionals. EVALUATION: After the beginning of the pandemic, the number of treated cases in general went from an average of 30.6 daily calls to 79.2, whereas the extremely critical cases went from 3.5 to 22 on average. In percentages, the extremely critical care cases went from 10.47 to 20%, with P < 0.001. Patient mortality remained unchanged. The number of critically ill cases and the number of treated patients increased 2-fold in relation to the prepandemic period, but the effectiveness of the RRT in relation to mortality was not affected. LESSONS LEARNED: The observation of these data is important for hospital managers to adjust the size of their RRTs according to the new scenario, aiming to maintain the intervention effectiveness.

Custo-efetividade de teste rápido de detecção de Klebsiella spp. para rastreio hospitalar / Cost effectiveness of rapid testing for detection of Klebsiella spp. for hospital screening

Introdução: A resistência bacteriana é um problema mundial, atingindo principalmente países em desenvolvimento. Estima-se que no futuro vai matar mais que o câncer e custar 100 trilhões de dólares até 2050. Objetivo: O presente trabalho teve por objetivo identificar a razão de custo-efetividade incremental (RCEI) do rastreio de infecção por Klebsiella pneumoniae produtora de carbapenemase (KPC) conforme protocolo vigente para produção de carbamapenase em comparação com a utilização de protocolo de triagem utilizando teste rápido (PCR em tempo real). Métodos: Foi realizado estudo do tipo análise de custo-efetividade, utilizando um modelo de árvore de decisão e foram utilizados no estudo dados secundários de fontes governamentais e da literatura científica, considerando-se a perspectiva do sistema de saúde público. A população foi composta por adultos internados em hospitais em risco de infecção por KPC. Resultados: O presente trabalho identificou que o uso de testes de identificação de KPC com técnicas em tempo real é dominante em relação ao teste convencional, com razão de custo-efetividade incremental de R$ -426,53/0,3, ou seja, 1.421,76 reais por caso corretamente identificado favorável a teste molecular. Conclusões: O uso de testes rápidos para detecção de KPC pode ser considerado como um método de rastreio eficiente.

Introduction: Bacterial resistance is a worldwide problem, affecting mainly developing countries. It is estimated that in the future will kill more than cancer and cost US$ 100 trillion by 2050. Objective: The aim of this study was to identify the incremental cost-effectiveness ratio (ICER) of the screening of Klebsiella pneumoniae that produces carbapenemase (KPC) infection according to the current protocol for carbamapenase production compared to the use of screening protocol using rapid test (real-time PCR). Methods: A cost-effectiveness analysis was performed using a decision tree model. Secondary data from governmental sources and the scientific literature will be used in the study, considering the perspective of the public health system. The population was composed of adult hospitalized patients at risk of KPC infection. Results: The present work identified that the use of KPC identification tests with real-time techniques are dominant in relation to the conventional test, with cost ratio incremental effectiveness of R$ -426.53/0.3, that is, 1,421.76 reais per case correctly identified favorable to the molecular test. Conclusions: The use of rapid tests for detection of KPC Can be regarded as an efficient screening method.

Evolution of chronic recurrent multifocal osteomyelitis in a child shown by MRI.

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare idiopathic inflammatory disease that mainly affects children and young adults. The clinical signs and symptoms are nonspecific, hindering and delaying the proper diagnosis. We report a case of CRMO in a child with chronic pain in the cervical and thoracic spine. Investigations of the pain revealed a diagnosis of osteomyelitis in the biopsy, indicating a course of antibiotic treatment. After a year, there was progressive worsening of the pain, and it soon spread to the left wrist and right ankle. Magnetic resonance imaging of the left wrist and right ankle revealed morphostructural changes. A new biopsy was performed on the wrist and ankle, and osteomyelitis was pinpointed again. In view of the clinical, radiological, and histopathological findings, the patient was diagnosed with CRMO. The following treatment consisted of nonsteroidal anti-inflammatory drugs, methotrexate, and pamidronate. The strength of this case is the fact that there was extensive imaging and more than one biopsy, and the patient was followed. Magnetic resonance imaging was valuable in assessing the extent and activity of a lesion.

