Peripherally Inserted Central Catheter Versus Centrally Inserted Central Catheter for In-Hospital Infusion Therapy: A Cost-Effectiveness Analysis

OBJECTIVES

To evaluate the comparative effectiveness and cost-effectiveness of peripherally inserted central catheters (PICCs) compared with centrally inserted central catheters (CICCs).

METHODS

Prospective cohort study was followed by an economic analysis over a 30-day time horizon. Propensity score matching was used to select hospitalized adults with similar indications for PICC or CICC. The composite outcome was device removal or replacement because of complications before the end of treatment. The economic evaluation was based on a decision tree model for cost-effectiveness analysis, with calculation of the incremental cost-effectiveness ratio (ICER) per catheter removal avoided. All costs are presented in Brazilian reais (BRL) (1 BRL = 0.1870 US dollar).

RESULTS

A total of 217 patients were followed in each group; 172 (79.3%) of those receiving a PICC and 135 (62.2%) of those receiving a CICC had no device-related complication, respectively. When comparing the events leading to device removal, the risk of composite endpoint was significantly higher in the CICC group (hazard ratio 0.20; 95% CI 0.11-0.35). The cost of PICC placement was BRL 1290.98 versus BRL 467.16 for a CICC. In the base case, the ICER for placing a PICC instead of a CICC was BRL 3349.91 per removal or replacement avoided. On univariate sensitivity analyses, the model proved to be robust within an ICER range of 2500.00 to 4800.00 BRL.

CONCLUSIONS

PICC placement was associated with a lower risk of complications than CICC placement. Although the cost of a PICC is higher, its use avoided complications and need for catheter replacement before the end of treatment.

Comparison of Incidence and Prognosis of Myocardial Injury in Patients with COVID-19-Related Respiratory Failure and Other Pulmonary Infections: A Contemporary Cohort Study

Myocardial injury (MI) is frequent in critically ill patients with COVID-19, but its pathogenesis remains unclear. We hypothesized that MI is not solely due to viral infection by SARS-CoV-2 but rather due to the common pathophysiological mechanisms associated with severe pulmonary infections and respiratory failure. This contemporary cohort study was designed to compare the incidence of MI in patients with acute respiratory failure caused by COVID-19 to patients with other pulmonary infections. In addition, we aimed to investigate whether MI was a distinct risk factor for in-hospital mortality in patients with COVID-19 compared to those with non-COVID-19 infections. This study included 1444 patients with COVID-19 (55.5% men; age 58 (46;68) years) and 182 patients with other pulmonary infections (46.9% men; age 62 (44;73) years). The incidence of MI at ICU admission was lower in COVID-19 patients (36.4%) compared to non-COVID-19 patients (56%), and this difference persisted after adjusting for age, sex, coronary artery disease, heart failure, SOFA score, lactate, and C-reactive protein (RR 0.84 (95% CI, 0.71-0.99)). MI at ICU admission was associated with a 59% increase in mortality (RR 1.59 (1.36-1.86); p < 0.001), and there was no significant difference in the mortality between patients with COVID-19 and those with other pulmonary infections (p = 0.271). We concluded that MI is less frequent in patients with critical COVID-19 pneumonia and respiratory failure compared to those with other types of pneumonia. The occurrence of MI is a significant risk factor for in-hospital mortality, regardless of the etiology of the pulmonary infection.

High plasma IL-6 levels following haploidentical allogeneic hematopoietic stem cell transplantation post-transplant cyclophosphamide as predictor of early death with worse outcome

INTRODUCTION

Haploidentical hematopoietic stem cell transplantation (haplo-HSCT) can be used as an alternative procedure in the absence of HLA-compatible donors. The use of high doses of cyclophosphamide after infusion improves the prognosis and eliminates the need for T cell depletion in vivo. Among the main complications of haplo-HSCT are acute graft-versus-host disease (a-GVHD) and cytokine release syndrome (CRS). This is a systemic inflammatory response that leads to the release of inflammatory proteins, including IL-6. This syndrome has several clinical features, with mild to severe symptoms. This study aimed to compare plasma IL-6 levels in patients submitted to different HSCT types and to associate them with the presence of acute graft versus host disease (a-GVHD), CRS and survival.

METHODS

A total of 84 patients (22 haploidentical and 62 non-haploidentical) were evaluated at different times. The IL-6 levels in haplo and non-haplo-HSCT recipients were measured before transplantation and on days D7, D14, D28, D60, and D100.

