Brazilian University Hospital Research Articles

Analysis of clinical outcomes in older individuals who received pharmaceutical care and posthospital discharge follow-up.

Previous evidence underscores the need to assess potential clinical outcomes resulting from pharmaceutical care interventions and to monitor patient's progress to evaluate their clinical evolution, which is crucial for bolstering the relevance of implementing pharmaceutical care in healthcare services. To conduct an in-depth analysis of pharmaceutical care practices in a geriatric ward and monitor the clinical outcomes of older people served. This interventionist study was conducted in the geriatrics ward of a Brazilian university hospital. The research intervention occurred between January and May 2022, with a follow-up conducted for up to 90 days after patients' hospital discharge. Older patients in the geriatrics ward received pharmaceutical care, including medication reconciliation, medication review,and pharmacotherapeutic follow-up, aimed at identifying and resolving drug-related problems (DRPs). The clinical relevance of DRPs and pharmaceutical recommendations was evaluated. Additionally, analyses were conducted on mortality and rehospitalization outcomes in older patients at 30, 60,and 90 days following initial hospital discharge. Of the patients evaluated, a significant 88.3% exhibited at least one DRP (with an average of 2.6 ± 1.9 DRPs per patient), with the majority classified as need/indication problems (38.9%). The acceptance rate of pharmaceutical recommendations was 80.9%, with the majority categorized as very significant relevance (60.4%). DRPs were predominantly of serious clinical relevance (50.9%). In patients whose clinical indicators could be monitored, 95.5% showed some clinical response (in vital signs, laboratory testsand/or clinical status evolution) potentially related to resolved DRPs. Association analysis revealed that a higher number of medications in use before hospitalization correlated with a greater identification of DRPs during hospitalization (p = 0.03). At hospital discharge, 23.6% of patients were no longer using polypharmacy. In total, 16 patients (26.7%) died during the study period. Among patients who did not die during hospitalization (n = 54), 20 patients (37%) experienced rehospitalizations within 90 days following discharge. This study facilitated the consolidation of pharmaceutical care implementation in a geriatric ward. We conducted identification, evaluation,and proposed evidence-based solutions, as well as monitored cases for outcome analysis. It is anticipated that this methodology will inspire future research and the implementation of pharmaceutical care-related services.

Impact of SARS-CoV-2 Pandemic on Ocular Tissue Donation in a Teaching Hospital

Objectives: To analyze the impact of the severe acute respiratory syndrome coronavirus (SARS-CoV-2) pandemic on ocular tissue donations, assessing lost opportunities for potential donors due to the suspension of collections and changes in eligibility criteria, as well as hospital eligibility rates of donors and causes of non-donation. Methods: Data from patients who died in cardiopulmonary arrest in a Brazilian university hospital in 2020 were analyzed. The number of donations made, the number of deaths potentially eligible for donation, and the causes of non-donation were compared during the three periods of 2020: period 1, pre-pandemic ( January 1 to March 18, 2020), period 2, with suspension of donations in cardiorespiratory arrest (March 19 to September 19, 2020), and period 3, of collections with epidemiological screening for SARS-CoV-2 and reduction of the age range of donors less than 65 years old (September 20 to December 31 2020). Results: There were 710 circulatory deaths in 2020. The hospital eligibility rate was 5.7% among 140 deaths in the pre-pandemic period 1, 11.9% among 395 patients during the suspension of uptake in pandemic period 2, and 3.4% among 175 patients during age group restrictions and coronavirus disease 2019 (COVID-19) screening (p:0.004). Forty-seven patients who died in period 2 represented a loss of donation opportunities due to the suspension of collections, and 13 (7.6%) of the 175 patients in period 3 were ineligible due to the reduction in age group. Due to pandemic restrictions, eighty-one percent of the 75 eligible patients without clinical contraindications had limited tissue donation offers. Only one patient was considered ineligible for donation due to clinical-epidemiological screening for SARS-CoV-2. Serious infections were the leading cause of non-donation in 50.7, 48.1, and 47.4% of deaths in the three periods (p:0.615). Conclusion: The SARS-CoV-2 pandemic significantly affected the procurement of ocular tissues for transplants due to the restrictive measures implemented for safety reasons, leading to the loss of donation opportunities for 81% of families. Age restrictions significantly reduced potential donor eligibility rates. Serious infections were the leading cause of non-donation of ocular tissue, but it did not increase significantly in this study during the pandemic, in the period studied.

