Clinical features, etiologies, and outcomes of central nervous system infections in intensive care: A multicentric retrospective study in a large Brazilian metropolitan area.

PURPOSE: The goal of this study was to investigate severe central nervous system infections (CNSI) in adults admitted to the intensive care unit (ICU). We analyzed the clinical presentation, causes, and outcomes of these infections, while also identifying factors linked to higher in-hospital mortality rates. MATERIALS AND METHODS: We conducted a retrospective multicenter study in Rio de Janeiro, Brazil, from 2012 to 2019. Using a prediction tool, we selected ICU patients suspected of having CNSI and reviewed their medical records. Multivariate analyses identified variables associated with in-hospital mortality. RESULTS: In a cohort of 451 CNSI patients, 69 (15.3%) died after a median 11-day hospitalization (5-25 IQR). The distribution of cases was as follows: 29 (6.4%) had brain abscess, 161 (35.7%) had encephalitis, and 261 (57.8%) had meningitis. Characteristics: median age 41 years (27-53 IQR), 260 (58%) male, and 77 (17%) HIV positive. The independent mortality predictors for encephalitis were AIDS (OR = 4.3, p = 0.01), ECOG functional capacity limitation (OR = 4.0, p < 0.01), ICU admission from ward (OR = 4.0, p < 0.01), mechanical ventilation ≥10 days (OR = 6.1, p = 0.04), SAPS 3 ≥ 55 points (OR = 3.2, p = 0.02). Meningitis: Age > 60 years (OR = 234.2, p = 0.04), delay >3 days for treatment (OR = 2.9, p = 0.04), mechanical ventilation ≥10 days (OR = 254.3, p = 0.04), SOFA >3 points (OR = 2.7, p = 0.03). Brain abscess: No associated factors found in multivariate regression. CONCLUSIONS: Patients' overall health, prompt treatment, infection severity, and prolonged respiratory support in the ICU all significantly affect in-hospital mortality rates. Additionally, the implementation of CNSI surveillance with the used prediction tool could enhance public health policies.

Factors associated with mortality in severe community-acquired pneumonia: A multicenter cohort study.

OBJECTIVE: Describe characteristics and outcomes of CAP admitted to public ICUs in Brazil. METHODS: Retrospective cohort study in 4 Tertiary Public Hospitals in Rio de Janeiro, Brazil during 2016. Patients admitted to ICUs with a diagnosis of community-acquired pneumonia were included. Clinical and outcomes data were collected from Epimed Monitor System. RESULTS: From 7902 admissions, 802 patients (10, 1%) were included and analyzed. Main source of admission was the emergency department (78, 3%). Median age was 66 (IQR 54-77) years, SAPS3 71(IQR 58-83) and SOFA D1 9(IQR 5-12) points. 67% of patients needed invasive mechanical ventilation, 12% hemodialysis. 47% required vasopressors. ICU and hospital mortality were 55.9% and 66.5% respectively. In a multivariate analysis, malnutrition [OR 2.28(1.21-4.3)], septic shock at admission [OR 1.95(1.39-2.75)], AIDS [3.04(1.16-7.93]), invasive mechanical ventilation [5.07(5.54-7.27)], age > 65 years [2.07(1.48-2.90)] and LOS >1 day before ICU admission [1.90(1.34-2.71)] were associated with increased mortality. CONCLUSION: CAP is associated with high mortality in patients admitted to public ICUs in Brazil. The current findings may help improve resource allocation and should aim at improving access to ICU care since delayed admission was associated with increased hospital mortality.

Energy Expenditure in Critically Ill Elderly Patients: Indirect Calorimetry vs Predictive Equations.

