Inflamação sistêmica e dilatação do átrio esquerdo na hemodiálise crônica sem doença cardiovascular conhecida / Systemic inflammation and left atrium dilation in chronic hemodialysis without overt cardiovascular disease

Objetivo: Verificar a presença de associações entre inflamação sistêmica e dilatação do átrio esquerdo (AE), em pacientes sob hemodiálise (HD) de manutenção, sem doença cardiovascular (DCV) clinicamente manifesta. Métodos: Estudo observacional transversal em população sob HD (> 3 meses), excluindo-se pacientes com doença inflamatória crônica, infecções, neoplasias, instabilidade hemodinâmica, uso de drogas anti-inflamatórias, hiperparatireodismo, arritmias, valvopatia mitral e DCV prévia. Foram obtidas dosagens de proteína C reativa (PCR) e interleucina 6 (IL-6) e ecodopplercardiograma. Coeficientes de correlação foram determinados para avaliar as associações entre as variáveis. Resultados: Incluídos 58 pacientes (28 homens, idade 55 ± 15 anos), sob HD há 24 ± 16 meses, 45% hipertensos, 26% diabéticos, com medianas de PCR 5,1mg/ml e IL-6 6,1pg/ml. A PCR correlacionou-se, significativamente, com dimensão do AE (p= 0,040), volume indexado do AE (VIAE, p= 0,02) e onda E do fluxo mitral (p= 0,014). A IL-6, apesar da forte associação com a PCR (r= 0,75, p < 0,001), não se correlacionou com índices ecocardiográficos. Indivíduos no quartil superior da PCR tiveram VIAE, significativamente, maior do que os demais (42 ± 17 versus 32 ± 11, p= 0,015). Conclusão: Em indivíduos sob HD sem DCV prévia, houve associação entre elevação da PCR e aumento do AE. Os achados sugerem uma ligação entre processos fisiopatológicos relacionados à dilatação atrial esquerda e o estado inflamatório sistêmico de pacientes sob HD.

Objective: To verify associations between systemic infl ammation and left atrium (LA) dilatation in patients under maintenance hemodialysis (HD) without clinically overt cardiovascular disease (CVD). Methods: Observational cross-sectional study in population under HD (> 3 months), excluding patients with chronic infl ammatory disease, infections, neoplasia, hemodynamic instability, use of anti-infl ammatory drugs, hyperparathyroidism, arrhythmias, mitral valve disease and prior CVD. Measurements of C-reative protein (CRP) and interleukin 6 (IL-6), and echocardiograms were obtained. Correlation coeffi cients were determined to assess associations between variables. Results: The study comprised 58 patients (28 men, age 55 ± 15 years) under HD for 24 ± 16 months, 45% hypertensive, 26% diabetic, with median CRP 5.1 mg/ml and median IL-6 6.1 pg/ml. CRP was signifi cantly correlated with LA dimension (p= 0.040), indexed LA volume (p= 0.02), and mitral infl ow E-wave (p = 0.014). IL-6, despite the strong association with CRP (r= 0.75, p < 0.001), did not correlate with echocardiographic indexes. Individuals in the upper quartile of CRP had indexed LA volume significantly greater than the rest (42 ± 17 versus 32 ± 11, p= 0.015). Conclusion: In patients under HD without prior CVD, there was an association between elevated CRP and increased LA. The findings suggest a link between pathophysiological processes related to left atrial enlargement and systemic infl ammatory state of patients under HD.

Impact of a guideline-based disease management team on outcomes of hospitalized patients with congestive heart failure.

BACKGROUND: Congestive heart failure is the most common reason for hospitalization in the United States, and guidelines to improve the quality of care for patients with congestive heart failure have been developed. However, adherence is typically low. We hypothesized that a guideline-based care management team would result in greater quality and efficiency of care than guidelines alone. METHODS: A faculty cardiologist and nurse care manager at an academic medical center reviewed each patient's data and made guideline-based recommendations. Hospital length of stay, total costs, and use of recommended guidelines were compared between 173 patients before team implementation but with available guidelines, 283 care-managed patients, and 126 concurrent non-care-managed patients. RESULTS: Care-managed patients achieved higher rates of use of angiotensin-converting enzyme inhibitor than baseline or non-care-managed patients (95%, 60%, and 75%, respectively; P<.001), as well as increased adherence to guidelines for daily weight monitoring and assessment of left ventricular function. Hospital length of stay was lower (median, 3, 4, and 5 days, respectively; P<.001) as were costs of hospitalization (median, $2934, $3209, and $4830, respectively; P<.01). These differences persisted after adjustment for severity of illness. CONCLUSIONS: When compared with dissemination of guidelines alone, an active care management approach was associated with significant improvements in quality and efficiency of care for hospitalized patients with congestive heart failure.

Design and implementation of an inpatient disease management program.

