Armênio Costa Guimarães

High-Dose Daptomycin Therapy for Left-Sided Infective Endocarditis: a Prospective Study from the International Collaboration on Endocarditis

ABSTRACT The use of daptomycin in Gram-positive left-sided infective endocarditis (IE) has significantly increased. The purpose of this study was to assess the influence of high-dose daptomycin on the outcome of left-sided IE due to Gram-positive pathogens. This was a prospective cohort study based on 1,112 cases from the International Collaboration on Endocarditis (ICE)-Plus database and the ICE-Daptomycin Substudy database from 2008 to 2010. Among patients with left-sided IE due to Staphylococcus aureus, coagulase-negative staphylococci, and Enterococcus faecalis, we compared those treated with daptomycin (cohort A) to those treated with standard-of-care (SOC) antibiotics (cohort B). The primary outcome was in-hospital mortality. Time to clearance of bacteremia, 6-month mortality, and adverse events (AEs) ascribable to daptomycin were also assessed. There were 29 and 149 patients included in cohort A and cohort B, respectively. Baseline comorbidities did not differ between the two cohorts, except for a significantly higher prevalence of diabetes and previous episodes of IE among patients treated with daptomycin. The median daptomycin dose was 9.2 mg/kg of body weight/day. Two-thirds of the patients treated with daptomycin had failed a previous antibiotic regimen. In-hospital and 6-month mortalities were similar in the two cohorts. In cohort A, median time to clearance of methicillin-resistant S. aureus (MRSA) bacteremia was 1.0 day, irrespective of daptomycin dose, representing a significantly faster bacteremia clearance compared to SOC (1.0 versus 5.0 days; P < 0.01). Regimens with higher daptomycin doses were not associated with increased incidence of AEs. In conclusion, higher-dose daptomycin may be an effective and safe alternative to SOC in the treatment of left-sided IE due to common Gram-positive pathogens.

Controle da hipertensão arterial em uma unidade de saúde da família

OBJETIVO: Avaliar o impacto da implantacao do Programa de Saude da Familia sobre o controle da hipertensao arterial, em uma Unidade Basica de Saude. METODOS: Foram selecionados 135 pacientes com o diagnostico confirmado de hipertensao, 45 de cada equipe da Unidade Basica de Saude, que iniciaram o tratamento entre dezembro de 2003 e dezembro de 2004, com seguimento ate julho de 2005, em Salvador, Bahia. Comparou-se a pressao arterial no inicio e no fim do periodo de observacao e sua associacao com fatores de risco cardiovascular, e com as variaveis genero, idade, indice de massa corporal, numero de consultas, quantidade de medicamentos anti-hipertensivos usados por paciente, escolaridade e renda familiar. Os dados foram expressos em valores absolutos, percentagem, media e desvio-padrao e foram realizados os testes de Wilcoxon, Kruskal-Wallis e qui-quadrado. RESULTADOS: As medias da pressao arterial inicial e final foram 155,9±24,1/95,3±13,9 mmHg e 137,2±16,1/85,7±8,7 mmHg (p<0,01), respectivamente. No inicio do tratamento, 28,9% dos hipertensos tinham niveis pressoricos controlados (<140/90 mmHg) contra 57% no final do periodo observacional (p<0,01). A media de consultas nesse periodo foi de 10,1±3,9, com 91,8% de adesao. Identificou-se uso de dois anti-hipertensivos por 50,4% e uso de um medicamento por 35,6% dos pacientes. As prevalencias dos demais fatores de risco avaliados quando da admissao no programa foram sobrepeso/obesidade (71,9%), dislipidemia (58,5%) e diabetes/intolerância a glicose (43,7%). Os resultados por equipe foram comparaveis. CONCLUSOES: O impacto da implantacao do Programa de Saude da Familia trouxe melhoria do controle da hipertensao arterial, mas os fatores de risco associados permaneceram acima dos niveis atualmente recomendados, necessitando controle adequado.