RESULTS

IL-6 levels were higher in haplo-HSCT recipients than in non-haplo-HSCT recipients, remaining elevated from D14 until D100 (P = 0.006) and a cut off ≥11 pg/mL on D7, which is related to worse overall survival. In our study, we found no association with a-GVHD (P = 0.239), a common complication of this type of transplant, but we found a relationship between the increase in IL-6 and CRS (P = 0.021).

CONCLUSION

IL6 can be used as a biomarker for patients submitted to haplo-HSCT, allowing clinical interference in patients having levels of IL-6 times larger than normality values, avoiding early death in this group of patients.

Quality management of the periodic medical examination at a university hospital, from the workers’ perspective

Introduction

Implementation of quality assessment methodologies at healthcare services enables the results achieved to be monitored in terms of established objectives and standards of care delivery.

Objectives

To assess the quality of the processes involved in provision of periodic medical examinations at a University Hospital, from the workers’ perspective.

Methods

This is a cross-sectional study using questionnaires to conduct quality assessment of the periodic medical examination processes, including Net Promoter Score satisfaction questions. Statistical analysis of the results was performed using SPSS version 18. Data on categorical variables are expressed as absolute frequencies and data on continuous variables as means and standard deviations. Chi-square tests and analysis of variance were used to identify associations. A significance level of 0.05 was adopted to determine the statistical relevance of findings.

Results

A total of 381 respondents with a mean age of 45.25 years were included, 66% of whom were female. There was a statistically significant (p < 0.001) association between duration of consultations and the number of items assessed in the periodic medical examination. In general, the findings from application of the Net Promoter Score for self-scheduling (45%) and service at reception (42%) indicate a need for process improvement, whereas clinical care (50%) rated as a quality process.

Conclusions

This study identified a set of information that can be used to describe, analyze, and improve the care delivered by the institution’s occupational health service and to identify opportunities for improvement of periodic medical examination processes.

Venous ulcer healing treated with conventional therapy and adjuvant laser: is there a difference?

OBJECTIVES

to evaluate the effects of venous ulcer healing in patients after six months of conventional treatment and adjuvant low-power laser therapy.

METHODS

prospective cohort study nested in a randomized clinical trial with 38 patients, allocated into an intervention group (conventional treatment and adjuvant laser therapy) and a control group (conventional treatment). Patients were followed up as outpatients, sociodemographic and clinical variables were collected, and indicators of the outcomes Wound healing: secondary intention (1103) and Tissue integrity: skin and mucous membranes(1101) of the Nursing Outcomes Classification. Generalized estimating equations, Kaplan-Meier tests, and robust Poisson regression were used in the analysis.

RESULTS

the clinical indicators Decreased wound size and Scar formation showed a statistically significant difference in the intervention group, higher number of healed wounds, lower rate, longer time to relapse.

CONCLUSIONS

laser therapy adjuvant to conventional treatment returned better results in healing and lower recurrence rates after six months of intervention.

Obesity as a predictive factor for chronic kidney disease in adults: systematic review and meta-analysis

Chronic kidney disease (CKD) is one of the main chronic diseases affecting the world population due to its high prevalence and increasing morbidity. Similarly, obesity gained the interest of the scientific community as it directly or indirectly increases mortality from cardiovascular causes, and its prevalence characterizes a pandemic. The objective of this study was to investigate obesity measured by body mass index as a predictor for end-stage renal disease in the general adult population. A systematic review and meta-analysis was carried out by searching 10 databases for prospective or retrospective cohort studies, with no restrictions on the language of publication, including adults with obesity without previous renal disease and who evolved to CKD (diagnosed by estimated glomerular filtration rate below 60 mL&mac_middot;min^-1&mac_middot;(1.73 m²)^-1 over the follow-up period. The R software and Meta package were used for data analysis. After removing duplicates, 5431 studies were submitted to the steps of the systematic review, and 21 articles were included in the data analysis. In total, 3,504,303 patients, 521,216 with obesity, and an average follow-up time of 9.86 years were included. The relative risk of obese people for developing CKD in the random effects model was 1.81 (95%CI: 1.52-2.16). The evidence found in this meta-analysis confirmed that obese people are at higher risk of developing CKD that the non-obese population (1.81 times higher), with obesity being a priority risk factor in preventive actions.

Nursing Guidelines on Cardiac Surgery and Parents' Anxiety: Randomized Clinical Trial

Objective

The preparation of parents of children who should undergo cardiac surgery requires special treatment such as the explanations about the event. This study aims to compare the effects of standardized nursing guidelines with routine institutional orientation on the anxiety of parents of children undergoing cardiac surgery.

