Incidence and risk factors for nasoenteral tube-related mechanical complications in a double cohort / Incidencia y factores de riesgo de complicaciones mecánicas relacionadas con la sonda nasoenteral en una doble cohorte

Introduction: nasoenteral tube-related mechanical complications are feared and little is known about their incidence and the risk factors associated with them. Objective: to evaluate the incidence of nasoenteral tube-related mechanical complications and the risk factors associated with them. Methods: a prospective double cohort of adult patients who used nasoenteral tube and were inpatients in nursing wards at a Brazilian high-complexity hospital. Data were collected daily. Cox regression and Generalized Estimating Equations were applied in the statistical analysis. Results: the sample was 494 patients, or 3,676 patient days. Traction (33 %) and obstruction (3.4 %) were frequent. Inadequate positioning of the distal end of the device and bleeding in the nasal mucosa occurred once each (0.2 %). There was no bronchoaspiration. Traction was associated with a history of stroke (HR: 1.69; 95 % CI: 1.09 to 2.64; p = 0.020), a higher score on the Glasgow Coma Scale (RR: 1.09; 95 % CI: 1.03 to 1.15; p = 0.002), and older age (RR: 1.02; 95 % CI: 1.00 to 1.04; p = 0.049). Being admitted to hospital already with the tube on (HR: 3.56; 95 % CI: 1.31 to 9.66; p = 0.013) and having opioids administered in the form of pills (RR: 6.09; 95 % CI: 1.37 to 27.2; p = 0.018) were risk factors for obstruction. Conclusion: traction or removal and obstruction of the device were frequent. A history of stroke, higher score on the Glasgow Coma Scale, and older age were risk factors for traction, whereas obstruction was more common in patients who already had the tube on at admission to the nursing ward, and who had opioids in the form of pills administered via the tube (AU)

Introducción: las complicaciones mecánicas relacionadas con el uso de la sonda nasoenteral son motivo de preocupación, pero se conoce poco sobre su incidencia y factores asociados. Objetivo: evaluar la incidencia y los factores de riesgo de complicaciones mecánicas relacionadas con el uso de la sonda nasoenteral. Métodos: doble cohorte prospectiva de pacientes adultos usuarios de sonda nasoenteral, ingresados en un hospital brasileño de alta complejidad. Se recogieron datos durante todos los días de su ingreso. Se emplearon la regresión de Cox y ecuaciones de estimación generalizada (GEE) para el análisis estadístico. Resultados: se siguió a 494 pacientes o 3676 pacientes-días. El desplazamiento accidental (33 %) y la obstrucción (3,4 %) fueron frecuentes. Hubo solo un caso de posicionamiento incorrecto del extremo distal y otro de sangrado de la mucosa nasal (0,2 %). No se observó broncoaspiración. El desplazamiento se asoció a historial de accidente cerebrovascular (HR: 1,69; IC 95 %: 1,09 a 2,64; p = 0,020), el mayor puntaje en la escala de coma de Glasgow (RR: 1,09; IC 95 %: 1,03 a 1,15; p = 0,002) y la mayor edad (RR: 1,02; IC 95 %: 1,00 a 1,04; p = 0,049). Los pacientes internados ya con sonda (HR: 3,56; IC 95 %: 1,31 a 9,66; p = 0,013) y la prescripción de opioides en comprimidos (RR: 6,09; IC 95 %: 1,37 a 27,2; p = 0,018) se asociaron a mayor riesgo de obstrucción. Conclusión: El desplazamiento o la retirada accidental de la sonda, así como su obstrucción se presentaron con frecuencia. El historial de accidente cerebrovascular, el puntaje superior en la escala de coma de Glasgow y la mayor edad son riesgos para el desplazamiento, mientras que la obstrucción es más frecuente en los pacientes con sonda ya al ingreso y en quienes reciben opioides en comprimidos vía sonda (AU)

Constipation in a cohort prospective in adult critically ill patients: How much occurs and why? / Estreñimiento en una cohorte prospectiva de adultos críticos: porcentaje y motivo de su incidencia.