Hospitalizations for asthma: impact of a program for the control of asthma and allergic rhinitis in Feira de Santana, Brazil

OBJECTIVE To evaluate the impact of the Programa de Controle da Asma e Rinite Alérgica em Feira de Santana (ProAR-FS, Program for the Control of Asthma and Allergic Rhinitis in Feira de Santana) on the frequency of hospitalizations for asthma in patients monitored at a referral center for one year. METHODS This was a historical control study involving 253 consecutive patients with asthma, ages ranging from 4 to 76 years. We compared the frequency of hospital admissions and visits to the emergency room (ER) in the 12 months prior to and after their admission to the ProAR-FS. During the program, patients received free treatment, including inhaled medications and education on asthma. Demographic and socioeconomic aspects were also assessed. RESULTS There was a significant reduction in the number of hospitalizations (465 vs. 21) and of visits to the ER (2,473 vs. 184) after their admission to ProAR-FS (p < 0.001 for both). Of the 253 patients who had been hospitalized and had had ER visits within the year prior to the admission to ProAR-FS, only 16 were hospitalized and 92 visited the ER during the follow-up year, representing a reduction of 94% and 64%, respectively. CONCLUSIONS Implementing a referral center for the treatment of asthma and rhinitis in the Unified Health Care System, with the free distribution of inhaled corticosteroids and the support of an education program, is a highly effective strategy for the control of asthma.

Fatores de risco para visitas à emergência por exacerbações de asma em pacientes de um programa de controle da asma e rinite alérgica em Feira de Santana, BA

OBJECTIVE: To determine the risk factors for ER visits due to asthma exacerbations in patients monitored at a referral center. METHODS: Prospective cohort study of 253 outpatients (children and adults) with asthma who were monitored for 12 months at the Referral Center of the Program for the Control of Asthma and Allergic Rhinitis in the city of Feira de Santana, Brazil. RESULTS: Exacerbations were common, and 36.5% of the patients sought ER treatment within the twelve-month period. The risk factors for asthma exacerbations were being over 20 years of age (OR = 1.34: (95% CI: 1.06-1.70), residing in an urban area (OR = 1.19; 95% CI: 1.06-1.33); having a low level of education (OR = 1.53: 95% CI: 1.00-2.39); having severe asthma (OR = 1.65; 95% CI: 1.24-2.18); and having chronic rhinitis (OR = 2.20; 95% CI: 1.00-4.80). CONCLUSIONS: In this cohort, having chronic rhinitis, having asthma that is more severe and having a low level of education were the main risk factors for ER visits due to asthma exacerbations. These results are similar to those reported for asthma patients who are receiving no regular treatment.

Profile of gestational and metabolic risk in the prenatal care service of a public maternity in the Brazilian Northeast

PURPOSE To assess the prevalence of obstetric risk factors and their association with unfavorable outcomes for the mother and fetus. METHODS A longitudinal, descriptive and analytical study was conducted on 204 pregnant women between May 2007 and December 2008. Clinical and laboratory assessments followed routine protocols. Risk factors included socio-demographic aspects; family, personal and obstetric history; high pre-gestational body mass index (BMI); excessive gestational weight gain and anemia. Adverse outcomes included pre-eclampsia (4.5%), gestational diabetes mellitus (3.4%), premature birth (4.4%), caesarian birth (40.1%), high birth weight (9.8%) and low birth weight (13.8%). RESULTS The average age was 26±6.4 years; the mothers were predominantly non-white (84.8%), 51.8% had incomplete or complete secondary level schooling, 67.2% were in a stable marital relationship and 51.0% had a regular paid job; 63.7% were admitted to the prenatal clinic during the second trimester and 16.7% during the first, with 42.6% being primiparous. A past history of chronic hypertension was reported by 2.9%, pre-eclampsia by 9.8%, excessive gestational weight gain by 15.2% and former gestational diabetes mellitus by 1.0%. In the current pregnancy, elevated pre-gestational BMI was found in 34.6%; 45.5% presented with excessive gestational weight gain, 25.3% with anemia and 47.3% with dyslipidemia. Of the 17.5% of cases with altered blood glucose, gestational diabetes mellitus was confirmed in 3.4% and proteinuria occurred in 16.4% of all cases. Adverse maternal fetal outcomes included pre-eclampsia (4.5%), gestational diabetes mellitus (3.4%), premature birth (4.4%), caesarean birth (40.1%) and high and low birth weight (9.8% and 13.8%, respectively). Independent predictors of adverse maternal fetal outcomes were identified by Poisson multivariate regression analysis: pre-gestational BMI>25 kg/m² was a predictor for pre-eclampsia (RR=17.17; 95%CI 2.14-137.46) and caesarian operation (RR=1.79; 95%CI 1.13-2.85), previous caesarean was a predictor for present caesarean operation (RR=2.28; 95%CI 1.32-3.92) and anemia and high gestational weight gain were predictors for high birth weight (RR=3.38; 95%CI 1.41-8.14 and RR=4.68; 95%CI 1.56-14.01, respectively). CONCLUSION Pre-gestational overweight/obesity, previous caesarean, excessive weight gain and anemia were major risk factors for pre-eclampsia, caesarean operations and high birth weight.