Sepsis death risk factor score based on systemic inflammatory response syndrome, quick sequential organ failure assessment, and comorbidities

ObjectiveIn this study, we aimed to evaluate the death risk factors of patients included in the sepsis protocol bundle, using clinical data from qSOFA, SIRS, and comorbidities, as well as development of a mortality risk score. DesignThis retrospective cohort study was conducted between 2016 and 2021. SettingTwo university hospitals in Brazil. ParticipantsPatients with sepsis. InterventionsSeveral clinical and laboratory data were collected focused on SIRS, qSOFA, and comorbidities. Main variable of interestIn-hospital mortality was the primary outcome variable. A mortality risk score was developed after logistic regression analysis. ResultsA total of 1,808 patients were included with a death rate of 36%. Ten variables remained independent factors related to death in multivariate analysis: temperature ≥38 °C (odds ratio [OR] = 0.65), previous sepsis (OR = 1.42), qSOFA ≥ 2 (OR = 1.43), leukocytes >12,000 or <4,000 cells/mm3 (OR = 1.61), encephalic vascular accident (OR = 1.88), age >60 years (OR = 1.93), cancer (OR = 2.2), length of hospital stay before sepsis >7 days (OR = 2.22,), dialysis (OR = 2.51), and cirrhosis (OR = 3.97). Considering the equation of the binary regression logistic analysis, the score presented an area under curve of 0.668, is not a potential model for death prediction. ConclusionsSeveral risk factors are independently associated with mortality, allowing the development of a prediction score based on qSOFA, SIRS, and comorbidities data, however, the performance of this score is low.

Impact of the COVID-19 pandemic on the pathologic diagnosis and treatment of breast cancer in a university hospital in Brazil

PurposeThe COVID-19 pandemic has led to the need for extraordinary restrictions and adjustments in health services, which may have compromised cancer screening and oncological treatments. The aim of our retrospective study was to evaluate the impact of the COVID-19 pandemic on breast cancer pathologic diagnosis, presentation, and treatment in a university hospital in Brazil.Materials and methodsWe extracted data from the medical records of all patients who were diagnosed with breast cancer and underwent treatment in a Southeast University Hospital in Brazil from March to December between 2018 and 2021. The primary objective was to compare breast cancer diagnosis, stage, and oncology treatments during the COVID-19 pandemic (2020–2021) with a prepandemic control cohort (2018–2019).ResultsWe collected data for 116 patients and 500 breast surgical specimens. There was a -12% decline in the diagnosis of new cases of breast cancer during the pandemic. The decrease was most pronounced when comparing 2019 and 2020 (-50%), and a recovery in the number of diagnoses was noted in 2021 compared to 2019 (+ 7.1%). In terms of therapeutic surgical approaches, an increase of 29.73% occurred during the pandemic period. The increase was most pronounced when comparing 2018 and 2020 (+ 41.18%). Overall, stage distribution and other tumor characteristics did not show statistically significant differences between the pandemic and prepandemic cohorts.ConclusionsOur results showed a decrease in the number of new breast cancer diagnoses (-12%) during the pandemic compared to the prepandemic period. However, the number of therapeutic surgical approaches performed increased, and a recovery in the number of breast cancer diagnoses during 2021 has been noticed. Concerted measures are needed to minimize the long-term negative impact of the COVID-19 pandemic on delayed diagnosis.

Sepsis death risk factor score based on systemic inflammatory response syndrome, quick sequential organ failure assessment, and comorbidities