Methods

Randomized clinical trial. The sample consisted of parents of children who underwent cardiac surgery from December 2010 to April 2011. Twenty-two parents were randomized to the intervention group (IG) and received the standard nursing guidelines and 22 participated in the control group (CG) and received the routine guidelines from the institution. Anxiety was assessed by the State-Trait Anxiety Inventory (STAI) applied in the preoperative period, between 12 and 20 hours before surgery and before receiving standard or institutional guidelines and 48 hours after surgery. The analysis of variance (ANOVA) for repeated measures was performed to evaluate the differences between the variations in STAI scores between the groups during the studied period. The level of significance was 0.05.

Results

There were no significant differences in baseline anxiety scores between groups with regard to trait anxiety as well as state anxiety: STAI-trait (CG 42.6±4.9 vs. IG 41.4±6.0, P=0.48); STAI-state (CG 42.3±5.7 vs. IG 45.6±8.3, P=0.18). Likewise, the variation in score after 48 hours was similar between groups (STAI-trait P=0.77; STAI-state P=0.61).

Conclusion

There were no significant differences in the parents’ anxiety levels when comparing the two types of guidelines: the standard nursing and the institutional orientation.

Variability index of tacrolimus serum levels in pediatric liver transplant recipients younger than 12 years: Non-adherence or risk of non-adherence?

MLVI has been used to assess adherence. To determine the MLVI in children <12 years of age at transplantation and to identify demographic correlates and consequences for the graft. This is a retrospective study of 50 outpatients (4.0 ± 3.5 years), at least 13-month post-liver transplantation. The outcomes evaluated were MLVI, ALT > 60 IU/L, ACR, death, and graft loss. We analyzed demographic and socioeconomic characteristics, indication for transplantation, and type of donor. Student's t test and the chi-square test were used. Statistical significance was set at P ≤ .05. Seventy-two percent were infants or preschoolers, 62% biliary atresia. Seventy-four percent of the mothers had middle-school education, and 54% of the families had an income ≤3632.4 US$/y. Twenty-two (44%) patients had a MLVI ≥ 2 SD; this was more prevalent in families with higher incomes (P = .045). ALT levels > 60 IU/L were more common in MLVI ≥ 2 SD group (P = .035). ACR episodes were similar between groups (P = 1.000). No patient died or lost the graft. MLVI ≥ 2 SD may be an indicator of the risk of medication non-adherence.

Feminicídios: estudo em capitais e municípios brasileiros de grande porte populacional

Resumo Este estudo objetiva analisar a relação entre feminicídios e indicadores socioeconômicos, demográficos, de acesso e saúde em capitais e municípios brasileiros de grande porte populacional. Trata-se de um estudo ecológico que utilizou o coeficiente médio padronizado da mortalidade feminina por agressão como marcador de feminicídio nos triênios de 2007-2009 e 2011-2013. Para a análise estatística foi utilizado o teste de Correlação de Pearson entre o desfecho e 17 variáveis independentes, e as que apresentaram significância estatística (p < 0,05) foram introduzidas em um modelo de regressão linear multivariada, método Backward. No primeiro triênio a taxa média de feminicídio foi de 4,5 óbitos por 100 mil mulheres, e no segundo período foi de 4,9/100 mil. Pobreza (β = -0,330; p = 0,006), pentecostalismo (β = 0,237; p = 0,002) e mortalidade masculina por agressão (β = 0,841; p = 0,000) estiveram associados aos feminicídios. A associação negativa entre pobreza e mortes femininas indica uma relação paradoxal, na medida em que as mulheres que morrem nas regiões mais ricas são pobres em sua maioria. Ainda, encontrou-se relação entre violência de gênero, fundamentalismos e violência urbana.