OBJECTIVE: To assess the incidence and factors associated with constipation in adult critical care patients. DESIGN: Prospective cohort study. SETTING: Intensive care unit (ICU) of a high-complexity hospital from November 2015 to October 2016. PATIENTS: Adults who were hospitalized for at least 72h in the ICU were followed from their admission to the ICU until their departure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In the 157 patients followed up, the incidence of constipation was 75.8%. The univariate analysis showed that constipated patients were younger, used more sedation and showed more respiratory and postoperative causes for hospitalization, while non-constipated patients were hospitalized more for gastrointestinal reasons. The use of vasoactive substances, mechanical ventilation and haemodialysis was similar between the constipated and non-constipated patients. Multivariate analysis, days of use of docusate+bisacodyl (HR: .79; 95% CI: .65-.96) of omeprazole or ranitidine (HR: .80; 95%CI: .73-.88) and lactulose (HR: .87; 95%CI: .76-.99) were independent protection factors for constipation. CONCLUSION: Constipation has a high incidence among adult critical care patients. Days of drug use acting on the digestive tract (lactulose, docusate+bisacodyl and omeprazole and/or ranitidine) are able to prevent this outcome.

A Vascular Complications Risk (VASCOR) score for patients undergoing invasive cardiac procedures in the catheterization laboratory setting: A prospective cohort study.

BACKGROUND: Vascular complications are still common in the catheterization laboratory setting. However, no risk scores for their prediction have been described. With a view to bridging this gap, the present study sought to develop and validate a score for prediction of vascular complications associated with arterial access in patients undergoing interventional cardiology procedures. METHODS: This prospective multicenter cohort study included adult patients who underwent cardiac catheterization via the femoral or radial route. The outcomes of interest were: access site hematoma; major and minor bleeding; and retroperitoneal hemorrhage, pseudoaneurysm, or arteriovenous fistula requiring surgical repair. Past medical history as well as pre-procedural, intra-procedural, and post-procedural variables were collected. Patients were randomly allocated to the derivation or validation cohorts at a 2:1 ratio. The following equation constituted the score: (>6F introducer sheath×4.0)+(percutaneous coronary intervention×2.5)+(history of vascular complication after prior interventional cardiology procedure×2.0)+(prior use of warfarin or phenprocoumon×2.0)+(female sex×1.5)+(age⩾60 years×1.5). The maximum score is 13.5 points. RESULTS: A score dichotomized at ⩾3 (best cutoff for balancing sensitivity and specificity) was moderately accurate (sensitivity=0.66 (95% confidence interval: 0.59-0.73); specificity=0.59 (95% confidence interval: 0.56-0.61)). Patients with a score ⩾3 were at increased risk of complications (odds ratio: 2.95; 95% confidence interval: 2.22-3.91). CONCLUSIONS: This study yielded a score that is capable of predicting vascular complications and easily applied in daily practice by providers working in the catheterization laboratory setting.

Dental treatment in Angelman syndrome patients. 8 case reports.

AIM: Angelman syndrome is a rare neurogenetic disorder resulting in delayed neuropsychological development, intellectual disability, speech impairment, movement or balance disorder and a behavioural uniqueness. It is caused by deletion of maternal chromosome 15q11-13. The syndrome has oral manifestations such as diastemas, tongue thrusting, sucking/swallowing disorder, mandibular prognathism, and wide mouth. The dental literature on the syndrome is scarce. CASE REPORT: We report our approach to dental procedures in Angelman syndrome patients, and the relationship between the dental staff and the patient and his family. The purpose of this paper is to highlight the possibility of dental treatment in general anaesthesia, due to the lack of cooperation of some of these patients.

Comparison of NCHS, CDC and WHO growth charts in the nutritional assessment of hospitalized children up to five years old.

