Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Hospitals with and without neurosurgery: a comparative study evaluating the outcome of patients with traumatic brain injury

Abstract Background We leveraged the data of the international CREACTIVE consortium to investigate whether the outcome of traumatic brain injury (TBI) patients admitted to intensive care units (ICU) in hospitals without on-site neurosurgical capabilities (no-NSH) would differ had the same patients been admitted to ICUs in hospitals with neurosurgical capabilities (NSH). Methods The CREACTIVE observational study enrolled more than 8000 patients from 83 ICUs. Adult TBI patients admitted to no-NSH ICUs within 48 h of trauma were propensity-score matched 1:3 with patients admitted to NSH ICUs. The primary outcome was the 6-month extended Glasgow Outcome Scale (GOS-E), while secondary outcomes were ICU and hospital mortality. Results A total of 232 patients, less than 5% of the eligible cohort, were admitted to no-NSH ICUs. Each of them was matched to 3 NSH patients, leading to a study sample of 928 TBI patients where the no-NSH and NSH groups were well-balanced with respect to all of the variables included into the propensity score. Patients admitted to no-NSH ICUs experienced significantly higher ICU and in-hospital mortality. Compared to the matched NSH ICU admissions, their 6-month GOS-E scores showed a significantly higher prevalence of upper good recovery for cases with mild TBI and low expected mortality risk at admission, along with a progressively higher incidence of poor outcomes with increased TBI severity and mortality risk. Conclusions In our study, centralization of TBI patients significantly impacted short- and long-term outcomes. For TBI patients admitted to no-NSH centers, our results suggest that the least critically ill can effectively be managed in centers without neurosurgical capabilities. Conversely, the most complex patients would benefit from being treated in high-volume, neuro-oriented ICUs. </jats:sec

Status of Sepsis Care in European Hospitals Results from an International Cross-Sectional Survey

Rationale: Early detection, standardized therapy, adequate infrastructure, and strategies for quality improvement should constitute essential components of every hospital’s sepsis plan. Objectives: To investigate the extent to which recommendations from the sepsis guidelines are implemented and the availability of infrastructure for the care of patients with sepsis in acute-care hospitals. Methods: A multidisciplinary cross-sectional questionnaire was used to investigate sepsis care in hospitals. This included the use of sepsis definitions, the implementation of sepsis guideline recommendations, diagnostic and therapeutic infrastructure, antibiotic stewardship, and quality improvement initiatives (QIIs) in hospitals. Measurements and Main Results: A total of 1,023 hospitals in 69 countries were included. Most of them, 835 (81.6%), were in Europe. Sepsis screening was used in 54.2% of emergency departments (EDs), 47.9% of wards, and 61.7% of ICUs. Sepsis management was standardized in 57.3% of EDs, 45.2% of wards, and 70.7% of ICUs. The implementation of comprehensive QIIs was associated with increased screening (EDs, 133.3%; wards, 144.4%; ICUs, 123.8% absolute difference) and increased standardized sepsis management (EDs, 133.6%; wards, 140.0%; ICUs, 117.7% absolute difference) compared with hospitals without QIIs. A total of 9.8% of hospitals had implemented ongoing QIIs, and 4.6% had invested in sepsis programs. Conclusions: The findings indicate that there is considerable room for improvement in a large number of mainly European hospitals, particularly with regard to early identification and standardized management of sepsis, the availability of guidelines, diagnostic and therapeutic infrastructure, and the implementation of QIIs. Further efforts are required to implement a more comprehensive and appropriate quality of care. Copyright © 2025 by the American Thoracic Society

Poor timing and failure of source control are risk factors for mortality in critically ill patients with secondary peritonitis