Weight gain adequacy and pregnancy outcomes in gestational diabetes: a meta-analysis

The Institute of Medicine updated guidelines for gestational weight gain in 2009, with no special recommendations for gestational diabetes. Our objectives were to describe the prevalence of weight gain adequacy and their association with adverse pregnancy outcomes in gestational diabetes. We searched MEDLINE, EMBASE, COCHRANE and SCOPUS. We calculated the pooled prevalence of gain adequacy and relative risks for pregnancy outcomes within Institute of Medicine categories. Thirty-three studies/abstracts (88,599 women) were included. Thirty-one studies provided data on the prevalence of weight gain adequacy; it was adequate in 34% (95% CI: 29-39%) of women, insufficient in 30% (95% CI: 27-34%) and excessive in 37% (95% CI: 33-41%). Excessive gain was associated with increased risks of pharmacological treatment, hypertensive disorders of pregnancy, caesarean section, large for gestational age and macrosomic babies, compared to adequate or non-excessive gain. Weight gain below the guidance had a protective effect on large babies (RR: 0.71; 95% CI: 0.56-0.90) and macrosomia (RR 0.57; 95% CI 0.40-0.83), and did not increase the risk of small babies (RR 1.40; 95% CI 0.86-2.27). Less than recommended weight gain would be beneficial, while effective prevention of excessive gain is of utmost importance, in gestational diabetes pregnancies. Nevertheless, no ideal range for weight gain could be established.

Women with HIV: gender violence and suicidal ideation

OBJECTIVE

To analyze the relationship between gender violence and suicidal ideation in women with HIV.

METHODS

A cross-sectional study with 161 users of specialized HIV/AIDS care services. The study investigated the presence of gender violence through the Brazilian version of the World Health Organization Violence against Women instrument, and suicidal ideation through the Suicidal Ideation Questionnaire. Statistical analyses were performed with the SPSS software, using the Chi-square test and Poisson multiple regression model.

RESULTS

Eighty-two women with HIV reported suicidal ideation (50.0%), 78 (95.0%) of who had suffered gender violence. Age at first sexual intercourse < 15 years old, high number of children, poverty, living with HIV for long, and presence of violence were statistically associated with suicidal ideation. Women who suffered gender violence showed 5.7 times more risk of manifesting suicidal ideation.

CONCLUSIONS

Women with HIV showed a high prevalence to gender violence and suicidal ideation. Understanding the relationship between these two grievances may contribute to the comprehensive care of these women and implementation of actions to prevent violence and suicide.

Bias of using odds ratio estimates in multinomial logistic regressions to estimate relative risk or prevalence ratio and alternatives

Recent studies have emphasized that there is no justification for using the odds ratio (OR) as an approximation of the relative risk (RR) or prevalence ratio (PR). Erroneous interpretations of the OR as RR or PR must be avoided, as several studies have shown that the OR is not a good approximation for these measures when the outcome is common (> 10%). For multinomial outcomes it is usual to use the multinomial logistic regression. In this context, there are no studies showing the impact of the approximation of the OR in the estimates of RR or PR. This study aimed to present and discuss alternative methods to multinomial logistic regression based upon robust Poisson regression and the log-binomial model. The approaches were compared by simulating various possible scenarios. The results showed that the proposed models have more precise and accurate estimates for the RR or PR than the multinomial logistic regression, as in the case of the binary outcome. Thus also for multinomial outcomes the OR must not be used as an approximation of the RR or PR, since this may lead to incorrect conclusions.

Femicídios: homicídios femininos no Brasil

OBJETIVO: Analisar a mortalidade feminina por agressão segundo indicadores sociodemográficos e de saúde. MÉTODOS: Estudo ecológico sobre a mortalidade feminina por agressão ocorrida no Brasil de 2003 a 2007. Os dados de 19.459 óbitos foram obtidos do Sistema de Informações sobre Mortalidade. Os coeficientes padronizados de mortalidade feminina por agressão foram relacionados (teste de correlação de Pearson) com 28 indicadores socioeconômicos, demográficos e de saúde. Foi realizada regressão linear múltipla com variáveis que apresentaram p < 0,20 e excluídas as variáveis que apresentaram multicolinearidade. RESULTADOS: O coeficiente padronizado de mortalidade foi de 4,1 óbitos/100.000 mulheres no período. Após o ajuste, três variáveis permaneceram significativas e associadas à mortalidade feminina por agressão: taxa de natalidade (p = 0,072), percentual de evangélicos (p = 0,019) e coeficiente de mortalidade por agressão no sexo masculino (p < 0,001). O modelo possui uma capacidade de predição do desfecho de 69% (r² = 0,699). Espírito Santo, Pernambuco, Mato Grosso, Rio de Janeiro, Rondônia, Alagoas, Mato Grosso do Sul, Roraima e Amapá apresentaram os maiores coeficientes no período. CONCLUSÕES: A mortalidade feminina por agressão no Brasil foi elevada e não homogênea entre as regiões. Entre as variáveis associadas ao evento, destaca-se a mortalidade masculina por agressão, indicando a importância da redução da violência estrutural como proteção das mulheres contra a violência.