Miguel Cendoroglo Neto

Positive Deviance: A New Strategy for Improving Hand Hygiene Compliance

OBJECTIVE To evaluate the effectiveness of a positive deviance strategy for the improvement of hand hygiene compliance in 2 adult step-down units. DESIGN A 9-month, controlled trial comparing the effect of positive deviance on compliance with hand hygiene. SETTING Two 20-bed step-down units at a tertiary care private hospital. METHODS The first phase of our study was a 3-month baseline period (from April to June 2008) in which hand hygiene episodes were counted by use of electronic handwashing counters. From July to September 2008 (ie, the second phase), a positive deviance strategy was implemented in the east unit; the west unit was the control unit. During the period from October to December 2008 (ie, the third phase), positive deviance was applied in both units. RESULTS During the first phase, there was no statistically significant difference between the 2 step-down units in the number of episodes of hand hygiene per 1,000 patient-days or in the incidence density of healthcare-associated infections (HAIs) per 1,000 patient-days. During the second phase, there were 62,000 hand hygiene episodes per 1,000 patient-days in the east unit and 33,570 hand hygiene episodes per 1,000 patient-days in the west unit (P < .01 ). The incidence density of HAIs per 1,000 patient-days was 6.5 in the east unit and 12.7 in the west unit (p = .04). During the third phase, there was no statistically significant difference in hand hygiene episodes per 1,000 patient-days (P = .16) or in incidence density of HAIs per 1,000 patient-days. CONCLUSION A positive deviance strategy yielded a significant improvement in hand hygiene, which was associated with a decrease in the overall incidence of HAIs.

Positive deviance: A program for sustained improvement in hand hygiene compliance

BACKGROUND There is a paucity of data evaluating whether positive deviance (PD) can sustain improvement in hand hygiene compliance. METHODS An observational study comparing the effect of PD on compliance with hand hygiene was conducted in two 20-bed step-down units (SDUs) at a private tertiary care hospital. In a 3-month baseline period (April-June 2008), hand hygiene counts were performed by electronic handwashing counters. Between July 1, 2008, and November 30, 2009, (East SDU) and between September 30, 2008, and December 2009 (West SDU), PD was applied in both units. RESULTS There was more than a 2-fold difference in the number of alcohol gel aliquots dispensed per month from April 2008 (before PD) to November 2009 (last month in PD) in the East SDU. There was also a 2-fold difference in the number of alcohol gel aliquots dispensed per month from September 2008 (before PD) to December 2009 (last month in PD) in the West SDU. The difference in the rate of health care‒associated infections (HAIs) between the baseline period and 2009 was statistically significant in the East SDU (5.8 vs 2.8 per 1,000 device-days; P = .008) and in the West SDU (3.7 vs 1.7 per 1,000 device-days; P = .023). CONCLUSIONS PD was responsible for a sustained improvement in hand hygiene in the inpatient setting and was associated with a decrease in the incidence of device-associated HAIs.

Stroke Epidemiology, Patterns of Management, and Outcomes in Fortaleza, Brazil A Hospital-Based Multicenter Prospective Study

Background and Purpose— Little information exists on the epidemiology and patterns of treatment of patients admitted to Brazilian hospitals with stroke. Our objective was to describe the frequency of risk factors, patterns of management, and outcome of patients admitted with stroke in Fortaleza, the fifth largest city in Brazil. Methods— Data were prospectively collected from consecutive patients admitted to 19 hospitals in Fortaleza with a diagnosis of stroke or transient ischemic attack from June 2009 to October 2010. Results— We evaluated 2407 consecutive patients (mean age, 67.7±14.4 years; 51.8% females). Ischemic stroke was the most frequent subtype (72.9%) followed by intraparenchymal hemorrhage (15.2%), subarachnoid hemorrhage (6.0%), transient ischemic attack (3%), and undetermined stroke (2.9%). The median time from symptoms onset to hospital admission was 12.9 (3.8–32.5) hours. Hypertension was the most common risk factor. Only 1.1% of the patients with ischemic stroke received thrombolysis. The median time from hospital admission to neuroimaging was 3.4 (1.2–26.5) hours. In-hospital mortality was 20.9% and the frequency of modified Rankin Scale score ⩽2 at discharge was less than 30%. Older age, prestroke disability, and having a depressed level of consciousness at admission were independent predictors of poor outcome; conversely, male gender was a predictor of good outcome. Conclusions— The prevalence of stroke risk factors and clinical presentation in our cohort were similar to previous series. Treatment with thrombolysis and functional independency after a stroke admission were infrequent. We also found long delays in hospital admission and in evaluation with neuroimaging and high in-hospital mortality.

