Brazilian University Hospital Research Articles

Teleconsultation for pediatric patients with type 1 diabetes mellitus during the COVID-19 pandemic: experience of a university hospital in Brazil

ObjectiveEvaluate the impact of teleconsultation on glycemic control and prevention of acute complications related to diabetes mellitus in children and adolescents treated in a reference hospital during the COVID-19 pandemic in 2020. MethodDescriptive study of data from pediatric diabetic patients who received teleconsultation between April and September 2020. ResultsDuring this period, 143 diabetic patients were evaluated, with a median of 3.4 teleconsultations per patient in the studied period, requiring adjustment of insulin doses in 84.6% of cases. The hospital admission rate was 8,4% due to diabetic decompensation. The metabolic control (HbA1c) became worse in 46% of the sample and improved in 37%. ConclusionThe teleconsultation promoted health care for patients with diabetes mellitus during the COVID-19 pandemic but was not able to guarantee adequate glycemic control.

Does the cytomegalovirus infection cause kidney transplant rejection in Erbil city patients, Kurdistan region of Iraq?

Does the cytomegalovirus infection cause kidney transplant rejection in Erbil city patients, Kurdistan region of Iraq?

DKA and new-onset type 1 diabetes in Brazilian children and adolescents during the COVID-19 pandemic.

We assess the severity and frequency of diabetic ketoacidosis (DKA) in new-onset type 1 diabetes mellitus (T1D) patients and in patients with previous diagnosis of T1D in a referral Brazilian university hospital in the first five months of the COVID-19 pandemic. We also compare the data with data from pre-pandemic periods. Forty-three new-onset T1D patients were diagnosed between April and August of the years 2017, 2018, 2019, and 2020. During the COVID-19 pandemic, the number of new-onset T1D was over twice the number of new-onset T1D in the same period in the three previous years. All the 43 patients survived and are now on outpatient follow-up. We also compared the characteristics of the T1D patients hospitalized between April and August of the years 2017, 2018, and 2019 (32 hospitalizations) to the characteristics of the T1D patients hospitalized between April and August/2020 (35 hospitalizations; 1 patient was hospitalized twice in this period). Fourteen of the 34 patients admitted during the pandemic presented with COVID-19-related symptoms (any respiratory symptom, fever, nausea, vomiting, and diarrhea), but only one had positive SARS-CoV-2 RT-PCR test. Samples from 32 out of these 34 patients were assayed for SARS-CoV-2 antibodies, and four patients were positive for total antibodies (IgM and IgG). In agreement with recent reports from European countries, we observed increased frequency of DKA and severe DKA in new-onset and previously diagnosed T1D children and adolescents in a large referral public hospital in Brazil in the first five months of the COVID-19 pandemic. The reasons for this outcome might have been fear of SARS-CoV-2 infection in emergency settings, the more limited availability of primary healthcare, and the lack of school personnel's attention toward children's general well-being.

Evaluation of profile and work capacity of the post Covid-19 patients at the outpatient clinic for occupational health-related diseases at an University hospital in Brazil: preliminary results

Evaluation of profile and work capacity of the post Covid-19 patients at the outpatient clinic for occupational health-related diseases at an University hospital in Brazil: preliminary results

Ergonomics of anatomical bra models for breastfeeding: a contribution of nursing.

to analyze the ergonomics of two models of breastfeeding bras. descriptive study carried out with 152 infants in a Brazilian university hospital. The prototypes were separated into two groups (A and B). To compare the two bra models, the Odds Ratio (OR) was used as a measure of the strength of the association. In subjective perceptions, the Modified Borg Scale, and the chi-square test of independence (χ2) were used. To compare the two prototypes, the Z test and logistic regression analysis were performed. A significance level of 5% was considered. the bra in group B was more suitable for ergonomics of physical and psycho-aesthetic comfort than the bra in group A (p < 0.0001), according to the logistic regression tests. modeling B was ergonomically adequate, with usability and evaluation criteria centered on breastfeeding women.

