Diego Milan Menegotto

Mortality among patients with tuberculosis requiring intensive care: a retrospective cohort study

BackgroundTo describe the characteristics of patients with tuberculosis (TB) requiring intensive care and to identify the factors that predicts in-hospital mortality in a city of a developing country with intermediate-to-high TB endemicity.MethodsWe conducted a retrospective, cohort study, between November 2005 and November 2007. The patients with TB requiring intensive care were included. Predictors of mortality were assessed. The primary outcome was the in-hospital mortality.ResultsDuring the study period, 67 patients with TB required intensive care. Of them, 62 (92.5%) had acute respiratory failure and required mechanical ventilation. Forty-four (65.7%) patients died. Coinfection with human immunodeficiency virus was present in 46 (68.7%) patients. Early intensive care unit admission and ventilator-associated pneumonia were independently associated with the in-hospital mortality.ConclusionsIn this study we found a high mortality rate in TB patients requiring intensive care, especially in those with an early ICU admission.

Effect of clinical pathways on the management of acute asthma in the emergency department: Five years of evaluation

There is a wide variability in clinical practice for treating acute asthma (AA) in the emergency department (ED), interfering in the quality of care. The purpose of this study was to evaluate the impact of a clinical pathway on the management of AA in the ED. We conducted a prospective before-after study of patients presenting with AA to the adult ED, during five separate periods (from January to March): in 2001 (pre-protocol group), 2002, 2003, 2004, and 2005 (6 months without educational reinforcement). We evaluated the effects of the recommendations on objective assessment of severity, diagnostic resource utilization, use of recommended and non-recommended therapy, and outcomes. The 2001, 2002, 2003, 2004, and 2005 groups comprised, respectively: 108, 96, 97, 98, and 101 patients. There was a significant increase in the use of pulse oximetry (8.3%, 77.1%, 88.7%, 95.9%, and 97.0%, respectively; p < 0.001). There was an increase in the use of peak expiratory flow rate from 2001 to 2004 (4.6%, 20.8%, 28.9%, and 48.0%) and a decrease after a period without educational efforts (29.7%, p < 0.001). Although the overall use of systemic corticosteroids was not changed, there was a significant increase in the use of oral steroids (p < 0.001). There was a decrease in aminophylline utilization (p = 0.005). Length of stay in the ED was significantly reduced (p = 0.04). There was no effect on hospital admission or emergency discharge (p = 0.193). The AA clinical pathway applied in the ED was associated with a positive effect on improving the quality of care.

Avaliação prognóstica precoce da asma aguda na sala de emergência

OBJETIVO: Estudar medidas clinicas e funcionais pulmonares utilizadas nos primeiros quinze minutos de manejo da asma aguda em um servico de emergencia, para predicao prognostica. METODOS: Estudo de coorte, prospectivo, que incluiu pacientes consecutivos com asma aguda, com idades entre doze e 55 anos e medida do pico de fluxo expiratorio menor ou igual a 50% do previsto. Realizaram-se avaliacoes na admissao, aos quinze minutos e em quatro horas apos o inicio do tratamento. O tratamento incluiu salbutamol e ipratropio, administrados por aerossol dosimetrado com espacador, e 100 mg de hidrocortisona intravenosa. O desfecho favoravel foi definido pelo pico de fluxo expiratorio maior ou igual a 50% do previsto apos a quarta hora de tratamento, e o desfecho desfavoravel pelo pico de fluxo expiratorio menor que 50% do previsto. RESULTADOS: Tiveram desfecho favoravel 27 pacientes e desfavoravel 24. A analise multivariada identificou o pico de fluxo expiratorio em porcentagem do previsto aos quinze minutos como variavel mais preditiva. O pico de fluxo expiratorio maior ou igual a 40% aos quinze minutos mostrou significativa contribuicao em predizer desfecho favoravel (sensibilidade = 0,74, especificidade = 1,00 e valor preditivo positivo = 1,00). O pico de fluxo expiratorio menor que 30% aos quinze minutos contribuiu para predizer desfecho desfavoravel (sensibilidade = 0,54, especificidade = 0,93 e valor preditivo positivo = 0,87). CONCLUSAO: O estudo sugeriu que a medida do pico de fluxo expiratorio aos quinze minutos do manejo da asma aguda em um servico de emergencia e um instrumento util para avaliacao prognostica.

Factors associated with uncontrolled asthma in Porto Alegre, Brazil

The prevalence of uncontrolled and controlled asthma, and the factors associated with uncontrolled asthma were investigated in a cross-sectional study. Patients aged 11 years with confirmed asthma diagnosis were recruited from the outpatient asthma clinic of Hospital de Clínicas de Porto Alegre, Brazil. Patients were excluded if they had other chronic pulmonary disease. They underwent an evaluation by a general questionnaire, an asthma control questionnaire (based on the 2006 Global Initiative for Asthma guidelines), assessment of inhaled device technique and pulmonary function tests. Asthma was controlled in 48 of 275 patients (17.5%), partly controlled in 74 (26.9%) and uncontrolled in 153 (55.6%). In the univariate analysis, asthma severity was associated with asthma control (P < 0.001). Availability of asthma medications was associated with asthma control (P = 0.01), so that most patients who could purchase medications had controlled asthma, while patients who depend on the public health system for access to medications had lower rates of controlled asthma. The use of inhaled corticosteroid was lower in the uncontrolled group (P < 0.001). Logistic regression analysis identified three factors associated with uncontrolled asthma: severity of asthma (OR = 5.33, P < 0.0001), access to medications (OR = 1.97, P = 0.025) and use of inhaled corticosteroids (OR = 0.17, P = 0.030). This study showed a high rate of uncontrolled asthma in patients who attended an outpatient asthma clinic. Severity of asthma, access to medications and adequate use of inhaled corticosteroids were associated with the degree of asthma control.

Incidência de infecção viral do trato respiratório em asma aguda atendida em sala de emergência

OBJETIVO: Avaliar a incidencia de infeccao viral em asma aguda em pacientes atendidos em setor de adultos de um servico de emergencia. METODOS: Conduzimos um estudo de coorte de pacientes que se apresentaram com asma aguda no setor de adultos do Servico de Emergencia do Hospital de Clinicas de Porto Alegre (idade > 12 anos). Um aspirado nasofaringeo foi obtido para deteccao de antigenos com a tecnica de coloracao de imunofluorescencia indireta para os virus sincicial respiratorio, adenovirus, influenza e parainfluenza tipos 1, 2, 3 e 4. Foram coletados dados referentes a caracteristicas demograficas, historia medica pregressa, crise que levou a atual visita ao servico de emergencia e desfechos da crise. RESULTADOS: No periodo de marco a julho de 2004, 49 pacientes foram examinados para infeccao viral do trato respiratorio. Foram identificados virus respiratorios em 6 pacientes (3 com adenovirus, 2 com influenza A e 1 com parainfluenza tipo 1). Os pacientes com infeccao viral do trato respiratorio apresentaram media de idade de 61,7 ± 11,5 anos, enquanto que os pacientes sem infeccao viral apresentaram media de idade de 41,7 ± 20,9 anos (p = 0,027). Nao houve outras diferencas significativas quanto as caracteristicas clinicas e desfechos. CONCLUSAO: Este estudo mostra uma incidencia de 12,24% de infeccao viral do trato respiratorio na asma aguda em pacientes com idade igual ou maior que doze anos atendidos em sala de emergencia, o que confirma a infeccao viral como um desencadeante nessa faixa etaria.