Purpose: To describe data on epidemiology, microbiology, clinical characteristics and outcome of adult patients admitted in the intensive care unit (ICU) with secondary peritonitis, with special emphasis on antimicrobial therapy and source control. Methods: Post hoc analysis of a multicenter observational study (Abdominal Sepsis Study, AbSeS) including 2621 adult ICU patients with intra-abdominal infection in 306 ICUs from 42 countries. Time-till-source control intervention was calculated as from time of diagnosis and classified into 'emergency' (&lt; 2 h), 'urgent' (2-6 h), and 'delayed' (&gt; 6 h). Relationships were assessed by logistic regression analysis and reported as odds ratios (OR) and 95% confidence interval (CI). Results: The cohort included 1077 cases of microbiologically confirmed secondary peritonitis. Mortality was 29.7%. The rate of appropriate empiric therapy showed no difference between survivors and non-survivors (66.4% vs. 61.3%, p = 0.1). A stepwise increase in mortality was observed with increasing Sequential Organ Failure Assessment (SOFA) scores (19.6% for a value ≤ 4-55.4% for a value &gt; 12, p &lt; 0.001). The highest odds of death were associated with septic shock (OR 3.08 [1.42-7.00]), late-onset hospital-acquired peritonitis (OR 1.71 [1.16-2.52]) and failed source control evidenced by persistent inflammation at day 7 (OR 5.71 [3.99-8.18]). Compared with 'emergency' source control intervention (&lt; 2 h of diagnosis), 'urgent' source control was the only modifiable covariate associated with lower odds of mortality (OR 0.50 [0.34-0.73]). Conclusion: 'Urgent' and successful source control was associated with improved odds of survival. Appropriateness of empirical antimicrobial treatment did not significantly affect survival suggesting that source control is more determinative for outcome

Epidemiology of intra-abdominal infection and sepsis in critically ill patients: "AbSeS", a multinational observational cohort study and ESICM Trials Group Project

Purpose To describe the epidemiology of intra-abdominal infection in an international cohort of ICU patients according to a new system that classifies cases according to setting of infection acquisition (community-acquired, early onset hospital-acquired, and late-onset hospital-acquired), anatomical disruption (absent or present with localized or diffuse peritonitis), and severity of disease expression (infection, sepsis, and septic shock). Methods We performed a multicenter (n = 309), observational, epidemiological study including adult ICU patients diagnosed with intra-abdominal infection. Risk factors for mortality were assessed by logistic regression analysis. Results The cohort included 2621 patients. Setting of infection acquisition was community-acquired in 31.6%, early onset hospital-acquired in 25%, and late-onset hospital-acquired in 43.4% of patients. Overall prevalence of antimicrobial resistance was 26.3% and difficult-to-treat resistant Gram-negative bacteria 4.3%, with great variation according to geographic region. No difference in prevalence of antimicrobial resistance was observed according to setting of infection acquisition. Overall mortality was 29.1%. Independent risk factors for mortality included late-onset hospital-acquired infection, diffuse peritonitis, sepsis, septic shock, older age, malnutrition, liver failure, congestive heart failure, antimicrobial resistance (either methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing Gram-negative bacteria, or carbapenem-resistant Gram-negative bacteria) and source control failure evidenced by either the need for surgical revision or persistent inflammation. Conclusion This multinational, heterogeneous cohort of ICU patients with intra-abdominal infection revealed that setting of infection acquisition, anatomical disruption, and severity of disease expression are disease-specific phenotypic characteristics associated with outcome, irrespective of the type of infection. Antimicrobial resistance is equally common in community-acquired as in hospital-acquired infection

Antimicrobial Lessons From a Large Observational Cohort on Intra-abdominal Infections in Intensive Care Units