Changes implemented in the work environment of nurses in the COVID-19 pandemic.

to describe the changes implemented in the work environment of nurses in university hospitals considering the COVID-19 pandemic. this qualitative and descriptive research was developed from an online survey with 75 nurses from three Brazilian university hospitals. Data processing occurred through textual analysis with the aid of software IRAMUTEQ. five semantic classes were obtained: Organization of units for exclusive care of patients with COVID-19; Adaptations in the use of personal protective equipment; Physical structure adaptation; Care flow institution; Increased number of beds and training courses. Final considerations: the results show the effort of healthcare and nursing professionals/managers in the development of structural adaptations and reorganizations of care processes, in the hospital context, to respond with quality and efficiency to the demands arising from the COVID-19 pandemic.

Economic impact of pharmaceutical interventions in a medium complexity Brazilian university hospital

Clinical pharmacists have been increasing their participation mainly through actions aimed at patient care, with international studies demonstrating favorable cost-benefit ratio from pharmacists interventions. However, there are few studies carried out in Brazil about the subject. This study aims to assess the economic impact of pharmaceutical interventions (PIs) in a hospital setting performed in October 2018. Each performed PI was registered and associated with the direct cost of drugs for economic impact analysis. A total of 185 PIs were evaluated, comprising 106 patients. The most intervened drugs were antibiotics, presenting the greatest economic impact, R$2,370. The total economic impact was R$2,578, mainly in the Pediatric Intensive Care Unit that represented R$1,701. Regarding the economic impact by PI as the “Suspension of drug without indication” saved R$1,360 while the “Inclusion of required drugs” cost R$807. It was estimated that the savings would be R$30,936 and, if PIs were performed at day zero, the savings would be R$79,728 per year. An average of 1.75 PI per patient was performed with an economic impact of R$14 per PI. Our results showed that clinical pharmacist’s role in the evaluation of pharmacotherapy is important for patients’ health and represents a positive economic impact.

Modified score function for monotone likelihood in the semiparametric mixture cure model.

The cure fraction models are intended to analyze lifetime data from populations where some individuals are immune to the event under study, and allow a joint estimation of the distribution related to the cured and susceptible subjects, as opposed to the usual approach ignoring the cure rate. In situations involving small sample sizes with many censored times, the detection of nonfinite coefficients may arise via maximum likelihood. This phenomenon is commonly known as monotone likelihood (ML), occurring in the Cox and logistic regression models when many categorical and unbalanced covariates are present. An existing solution to prevent the issue is based on the Firth correction, originally developed to reduce the estimation bias. The method ensures finite estimates by penalizing the likelihood function. In the context of mixture cure models, the ML issue is rarely discussed in the literature; therefore, this topic can be seen as the first contribution of our paper. The second major contribution, not well addressed elsewhere, is the study of the ML issue in cure mixture modeling under the flexibility of a semiparametric framework to handle the baseline hazard. We derive the modified score function based on the Firth approach and explore finite sample size properties of the estimators via a Monte Carlo scheme. The simulation results indicate that the performance of coefficients related to the binary covariates are strongly affected to the imbalance degree. A real illustration, in the melanoma dataset, is discussed using a relatively novel data set collected in a Brazilian universityhospital.

Survival and recurrence with or without axillary dissection in patients with invasive breast cancer and sentinel node metastasis

To evaluate overall survival and locoregional recurrence between patients with invasive breast tumours and sentinel node metastasis undergoing sentinel lymph node dissection (SLND) alone and those undergoing complete axillary lymph node dissection (ALND). In this retrospective cohort study, we reviewed the medical records of patients with invasive breast carcinoma who underwent lumpectomy at a public university hospital in Brazil between 2008 and 2018. We evaluated the overall survival and the locoregional recurrence using Kaplan–Meier and Cox regression analyses, respectively. Overall, 97 participants who underwent lumpectomy were enroled; 41 in the ALND group, and 56 in the SLND group, according to Z0011 criteria. Only 17% of the patients in the ALND group had an additional biopsy-proven axillary disease, and 83% were treated with complete dissection unnecessarily. The 5-year survival rates were 80.1% and 87.5% for SLND and ALND, respectively (p = 0.376). Locoregional recurrence was rare (1.7% and 7.3% in the SLND and ALND, respectively; p = 0.3075). Overall survival and locoregional recurrence were similar between the two groups. The de-escalation of ALND to SLND in women with metastasis in the sentinel lymph node treated with conservative surgery and radiotherapy that meet the Z0011 criteria is feasible even in developing countries.