BACKGROUND: Predictive equations (PEs) are used for estimating resting energy expenditure (REE) when the measurements obtained from indirect calorimetry (IC) are not available. This study evaluated the degree of agreement and the accuracy between the REE measured by IC (REE-IC) and REE estimated by PE (REE-PE) in mechanically ventilated elderly patients admitted to the intensive care unit (ICU). METHODS: REE-IC of 97 critically ill elderly patients was compared with REE-PE by 6 PEs: Harris and Benedict (HB) multiplied by the correction factor of 1.2; European Society for Clinical Nutrition and Metabolism (ESPEN) using the minimum (ESPENmi), average (ESPENme), and maximum (ESPENma) values; Mifflin-St Jeor; Ireton-Jones (IJ); Fredrix; and Lührmann. Degree of agreement between REE-PE and REE-IC was analyzed by the interclass correlation coefficient and the Bland-Altman test. The accuracy was calculated by the percentage of male and/or female patients whose REE-PE values differ by up to ±10% in relation to REE-IC. RESULTS: For both sexes, there was no difference for average REE-IC in kcal/kg when the values obtained with REE-PE by corrected HB and ESPENme were compared. A high level of agreement was demonstrated by corrected HB for both sexes, with greater accuracy for women. The best accuracy in the male group was obtained with the IJ equation but with a low level of agreement. CONCLUSIONS: The effectiveness of PEs is limited for estimating REE of critically ill elderly patients. Nonetheless, HB multiplied by a correction factor of 1.2 can be used until a specific PE for this group of patients is developed.

Effects of Organizational Characteristics on Outcomes and Resource Use in Patients With Cancer Admitted to Intensive Care Units.

PURPOSE: To investigate the impact of organizational characteristics and processes of care on hospital mortality and resource use in patients with cancer admitted to intensive care units (ICUs). PATIENTS AND METHODS: We performed a retrospective cohort study of 9,946 patients with cancer (solid, n = 8,956; hematologic, n = 990) admitted to 70 ICUs (51 located in general hospitals and 19 in cancer centers) during 2013. We retrieved patients' clinical and outcome data from an electronic ICU quality registry. We surveyed ICUs regarding structure, organization, staffing patterns, and processes of care. We used mixed multivariable logistic regression analysis to identify characteristics associated with hospital mortality and efficient resource use in the ICU. RESULTS: Median number of patients with cancer per center was 110 (interquartile range, 58 to 154), corresponding to 17.9% of all ICU admissions. ICU and hospital mortality rates were 15.9% and 25.4%, respectively. After adjusting for relevant patient characteristics, presence of clinical pharmacists in the ICU (odds ratio [OR], 0.67; 95% CI, 0.49 to 0.90), number of protocols (OR, 0.92; 95% CI, 0.87 to 0.98), and daily meetings between oncologists and intensivists for care planning (OR, 0.69; 95% CI, 0.52 to 0.91) were associated with lower mortality. Implementation of protocols (OR, 1.52; 95% CI, 1.11 to 2.07) and meetings between oncologists and intensivists (OR, 4.70; 95% CI, 1.15 to 19.22) were also independently associated with more efficient resource use. Neither admission to ICUs in cancer centers compared with general hospitals nor annual case volume had an impact on mortality or resource use. CONCLUSION: Organizational aspects, namely the implementation of protocols and presence of clinical pharmacists in the ICU, and close collaboration between oncologists and ICU teams are targets to improve mortality and resource use in critically ill patients with cancer.

Robust lane sensing and departure warning under shadows and occlusions.

A prerequisite for any system that enhances drivers' awareness of road conditions and threatening situations is the correct sensing of the road geometry and the vehicle's relative pose with respect to the lane despite shadows and occlusions. In this paper we propose an approach for lane segmentation and tracking that is robust to varying shadows and occlusions. The approach involves color-based clustering, the use of MSAC for outlier removal and curvature estimation, and also the tracking of lane boundaries. Lane boundaries are modeled as planar curves residing in 3D-space using an inverse perspective mapping, instead of the traditional tracking of lanes in the image space, i.e., the segmented lane boundary points are 3D points in a coordinate frame fixed to the vehicle that have a depth component and belong to a plane tangent to the vehicle's wheels, rather than 2D points in the image space without depth information. The measurement noise and disturbances due to vehicle vibrations are reduced using an extended Kalman filter that involves a 6-DOF motion model for the vehicle, as well as measurements about the road's banking and slope angles. Additional contributions of the paper include: (i) the comparison of textural features obtained from a bank of Gabor filters and from a GMRF model; and (ii) the experimental validation of the quadratic and cubic approximations to the clothoid model for the lane boundaries. The results show that the proposed approach performs better than the traditional gradient-based approach under different levels of difficulty caused by shadows and occlusions.