ObjectiveIn this study, we aimed to evaluate the death risk factors of patients included in the sepsis protocol bundle, using clinical data from qSOFA, SIRS, and comorbidities, as well as development of a mortality risk score. DesignThis retrospective cohort study was conducted between 2016 and 2021. SettingTwo university hospitals in Brazil. ParticipantsPatients with sepsis. InterventionsSeveral clinical and laboratory data were collected focused on SIRS, qSOFA, and comorbidities. Main variable of interestIn-hospital mortality was the primary outcome variable. A mortality risk score was developed after logistic regression analysis. ResultsA total of 1,808 patients were included with a death rate of 36%. Ten variables remained independent factors related to death in multivariate analysis: temperature ≥38 °C (odds ratio [OR] = 0.65), previous sepsis (OR = 1.42), qSOFA ≥ 2 (OR = 1.43), leukocytes >12,000 or <4,000 cells/mm3 (OR = 1.61), encephalic vascular accident (OR = 1.88), age >60 years (OR = 1.93), cancer (OR = 2.2), length of hospital stay before sepsis >7 days (OR = 2.22,), dialysis (OR = 2.51), and cirrhosis (OR = 3.97). Considering the equation of the binary regression logistic analysis, the score presented an area under curve of 0.668, is not a potential model for death prediction. ConclusionsSeveral risk factors are independently associated with mortality, allowing the development of a prediction score based on qSOFA, SIRS, and comorbidities data, however, the performance of this score is low.

Recurrent Aphthous Stomatitis: Clinical Experience From a University Hospital in Brazil

Recurrent Aphthous Stomatitis: Clinical Experience From a University Hospital in Brazil

Role of fiberoptic endoscopic evaluation of swallowing (FEES) in children with suspected dysphagia

ObjectiveTo assess FEES findings in defining oral feeding safety in children with suspected dysphagia, comparing them with clinical feeding evaluation results. MethodsThis study comprised a case series involving children with suspected dysphagia, referred for evaluation by otolaryngologists and speech-language pathologists (SLPs) at a Brazilian quaternary public university hospital. These children underwent both clinical evaluations and fiberoptic endoscopic evaluation of swallowing (FEES), with a comprehensive collection of demographic and clinical data. Subsequently, the authors performed a comparative analysis of findings from both assessments. ResultsMost patients successfully completed the FEES procedure (93.7%), resulting in a final number of 60 cases included in the study. The prevalence of dysphagia was confirmed in a significant 88% of these cases. Suspected aspiration on clinical SLP evaluation was present in 34 patients. Of these, FEES confirmed aspiration or penetration in 28 patients. Among the 35 patients with aspiration or penetration on FEES, 7 (20%) had no suspicion on SLP clinical assessment. All seven patients in whom clinical SLP evaluation failed to predict penetration/aspiration had neurological disorders. The median age of the children was 2.8 years, and 49 (81.6%) had neurological disorders, while 35 (58.3%) had chronic pulmonary disease. The most prevalent complaints were choking (41.6%) and sialorrhea (23.3%). ConclusionFEES can diagnose structural anomalies of the upper aerodigestive tract and significantly contribute to the detection of aspiration and penetration in this group of patients with suspected dysphagia, identifying moderate and severe dysphagia even in cases where clinical assessment had no suspicion.

Performance of the first-trimester Fetal Medicine Foundation competing risks model for preeclampsia prediction: an external validation study in Brazil

Background: The current version of the Fetal Medicine Foundation competing risks model for preeclampsia prediction has not been previously validated in Brazil.Objectives: (1) To validate the Fetal Medicine Foundation combined algorithm for the prediction of preterm preeclampsia in the Brazilian population and (2) to describe the accuracy and calibration of the Fetal Medicine Foundation algorithm when considering the prophylactic use of aspirin, by clinical criteria.Study design: Cohort study, including consecutive singleton pregnancies undergoing preeclampsia screening at 11-14 weeks, examining maternal characteristics, medical history, and biophysical markers between October 2010 and December 2018 in a university hospital in Brazil. Risks were calculated using the 2018 version of the algorithm available on the Fetal Medicine Foundation website, and cases were classified as low- or high-risk using cut-off of 1/100 to evaluate predictive performance. Expected and observed cases with PE according to the FMF estimated risk range (≥1 in 10; 1 in 11 to 1 in 50; 1 in 51 to 1 in 100; 1 in 101 to 1 in 150; and <1 in 150) were compared. After identifying high-risk pregnant women who used aspirin, the treatment effect of 62% reduction in preterm preeclampsia identified in the ASPRE trial was used to evaluate the predictive performance adjusted for the effect of aspirin. The number of potentially unpreventable cases in the group without aspirin use was estimated.Results: Among 2,749 pregnancies, preterm preeclampsia occurred in 84 (3.1%). With a risk cut-off of 1/100, the screen-positive rate was 25.8%. The detection rate was 71.4%, with a false positive rate of 24.4%. The area under the curve was 0.818 (95% confidence interval 0.773 to 0.863). In the risk range ≥1/10, there is an agreement between the number of expected and observed cases, and in the other ranges, the predicted risk was lower than the observed rates. Accounting for the effect of aspirin resulted in an increase in detection rate and positive predictive values and a slight decrease in the false positive rate. With 27 cases of preterm preeclampsia in the high-risk group without aspirin use, we estimate that 16 of these cases of preterm preeclampsia would have been avoided if this group had received prophylaxis.Conclusions: In a high prevalence setting, the Fetal Medicine Foundation algorithm can identify women who are more likely to develop preterm preeclampsia. Not accounting for the effect of aspirin underestimates the screening performance.