Understanding professional stratification and hybridisation in the medical profession: exploratory evidence from Brazilian federal university hospitals

Abstract This paper explores drivers, implications, and trends of professional stratification and hybridisation in the medical profession employed in Brazilian substituir por: federal university hospitals (HUFs). Drawing on exploratory findings, we examine some repercussions of the migration of university hospitals to EBSERH, a public company established by the federal government to manage and organise HUFs integrated into the Unified Health System (SUS). Our research shows that transferring hospital administration to EBSERH has led to further internal stratification of the medical workforce. The shift from the logic of medical-academic professionalism to the new logic of business-like healthcare, with the adoption of distinct job contracts and more managerial logics of work and control, may well be changing subjective and formal links established between professionals, universities, and hospitals. We identify and discuss trends towards hybridisation and dehybridisation. These findings are relevant because this shift can have profound implications for the academic nature of HUFs and for the future of professionalism within these health and teaching organisations.

Applicability of the GLIM criteria for the diagnosis of malnutrition in older adults in the emergency ward: A pilot validation study

Acutely ill older adults are at higher risk of malnutrition. This study aimed to explore the applicability and accuracy of the GLIM criteria to diagnose malnutrition in acutely ill older adults in the emergency ward (EW). We performed a retrospective secondary analysis, of an ongoing cohort study, in 165 participants over 65 years of age admitted to the EW of a Brazilian university hospital. Nutrition assessment included anthropometry, the Simplified Nutritional Assessment Questionnaire (SNAQ), the Malnutrition Screening Tool (MST), and the Mini-Nutritional Assessment (MNA). We diagnosed malnutrition using GLIM criteria, defined by the parallel presence of at least one phenotypic [nonvolitional weight loss (WL), low BMI, low muscle mass (MM)] and one etiologic criterion [reduced food intake or assimilation (RFI), disease burden/inflammation]. We used the receiver operating characteristic (ROC) curves and Cox and logistic regression for data analyses. GLIM criteria, following the MNA-SF screening, classified 50.3% of participants as malnourished, 29.1% of them in a severe stage. Validation of the diagnosis using MNA-FF as a reference showed good accuracy (AUC=0.84), and moderate sensitivity (76%) and specificity (75.1%). All phenotypic criteria combined with RFI showed the best metrics. Malnutrition showed a trend for an increased risk of transference to intensive care unit (OR=2.08, 95% CI 0.99, 4.35), and severe malnutrition for in-hospital mortality (HR=4.23, 95% CI 1.2, 14.9). GLIM criteria, following MNA-SF screening, appear to be a feasible approach to diagnose malnutrition in acutely ill older adults in the EW. Nonvolitional WL combined with RFI or acute inflammation were the best components identified and are easily accessible, allowing their potential use in clinical practice.

Financial impact of healthcare-associated infections on intensive care units estimated for fifty Brazilian university hospitals affiliated to the unified health system

Studies show that healthcare-associated infections (HAIs) represent a crucial issue in healthcare and can lead to substantial economic impacts in intensive care units (ICUs). To estimate direct costs associated with the most significant HAIs in 50 teaching hospitals in Brazil, affiliated to the unified health system (Sistema Único de Saúde: SUS). A Monte Carlo simulation model was designed to estimate the direct costs of HAIs; first, epidemiologic and economic parameters were established for each HAI based on a cohort of 949 critical patients (800 without HAI and 149 with); second, simulation based on three Brazilian prevalence scenarios of HAIs in ICU patients (29.1%, 51.2%, and 61.6%) was used; and third, the annual direct costs of HAIs in 50 university hospitals were simulated. Patients with HAIs had 16 additional days in the ICU, along with an extra direct cost of US$13.892, compared to those without HAIs. In one hypothetical scenario without HAI, the direct annual cost of hospital care for 26,649 inpatients in adult ICUs of 50 hospitals was US$112,924,421. There was an increase of approximately US$56 million in a scenario with 29.1%, and an increase of US$147 million in a scenario with 61.6%. The impact on the direct cost became significant starting at a 10% prevalence of HAIs, where US$2,824,817 is added for each 1% increase in prevalence. This analysis provides robust and updated estimates showing that HAI places a significant financial burden on the Brazilian healthcare system and contributes to a longer stay for inpatients.