Transfusão de sangue em terapia intensiva: um estudo epidemiológico observacional / Blood transfusion in intensive care: an epidemiological observational study

JUSTIFICATIVA E OBJETIVOS: A transfusão de concentrado de hemácias (CHA) é muito freqüente no centro de tratamento intensivo (CTI), mas as conseqüências da anemia nos pacientes gravemente enfermos ainda são obscuras. Os objetivos desse estudo foram avaliar a freqüência, as indicações, os limiares transfusionais e o prognóstico dos pacientes criticamente enfermos que receberam CHA. MÉTODO: Estudo prospectivo de coorte realizado no CTI médico-cirúrgico de um Hospital Universitário durante 16 meses. Foram coletados dados demográficos, clínicos e os relacionados a transfusão de CHA. Regressão logística binária foi utilizada após as análises univariadas. RESULTADOS: Dos 698 pacientes internados, 244 (35 por cento) foram transfundidos com CHA. Os pacientes clínicos e em pós-operatório de urgência foram mais transfundidos. Os limiares transfusionais foram: hematócrito = 22,8 por cento ± 4,5 por cento e hemoglobina = 7,9 ± 1,4 g/dL. Os pacientes transfundidos receberam em média 4,4 ± 3,7 CHA e apresentaram maior letalidade no CTI (39,8 por cento versus 13,2 por cento; p < 0,0001) e no hospital (48,8 por cento versus 20,3 por cento; p < 0,0001). A letalidade correlacionou-se com o número de CHA transfundidos (R² = 0,91). Na análise multivariada, os fatores relacionados com a necessidade de transfusão foram cirrose hepática, ventilação mecânica (VM), tipo e duração da internação no CTI, hematócrito e escore SAPS II. Os fatores independentes relacionados à letalidade hospitalar foram: VM, número de transfusões de CHA > 5 unidades e escore SAPS II. CONCLUSÕES: A transfusão de CHA é freqüente no CTI, particularmente nos pacientes internados por problemas clínicos e após cirurgias de emergência, com internação prolongada, em VM e com cirrose hepática. O limiar transfusional observado foi mais baixo que aquele assinalado pela literatura. A transfusão de CHA foi associada com maior letalidade.

BACKGROUND AND OBJECTIVES: Packed red blood cell (PRBC) transfusion is frequent in intensive care unit (ICU). However, the consequences of anemia in ICU patients are poorly understood. Our aim was to evaluate the prevalence, indications, pre-transfusion hematocrit and hemoglobin levels, and outcomes of ICU patients transfused with PRBC. METHODS: Prospective cohort study conducted at a medical-surgical ICU of a teaching hospital during a 16-month period. Patients' demographic, clinical, laboratory and transfusion-related data were collected. Logistic regression was used after univariate analyses. RESULTS: A total of 698 patients were evaluated and 244 (35 percent) received PRBC, mainly within the first four days of ICU (82.4 percent). Transfusion was more frequent in medical and emergency surgical patients. The mean pre-transfusion hematocrit and hemoglobin were 22.8 percent ± 4.5 percent and 7.9 ± 1.4 g/dL, respectively. Transfused patients received 4.4 ± 3.7 PRBC during ICU stay and 2.2 ± 1 PRBC at each transfusion. The ICU (39.8 percent versus 13.2 percent; p < 0.0001) and hospital (48.8 percent versus 20.3 percent; p < 0.0001) mortality rates were higher in transfused patients. Mortality increased as the number of transfused PRBC increased (R² = 0.91). In logistic regression, predictive factors for PRBC transfusion were hepatic cirrhosis, mechanical ventilation (MV), type and duration of ICU admission, and hematocrit. The independent factors associated to hospital mortality were MV, transfusions of more than five PRBC and SAPS II score. CONCLUSIONS: PRBC transfusions are frequent in ICU patients, especially in those with medical and emergency surgical complications, longer ICU stay, and hepatic cirrhosis and in need of MV. Pre-transfusion hemoglobin levels were lower than those previously reported. In our study, PRBC transfusion was associated with increased mortality.