evere intra-abdominal infection commonly requires intensive care. Mortality is high and is mainly determined by disease-specific characteristics, i.e. setting of infection onset, anatomical barrier disruption, and severity of disease expression. Recent observations revealed that antimicrobial resistance appears equally common in community-acquired and late-onset hospital-acquired infection. This challenges basic principles in anti-infective therapy guidelines, including the paradigm that pathogens involved in community-acquired infection are covered by standard empiric antimicrobial regimens, and second, the concept of nosocomial acquisition as the main driver for resistance involvement. In this study, we report on resistance profiles of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecalis and Enterococcus faecium in distinct European geographic regions based on an observational cohort study on intra-abdominal infections in intensive care unit (ICU) patients. Resistance against aminopenicillins, fluoroquinolones, and third-generation cephalosporins in E. coli, K. pneumoniae and P. aeruginosa is problematic, as is carbapenem-resistance in the latter pathogen. For E. coli and K. pneumoniae, resistance is mainly an issue in Central Europe, Eastern and South-East Europe, and Southern Europe, while resistance in P. aeruginosa is additionally problematic in Western Europe. Vancomycin-resistance in E. faecalis is of lesser concern but requires vigilance in E. faecium in Central and Eastern and South-East Europe. In the subcohort of patients with secondary peritonitis presenting with either sepsis or septic shock, the appropriateness of empiric antimicrobial therapy was not associated with mortality. In contrast, failure of source control was strongly associated with mortality. The relevance of these new insights for future recommendations regarding empiric antimicrobial therapy in intra-abdominal infections is discussed.Severe intra-abdominal infection commonly requires intensive care. Mortality is high and is mainly determined by diseasespecific characteristics, i.e. setting of infection onset, anatomical barrier disruption, and severity of disease expression. Recent observations revealed that antimicrobial resistance appears equally common in community-acquired and late-onset hospital-acquired infection. This challenges basic principles in anti-infective therapy guidelines, including the paradigm that pathogens involved in community-acquired infection are covered by standard empiric antimicrobial regimens, and second, the concept of nosocomial acquisition as the main driver for resistance involvement. In this study, we report on resistance profiles of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecalis and Enterococcus faecium in distinct European geographic regions based on an observational cohort study on intra-abdominal infections in intensive care unit (ICU) patients. Resistance against aminopenicillins, fluoroquinolones, and third-generation cephalosporins in E. coli, K. pneumoniae and P. aeruginosa is problematic, as is carbapenem-resistance in the latter pathogen. For E. coli and K. pneumoniae, resistance is mainly an issue in Central Europe, Eastern and South-East Europe, and Southern Europe, while resistance in P. aeruginosa is additionally problematic in Western Europe. Vancomycin-resistance in E. faecalis is of lesser concern but requires vigilance in E. faecium in Central and Eastern and South-East Europe. In the subcohort of patients with secondary peritonitis presenting with either sepsis or septic shock, the appropriateness of empiric antimicrobial therapy was not associated with mortality. In contrast, failure of source control was strongly associated with mortality. The relevance of these new insights for future recommendations regarding empiric antimicrobial therapy in intra-abdominal infections is discussed

Epidemiology of intra-abdominal infection and sepsis in critically ill patients: "AbSeS", a multinational observational cohort study and ESICM Trials Group Project

PURPOSE: To describe the epidemiology of intra-abdominal infection in an international cohort of ICU patients according to a new system that classifies cases according to setting of infection acquisition (community-acquired, early onset hospital-acquired, and late-onset hospital-acquired), anatomical disruption (absent or present with localized or diffuse peritonitis), and severity of disease expression (infection, sepsis, and septic shock). METHODS: We performed a multicenter (n = 309), observational, epidemiological study including adult ICU patients diagnosed with intra-abdominal infection. Risk factors for mortality were assessed by logistic regression analysis. RESULTS: The cohort included 2621 patients. Setting of infection acquisition was community-acquired in 31.6%, early onset hospital-acquired in 25%, and late-onset hospital-acquired in 43.4% of patients. Overall prevalence of antimicrobial resistance was 26.3% and difficult-to-treat resistant Gram-negative bacteria 4.3%, with great variation according to geographic region. No difference in prevalence of antimicrobial resistance was observed according to setting of infection acquisition. Overall mortality was 29.1%. Independent risk factors for mortality included late-onset hospital-acquired infection, diffuse peritonitis, sepsis, septic shock, older age, malnutrition, liver failure, congestive heart failure, antimicrobial resistance (either methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing Gram-negative bacteria, or carbapenem-resistant Gram-negative bacteria) and source control failure evidenced by either the need for surgical revision or persistent inflammation. CONCLUSION: This multinational, heterogeneous cohort of ICU patients with intra-abdominal infection revealed that setting of infection acquisition, anatomical disruption, and severity of disease expression are disease-specific phenotypic characteristics associated with outcome, irrespective of the type of infection. Antimicrobial resistance is equally common in community-acquired as in hospital-acquired infection.status: publishe

International Nosocomial Infection Control Consortiu (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module