Intensidade da dor em pacientes com síndrome do ombro doloroso

The aim of this study was to assess the severity of pain and its correlations to clinical characteristics in Painful Shoulder Syndrome (PSS) patients. A descriptive study was conducted using retrospective data from 77 medical record files. The Visual Numerical Scale (VNS) was used as an assessment instrument. The following variables of interest were considered: VNS (77), diagnosis (57), affected shoulder (77), sex (77), age (76), pain site (77), use of medications (59) and associated cervical pain (77). 53.2% of the patients were females and the mean age was 50.4±15.7 years. The right shoulder was the most affected side (57.1%). Severe pain was reported by 41.6% of patients, more frequently in women (56.1% vs 25.0%; p=0.006), and on left shoulder (57.7% vs 31.8%, p=0.034). Of the studied patients, 59 (81.3%) used medications, most frequently anti-inflammatory drugs. The rotator cuff syndrome was present in 80.7% (57) and associated cervical pain in 15.6% (77). Pain exclusively on the shoulder accounted for 76.5%. The rotator cuff syndrome was shown to be the most frequent cause of PSS, more commonly and severely affecting women close to 51 years old. EVN was shown to be a relevant instrument for measuring pain in PSS.

Association between birth weight and cardiovascular risk factors in adolescents.

Background Birth weight (BW) is a medium- and long-term risk determinant of cardiovascular risk factors. Objective To assess the association between BW and cardiovascular risk factors in adolescents of the city of Salvador, Bahia state. Methods Cross-sectional study with comparison of BW groups. Sample comprising 250 adolescents classified according to the BMI as follows: high-normal (≥ 50th percentile and < 85th percentile); overweight (≥ 85th percentile and < 95th percentile); and obesity (≥ 95th percentile). The risk variables compared were as follows: waist circumference (WC); arterial blood pressure; lipid profile; glycemia; serum insulin; HOMA-IR; and metabolic syndrome. The BW was informed by parents and classified as follows: low (BW ≤ 2,500g); normal (BW > 2,500g and < 4,000g); and high (BW ≥ 4,000g). Results One hundred and fifty-three (61.2%) girls, age 13.74 ± 2.03 years, normal BW 80.8%, low BW 8.0%, and high BW 11.2%. The high BW group as compared with the normal BW group showed a higher frequency of obesity (42.9%, p=0.005), elevated SBP and DBP (42.9%, p=0.000 and 35.7%, p=0.007, respectively), and metabolic syndrome (46.4%, p=0.002). High BW adolescents as compared with normal BW adolescents had a prevalence ratio for high SBP 3.3 (95% CI: 1.7-6.4) and obesity 2.6 (95% CI: 1.3-5.2). The WC of high BW adolescents was 83.3 ± 10.1 (p=0.038). The lipid profile showed no statistically significant differences. Conclusion Our findings suggest that obesity, elevated SBP and DBP, and metabolic syndrome during adolescence might be associated with high BW.