[Blood transfusion in intensive care: an epidemiological observational study]. / Transfusão de sangue em terapia intensiva: um estudo epidemiológico observacional.

BACKGROUND AND OBJECTIVES: Packed red blood cell (PRBC) transfusion is frequent in intensive care unit (ICU). However, the consequences of anemia in ICU patients are poorly understood. Our aim was to evaluate the prevalence, indications, pre-transfusion hematocrit and hemoglobin levels, and outcomes of ICU patients transfused with PRBC. METHODS: Prospective cohort study conducted at a medical-surgical ICU of a teaching hospital during a 16-month period. Patients' demographic, clinical, laboratory and transfusion-related data were collected. Logistic regression was used after univariate analyses. RESULTS: A total of 698 patients were evaluated and 244 (35%) received PRBC, mainly within the first four days of ICU (82.4%). Transfusion was more frequent in medical and emergency surgical patients. The mean pre-transfusion hematocrit and hemoglobin were 22.8% ± 4.5% and 7.9 ± 1.4 g/dL, respectively. Transfused patients received 4.4 ± 3.7 PRBC during ICU stay and 2.2 ± 1 PRBC at each transfusion. The ICU (39.8% versus 13.2%; p < 0.0001) and hospital (48.8% versus 20.3%; p < 0.0001) mortality rates were higher in transfused patients. Mortality increased as the number of transfused PRBC increased (R² = 0.91). In logistic regression, predictive factors for PRBC transfusion were hepatic cirrhosis, mechanical ventilation (MV), type and duration of ICU admission, and hematocrit. The independent factors associated to hospital mortality were MV, transfusions of more than five PRBC and SAPS II score. CONCLUSIONS: PRBC transfusions are frequent in ICU patients, especially in those with medical and emergency surgical complications, longer ICU stay, and hepatic cirrhosis and in need of MV. Pre-transfusion hemoglobin levels were lower than those previously reported. In our study, PRBC transfusion was associated with increased mortality.

Abdominal echinococcosis during pregnancy: clinical aspects and management of a series of cases in Chile.

Twelve pregnant women with hydatid disease are presented with median age of 29; 11 (91.7%) had a liver cyst and one (8.3%) had a kidney cyst as the primary disease location. Four (33.3%) had additional cysts located in the pelvis, peritoneal cavity and/or spleen; eight (66.7%) had two or more abdominal cysts. Three patients (25.0%) had surgery at the 3rd month after delivery and nine (75.0%) during their pregnancy. There was no histological evidence of hydatid disease in placentas, and no serological evidence of echinococcosis in the newborns was confirmed. One patient died after surgery. After a mean follow-up time of 39.5 months, we found one recurrent case of pelvic hydatid disease. Management of abdominal echinococcosis during pregnancy is an uncommon and difficult problem owing to the serious potential risks for mother and child.

Gráfica regional de crecimiento fetal normal / Regional graphic of normal fetal growth

Se presentan tablas y gráficos de crecimiento fetal oservadas en una cohorte de 1.223 recién nacidos (RN) con un total de 2168 ecografías de crecimiento de embarazos "normales", de la ciudad de Temuco, Chile, entre abril de 1994 y agosto de 1999. Se describen percentiles 10, 50 y 90, observados para las variables: diámetro biparietal, circunferencia de cráneo, circunferencia abdominal y longitud femoral. Se presentan las relaciones de proporción Indice Cefálico, Cráneo/Abdomen, Fémur/Abdomen, en percentiles 3.50 y 97. En aquellos recién nacidos con una ecografía a menos de una semana del parto se presenta por semana de gestación (26 a 40 semanas) la comparación entre el peso neonatal promedio y los pesos fetales estimados según fórmula de Hadlock y las nacionales de Vaccaro y Herrera (UC2).