Cost-minimization in Health: Linezolid versus vancomycin with serum monitoring in patients with incipient renal failure – a simulation and real-life / Minimização de custos em Saúde: Linezolida versus vancomicina com monitoramento sérico em pacientes com insuficiência renal incipiente - uma simulação e vida real

Vancomycin serum levels (VSL) were measured to prevent dose-dependent side effects. However, the cost of VSL is high, therefore in some cases alternative antibacterial treatments, such as linezolid, can be used. The aim of this study was to perform an economic analysis of the cost of linezolid compared to vancomycin plus therapeutic drug monitoring. This is an ecological, retrospective, quantitative study, conducted in a Brazilian public university hospital. The study period was from January 2018 to January 2019. First part from January/18 - July/18 based on pre-linezolid data (T1) and another after the introduction of linezolid from August/18 - January/19 (T2). A breakeven analysis to vancomycin substitution was performed following 3 scenarios: (i) in all patients, (ii) in critically ill patients with renal failure or (iii) only in patients in hemodialysis. The DDD/1000-patients day, MRSA incidence, costs with VSL, as well as the costs of drugs (vancomycin and linezolid) and infusion kits were evaluated. Vancomycin was substituted in critically ill patients with renal failure from T1 to T2. The incidence of MRSA infections did not vary between T1 and T2. Vancomycin consume maintained constant (p=0.157); while linezolid consuming increased (0 DDD/1000PD versus 33.4 DDD/1000PD; p=0.002). Vancomycin and linezolid costs was lower in T1 than T2 (USD 9202,00 versus 11331,00; p=0.015). Linezolid implementation as a strategy to avoid vancomycin plus VSL was not cost-effective in critically ill patients with renal failure. More studies are needed to understand if linezolid implementation may be cost-effective in different scenarios.

Bioethics in Childbirth Care: Protocol for a Scoping Review.

BackgroundEnsuring women’s rights during childbirth care based on humanized and bioethical principles results in better quality of care and patient safety and provides positive childbirth experiences.ObjectiveWe aim to explore the available evidence on the application of bioethical principles in the general context of childbirth care.MethodsOur scoping review will follow the Joanna Briggs Institute Reviewer’s Manual. Published and unpublished bibliographic materials will be considered based on the following inclusion criteria: reports of the application of bioethical principles (concept) in assistance to the predelivery, childbirth, and postpartum periods (population) in the hospital context (context). We will search for relevant studies in PubMed and the Virtual Health Library, including MEDLINE, LILACS, BDENF, SCiELO, Web of Science, and Google Scholar. Two reviewers will perform the screening of titles and abstracts, read the full texts, and extract data from the selected articles. The data will then be organized and expressed into categories based on their content.ResultsThe analyzed data will be presented through flowcharts, tables, and descriptive narratives. A paper summarizing the findings from this review will be published in a peer-reviewed journal. In addition, a synthesis of the key findings will be disseminated to health services linked to university hospitals in Brazil. They will also be shared with the academic community and policy makers involved in the Childbirth Assistance Network, which will potentially adopt our recommendations in their decision-making process regarding childbirth care practice in Brazil.ConclusionsThe findings from this review will inform, through the translation of knowledge, childbirth support groups, feminist movements, movements in favor of humanization of childbirth, and other childbirth support networks in the country.Trial RegistrationOpen Science Framework; https://osf.io/kczyr/

Derivation and validation of a national multicenter mortality risk stratification model – the ExCare model: a study protocol