Maior Letalidade e Morbidade por Infarto Agudo do Miocárdio em Hospital Público, em Feira de Santana - Bahia

FUNDAMENTO: Fatores relacionados ao nivel socio-economico, a qualidade e a gestao assistencial podem influenciar na letalidade e morbidade por infarto agudo do miocardio (IAM). OBJETIVO: Comparar letalidade e morbidade por IAM entre hospital publico e privado. METODOS: Estudo observacional, com grupos de comparacao. Avaliacao clinica na admissao e registro de dados diagnosticos, terapeuticos e evolutivos ate a alta ou o obito. Comparacao das caracteristicas clinicas por analise univariada seguida de analise bivariada, avaliando a associacao de preditores com obito e morbidade (Killip >I), SPSS, versao 13,0. RESULTADOS: Avaliados 150 pacientes, 63 (42,0%) privados e 87 (58,0%) publicos, com 63,1% e 62,1% de homens e idades de 61,1±13,8 e 60,0±11,6 anos, respectivamente. A letalidade por IAM foi de 19,5% nos publicos vs 4,8% nos privados (p=0,001) e a morbidade (Killip classe >1) de 34,3% nos publicos vs 15,0% nos privados (p=0,012). Houve diferenca significativa nos publicos devido a menor renda familiar e escolaridade (70,1% com um a dois salarios vs 19,0%, p 1 hora: 76,9% vs 48,6%; p=0,003) e maior tempo para ser medicado (THM>15 minutos: 47,1% vs 8,0%, p<0,001), UTI para 8% vs 94% nos privados e trombolise para 20,6% vs 54,0%, respectivamente (p<0,001). CONCLUSAO: Letalidade e morbidade maior no paciente publico, que se apresentou mais grave, mais tardiamente e recebeu tratamento de menor qualidade.BACKGROUND Factors related to socioeconomic status and health care quality and management may influence mortality and morbidity rates due to acute myocardial infarction (AMI). OBJECTIVE To compare mortality and morbidity in patients with AMI hospitalized in public and private hospitals. METHODS An observational study, with comparison groups. Clinical evaluation on admission, and recording of diagnostic, therapeutic and evolution data until discharge or death. Comparison of clinical characteristics by univariate analysis followed by bivariate analysis, evaluating the combination of predictors with death and morbidity (Killip> I), SPSS, version 13.0. RESULTS 150 patients were evaluated, 63 (42.0%) of private hospitals and 87 (58.0%) of public hospitals, with 63.1% and 62.1% of males, aged 61.1 +/- 13.8 and 60.0 +/- 11.6 years, respectively. The mortality from AMI was 19.5% in public hospitals vs 4.8% in private hospitals (p = 0.001), and morbidity (Killip class> I) was 34.3% in public hospitals vs 15.0% in private hospitals (p = 0.012). There was a significant difference between public and private patients, due to lower family income and education (70.1% with one to two salaries vs 19.0%, p <0.001, and 49.4% of illiterates vs 6.3%, p <0.001, respectively ); late arrival at the hospital (HAT> 1 hour: 76.9% vs 48.6%, p = 0.003); and a longer period of time before being medicated (AMT > 15 minutes: 47.1% vs 8.0%; p <0.001); ICU for 8% of the patients in public hospitals vs 94% in private hospitals; and thrombolysis for 20.6% vs 54.0%, respectively (p <0.001). CONCLUSION Mortality and morbidity were greater among public patients, which presented more serious conditions, arrived later at the hospital and received lower quality treatment.

Increased mortality and morbidity due to acute myocardial infarction in a public hospital, in Feira de Santana, Bahia