A multicenter study using positive deviance for improving hand hygiene compliance

BACKGROUND Positive deviance (PD) can be a strategy for the improvement of hand hygiene (HH) compliance. METHODS This study was conducted in 8 intensive care units and 1 ward at 7 tertiary care, private, and public hospitals. Phase 1 was a 3-month baseline period (from August to October 2011) in which HH counts were performed by observers using iPods (iScrub program). From November 2011 to July 2012, phase 2, a PD intervention was performed in all the participating centers. We evaluated the consumption of HH products (alcohol gel and chlorhexidine) and the incidence density of health care-associated infections. RESULTS There was a total of 5,791 HH observations in the preintervention phase and 11,724 HH observations in the intervention phase (PD). A statistically significant difference was found in overall HH compliance with 46.5% in the preintervention phase and 62.0% in the PD phase (P < .001). There was a statistically significant reduction in the incidence of density of device-associated infections per 1,000 patient-days and also in the median of length of stay between the preintervention phase and the PD phase (13.2 vs 7.5 per 1,000 patient-days, respectively, P = .039; and 11.0 vs 6.8 days, respectively, P < .001, respectively). CONCLUSION PD demonstrated great promise for improving HH in multiple inpatient settings and was associated with a decrease in the median length of stay and the incidence of device-associated HAIs.

Removal of cytokine inducing substances by polymyxin-B immobilized polystyrene-derivative fibers during in vitro hemoperfusion of 10% human plasma containing Staphylococcus aureus challenge.

Staphylococcus aureus (S. aureus) is frequently isolated from blood cultures in the hospital setting. The pathogenesis of S. aureus bacteremia probably replicates mechanisms implicated in gram negative bacterial infections. Cell wall components, such as peptidoglycans and lipoteichoic acids (LTA), can trigger cytokine production. Polymyxin-B (PMX-B) is a cationic peptide that binds endotoxin (ET) and inhibits its activity. Based on this principle, PMX-B was incorporated in polystyrene-derivative fibers, creating a hemoperfusion column (PMX-20R) that removes ET. The authors assessed whether S. aureus possesses PMX-B suppressible cytokine-inducing substances, and whether LTA, an anionic molecule, is one such substance. Heparinized blood was obtained from healthy volunteers, peripheral blood mononuclear cells (PBMC) were isolated by Ficoll-Hypaque separation, and 10% human plasma prepared. PBMC were incubated with 1, 5, or 10 μg/ml of S. aureus LTA, with and without 10 μg/ml of PMX-B. Also, using PMX-20R, in vitro hemoperfusion (IVH) was performed with 10% human plasma containing a 1:1,000 dilution of S. aureus challenge at 100 ml/min for 2 hours at 37°C, and plasma obtained before and after IVH was incubated with PBMC. After a 24 hour incubation at 37°C, PBMC were subjected to three freeze-thaw cycles, and total TNFα was measured by radioimmunoassay. TNFα production by PBMC incubated with LTA was 164 ± 4 pg, 324 ± 54 pg, 657 ± 55 pg, and 1143 ± 215 pg in control, and LTA 1, 5, and 10 μg/ml, respectively. The addition of PMX-B resulted in a 40 ± 12% (p = 0.02), 61 ± 6% (p = 0.002), and 62 ± 14% (p = 0.02) decrease in TNFα production, respectively. Before IVH, TNFα production by PBMC incubated with 10% plasma containing S. aureus challenge was 1275 ± 70 pg. After 2 hours of IVH, the decrease in TNFα production was 20 ± 4% (p = 0.002). In conclusion, S. aureus LTA induces TNFα production that is significantly suppressed by PMX-B. Consequently, S. aureus cytokine-inducing substances are removed during IVH with PMX-20R, and this may be due to stoichiometric binding of LTA to PMX-B.

Association of endothelial nitric oxide synthase gene intron 4 polymorphism with end-stage renal disease.