Effectiveness of rapid response teams in reducing intrahospital cardiac arrests and deaths: a systematic review and meta-analysis. / Efetividade do uso de times de resposta rápida para reduzir a ocorrência de parada cardíaca e mortalidade hospitalar: uma revisão sistemática e metanálise.

OBJECTIVE: To evaluate the effectiveness of rapid response teams using early identification of clinical deterioration in reducing the occurrence of in-hospital mortality and cardiorespiratory arrest. DATA SOURCES: The MEDLINE, LILACS, Cochrane Library, Center for Reviews and Dissemination databases were searched. STUDY SELECTION: We included studies that evaluated the effectiveness of rapid response teams in adult hospital units, published in English, Portuguese, or Spanish, from 2000 to 2016; systematic reviews, clinical trials, cohort studies, and prepost ecological studies were eligible for inclusion. The quality of studies was independently assessed by two researchers using the Newcastle-Ottawa, modified Jadad, and Assessment of Multiple Systematic Reviews scales. DATA EXTRACTIONS: The results were synthesized and tabulated. When risk measures were reported by the authors of the included studies, we estimated effectiveness as 1-RR or 1-OR. In pre-post studies, we estimated effectiveness as the percent decrease in rates following the intervention. RESULTS: Overall, 278 studies were identified, 256 of which were excluded after abstract evaluation, and two of which were excluded after full text evaluation. In the meta-analysis of the studies reporting mortality data, we calculated a risk ratio of 0.85 (95%CI 0.76 - 0.94); and for studies reporting cardiac arrest data the estimated risk ratio was 0.65 (95%CI 0.49 - 0.87). Evidence was assessed as low quality due to the high heterogeneity and risk of bias in primary studies. CONCLUSION: We conclude that rapid response teams may reduce in-hospital mortality and cardiac arrests, although the quality of evidence for both outcomes is low.

OBJETIVO: Avaliar a efetividade de times de resposta rápida com uso de identificação precoce de deterioração clínica, na redução das ocorrências de parada cardiorrespiratória e morte no hospital. FONTES DE DADOS: Realizaram-se buscas nas bases de dados MEDLINE, LILACS, Cochrane Library e Center for Reviews and Dissemination. SELEÇÃO DE ESTUDOS: Incluímos trabalhos que avaliaram a efetividade de times de resposta rápida em unidades hospitalares de pacientes adultos, publicados em inglês, português ou espanhol, no período entre 2000 e 2016. Consideraram-se elegíveis revisões sistemáticas, ensaios clínicos, estudos de coorte e ecológicos pré-pós. A qualidade dos trabalhos foi avaliada de forma independente por dois dos pesquisadores com utilização das escalas Newcastle-Ottawa e Jadad modificada, e da ferramenta Assessment of Multiple Systematic Reviews. EXTRAÇÃO DOS DADOS: Os resultados foram resumidos e tabulados. Quando os autores dos estudos incluídos relataram medidas de risco, estimamos a efetividade como 1-RR ou 1-OR. Nos estudos pré-pós, estimamos a efetividade como a diminuição porcentual nas taxas após a intervenção. RESULTADOS: Identificou-se um total de 278 trabalhos, dos quais 256 foram excluídos após avaliação do resumo, e dois outros após avaliação do texto completo. Na metanálise dos estudos que relataram dados de mortalidade, calculamos uma proporção de risco de 0,85 (IC95% 0,76 - 0,94); para os trabalhos que relataram dados de parada cardíaca, o cálculo da proporção de risco foi de 0,65 (IC95% 0,49 - 0,87). A evidência foi de baixa qualidade em razão da heterogeneidade e do risco de viés nos ensaios primários. CONCLUSÃO: Os times de resposta rápida podem reduzir a incidência de morte e parada cardíaca no hospital, embora a qualidade da evidência seja baixa para ambos os desfechos.