Made available in DSpace on 2019-09-12T16:53:30Z (GMT). No. of bitstreams: 0 Previous issue date: 2014We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line-associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U. S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN. Copyright (C) 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.[Rosenthal, Victor Daniel] Int Nosocomial Infect Control Consortium, Corrientes Ave 4580,Fl 12,Apt D, RA-1195 Buenos Aires, DF, Argentina[Maki, Dennis George] Univ Wisconsin, Madison, WI USA[Mehta, Yatin] Medanta Medicity, New Delhi, India[Leblebicioglu, Hakan] Ondokuz Mayis Univ, Samsun, Turkey[Memish, Ziad Ahmed] Minist Hlth, Riyadh, Saudi Arabia[Al-Mousa, Haifaa Hassan] Minist Hlth, Kuwait, Kuwait[Balkhy, Hanan] King Saud Bin Abdulaziz Univ Hlth Sci, Riyadh, Saudi Arabia[Hu, Bijie] Fudan Univ, Zhongshan Hosp, Shanghai 200433, Peoples R China[Alvarez-Moreno, Carlos] Univ Nacl Colombia, Clin Univ Colombia, Bogota, Colombia[Medeiros, Eduardo Alexandrino] Hosp Sao Paulo, Sao Paulo, Brazil[Apisarnthanarak, Anucha] Thammasat Univ Hosp, Pathum Thani, Thailand[Raka, Lul] Prishtina Univ, Kosova & Med Sch, Natl Inst Publ Hlth, Prishtina, Kosovo, Serbia[Cuellar, Luis E.] Inst Nacl Enfermedades Neoplas, Lima, Peru[Ahmed, Altaf] Indus Hosp, Karachi, Pakistan[Navoa-Ng, Josephine Anne] St Lukes Med Ctr, Manila, Philippines[El-Kholy, Amani Ali] Cairo Univ Abu El Reesh, Children Hosp, Cairo, Egypt[Kanj, Souha Sami] Amer Univ, Beirut Med Ctr, Beirut, Lebanon[Bat-Erdene, Ider] Cent State Hosp 1, Ulaanbaatar, Mongol Peo Rep[Duszynska, Wieslawa] Wroclaw Univ Hosp, Wroclaw, Poland[Nguyen Van Truong] Hung Vuong Hosp, Ho Chi Minh City, Vietnam[Pazmino, Leonardo N.] Hosp Valles, Hosp Eugenio Espejo, Quito, Ecuador[See-Lum, Lucy Chai] Univ Malaya, Med Ctr, Kuala Lumpur, Malaysia[Fernandez-Hidalgo, Rosalia] Hosp Clin Bibl, San Jose, Costa Rica[Di-Silvestre, Gabriela] Hosp Clin Caracas, Caracas, Venezuela[Zand, Farid] Shiraz Univ Med Sci, Nemazee Hosp, Shiraz, Iran[Hlinkova, Sona] Catholic Univ Ruzomberok, Cent Mil Hosp Ruzomberok, Fac Hlth, Ruzomberok, Slovakia[Belskiy, Vladislav] Privolzhskiy Dist Med Ctr, Nizhnii Novgorod, Russia[Al-Rahma, Hussain] Dubai Hosp, Dubai, U Arab Emirates[Tulio Luque-Torres, Marco] Hosp Especialidades Ctr Med La Raza, Inst Hondureho Seguridad Social, Tegucigalpa, Honduras[Bayraktar, Nesil] Burhan Nalbantoglu Devlet Hastanesi, Nicosia, Cyprus[Mitrev, Zan] Special Hosp Surg Dis Filip Vtori, Skopje, Macedonia[Gurskis, Vaidotas] Hosp Lithuanian Univ, Hlth Sci Kauno Klin, Kaunas, Lithuania[Fisher, Dale] Natl Univ Singapore Hosp, Singapore, Singapore[Abu-Khader, Ilham Bulos] Jordan Univ Hosp, Amman, Jordan[Berechid, Kamal] Ibn Sina, Rabat, Morocco[Rodriguez-Sanchez, Arnaldo] Hosp Episcopal San Lucas Guayama, Guayama, Puerto Rico[Horhat, Florin George] Univ Med & Farm Timisoara, Clin Cty Hosp, Timisoara, Romania[Requejo-Pino, Osiel] Hosp Univ Gral Calixto Garc, Havana, Cuba[Hadjieva, Nassya] Univ Hosp Queen Giovanna ISUL, Sofia, Bulgaria[Ben-Jaballah, Nejla] Hop Enfants, Tunis, Tunisia[Garcia-Mayorca, Elias] Hosp Santo Tomas, Panama City, Panama[Kushner-Davalos, Luis] Caja Salud Banca Privada Reg Paz, La Paz, Bolivia[Pasic, Srdjan] Inst Mother Child Hlth Care Vukan Cupic, Belgrade, Serbia[Pedrozo-Ortiz, Luis