No good choices, only hard decisions: the delicate nature of team family communication in pompe disease

Objective: To describe the experience of a family going through the palliative care decision-making for a child with Pompe disease. Method: Qualitative research, case study design, approved by Ethics Committee (CAAE: 58643816400005327), conducted between 2017/2018. The setting was the Pediatric Intensive Care Unit of a university hospital in Brazil. Participants were family members of children admitted to the Intensive Care Unit and referred for palliative care. Results: The case study relates the decision-making on palliative care for a child with Pompe disease. The parents, surrounded by the palliative care available for the situation, experience the existential reality of the decision-making process to adopt palliative care for their child, together with the multi-professional team. Conclusions: Understanding the concept of quality of life that each family develops when faced with the seriousness of their child's illness, when the possibilities of cure have been exhausted, is fundamental to the decision making process for adopting palliative care. It is essential to include the participation of the child's or adolescent's parents and other family members in the palliative care decision-making process, in order to give the family a voice, minimising their doubts and suffering, as well as offering shelter in a situation of extreme existential vulnerability.

Using exome analysis as a tool for genetics acquaintance in a psychiatry residence program

Objective: In this paper, a residency program at a Brazilian University Hospital shares its experience with a genetic screening test during the investigation of an inpatient with schizophrenia features. Method: A whole exome sequencing study investigation of a clozapine-refractory patient with schizophrenia served as a facilitator for mastering skills in genetics. Results: During the hospitalization of a 26-year-old patient with clozapine-refractory schizophrenia, the medical residency team noted syndromic features, such as retrognathia, large ear pinnae, pectus excavatum, and a longer wingspan relative to height. These findings led to an interest in genetic evaluation using exome sequencing. The exam showed variations in TMEM106B, IRF2BPL, and ALKBH8, leading to the hypothesis of polygenic heritage. The variations found are previously linked to a wide variety of neuropsychiatric syndromes. Conclusions: Clinical practice in modern psychiatry demands deep knowledge in genetics as genetic and pharmacogenetic tests become more accessible. Genetic training is imperative for the 21st-century psychiatric resident so that one can critically assess this field of knowledge. In this paper, a residency program at a Brazilian University Hospital shares its experience in genetics learning.

Frailty does not affect prognostic markers in patients with acute coronary syndrome: results from a Brazilian university hospital

Objective: To evaluate frailty and its relationship with prognostic markers in hospitalized patients with acute coronary syndrome. Methods: This cross-sectional study with a prospective variable analysis (prognostic markers) involved adults of both sexes aged ≥ 50 years with acute coronary syndrome. Patients with ≥ 3 of the following criteria were considered frail: 1) unintentional weight loss; 2) exhaustion (assessed by self-reported fatigue); 3) low handgrip strength; 4) low physical activity level; and 5) low gait speed. The included prognostic markers were: metabolic changes (lipid and glycemic profile), changes in inflammatory status (C-reactive protein), thrombolysis in myocardial infarction risk score, troponin level, angioplasty or surgery, hospitalization in the intensive care unit, length of hospital stay, and hospital outcome. Results: The sample consisted of 125 patients, whose mean age was 65.5 (SD, 8.7) years. The prevalence of frailty was 48.00%, which was higher in women (PR = 1.55; 95%CI 1.08– 2.22; p = 0.018) and patients with systemic arterial hypertension (PR = 2.18; 95%CI 1.01–5.24; p = 0.030). Frailty was not associated with age, cardiac diagnosis, or prognostic markers (p &gt; 0.05). Conclusions: Frailty was highly prevalent in patients with acute coronary syndrome, affecting almost half of the sample, particularly women and patients with hypertension, irrespective of age. However, despite its high prevalence, frailty was not associated with markers of metabolic change or poor prognosis.