Background:  Nitric oxide (NO) released from endothelial cells is related to the maintenance of physiological vascular tone. The impairment of endothelial NO generation brought about by gene polymorphism is considered one of the deterioration factors in progressive renal disease. In the endothelial nitric oxide synthase (eNOS) intron 4 polymorphism, the presence of the aa genotype has been associated with cardiovascular and renal disease. The aim of this study was to investigate the presence of eNOS gene intron 4 polymorphism in patients with end‐stage renal disease (ESRD).

Effectiveness of Oral Energy-Protein Supplementation in Severely Malnourished Hemodialvsis Patients

■ Objective: To evaluate the effect of an oral energy-protein supplementation on the nutritional status of severely malnourished uremic hemodialysis patients. ■ Design: A cohort study of malnourished patients orally supplemented for 4 months. ■ Setting: A satellite hemodialysis unit at the Escola Paulista de Medicina, Sao Paulo, Brazil. ■ Patients: In a population-based sample, 14 of 123 chronic severe malnourished patients selected by clinical and anthropometric criteria initiated the study. Ten patients completed the trial. ■ Interventions: In addition to the instructed diet, each patient received a flavored oral powder supplement containing egg albumin, corn and coconut oils, hydrogenated fat, and malto-dextrin, providing 800 kcal and 19.6 g protein/d. ■ Main outcome measures: The following parameters were obtained: 3-day dietary diaries, protein catabolic rate (PCR), body weight (BW), triceps skinfold thickness (TSF), midarm circumference (MAC), body mass index, body fat (BF), percentage of body fat (PF), lean body mass (LBM), midarm muscle area (MAMA), and hematological and biochemical indices. ■ Results: At the end of the study, significant increases in total energy (27 ± 6 to 43 ± 6 kcal/kg/d) and protein consumption (1.07 ± 0.4 to 1.57 ± 0.4 g/kg/d) were observed. Significant increases were also observed in BW (48.9 ± 8.4 to 50.4 ± 8.9 kg), MAC (23 ± 2.6 to 23.8 ± 2.5 cm), TSF (6.5 ± 3.1 to 7.9 ± 3.6 mm), and BF (7.2 ± 2.8 to 8.6 ± 3.3 kg). There were no modifications in LBM and MAMA. Changes in BW correlated significantly with changes in PF ( r = 0.47; P r = 0.63; P ■ Conclusion: The oral supplement was well tolerated and was effective in improving the nutritional status of malnourished hemodialysis patients.

Acute renal failure needing dialysis in the intensive care unit and prognostic scores.

Background: Generic prognostic scores used in acute renal failure (ARF) give imprecise results; disease‐specific indices applied to distinct populations or intensive care practices becomes inaccurate. The current study evaluates the adequacy of prognostic scores, in patients with severe ARF needing dialysis. Methods: Known generic (APACHE II) and disease‐specific (ATN‐ISS) indices were applied to a cohort (n = 280) with ARF needing dialysis, under intensive care. Possible risk factors as causal factors, organ dysfunctions and clinical variables were examined, and a local index assembled by multivariate logistic regression analysis. Area under the receiver operating characteristics (ROC) curves evaluated the indices discriminating capacity. Goodness‐of‐fit testing and linear regression analysis appraised calibration. Validation was accomplished by the bootstrapping technique. The end‐point was hospital mortality. Results: Overall mortality was 85%. Female gender < 44 years (OR: 0.29; 95% CI: 0.10–0.84), liver/obstructive biliary disease (OR: 6.03; 95%CI: 1.65–22.08), being conscious (OR: 0.49; 95%CI: 0.21–1.14), use of vasoactive drug (OR: 3.13; 95%CI: 1.25–7.83), respiratory dysfunction (OR: 5.20; 95%CI: 1.25–7.83) or sepsis (OR: 2.62; 95%CI: 1.14–6.02) were associated with outcome. Areas under the ROC curve of 0.815, 0.652 and 0.814; Goodness‐of‐fit test P = 0.593, P < 0.001 and P = 0.002; and linear regression R2 = 0.973, R2 = 0.526 and R2 = 0.919 for the local index, APACHE II and ATN‐ISS, respectively, indicate better performance by the local index. The local index median area under the ROC curve, by bootstrapping, was 0.820 (95% CI: 0.741–0.907). Conclusions: APACHE II score was inaccurate, and ATN‐ISS poorly calibrated. When mortality or intensive care practices significantly deviate, local scores may better evaluate prognosis in severe ARF.

