Effect of a multifaceted intervention on use of evidence-based therapies in patients with acute coronary syndromes in Brazil: the BRIDGE-ACS randomized trial.

CONTEXT: Studies have found that patients with acute coronary syndromes (ACS) often do not receive evidence-based therapies in community practice. This is particularly true in low- and middle-income countries. OBJECTIVE: To evaluate whether a multifaceted quality improvement (QI) intervention can improve the use of evidence-based therapies and reduce the incidence of major cardiovascular events among patients with ACS in a middle-income country. DESIGN, SETTING, AND PARTICIPANTS: The BRIDGE-ACS (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes) trial, a cluster-randomized (concealed allocation) trial conducted among 34 clusters (public hospitals) in Brazil and enrolling a total of 1150 patients with ACS from March 15, 2011, through November 2, 2011, with follow-up through January 27, 2012. INTERVENTION: Multifaceted QI intervention including educational materials for clinicians, reminders, algorithms, and case manager training, vs routine practice (control). MAIN OUTCOME MEASURES: Primary end point was the percentage of eligible patients who received all evidence-based therapies (aspirin, clopidogrel, anticoagulants, and statins) during the first 24 hours in patients without contraindications. RESULTS: Mean age of the patients enrolled was 62 (SD, 13) years; 68.6% were men, and 40% presented with ST-segment elevation myocardial infarction, 35.6% with non-ST-segment elevation myocardial infarction, and 23.6% with unstable angina. The randomized clusters included 79.5% teaching hospitals, all from major urban areas and 41.2% with 24-hour percutaneous coronary intervention capabilities. Among eligible patients (923/1150 [80.3%]), 67.9% in the intervention vs 49.5% in the control group received all eligible acute therapies (population average odds ratio [OR(PA)], 2.64 [95% CI, 1.28-5.45]). Similarly, among eligible patients (801/1150 [69.7%]), those in the intervention group were more likely to receive all eligible acute and discharge medications (50.9% vs 31.9%; OR(PA),, 2.49 [95% CI, 1.08-5.74]). Overall composite adherence scores were higher in the intervention clusters (89% vs 81.4%; mean difference, 8.6% [95% CI, 2.2%-15.0%]). In-hospital cardiovascular event rates were 5.5% in the intervention group vs 7.0% in the control group (OR(PA), 0.72 [95% CI, 0.36-1.43]); 30-day all-cause mortality was 7.0% vs 8.4% (ORPA, 0.79 [95% CI, 0.46-1.34]). CONCLUSION: Among patients with ACS treated in Brazil, a multifaceted educational intervention resulted in significant improvement in the use of evidence-based therapies. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00958958.

A multifaceted intervention to narrow the evidence-based gap in the treatment of acute coronary syndromes: rationale and design of the Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes (BRIDGE-ACS) cluster-randomized trial.

Translating evidence into clinical practice in the management of acute coronary syndromes (ACS) is challenging. Few ACS quality improvement interventions have been rigorously evaluated to determine their impact on patient care and clinical outcomes. We designed a pragmatic, 2-arm, cluster-randomized trial involving 34 clusters (Brazilian public hospitals). Clusters were randomized to receive a multifaceted quality improvement intervention (experimental group) or routine practice (control group). The 6-month educational intervention included reminders, care algorithms, a case manager, and distribution of educational materials to health care providers. The primary end point was a composite of evidence-based post-ACS therapies within 24 hours of admission, with the secondary measure of major cardiovascular clinical events (death, nonfatal myocardial infarction, nonfatal cardiac arrest, and nonfatal stroke). Prescription of evidence-based therapies at hospital discharge were also evaluated as part of the secondary outcomes. All analyses were performed by the intention-to-treat principle and took the cluster design into account using individual-level regression modeling (generalized estimating equations). If proven effective, this multifaceted intervention would have wide use as a means of promoting optimal use of evidence-based interventions for the management of ACS.

Pseudocardiomegalia por gordura epicárdica associada à Síndrome metabólica / Pseudocardiomegaly by epicardial adipose tissue associated with metabolic syndrome

Pseudocardiomegalia tem sido relatada nos casos de linfoma, timomas, efusões pericárdicas, pectus escavatum, timolipomas, hérnias viscerais e outras situações. O tecido adiposo epicárdico é, geralmente, medido na parede livre do ventrículo direito (VD). Descreve-se caso de pseudocardiomegalia ocasionada por gordura epicárdica de ventrículo esquerdo (VE), associada à síndrome metabólica.

Derrame pericárdico associado a abscesso prostático em paciente diabético / Pericardial efusion in a diabetic patient with prostatic abscess

Pericardite purulenta é doença rara e potencialmente fatal. O diagnóstico e tratamento são difíceis. Antibioticoterapia e drenagem do pericárdio são essenciais para o tratamento de pericardite purulenta. Descrevemos caso não usual de paciente diabético com pericardite purulenta e abscesso prostático com boa evolução após tratamento adequado.

Detección precoz de lepra infantile a tra´ves del entrenamiento de profesores de esucelas primarias: experiencia en un barrio periférico de Cuiabá-Mato Grosso (Brasil) / No disponible

La lepra continúa siendo hoy un problema de Salud Pública muy importante en algunos países, como el Brasil. A pesar de los importantes avances en materia de tratamientos en los últimos 10 años, la inexistencia de un medio diagnóstico que detecte la microbacteria en los estadios iniciales de la enfermedad y la también inexistencia de vacuna eficaz para prevención primaria hacen del tratamiento precoz la única arma de que disponemos para evitar en los posible la aparición de las incapacidades. Por otra parte, la alta 0prevalencia de la lepra en muchos países coexiste con una situación de desamparo social y sanitario, permaneciendo los pacientes en estadios iniciales – en su mayoría niños- lejos de los circuitos habituales de los servicios médicos. Es por ello que los profesores de las escuelas primarias ocupan un lugar destacado en el plan de detección precoz, pues son elementos en constante contacto con los niños, cumpliendo una doble misión: por un lado, siendo agentes multiplicadores de educación sanitaria, enseñando a los alumnos los signos y síntomas precoces de la lepra y modificando actitudes de repulsa hacia los enfermos; por otra parte, profesores entrenados para detectar estos signos precoces serán centinelas “de punta”, detectando con prontitud la aparición de la primera mancha en el niño. El trabajo muestra los resultados de detección de nuevos casos entre los niños de una escuela primaria de un barrio periférico de Cuiaba-Mato Grosso (Brasil) realizada por los propios profesores tras un breve entrenamiento por parte del equipo de atención primaria del barrio (AU)

Leprosy is still a public health problem in several countries in the World including Brazil. Although during the last 10 years there have been important advances in the field of treatment there is still no diagnostic test for early detection or an effective vaccine for primary prevention, so we have to depend entirely on early treatment to prevent possible patient incapacities. On the other hand, the high prevalence of leprosy exists together with social and health needs, so that the patient remains at the early stage of disease (mainly children) able to access the public health services. This is why the teachers at the primary school level have such an important role in early detection since they are in constant contact with the school children carrying on an important double mission: on one hand multiplying health, teaching the children the signs and symptoms of the disease and changing the negative social attitudes towards the affected individuals. So, thee teachers are “first level” guards detecting the first signs of disease. This study presents the results on early case detection in children form the primary school in the neighborhood of Cuiabá-Mato Grosso (Brazil) carried put by the teachers after attending a short training course by the local primary health care team (AU)