FUNDAMENTO: Fatores relacionados ao nivel socio-economico, a qualidade e a gestao assistencial podem influenciar na letalidade e morbidade por infarto agudo do miocardio (IAM). OBJETIVO: Comparar letalidade e morbidade por IAM entre hospital publico e privado. METODOS: Estudo observacional, com grupos de comparacao. Avaliacao clinica na admissao e registro de dados diagnosticos, terapeuticos e evolutivos ate a alta ou o obito. Comparacao das caracteristicas clinicas por analise univariada seguida de analise bivariada, avaliando a associacao de preditores com obito e morbidade (Killip >I), SPSS, versao 13,0. RESULTADOS: Avaliados 150 pacientes, 63 (42,0%) privados e 87 (58,0%) publicos, com 63,1% e 62,1% de homens e idades de 61,1±13,8 e 60,0±11,6 anos, respectivamente. A letalidade por IAM foi de 19,5% nos publicos vs 4,8% nos privados (p=0,001) e a morbidade (Killip classe >1) de 34,3% nos publicos vs 15,0% nos privados (p=0,012). Houve diferenca significativa nos publicos devido a menor renda familiar e escolaridade (70,1% com um a dois salarios vs 19,0%, p 1 hora: 76,9% vs 48,6%; p=0,003) e maior tempo para ser medicado (THM>15 minutos: 47,1% vs 8,0%, p<0,001), UTI para 8% vs 94% nos privados e trombolise para 20,6% vs 54,0%, respectivamente (p<0,001). CONCLUSAO: Letalidade e morbidade maior no paciente publico, que se apresentou mais grave, mais tardiamente e recebeu tratamento de menor qualidade.BACKGROUND Factors related to socioeconomic status and health care quality and management may influence mortality and morbidity rates due to acute myocardial infarction (AMI). OBJECTIVE To compare mortality and morbidity in patients with AMI hospitalized in public and private hospitals. METHODS An observational study, with comparison groups. Clinical evaluation on admission, and recording of diagnostic, therapeutic and evolution data until discharge or death. Comparison of clinical characteristics by univariate analysis followed by bivariate analysis, evaluating the combination of predictors with death and morbidity (Killip> I), SPSS, version 13.0. RESULTS 150 patients were evaluated, 63 (42.0%) of private hospitals and 87 (58.0%) of public hospitals, with 63.1% and 62.1% of males, aged 61.1 +/- 13.8 and 60.0 +/- 11.6 years, respectively. The mortality from AMI was 19.5% in public hospitals vs 4.8% in private hospitals (p = 0.001), and morbidity (Killip class> I) was 34.3% in public hospitals vs 15.0% in private hospitals (p = 0.012). There was a significant difference between public and private patients, due to lower family income and education (70.1% with one to two salaries vs 19.0%, p <0.001, and 49.4% of illiterates vs 6.3%, p <0.001, respectively ); late arrival at the hospital (HAT> 1 hour: 76.9% vs 48.6%, p = 0.003); and a longer period of time before being medicated (AMT > 15 minutes: 47.1% vs 8.0%; p <0.001); ICU for 8% of the patients in public hospitals vs 94% in private hospitals; and thrombolysis for 20.6% vs 54.0%, respectively (p <0.001). CONCLUSION Mortality and morbidity were greater among public patients, which presented more serious conditions, arrived later at the hospital and received lower quality treatment.

Acute viral bronchiolitis and risk of asthma in schoolchildren: analysis of a Brazilian newborn cohort,

OBJECTIVE To verify whether the occurrence of acute viral bronchiolitis in the first year of life constitutes a risk factor for asthma at age 6 considering a parental history of asthma. METHODS Cross-sectional study in a cohort of live births. A standardized questionnaire of the International Study of Asthma and Allergies in Childhood was applied to the mothers to identify asthma in children at the age of 6 years. Acute viral bronchiolitis diagnosis was performed by maternal report of a medical diagnosis and/or presence of symptoms of coryza accompanied by cough, tachypnea, and dyspnea when participants were 3, 6, 9, and 12 months. Socioeconomic, environmental data, parental history of asthma, and data related to pregnancy were collected in the first 72h of life of the newborn and in prospective home visits by trained interviewers. The association between acute viral bronchiolitis and asthma was evaluated by logistic regression analysis and potential modifier effect of parental history was verified by introducing an interaction term into the adjusted logistic regression model. RESULTS Prevalence of acute viral bronchiolitis in the first year of life was 68.6% (461). The occurrence of acute viral bronchiolitis was a risk factor for asthma at 6 years of age in children with parental history of asthma OR: 2.66, 95% CI (1.10-6.40), modifier effect p=0.002. Parental history of asthma OR: 2.07, 95% CI (1.29-3.30) and male gender OR: 1.69, 95% CI, (1.06-2.69) were other identified risk factors for asthma. CONCLUSION Acute viral bronchiolitis in the first year of life is a risk factor for asthma in children with parental history of asthma.