AIMS: This study evaluated the agreement of growth charts proposed by the National Center for Health Statistics (NCHS/1977), Centers for Disease Control and Prevention (CDC/2000) and World Health Organization (WHO/2006). METHODS: Were assessed children between 0 and 5 years old, hospitalized in the pediatric wards of a Brazilian school hospital. Z-score indexes: stature/age (S/A), weight/age (W/A) and weight/stature (W/S) was evaluated, in each of the three references (NCHS, CDC and WHO). ANOVA and test Bland & Altman and Lin plots were used in the comparison of the 3 charts. The agreement of the nutritional state categories was also evaluated, through kappa coefficient. The study was approved by the Institution's Research Ethics Committee. RESULTS: The study analyzed 337 children, whose median age was 0.52 (IQR: 0.21-1.65) years, 65.3% of them were below 1 year old, 60.2% were male and 50% hospitalized due to acute respiratory disease. Lower Z-scores of W/A and S/A were obtained with the WHO charts and lower W/S with the CDC chart. High correlation and agreement were observed among the criteria, but more patients were classified as presenting shortness through the WHO criteria. CDC and WHO criteria were more rigorous than the NCHS criteria for the diagnosis of underweight (W/A) and malnutrition (W/S). CONCLUSION: Despite the strong agreement of the 3 charts, the adoption of the WHO charts seems to be more helpful for the children's nutritional screening for admission, as it enables to detect a higher number of malnourished children or at nutritional risk, who will benefit from an early intervention.

Influence of the assessment method on the prevalence of hospital malnutrition: a comparison between two periods / Influencia del método de evaluación de la prevalencia de la desnutrición hospitalaria: una comparación entre dos períodos

There is no consensus on the best method to assess the nutritional status of hospitalized adults although many methods are available. This study evaluated the prevalence of malnutrition in adults at different times of hospitalization (admission, 7th, 14th, 21st, and 28th days) in two years(2002 and 2006). All patients were submitted to anthropometric assessment, Subjective Global Assessment (SGA),determination of serum albumin, and lymphocyte count. There were no differences in prevalence of malnutrition between the years of assessment, but great variability was found when different methods were used. An increase in malnutrition was detected when the diagnostic criterion was the total count of lymphocytes, while a decrease was detected in the case of the Body Mass Index (BMI). In both years, the increase in malnutrition was not statistically significant over the weeks of hospitalization. Over the years, malnutrition remains an important health problem of hospitalized adults, requiring appropriate diagnosis and management. Each institution is recommended to adopt one or more appropriate methods of nutritional assessment, which have been validated for the population under their care (AU)

No hay consenso sobre el mejor método para evaluar el estado nutricional de adultos hospitalizados aunque muchos métodos estén disponibles. Este estudio evaluó la prevalencia de desnutrición en los adultos en distintos momentos de la hospitalización (admisión, 7, 14, 21y 28 días) en dos años: 2002 y 2006. Todos los pacientes se sometieron a la evaluación antropométrica, Valoración Subjetiva Global (VSG), la determinación de la albúmina sérica y linfocitos. No hubo diferencias en la prevalencia de desnutrición entre los años de evaluación, pero se encontró gran variabilidad en el empleo de diferentes métodos. Se ha detectado mayor desnutrición cuando el criterio de diagnóstico fue el recuento total de linfocitos y menor al adoptar el Índice de Masa Corporal (IMC). En ambos años, a lo largo de las semanas de hospitalización, hubo aumento, pero no estadísticamente significativo, de la desnutrición. A lo largo de los años, la desnutrición sigue siendo un importante problema de salud de los adultos hospitalizados, lo que requiere diagnóstico y tratamiento adecuados. Se recomienda que cada institución adopte uno o más métodos de evaluación nutricional, adecuada y validada para la población bajo su cuidado (AU)

Influence of the assessment method on the prevalence of hospital malnutrition: a comparison between two periods.

There is no consensus on the best method to assess the nutritional status of hospitalized adults although many methods are available. This study evaluated the prevalence of malnutrition in adults at different times of hospitalization (admission, 7th, 14th, 21st, and 28th days) in two years (2002 and 2006). All patients were submitted to anthropometric assessment, Subjective Global Assessment (SGA), determination of serum albumin, and lymphocyte count. There were no differences in prevalence of malnutrition between the years of assessment, but great variability was found when different methods were used. An increase in malnutrition was detected when the diagnostic criterion was the total count of lymphocytes, while a decrease was detected in the case of the Body Mass Index (BMI). In both years, the increase in malnutrition was not statistically significant over the weeks of hospitalization. Over the years, malnutrition remains an important health problem of hospitalized adults, requiring appropriate diagnosis and management. Each institution is recommended to adopt one or more appropriate methods of nutritional assessment, which have been validated for the population under their care.

Accuracy of nutritional assessment tools for predicting adverse hospital outcomes.