Efetividade do uso de times de resposta rápida para reduzir a ocorrência de parada cardíaca e mortalidade hospitalar: uma revisão sistemática e metanálise / Effectiveness of rapid response teams in reducing intrahospital cardiac arrests and deaths: a systematic review and meta-analysis

RESUMO Objetivo: Avaliar a efetividade de times de resposta rápida com uso de identificação precoce de deterioração clínica, na redução das ocorrências de parada cardiorrespiratória e morte no hospital. Fontes de dados: Realizaram-se buscas nas bases de dados MEDLINE, LILACS, Cochrane Library e Center for Reviews and Dissemination. Seleção de estudos: Incluímos trabalhos que avaliaram a efetividade de times de resposta rápida em unidades hospitalares de pacientes adultos, publicados em inglês, português ou espanhol, no período entre 2000 e 2016. Consideraram-se elegíveis revisões sistemáticas, ensaios clínicos, estudos de coorte e ecológicos pré-pós. A qualidade dos trabalhos foi avaliada de forma independente por dois dos pesquisadores com utilização das escalas Newcastle-Ottawa e Jadad modificada, e da ferramenta Assessment of Multiple Systematic Reviews. Extração dos dados: Os resultados foram resumidos e tabulados. Quando os autores dos estudos incluídos relataram medidas de risco, estimamos a efetividade como 1-RR ou 1-OR. Nos estudos pré-pós, estimamos a efetividade como a diminuição porcentual nas taxas após a intervenção. Resultados: Identificou-se um total de 278 trabalhos, dos quais 256 foram excluídos após avaliação do resumo, e dois outros após avaliação do texto completo. Na metanálise dos estudos que relataram dados de mortalidade, calculamos uma proporção de risco de 0,85 (IC95% 0,76 - 0,94); para os trabalhos que relataram dados de parada cardíaca, o cálculo da proporção de risco foi de 0,65 (IC95% 0,49 - 0,87). A evidência foi de baixa qualidade em razão da heterogeneidade e do risco de viés nos ensaios primários. Conclusão: Os times de resposta rápida podem reduzir a incidência de morte e parada cardíaca no hospital, embora a qualidade da evidência seja baixa para ambos os desfechos.

ABSTRACT Objective: To evaluate the effectiveness of rapid response teams using early identification of clinical deterioration in reducing the occurrence of in-hospital mortality and cardiorespiratory arrest. Data sources: The MEDLINE, LILACS, Cochrane Library, Center for Reviews and Dissemination databases were searched. Study selection: We included studies that evaluated the effectiveness of rapid response teams in adult hospital units, published in English, Portuguese, or Spanish, from 2000 to 2016; systematic reviews, clinical trials, cohort studies, and prepost ecological studies were eligible for inclusion. The quality of studies was independently assessed by two researchers using the Newcastle-Ottawa, modified Jadad, and Assessment of Multiple Systematic Reviews scales. Data extractions: The results were synthesized and tabulated. When risk measures were reported by the authors of the included studies, we estimated effectiveness as 1-RR or 1-OR. In pre-post studies, we estimated effectiveness as the percent decrease in rates following the intervention. Results: Overall, 278 studies were identified, 256 of which were excluded after abstract evaluation, and two of which were excluded after full text evaluation. In the meta-analysis of the studies reporting mortality data, we calculated a risk ratio of 0.85 (95%CI 0.76 - 0.94); and for studies reporting cardiac arrest data the estimated risk ratio was 0.65 (95%CI 0.49 - 0.87). Evidence was assessed as low quality due to the high heterogeneity and risk of bias in primary studies. Conclusion: We conclude that rapid response teams may reduce in-hospital mortality and cardiac arrests, although the quality of evidence for both outcomes is low.

Bed management team with Kanban web-based application.

OBJECTIVE: To measure the effectiveness of the bed management process that uses a web-based application with Kanban methodology to reduce hospitalization time of hospitalized patients. DESIGN: Before-after study was performed. SETTING: The study was conducted between July 2013 and July 2017, at the Unimed Regional Hospital of Fortaleza, which has 300 beds, of which 60 are in the intensive care unit (ICU). It is accredited by International Society for Quality in Healthcare. POPULATION: Patients hospitalized in the referred period. INTERVENTION: Bed management with an application that uses color logic to signal at which stage of high flow the patients meet, in which each patient is interpreted as a card of the classical Kanban theory. It has an automatic user signaling system for process movement, and a system for monitoring and analyzing discharge forecasts. MAIN OUTCOME MEASURES: Length of hospital stay, number of customer complaints related to bed availability. RESULTS: After the intervention, the hospital's overall hospital stay time was reduced from 5.6 days to 4.9 days (P = 0.001). The units with the greatest reduction were the ICUs, with reduction from 6.0 days to 2.0 (P = 0.001). The relative percentage of complaints regarding bed availability in the hospital fell from 27% to 0%. CONCLUSION: We conclude that the use of an electronic tool based on Kanban methodology and accessed via the web by a bed management team is effective in reducing patients' hospital stay time.