Searching for Care Excellence in a Brazilian University Hospital: The Evidence Based Nursing Nucleus

Searching for Care Excellence in a Brazilian University Hospital: The Evidence Based Nursing Nucleus

Beyond Guidelines: The Persistent Challenge of Preoperative Fasting Times

Despite the advancements in evidence-based medicine, many hospitals still maintain high rates of patients undergoing prolonged preoperative fasting. The goal of this study is to determine the prevalence of prolonged fasting time among patients undergoing elective surgeries at a Brazilian university hospital and its associations with clinical and sociodemographic variables. This cross-sectional study was conducted between May and November 2019 and included patients of all ages undergoing elective surgeries. Out of the 293 patients analyzed, 64.2% were male, with ages ranging from 1 to 85 years, and 93.9% were classified as ASA I or II. The prevalence of preoperative fasting exceeding 8 h was 89.4%. An average fasting time exceeding 11 h was observed across all age groups. Patients who underwent procedures in the afternoon had an average fasting time that was 24% longer than those in the morning period (14.9 vs. 12 h, p &lt; 0.001). Surgery time (r = 0.134, p &lt; 0.03) and anesthesia times (r = 0.121, p &lt; 0.04) demonstrated a weak correlation with fasting time. Despite the international consensus on preoperative fasting time, our study demonstrated low adherence to current recommendations. Therefore, healthcare professionals should ensure the comprehension of fasting guidelines, and further studies should aim to identify effective solutions to mitigate prolonged fasting.

Successful Liberation from Acute Kidney Replacement Therapy in Critically Ill Patients: A Prospective Cohort Study

Introduction: Recovery of kidney function to liberate patients from acute kidney replacement therapy (AKRT) is recognized as a vital patient-centered outcome. The lack of specific guidelines providing specific recommendations on therapy interruption is an important obstacle. We aimed to determine the prevalence of successful discontinuation of AKRT and its predictive factors after the elaboration of clinical protocol with these recommendations. Methodology: A prospective cohort study was performed with 156 patients at a public Brazilian university hospital between July 2020 and July 2021. Results: Success and hospital discharge were achieved for most patients (84.6% and 89%, respectively). Multivariable logistic regression analysis showed that C-reactive protein (CRP), urine output, and creatinine clearance at the time of interruption were variables associated with discontinuation success (OR: 0.943, CI: 0.905–0.983, p = 0.006; OR: 1.078, CI: 1.008–1.173, p = 0.009 and OR: 1.091, CI: 1.012–1.213, p = 0.004; respectively). The areas under the curve for CRP, urine output, and creatinine clearance at the time of interruption were 0.78, 0.62, and 0.82, respectively. Both CRP and creatinine clearance were good predictors of successful liberation of AKRT. The optimal cutoff value of them had sensitivity and specificity of 0.88 and 0.87, 0.91 and 0.90, respectively. The use of noradrenalin at the time of interruption (OR: 0.143, CI: 0.047–0.441, p = 0.001) and successful discontinuation (OR: 3.745, CI: 1.047–13.393, p = 0.042) were identified as variables associated with hospital discharge. Conclusion: Our results show the factors related to success in discontinuing AKRT are the CRP, creatinine clearances, and urinary output at the time of AKRT interruption and it was associated with lower mortality.

Abstract 14074: Prodromal Symptom Cluster is Associated With Length of Hospital Stay After Cardiac Arrest Resuscitation

Introduction: Little is known about the impact of cardiac arrest prodromal symptom clusters on survival after resuscitation. Hypothesis: Clusters of prodromal cardiac arrest symptoms are associated with the length of hospital stay until death or hospital discharge after resuscitation. Methods: This retrospective study included records of in-hospital and out-of-hospital cardiac arrest victims referred to a University Hospital in Brazil between 2010 and 2020. Data concerning the prodromal symptoms and length of hospital stay until death or hospital discharge were collected. Symptom clusters were examined by multiple correspondence analyses. Survival analysis and comparisons between those with and without symptoms were done by the Kaplan-Meier method and the Log-Rank test. Results: There were 120 eligible records (58.7 years old, 54.2% female, 86.7% White). Prodromal symptoms began during the 24 hours preceding the event in 67.2% of the victims; 64.1% had a return of spontaneous circulation. There were three symptom clusters. Symptoms of cluster 1 (dyspnea, cough, and edema), cluster 2 (mental confusion, restlessness, palpitations, reports of skin color changes, sweating, malaise, and stroke symptoms), and cluster 3 (fever, level of consciousness alterations, syncope, chest pain, abdominal pain, headache, and nausea), were found in 50.0%, 18.3%, and 54.1% of the records, respectively. Only individuals with symptoms of cluster 2 (Figure 1) had significantly lower lengths of hospital stay due to death than those without such symptoms (p = .04). Conclusions: Prodromal cardiac arrest symptoms occur in clusters that may indicate a worse prognosis after resuscitation.