BACKGROUND AND AIMS: The ability of nutritional status assessment methods to predict clinical outcomes in hospitalized patients has not been completely evaluated. This study compared the accuracy of traditionally used nutritional tools and parameters in predicting death, infection, and length of hospital stay (LOS) in hospitalized adults. RESEARCH METHODS & PROCEDURES: Patients admitted at clinical and surgical wards were evaluated by body mass index, percentage of weight loss, Subjective Global Assessment, albumin, lymphocyte count, and followed until discharge. Clinical outcomes considered were in-hospital death, infection, and LOS. Overall accuracy of each method to predict these outcomes was assessed from ROC curves and C-statistic. RESULTS: Among 434 patients evaluated, 51% had a prolonged LOS, 23% developed infection, and 7.8% died during hospitalization. In univariate analysis, serum albumin was the strongest predictive parameter for death (Cstatistic: 0.77; CI95%: 0.69-0.86) and hospital infection (C-statistic: 0.67; CI95%: 0.61-0.74). For longer stay, lymphocyte count (C-statistic: 0.60; CI95%: 0.55-0.65) emerged as the most predictive variable. After adjustment for non-surgical hospitalization and cancer diagnosis, weight loss > 5% (OR: 1.58; CI95%: 1.06-3.35), and serum albumin < 3.5 g/dL (OR: 2.40; CI95%: 1.46-3.94) were associated to LOS. Albumin was the only independent variable related to infection (OR: 5.01; CI95%: 3.06-8.18) and, for hospital death, albumin (OR: 7.20; CI95%: 3.39-15.32) adjusted for age (OR: 1.03; CI95%: 1.01-1.06). CONCLUSIONS: Nutritional assessment methods evaluated were weakly predictors of hospital outcomes. Except for low serum albumin, isolated use of these methods adds little information in identifying the effect of nutritional status on clinically relevant outcomes.

Three-stent placement for treatment of carotid artery pseudoaneurysm. A case report.

SUMMARY: Pseudoaneurysm treatment with overlapping stents may be a useful technique to reduce flow and enhance thrombosis in the aneurysmal sac. We treated a pseudoaneurysm of the left carotid artery in a patient with a history of bilateral carotid thromboendarterectomy by placing three stents and overlapping them at the level of the aneurysmal neck. Nine month follow-up revealed almost complete pseudoaneurysm exclusion and patency of the carotid artery.

Comparison of data on Early Childhood Caries (ECC) with previous data for Baby Bottle Tooth Decay (BBTD) in an Italian kindergarten population.

AIM: This was to assess the prevalence of Early Childhood Caries (ECC) among preschool children attending nursery schools and to compare the results with those of a previous survey where the investigators used the term and diagnosis for Baby Bottle Tooth Decay (BBTD) syndrome. METHODS: A cross-sectional survey of 1006 children aged 1-6 years was carried out. WHO recommendations for oral health surveys were used for caries diagnosis (non cavitated lesions were excluded). In addition, a comparison was made for prevalence of ECC between immigrant and native born children. Data were compared for ECC in the present survey with BBTD data in a previous study (1994) in the same area with a sample of 401 children aged 4 years. All examinations were by one examiner (Cohen's Kappa=0.96). RESULTS: Of the 1006 children originally selected 52 children aged more than 71 months were excluded according to published ECC definition and diagnostic criteria. The overall sample was 29 children aged <36 months; 271 aged 3 years; 364 aged 4 years and 290 aged 5 years. ECC was diagnosed in 19.7% of the overall sample. The prevalence of ECC (and S-ECC) were respectively by age: <36 months S-ECC=17.2%; at 3 years: 13.28% (6.64%); at 4 years: 18.95% (9.34%); at 5 years: 26.9% (12.75%). In the native born children (916) the ECC was 18.34%, while in immigrants (38) it was 52.63% (p<0.001). In 1994 the prevalence of BBTD syndrome was 11.9% and in the present study 6.5%. CONCLUSION: The ECC prevalence, as, ECC and severe (S-ECC),increased with age. In immigrant children ECC was 3 times (S-ECC 6 times) more frequent than in native born. Using the BBTD diagnosis the prevalence had dropped from 11.9% in 1994 to 6.5% in the present survey.