Prevalência de risco moderado e alto de aspiração em pacientes hospitalizados e custo-efetividade da aplicação de protocolo preventivo / Prevalence of moderate and high risk of aspiration in hospitalized patients and cost-effectiveness of a preventive protocol application

Objetivo: O objetivo deste estudo foi estimar a prevalência de risco de broncoaspiração e a verificação do custo-efetividade da aplicação de protocolo preventivo. Métodos: Realizou-se estudo transversal de base hospitalar com amostra aleatória simples, seguido de análise estatística de associação e econômica do tipo árvore de decisão e custo-efetividade. Resultados: Verificou-se que a prevalência de risco de broncoaspiração é alta em hospitais gerais de grande porte, com a magnitude de 56%, e que a aplicação de protocolo preventivo com avaliação precoce de fonoaudiologista é custo-efetiva, com ganho de quase R$ 900,00 por internação hospitalar, além de redução de 0,15 dia de internação também por paciente, com razão de custo-efetividade incremental de economia de R$ 5.607,83. Conclusão: Conclui-se que a adoção de programa preventivo com a participação de fonoaudiólogos é altamente custo-efetiva.

Objective: The objective of this study was to estimate the prevalence of risk of aspiration and analysis of the cost effectiveness of the implementation of a preventive protocol. Methods: A cross-sectional study of hospital base with simple random sample, followed by statistical analysis of association and economic cost-effectiveness analysis using a decision tree. Results: It was found that the prevalence of risk of aspiration is high in general hospitals, with the magnitude of 56%, and that the implementation of preventive protocol with early evaluation of speech therapy is cost effective, with a gain of almost R$ 900.00 per hospitalization, as well as a reduction of 0.15 days of hospitalization also per patient, with incremental cost-effectiveness ratio of R$ 5,607.83 of economy. Conclusion: It is concluded that the adoption of preventive program with participation of speech therapy is highly cost-effective.

A longterm prospective real-life experience with leflunomide in juvenile idiopathic arthritis.

OBJECTIVE: To describe a clinical practice with leflunomide (LEF) in juvenile idiopathic arthritis (JIA). METHODS: Patients with JIA seen between May 2008 and May 2012 and considered nonresponsive to methotrexate (MTX) were given LEF and prospectively followed. Primary outcome was a 28-joint Disease Activity Score (DAS28) of low disease activity (< 3.2) in less than 6 months. Childhood Health Assessment Questionnaire (CHAQ) scores and safety data were recorded. RESULTS: Forty-three patients (33 female) were included with 25 (58.1%) polyarticular, 10 oligoarticular (7 extended; 3 persistent), 6 systemic, and 2 enthesitis-related. Ten (23.2%) were rheumatoid factor-positive and 7 (16.3%) had antinuclear antibodies. Prior drugs other than MTX: 11 (25.5%) chloroquine diphosphate + MTX and 2 (4.6%) sulfasalazine + MTX; mean prednisone dose was 6.4 ± 9.3 mg. The MTX dose prior to LEF was 14.5 ± 4.5 mg/m(2)/week. LEF dose and duration of therapy were 16.6 ± 5.2 mg/d and 3.6 ± 2.2 years, respectively. Nineteen patients (44.2%) interrupted LEF: 1 entered remission, 11 were nonresponsive, and 7 were intolerant (16.2%). Baseline DAS28 (5.57 ± 0.7) dropped to 3.7 ± 1.2 at final analysis (p < 0.001) and 16 patients (37.2%) had a low DAS28 [< 3.2; 12 (27.9%) while taking LEF + MTX and 4 (9.3%) while taking monotherapy]. At last followup, the number of patients with DAS28 > 5.1 dropped from 34 (79%) to 9 (20.9%) and CHAQ scores from 0.86 ± 0.7 to 0.44 ± 0.5 (p < 0.001). CONCLUSION: LEF isolated or combined with MTX is effective and safe to treat JIA in patients refractory to MTX.