Gráfica regional de crecimiento fetal normal / Regional graphic of normal fetal growth

Se presentan tablas y gráficos de crecimiento fetal oservadas en una cohorte de 1.223 recién nacidos (RN) con un total de 2168 ecografías de crecimiento de embarazos "normales", de la ciudad de Temuco, Chile, entre abril de 1994 y agosto de 1999. Se describen percentiles 10, 50 y 90, observados para las variables: diámetro biparietal, circunferencia de cráneo, circunferencia abdominal y longitud femoral. Se presentan las relaciones de proporción Indice Cefálico, Cráneo/Abdomen, Fémur/Abdomen, en percentiles 3.50 y 97. En aquellos recién nacidos con una ecografía a menos de una semana del parto se presenta por semana de gestación (26 a 40 semanas) la comparación entre el peso neonatal promedio y los pesos fetales estimados según fórmula de Hadlock y las nacionales de Vaccaro y Herrera (UC2). (AU)

Estado nutricional y conversión baciloscópica en pacientes ambulatorios con tuberculosis pulmonar BK positivos en el Hospital Goyeneche

El nivel nutricional de la población de un país es considerado como uno de los más importantes indicadores de desarrollo; la tuberculosis es una enfermedad frecuente en países subdesarrollados; y se dice que el estado nutricional es un factor importante en la suceptibilidad capacidad de respuesta, evolución natural de la enfermedad y en la respuesta del tratamiento. En el Hospital Goyeneche de la Ciudad de Arequipa, se evalua a 46 pacientes ambulatorios con tuberculosis pulmonar BK positivos, casos nuevos y mayores de 18 años, que inician tratamiento antiberculoso entre Enero y Julio de 1997, a los cuales se les hace un seguimiento durante el esquema I de tratamiento (seis meses) que concluye en Diciembre de 1997, para lo cual se evalua el estado nutricional (IMC) inicial mediante el Indice de Masa Corporal (p/t2), luego un seguimiento mensual de la baciloscopía para determinar el tiempo de conversión; y establecer si hay relación entre el estado nutricional (IMC) inicial y el tiempo de conversión baciloscópica. Nuestro resultados fueron los siguientes: 1. El estado nutricional según el Indice de Masa Corporal (p/t2) de los pacientes ambulatorios con tuberculosis pulmonar tratados en el Hospital Goyeneche fue de 50 por ciento (23 pacientes) con un estado nutricional normal, seguido de 34.8 por ciento (16 pacientes) con bajo peso y 15.2 por ciento (7 pacientes) con sobrepeso; además al comparar el IMC al inicio y al final del tratamiento se encontró que el indice de Mas Corporal tiende a aumentar con una diferncia estadísticamente significativa p<0.05 en mujeres y una diferencia no significativa en varones p>0.05. 2. La conversión baciloscópica de los pacientes fue en 100 por ciento antes de los tres meses, convirtiendo en el primer mes el 76 por ciento (35 pacientes), en el segundo mes el 21.7 por ciento (10 pacientes) y en el tercer mes 2.2 por ciento (1 paciente). 3. No encontramos relación entre el tiempo de conversión baciloscópica y el Indice de Masa Corporal inicial p>0.05. Recomendamos: continuar con estudios similares más complejos que incluyan el dosaje de proteínas así como otros indicadores bioquímicos. Continuar y mejorar el apoyo alimentario, actividades educativas y evaluación nutricional al paciente tuberculoso, de parte del programa de Alimentación al paciente tuberculoso, de parte del Programa de Alimentación y Nutrición al Paciente con Tuberculosis y Familia (PANTEC).

Transfusión intravascular en el manejo de la enfermedad hemolítica perinatal: reevaluación de nuestra experiencia / Intravascular transfusion in the treatment of perinatal hemolytic disease: reevaluation of our experience

Presentamos la reevaluación de nuestra experiencia en transfusión intravascular, experiencia acumulada desde 1989 a la fecha. Los resultados alcanzados en 82 procedimientos en 26 pacientes, con sobrevida de 8 de 10 fetos hidrópicos y 13 de los 16 no hidrópicos, son comparables a los presentados pr otros centros cuyos datos están disponibles para su análisis en la literatura de la especialidad. Compartimos además, lo que hemos aprendido en la práctica de este procedimiento durante los últimos años