OBJECTIVE: To describe the development and implementation of an inpatient disease management program. STUDY DESIGN: Prospective observational study. PATIENTS AND METHODS: On the basis of opportunities for improving quality or efficiency of inpatient and emergency department care, 4 diagnoses, including congestive heart failure (CHF), gastrointestinal hemorrhage, community-acquired pneumonia and sickle-cell crisis were selected for implementation of a disease management program. For each diagnosis, a task force assembled a disease management team led by a "physician champion" and nurse care manager and identified opportunities for improvement through medical literature review and interviews with caregivers. A limited number of disease-specific guidelines and corresponding interventions were selected with consensus of the team and disseminated to caregivers. Physician and nurse team leaders were actively involved in patient care to facilitate adherence to guidelines. RESULTS: For quarter 2 to 4 of 1997, there were improvements in angiotensin-converting enzyme inhibitor use, daily weight compliance, assessment of left ventricular function, hospital costs, and length of stay for care-managed patients with CHF. Differences in utilization-related outcomes persisted even after adjustment for severity of illness. For the other 3 diagnoses, the observational period was shorter (quarter 4 only), and hence preliminary data showed similar hospital costs and length of stay for care-managed and noncare-managed patients. CONCLUSIONS: An interdisciplinary approach to inpatient disease management resulted in substantial improvements in both quality and efficiency of care for patients with CHF. Additional data are needed to determine the program's impact on outcomes of other targeted diagnoses.

Attitudes of faculty, housestaff, and medical students toward clinical practice guidelines.

PURPOSE: To examine attitudes of faculty, housestaff, and medical students toward clinical practice guidelines. METHOD: In a 1997 cross-sectional survey, a two-part, 26-item, self-administered questionnaire was mailed to all faculty, housestaff, and medical students in the department of internal medicine at Case Western Reserve University School of Medicine. The questionnaire asked for demographic information and attitudes toward clinical guidelines. RESULTS: Of 379 persons surveyed, 254 (67%) returned usable questionnaires: 56% of the medical students, 70% of the housestaff, and 73% of the full-time faculty. Medical students reported learning about guidelines predominantly during clerkships in internal medicine (71%) and pediatrics (68%). Overall, the respondents agreed most strongly that guidelines are "useful for the care of common problems," and least strongly that guidelines are "difficult to apply to individual patients" and "reduce physician options in patient care." Faculty were more likely to consider guidelines a "good educational tool" and less likely than were medical students and housestaff to agree that they promote "cookbook medicine." Of 11 influences on clinical decision making, the three groups together rated practice guidelines eighth or ninth. The use of guidelines for academic investigations was rated most appropriate, overall. In terms of their appropriateness, faculty consistently rated the use of guidelines more favorably except for use in malpractice suits. CONCLUSION: Faculty, housestaff, and medical students have significantly different perceptions of and attitudes toward clinical practice guidelines. Further studies are needed to explain the reasons for these differences. Considerable education and involvement must occur at all levels for practice guidelines to be successfully implemented and understood.

Favorable results of implantable cardioverter-defibrillator implantation in patients older than 70 years.

BACKGROUND: The clinical results of implantable cardioverter-defibrillator (ICD) implantation in the elderly have received limited documentation. As the longevity of the U.S. population has increased, so has the need for ICD implantation in the elderly. We evaluated the efficacy and outcome of ICD implantation in elderly patients (>70 years) compared with younger patients. METHODS: The case records of all consecutive patients who underwent ICD implantation at our institution between 1986 and 1994 were reviewed. Of a total of 238 patients, 78 patients were 70 years of age or older and 160 patients were younger than 70 years of age. RESULTS: The mean age of the younger group was 58 years and that of the elderly group was 74 years. There were no statistical differences in the presence of coronary artery disease, left ventricular systolic function, the inducibility of arrhythmias, or the history of sudden cardiac death. The hospital morbidity rate was similar in both groups (6.9% in the younger group and 7.7% in the elderly group; p = not significant). The operative mortality rate was 1.9% for the younger group and 1.3% for the elderly group (p = not significant). At a mean follow-up of 33 +/- 26 months, Kaplan-Meier survival curves demonstrated similar survival rates, with 93%, 82%, and 65% of the patients alive at 1, 3, and 6 years, respectively. CONCLUSIONS: Implantable cardioverter-defibrillator implantation was equally effective in the treatment of patients older than 70 years as in younger patients. No differences in theoretic survival or morbidity were observed.

[The organization of a working group for the prevention of decubitus lesions]. / Organizzazione di un gruppo di lavoro per la prevenzione delle lesioni da decubito.

The authors report the results of a two years monitoring program focused on patients at risk of and with bedsores in the general hospital of Castelfranco Veneto. The purpose of the multidisciplinary exercise (which saw the participation of nurses, pharmacists, doctors) was the activation and the evaluation of treatment protocols. The overall recruited sample included 679 patients, with a prevalence of 61% of lesions at the occasion of the first observation, and of 57% in the last one. The hardly quantitatively different prevalence is better understood from a qualitative point of view: the number of lesions per patients drops slightly from 1.9 to 1.7; one out of four of the "at risk" patients became "at no risk"; a 30% improvement is observed with respect to treatment efficacy. It is suggested that a positive effect may be obtained through a sustained attention to the problem and the careful definition of the interventions to be planned.