Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial.

BACKGROUND: Transfusion of blood components prior to invasive procedures in cirrhosis patients is high and associated with adverse events. OBJECTIVES: We compared three transfusion strategies prior to central venous catheterization in cirrhosis patients. PATIENTS/METHODS: Single center randomized trial that included critically ill cirrhosis patients with indication for central venous line in a tertiary private hospital in Brazil. INTERVENTIONS: Restrictive protocol, thromboelastometry-guided protocol, or usual care (based on coagulogram). The primary endpoint was the proportion of patients transfused with any blood component (ie, fresh frozen plasma, platelets, or cryoprecipitate). The secondary endpoints included incidence of bleeding and transfusion-related adverse events. RESULTS: A total of 57 patients (19 per group; 64.9% male; mean age, 53.4 ± 11.3 years) were enrolled. Prior to catheterization, 3/19 (15.8%) in the restrictive arm, 13/19 (68.4%) in the thromboelastometry-guided arm, and 14/19 (73.7%) in the coagulogram-guided arm received blood transfusion (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01-0.45; P = .002 for restrictive versus coagulogram-guided arm; OR, 0.09; 95% CI, 0.01-0.56; P = .006 for restrictive versus thromboelastometry-guided arm; and OR, 0.77; 95% CI, 0.14-4.15; P = .931 for thromboelastometry-guided versus coagulogram-guided arm). The restrictive protocol was cost saving. No difference in bleeding, length of stay, mortality, and transfusion-related adverse events was found. CONCLUSIONS: The use of a restrictive strategy is associated with a reduction in transfusion prior to central venous catheterization and costs in critically ill cirrhosis patients. No effect on bleeding was found among the groups.

Self-Reported High-Cholesterol Prevalence in the Brazilian Population: Analysis of the 2013 National Health Survey.

BACKGROUND:: Data on the prevalence of dyslipidemia in Brazil are scarce, with surveys available only for some towns. OBJECTIVE:: To evaluate the prevalence of the self-reported medical diagnosis of high cholesterol in the Brazilian adult population by use of the 2013 National Health Survey data. METHODS:: Descriptive study assessing the 2013 National Health Survey data, a household-based epidemiological survey with a nationally representative sample and self-reported information. The sample consisted of 60,202 individuals who reported a medical diagnosis of dyslipidemia. The point prevalence and 95% confidence interval (95%CI) for the medical diagnosis of high cholesterol/triglyceride by gender, age, race/ethnicity, geographic region and educational level were calculated. Adjusted odds ratio was calculated. RESULTS:: Of the 60,202 participants, 14.3% (95%CI=13.7-14.8) never had their cholesterol or triglyceride levels tested, but a higher frequency of women, white individuals, elderly and those with higher educational level had their cholesterol levels tested within the last year. The prevalence of the medical diagnosis of high cholesterol was 12.5% (9.7% in men and 15.1% in women), and women had 60% higher probability of a diagnosis of high cholesterol than men. The frequency of the medical diagnosis of high cholesterol increased up to the age of 59 years, being higher in white individuals or those of Asian heritage, in those with higher educational level and in residents of the Southern and Southeastern regions. CONCLUSION:: The importance of dyslipidemia awareness in the present Brazilian epidemiological context must be emphasized to guide actions to control and prevent coronary heart disease, the leading cause of death in Brazil and worldwide. FUNDAMENTO:: A prevalência de hipercolesterolemia no Brasil não é conhecida para todo o país, havendo somente inquéritos em algumas cidades. OBJETIVO:: Avaliar a prevalência de diagnóstico médico de colesterol alto autorreferido na população adulta brasileira, utilizando-se dos dados da Pesquisa Nacional de Saúde (PNS) de 2013. MÉTODOS:: Estudo descritivo que avaliou os dados da PNS de 2013, um inquérito epidemiológico de base domiciliar, representativo para o Brasil, com informações autorreferidas. A amostra compreendeu 60.202 indivíduos entrevistados com autorrelato de diagnóstico médico de colesterol. Calculou-se a prevalência de ponto e o intervalo de confiança de 95% (IC95%) para diagnóstico médico de colesterol/triglicerídeos alto(s) por sexo, idade, cor da pele, região geográfica, escolaridade. Foram calculadas as razões de chance ajustadas. RESULTADOS:: Dos 60.202 participantes adultos, 14,3% (IC95%=13,7-14,8) nunca tiveram colesterol ou triglicerídeos dosados, sendo que um maior número de mulheres, idosos, indivíduos com instrução superior completa e de raça branca relatou aferição há menos de um ano. A prevalência de diagnóstico médico de colesterol alto foi de 12,5%, maior nas mulheres (15,1%) do que nos homens (9,7%). A frequência de diagnóstico médico de colesterol alto foi maior naqueles com idade até 59 anos, em brancos ou aqueles de origem asiática, em pessoas com maior escolaridade e entre os moradores das macrorregiões Sul e Sudeste do país. CONCLUSÃO:: A importância do conhecimento da dislipidemia no atual contexto epidemiológico brasileiro deve ser ressaltada para orientar as ações de prevenção das doenças coronarianas, que representam a primeira causa de óbito no Brasil e no mundo.