IntroductionSurgical care is essential for proper management of various diseases. However, it can result in unfavorable outcomes. In order to identify patients at higher risk of complications, several risk stratification models have been developed. Ideally, these tools should be simple, reproducible, accurate, and externally validated. Unfortunately, none of the best-known risk stratification instruments have been validated in Brazil. In this sense, the Ex-Care model was developed by retrospective data analysis of surgical patients in a major Brazilian university hospital. It consists of four independent predictors easily collected in the preoperative evaluation, showing high accuracy in predicting death within 30 days after surgery. ObjectivesTo update and validate a Brazilian national-based model of postoperative death probability within 30 days based on the Ex-Care model. Also, to develop an application for smartphones that allows preoperative risk stratification by Ex-Care model. MethodsTen participating centers will collect retrospective data from digital databases. Variables age, American Society of Anesthesiologists (ASA) physical status, surgical severity (major or non-major) and nature (elective or urgent) will be evaluated as predictors for in-hospital mortality within 30 postoperative days, considered the primary outcome. Expected resultsWe believe that the Ex-Care model will present discriminative capacity similar to other classically used scores validated for surgical mortality prediction. Furthermore, the mobile application to be developed will provide a practical and easy-to-use tool to the professionals enrolled in perioperative care.

Educating diabetic patients through an SMS intervention: a randomized controlled trial at a Brazilian public hospital.

Diabetes mellitus (DM) has a high healthcare system cost worldwide. Educational strategies are important to improve self-care and control this disease. This study aimed to evaluate satisfaction and clinical efficacy of a Short Message Service (SMS) educational intervention in self-care and nutrition at a Brazilian university hospital. We conducted a trial of educational intervention and assigned eligible patients with DM to either receive weekly educational SMS for 6 months (intervention group [IG]) or no SMS at all (control group). A satisfaction questionnaire was applied before and after the intervention in both groups. Laboratory (fasting glucose, hemoglobin [Hb] A1c, total cholesterol, triglycerides, high-density lipoprotein, and low-density lipoprotein) and clinical (blood pressure) data were also collected. Data were analyzed using nonparametric tests with the Statistical Package for the Social Sciences. We included 128 patients (64 in each group). Responses to the satisfaction questionnaire with self-care and healthcare professionals from 112 patients revealed an improvement in the perception of receiving information regarding helpful eating habits and in healthy eating behavior and an improvement in satisfaction with their diabetes care in the IG. In the post-intervention period, improved systolic blood pressure and HbA1c levels were observed in the IG as illustrated by delta % (post-intervention minus pre-intervention data divided by pre-intervention data multiplied by 100) reductions of 2.3% and 3.9%, respectively. SMS intervention was useful as an educational tool for improving satisfaction and glycemic and blood pressure control of patients with DM observed at a Brazilian university hospital.

COVID-19 and invasive fungal coinfections: A case series at a Brazilian referral hospital

BackgroundCOVID-19 co-infections have been described with different pathogens, including filamentous and yeast fungi. MethodologyA retrospective case series study conducted from February to December 2020, at a Brazilian university hospital. Data were collected from two hospital surveillance systems: Invasive fungal infection (IFI) surveillance (Mycosis Resistance Program - MIRE) and COVID-19 surveillance. Data from both surveillance systems were cross-checked to identify individuals diagnosed with SARS-CoV-2 (by positive polymerase chain reaction (PCR)) and IFI during hospital stays within the study period. ResultsDuring the study period, 716 inpatients with COVID-19 and 55 cases of IFI were identified. Fungal co-infection with SARS-CoV-2 was observed in eight (1%) patients: three cases of aspergillosis; four candidemia and one cryptococcosis. The median age of patients was 66 years (IQR 58-71 years; range of 28-77 years) and 62.5% were men. Diagnosis of IFI occurred a median of 11.5 days (IQR 4.5-23 days) after admission and 11 days (IQR 6.5-16 days) after a positive PCR result for SARS-CoV-2. In 75% of cases, IFI was diagnosed in the intensive care unit (ICU). Cases of aspergillosis emerged earlier than those of candidemia: an average of 8.6 and 28.6 days after a positive PCR for SARS-CoV-2, respectively. All the patients with both infections ultimately died. ConclusionA low rate of COVID-19 co-infection with IFI was observed, with high mortality. Most cases were diagnosed in ICU patients. Aspergillosis diagnosis is highly complex in this context and requires different criteria.