The Large-Scale Implementation of a Health Information System in Brazilian University Hospitals: Process and Outcomes.

Governments around the globe are paving the way for healthcare services that can have a profound impact on the overall well-being and development of their nations. However, government programs to implement health information technologies on a large-scale are challenging, especially in developing countries. In this article, the process and outcomes of the large-scale implementation of a hospital information system for the management of Brazilian university hospitals are analyzed. Based on a qualitative approach, this research involved 21 hospitals and comprised a documentary search, interviews with 24 hospital managers and two system user focus groups, and a questionnaire of 736 respondents. Generally, we observed that aspects relating to the wider context of system implementation (macro level), the managerial structure, cultural nuances, and political dynamics within each hospital (meso level), as well as the technology, work activities, and individuals themselves (micro level) acted as facilitators and/or obstacles to the implementation process. The dynamics and complex interactions established between these aspects had repercussions on the process, including the extended time necessary to implement the national program and the somewhat mixed outcomes obtained by hospitals in the national network. Mostly positive, these outcomes were linked to the eight emerging dimensions of practices and work processes; planning, control, and decision making; transparency and accountability; optimization in the use of resources; productivity of professionals; patient information security; safety and quality of care; and improvement in teaching and research. We argued here that to maximize the potential of information technology in healthcare on a large-scale, an integrative and cooperative vision is required, along with a high capacity for change management, considering the different regional, local, and institutional contexts.

Simple or simplistic? Sensitivity of an operating room CFD model to refinement and detailing

Indoor air quality is critical in healthcare facilities since it directly relates to infection risk, mainly in operating rooms (OR). Nowadays, air movement in such environments is often evaluated with computational fluid dynamics (CFD) simulations. However, many users typically oversimplify their OR models by including only major equipment (such as operating tables and surgical lights) that do not require refined computational meshes. This work analyzes the sensitivity of CFD simulations to mesh refinement, air circulation layout, geometry detailing, placement of furniture and equipment, as well as the presence of the surgical staff in the OR. An OR of a Brazilian university hospital was modeled and validated with environmental parameters assessed in-loco. Results showed relative differences up to 375% in air velocity depending on mesh resolution. Including small furniture and changing the OR layout resulted in nine-fold differences in air velocity. Finally, modeling the surgical staff in the OR significantly interfered with air circulation patterns, preventing inflow from the polluted towards the clean and sterile zone. The present work demonstrates the alarming fact that even a validated, sound, but overly simple CFD model may be phenomenologically insufficient to assess real contamination risks in an OR — and, by extension, in other healthcare facilities. Therefore, detailed CFD models regarding the number of elements in the simulation mesh, the positioning and the operating condition of the ventilation system, the inclusion and detailing of furniture, and the presence of the surgical staff in the OR should be employed since early design stages.

Factors Associated with Late Diagnosis of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) in a University Hospital in Brazil: Challenges to Achieving the 2030 Target.

This study aimed to identify factors associated with late diagnosis and clinically monitor newly diagnosed HIV/AIDS patients. Retrospective study, based on secondary data from a specialized unit at the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto of the University of Sao Paulo. Data collection included sociodemographic, behavioral, clinical, and laboratory data of newly diagnosed HIV patients between 2015 and 2019. Data analysis was undertaken using inferential statistical tests. A total of 314 individuals were newly diagnosed with HIV/AIDS, 86.6% (272) had a late diagnosis and 53.8% (169) were diagnosed very late. Using the adjusted odds ratio, we observed that bisexual and MSM patients were less likely to have a late diagnosis compared to straight patients. Individuals who entered through the emergency department and Outpatient Clinic had a lower chance of having a very late diagnosis compared to those diagnosed in the ward/inpatient unit. Having a higher education and university education were protective factors against having a very late diagnosis of HIV infection compared to elementary school education only. In addition, male patients were more likely to have a very late diagnosis compared to female patients. This study evidenced a high prevalence of late and very late diagnoses. Therefore, attention should be directed towards factors related to late and very late presentation.