Self-Reported High-Cholesterol Prevalence in the Brazilian Population: Analysis of the 2013 National Health Survey / Prevalência de Diagnóstico Médico de Colesterol Alto Autorreferido na População Brasileira: Análise da Pesquisa Nacional de Saúde, 2013

Abstract Background: Data on the prevalence of dyslipidemia in Brazil are scarce, with surveys available only for some towns. Objective: To evaluate the prevalence of the self-reported medical diagnosis of high cholesterol in the Brazilian adult population by use of the 2013 National Health Survey data. Methods: Descriptive study assessing the 2013 National Health Survey data, a household-based epidemiological survey with a nationally representative sample and self-reported information. The sample consisted of 60,202 individuals who reported a medical diagnosis of dyslipidemia. The point prevalence and 95% confidence interval (95%CI) for the medical diagnosis of high cholesterol/triglyceride by gender, age, race/ethnicity, geographic region and educational level were calculated. Adjusted odds ratio was calculated. Results: Of the 60,202 participants, 14.3% (95%CI=13.7-14.8) never had their cholesterol or triglyceride levels tested, but a higher frequency of women, white individuals, elderly and those with higher educational level had their cholesterol levels tested within the last year. The prevalence of the medical diagnosis of high cholesterol was 12.5% (9.7% in men and 15.1% in women), and women had 60% higher probability of a diagnosis of high cholesterol than men. The frequency of the medical diagnosis of high cholesterol increased up to the age of 59 years, being higher in white individuals or those of Asian heritage, in those with higher educational level and in residents of the Southern and Southeastern regions. Conclusion: The importance of dyslipidemia awareness in the present Brazilian epidemiological context must be emphasized to guide actions to control and prevent coronary heart disease, the leading cause of death in Brazil and worldwide.

Resumo Fundamento: A prevalência de hipercolesterolemia no Brasil não é conhecida para todo o país, havendo somente inquéritos em algumas cidades. Objetivo: Avaliar a prevalência de diagnóstico médico de colesterol alto autorreferido na população adulta brasileira, utilizando-se dos dados da Pesquisa Nacional de Saúde (PNS) de 2013. Métodos: Estudo descritivo que avaliou os dados da PNS de 2013, um inquérito epidemiológico de base domiciliar, representativo para o Brasil, com informações autorreferidas. A amostra compreendeu 60.202 indivíduos entrevistados com autorrelato de diagnóstico médico de colesterol. Calculou-se a prevalência de ponto e o intervalo de confiança de 95% (IC95%) para diagnóstico médico de colesterol/triglicerídeos alto(s) por sexo, idade, cor da pele, região geográfica, escolaridade. Foram calculadas as razões de chance ajustadas. Resultados: Dos 60.202 participantes adultos, 14,3% (IC95%=13,7-14,8) nunca tiveram colesterol ou triglicerídeos dosados, sendo que um maior número de mulheres, idosos, indivíduos com instrução superior completa e de raça branca relatou aferição há menos de um ano. A prevalência de diagnóstico médico de colesterol alto foi de 12,5%, maior nas mulheres (15,1%) do que nos homens (9,7%). A frequência de diagnóstico médico de colesterol alto foi maior naqueles com idade até 59 anos, em brancos ou aqueles de origem asiática, em pessoas com maior escolaridade e entre os moradores das macrorregiões Sul e Sudeste do país. Conclusão: A importância do conhecimento da dislipidemia no atual contexto epidemiológico brasileiro deve ser ressaltada para orientar as ações de prevenção das doenças coronarianas, que representam a primeira causa de óbito no Brasil e no mundo.

A time-series analysis of the relation between unemployment rate and hospital admission for acute myocardial infarction and stroke in Brazil over more than a decade.