What can be expected to be seen in a Neurology ward? Eleven-year experience in a Brazilian university hospital.

Neurological disorders are significant causes of morbidity and mortality worldwide. However, data about general neurological inpatient admissions in Brazil is limited. Objective: To investigate the prevalence of neurological disorders according to disease group and lesion site among patients admitted to a general Neurology ward. This was an observational and descriptive study. The hospital discharge database for the Neurology ward was surveyed in accordance with the International Classification of Diseases, 10th edition (ICD-10), from September 2008 to October 2019. The final diagnosis was classified into neurological disorder groups and site. Overall, 2,606 clinical neurological patient files were included, with mean length of hospitalization of 16.7 days and a total of 325 readmissions (12.5%). The overall mortality rate in the ward was 3.8% (100 patients). Among all the diagnoses, cerebrovascular disease was the most prevalent (45.8%), followed by inflammatory disorders (22.2%). The brain was the most common lesion site (66.0%), followed by peripheral nerves (10.0%) and meninges and cerebrospinal fluid (7.7%). The disease pattern upon admission showed that a majority of the cases consisted of cerebrovascular disorders and that the brain was the most frequently affected structure, although we observed that a wide variety of cases were admitted, encompassing all neurological disorders.

A cost of illness comparison for toxigenic Clostridioides difficile diagnosis algorithms in developing countries

BackgroundAvailability of several commercial tests with different Clostridioides difficile targets contributes to uncertainty and controversies around the optimal diagnostic algorithm. While numerous studies have estimated the financial impact of C. difficile infection, models to guide testing strategies decisions in developing countries, where economic value significantly impacts clinical practice, are currently not available. AimTo determine the cost of illness of different C. difficile infection (CDI) diagnostic strategies in developing countries. MethodsCost-comparison analysis was performed to compare eleven different algorithms of CDI diagnosis. The basis of calculation was a hypothetical cohort of 1000 adult inpatients suspected of CDI. We analyzed turnaround time of test results (i.e., time from taking sample to results emission), test performance (i.e., sensitivity and specificity) and testing costs. Patients were divided in true positive, false positive, true negative and false negative in order to integrate test performance and economics effects. Additional medical costs were calculated: costs of hygiene, medication, length of stay and intensive care unit costs, based on a Brazilian University Hospital costs. CDI prevalence was considered 22.64%. FindingsFrom laboratory-assisted tests, simultaneous glutamate dehydrogenase (GDH) and toxin A/B rapid immunoassay arbitrated by nucleic acid amplification test (NAAT) presented the lowest cost of illness (450,038.70 USD), whereas standalone NAAT had the highest (523,709.55 USD). Empirical diagnosis only presented the highest overall cost (809,605.44 USD). ConclusionThe two-step algorithm with simultaneous GDH and toxin A/B rapid immunoassay arbitrated by NAAT seems to be the best strategy for CDI diagnosis in developing countries.

Controversies as method for ANTi-history: An inquiry into public administration practices

Drawing on Actor-Network Theory and the cartography of controversies, we present a method for ANTi-History research to investigate the implementation of a contract between a labour services company and a public university hospital in Brazil. The research question focuses on how the past is enacted in the present. The method is a general guideline based on five focal points used to organize the fieldwork: identifying controversies; mapping the actor-network; drawing out the translation process; politics of actor-networks and multiple reality/power relations. The proposed method makes two contributions to ANTi-History literature. First, although these focal points have been discussed by ANTi-History scholars, they are scattered throughout the literature. We unite them to offer a guide to doing historically embedded research. Second, we show how controversy analysis can be helpful for mapping the politics of actor-networks and describing multiple realities in the construction of history.