Endotoxin Removal by Polymyxin-B Immobilized Polystyrene-Derivative Fibers During In Vitro Hemoperfusion of 10% Human Plasma

During gram-negative bacterial sepsis, lipid A, the biologically active moiety of endotoxin (ET), activates monocytes and induces the release of cytokines. PMX-B, a cationic peptide, binds to lipid A and inhibits its activity. Based on this principle, PMX-B was incorporated in polystyrene-derivative fibers, creating a hemoperfusion column (PMX-20R) that removes ET. After in vitro characterization of the cytokine inducing potency of three gram-negative bacterial challenges, the authors evaluated the in vitro efficacy of PMX-20R in a model using 10% human plasma. Cytokine production by peripheral blood mononuclear cells (PBMC) incubated with plasma before and after in vitro hemoperfusion (IVH) was used as the index of ET removal. One hundred forty milliliters of heparinized blood were obtained from healthy volunteers. Forty milliliters were used to harvest PBMC at baseline, and 10% plasma prepared from the rest, was challenged with: 1) 0.01, 1, or 100 ng/ml of purified Escherichia coli ET; or 2) 1:1,000 dilution of E. coli, Pseudomonas aeruginosa, or Klebsiella pneumoniae. IVH was performed at 100 ml/min at 37°C for up to 6 hours. One half milliliter samples, drawn before and at designated time intervals after the start of IVH, were mixed with a 0.5 ml suspension of 5 × 106 PBMC/ml from the same donor, and incubated for 24 hours at 37°C. PBMC were subjected to three freeze-thaw cycles, and total tumor necrosis factor alpha (TNFα) was measured by radioimmunoassay. Before IVH, TNFα production by PBMC incubated with 10% plasma containing 0.01, 1, or 100 ng/ml of purified E. coli ET was 1905 ± 391 pg, 2076 ± 552 pg, and 5304 ± 1001 pg, respectively. After 2 hours of IVH, the respective decrease in TNFα production was 82 ± 5% (p = 0.005), 78 ± 10% (p = 0.01), and 95 ± 1% (p = 0.002). Before IVH, TNFα production by PBMC incubated with 10% plasma containing 1:1,000 dilution of E. coli, P. aeruginosa or K. pneumoniae was 2896 ± 273 pg, 1816 ± 122 pg, and 1131 ± 125 pg, respectively. After 2 hours of IVH, the respective decrease in TNFα production was 83 ± 4% (p < 0.001), 53 ± 4% (p < 0.001), and 70 ± 5% (p < 0.001). When IVH was extended to 6 hours, the further decrease in TNFα production was not statistically significant. These results suggest an impressive in vitro removal of ET by PMX-20R from 10% human plasma containing either purified E. coli ET or E. coli, P. aeruginosa, or K. pneumoniae. Further in vitro studies are required, using whole blood challenged with gram-negative bacteria.

Epidemiology of total hip and knee replacement: a cross-sectional study

ABSTRACT Objective: To describe the epidemiologic characteristics and adverse events of patients submitted to total hip and total knee replacement. Methods: A cross-sectional study retrospectively assessing medical chart data of all total hip and total knee replacements performed at a private hospital, between January 2007 and December 2010 Patients submitted to total hip and total knee replacement, with consent of surgeons were included. Incomplete records and/or missing data of the hospital database were excluded. The categorical variables analyzed were age, gender, type of arthroplasty (primary or secondary), type of procedure, duration of surgery, use of drains, risk of infection, compliance to protocol for prevention of deep venous thrombosis and embolism pulmonary, and compliance to the protocol for prevention of infection. The outcomes assessed were adverse events after surgery. Results: A total of 510 patients were included; in that, 166 admissions for knee replacements (92 male) and 344 admissions for hip replacements (176 female). The mean age of patients was 71 years (range 31-99 years). Adverse events were reported in 76 patients (14.9%); there was no correlation between assessed variables and number of complications. Conclusion: The results showed no individual factors favoring complications in patients submitted to total hip and total knee replacement; hence, surgeons should consider prophylaxis to avoid complications.