Aerosolized lidocaine to reduce tracheal suction-associated pain after pediatric congenital heart surgery: A randomized, double-blind, placebo-controlled trial

BackgroundIn children undergoing heart surgery for congenital heart disease (CHD), postoperative pain is associated with changes in the respiratory system that can lead to complicated courses and poor outcomes. Respiratory therapy (RT) can restore respiratory function through manual techniques and tracheal suction (TS). However, TS itself can cause pain, leading to hemodynamic and respiratory manifestations, such as tachycardia, hyper- or hypotension, tachypnea, increased work-of-breathing, patient-ventilator asynchrony, among others. ObjectivesThe aim of this study was to investigate whether RT/TS increases pain and whether inhaled lidocaine can attenuate pain increase in infants and children undergoing surgery for CHD. MethodsDouble-blind, randomized, placebo-controlled trial at a pediatric intensive care unit in a Brazilian tertiary-care university hospital. Patients <18 years submitted to open-heart surgery for CHD were included and randomized to receive either aerosolized lidocaine (1 mg/kg) or placebo before RT/TS. Pain was assessed by the Face, Legs, Activity, Cry, Consolability pain scale – revised (FLACC-R), along with hemodynamic and ventilatory parameters, before and 10 min after RT/TS start on postoperative days 1, 3, and 7 given they were on mechanical ventilation. Results119 patients were included. RT/TS induced minor changes in pain, which were not attenuated by lidocaine (confirmed in multivariate analysis). RT/TS also caused minor, clinically not relevant effects in hemodynamic and ventilatory parameters, which were also not modified by lidocaine. ConclusionRespiratory therapy with tracheal suction did not increase postoperative pain in ventilated children after congenital heart surgery until the 7th day, nor did aerosolized lidocaine exhibit any clinically significant effect on pain or other hemodynamic or ventilatory parameters.Registered at REBEC: RBR-10vtd55m.

CLINICAL OUTCOME AND SEVERITY OF CLOSTRIDIOIDES (CLOSTRIDIUM) DIFFICILE INFECTION AT A TERTIARY REFERRAL HOSPITAL IN BRAZIL.

•The outcomes of CDI were evaluated in 65 patients with CDI in a Brazilian tertiary hospital. •Lack of clinical improvement after treatment and the severity score (ATLAS) increased the risk of death. •The use of multiple antimicrobial agents was associated with longer hospital stays. •Patients with high Charlson comorbidity index (>7) were more likely to recur. Background - Clostridioides difficile infection (CDI) is a potentially severe disease that can present with refractoriness, recurrence, and evolution to death. In Brazil, the epidemiology of CDI seems to differ from that of the United States and most European countries, with only one ribotype (RT) 027-related case and a high prevalence of RT106. Objective - The aim of this study was to evaluate the outcomes of CDI and its possible association with ribotypes at a university hospital in Brazil. Methods - A total of 65 patients with CDI were included and stool samples were submitted to A/B toxin detection and toxigenic culture, and toxigenic isolates (n=44) were also PCR ribotyped. Results - Patients' median age was 59 (20-87) years and there were 16 (24.6%) deaths. The median Charlson comorbidity index (CCI) was 4 (0-15) and 16.9% of the patients had CCI ≥8. The ATLAS score and non-improvement of diarrhea were related to higher mortality. A longer length of hospitalization was related to the enteral nutrition and use of multiple antibiotics. The period between CDI diagnosis and hospital discharge was longer in those who received new antibiotics after diagnosis, multiple antibiotics, and required intensive care treatment. Recurrence was associated with CCI >7. Twenty ribotypes were identified and RT106 was the most frequently detected strain (43.2%). No relationship was observed between the ribotypes and outcomes. CDI was present in patients with more comorbidities. Conclusion - Risk factors for higher mortality, longer hospital stay and recurrence were identified. A diversity of ribotypes was observed and C. difficile strains were not related to the outcomes.