BACKGROUND: The effect of socioeconomic stressors on the incidence of cardiovascular disease (CVD) is currently open to debate. Using time-series analysis, our study aimed to evaluate the relationship between unemployment rate and hospital admission for acute myocardial infarction (AMI) and stroke in Brazil over a recent 11-year span. METHODS AND RESULTS: Data on monthly hospital admissions for AMI and stroke from March 2002 to December 2013 were extracted from the Brazilian Public Health System Database. The monthly unemployment rate was obtained from the Brazilian Institute for Applied Economic Research, during the same period. The autoregressive integrated moving average (ARIMA) model was used to test the association of temporal series. Statistical significance was set at p<0.05. From March 2002 to December 2013, 778,263 admissions for AMI and 1,581,675 for stroke were recorded. During this time period, the unemployment rate decreased from 12.9% in 2002 to 4.3% in 2013, while admissions due to AMI and stroke increased. However, the adjusted ARIMA model showed a positive association between the unemployment rate and admissions for AMI but not for stroke (estimate coefficient=2.81±0.93; p=0.003 and estimate coefficient=2.40±4.34; p=0.58, respectively). CONCLUSIONS: From 2002 to 2013, hospital admissions for AMI and stroke increased, whereas the unemployment rate decreased. However, the adjusted ARIMA model showed a positive association between unemployment rate and admissions due to AMI but not for stroke. Further studies are warranted to validate our findings and to better explore the mechanisms by which socioeconomic stressors, such as unemployment, might impact on the incidence of CVD.

Focused cardiac ultrasound: a training course for pediatric intensivists and emergency physicians.

BACKGROUND: Focused echocardiographic examinations performed by intensivists and emergency room physicians can be a valuable tool for diagnosing and managing the hemodynamic status of critically ill children. The aim of this study was to evaluate the learning curve achieved using a theoretical and practical training program designed to enable pediatric intensivists and emergency physicians to conduct targeted echocardiograms. METHODS: Theoretical and practical training sessions were conducted with 16 pediatric intensivist/emergency room physicians. The program included qualitative analyses of the left ventricular (LV) and right ventricular (RV) functions, evaluation of pericardial effusion/cardiac tamponade and valvular regurgitation and measurements of the distensibility index of the inferior vena cava (dIVC), ejection fraction (EF) and cardiac index (CI). The practical training sessions were conducted in the intensive care unit; each student performed 24 echocardiograms. The students in training were evaluated in a practical manner, and the results were compared with the corresponding examinations performed by experienced echocardiographers. The evaluations occurred after 8, 16 and 24 practical examinations. RESULTS: The concordance rates between the students and echocardiographers in the subjective analysis of the LV function were 81.3% at the first evaluation, 96.9% at the second evaluation and 100% at the third evaluation (p < 0.001). For the dIVC, we observed a concordance of 46.7% at the first evaluation, 90.3% at the second evaluation and 87.5% at the third evaluation (p = 0.004). The means of the differences between the students' and echocardiographers' measurements of the EF and CI were 7% and 0.56 L/min/m2, respectively, after the third stage of training. CONCLUSIONS: The proposed training was demonstrated to be sufficient for enabling pediatric physicians to analyze subjective LV function and to measure dIVC, EF and CI. This training course should facilitate the design of other echocardiography training courses that could be implemented in medical residency programs to improve these physicians' technical skills and the care of critically ill patients.

Early identification of leptospirosis-associated pulmonary hemorrhage syndrome by use of a validated prediction model.

OBJECTIVE: To identify prediction factors for the development of leptospirosis-associated pulmonary hemorrhage syndrome (LPHS). METHODS: We conducted a prospective cohort study. The study comprised of 203 patients, aged > or =14 years, admitted with complications of the severe form of leptospirosis at the Emílio Ribas Institute of Infectology (Sao Paulo, Brazil) between 1998 and 2004. Laboratory and demographic data were obtained and the severity of illness score and involvement of the lungs and others organs were determined. Logistic regression was performed to identify independent predictors of LPHS. A prospective validation cohort of 97 subjects with severe form of leptospirosis admitted at the same hospital between 2004 and 2006 was used to independently evaluate the predictive value of the model. RESULTS: The overall mortality rate was 7.9%. Multivariate logistic regression revealed that five factors were independently associated with the development of LPHS: serum potassium (mmol/L) (OR = 2.6; 95% CI = 1.1-5.9); serum creatinine (micromol/L) (OR = 1.2; 95% CI = 1.1-1.4); respiratory rate (breaths/min) (OR = 1.1; 95% CI = 1.1-1.2); presenting shock (OR = 69.9; 95% CI = 20.1-236.4), and Glasgow Coma Scale Score (GCS) < 15 (OR = 7.7; 95% CI = 1.3-23.0). We used these findings to calculate the risk of LPHS by the use of a spreadsheet. In the validation cohort, the equation classified correctly 92% of patients (Kappa statistic = 0.80). CONCLUSIONS: We developed and validated a multivariate model for predicting LPHS. This tool should prove useful in identifying LPHS patients, allowing earlier management and thereby reducing mortality.