E.] Hosp Reg Salto, Salto, Uruguay[Apostolopoulou, Eleni] Sotiria, Athens, Greece[Mejia, Nepomuceno] Hosp Gen Plaza Salud, Santo Domingo, Dominican Rep[Gamar-Elanbya, May Osman] Royal Care Int Hosp, Khartoum, Sudan[Jayatilleke, Kushlani] Sri Jayewardenepura Gen Hosp, Khartoum, Sudan[de Lourdes-Duenas, Miriam] Hosp Nacl Ninos Benjamin Bloom, San Salvador, El Salvador[Aguirre-Avalos, Guadalupe] Hosp Civil Guadalajara Fray Antonio Alcalde, Unidad Terapia Intens Adultos, Guadalajara, Mexico[Marcelo Maurizi, Diego; Montanini, Adriana; Laura Spadaro, Maria] Hosp Municipal Agudos Dr Leonidas Lucero, Bahia Blanca, Buenos Aires, Argentina[Santiago Marcos, Lorenzo; Botta, Priscila; Maria Jerez, Florencia; Constanza Chavez, Maria; Ramasco, Lucia; Isabel Colqui, Maria; Silvia Olivieri, Maria; Silvia Rearte, Ana; Edith Correa, Gladys; Deolinda Juarez, Paola; Fabiana Gallardo, Paola; Patricia Brito, Miriam; Horacio Mendez, Gabriel; Rosa Valdez, Julia; Paola Cardena, Lorena] Hosp Nino Jesus de Tucuman, San Miguel De Tucuman, Argentina[Maria Harystoy, Jose; Jorge Chaparro, Gustavo] Inst Med Platense, La Plata, Buenos Aires, Argentina[Gabriela Rodriguez, Claudia; Toomey, Rodolfo] Inst Med Adrogue, Almirante Brown, Argentina[Caridi, Maria] Centro Gallego Buenos Aires, Buenos Aires, Argentina[Viegas, Monica] Hosp Interzonal Gen Agudos Presidente Peron, Avellaneda, Argentina[Liliana Bernan, Marisa] Hgza San Roque Gonnet, La Plata, Argentina[Romani, Adriana] Clin Modelo Imagmed Soc Anonima, Lanus, Argentina[Beatriz Dominguez, Claudia] Obra Social Empleados Publ Sanatorio Fleming, Mendoza, Argentina[Kushner Davalos, Luis] Caja Salud Banca Privada Reg, La Paz, Bolivia[Richtmann, Rosana; Silva, Camila Almeida; Rodrigues, Tatiane T.] Hosp Maternidade Santa Joana, Sao Paulo, Brazil[Mielle Filho, Amaury; Seerig Palme, Ernandi Dagoberto; Besen, Aline; Lazzarini, Caroline; Cardoso, Caroline Batista] Hosp Santa Catarina, Blumenau, Brazil[Azevedo, Francisco Kennedy; Fontes Pinheiro, Ana Paula; Camacho, Aparecida] Hosp Jardim Cuiaba, Cuiaba, Brazil[De Carvalho, Braulio Matias; Monteiro De Assis, Maria Jose; Vasconcelos Carneiro, Ana Paula; Maciel Canuto, Maria Lilian; Pinto Coelho, Keyla Harten; Moreira, Tamiris; Oliveira, Agamenon Alves; Sousa Colares, Marcela Maria; De Paula Bessa, Marcia Maria; Pinheiro Gomes Bandeira, Tereza De Jesus; De Moraes, Renata Amaral; Campos, Danilo Amancio; Lima De Barros Araujo, Tania Mara] Hosp Messejana, Fortaleza, Brazil[Freitas Tenorio, Maria Tereza; Amorim, Simone; Amaral, Manuela; Lima, Julianne Da Luz; Da Silva Neta, Lindalva Pino; Batista, Caphiane; De Lima Silva, Fabio Jorge; Ferreira De Souza, Maria C.; Guimaraes, Katia Arruda] Santa Casa Misericordia Maceio, Maceio, Brazil[Maluf Lopes, Julia Marcia] Hosp Infantil Joao Paulo 2 Fhemig, Belo Horizonte, Brazil[Nogueira Napoles, Karina M.; Silva Neto Avelar, Lorena Luiza; Vieira, Lilian Aguiar] Santo Ivo, Belo Horizonte, Brazil[De Oliveira Cardo, Luis Gustavo] Hosp Clin Unicamp, Campinas, Brazil[Takeda, Christianne F. V.; Ponte, Glaydson A.; Aguiar Leitao, Fco Eduardo] Hosp Antonio Prudente, Fortaleza, Brazil[Kuchenbecker, Ricardo De Souza; Dos Santos, Rodrigo Pires] Hosp Clin Porto Alegre, Porto Alegre, Brazil[Onzi Siliprandi, Erci Maria] Inst Cardiologia Rio Grande Sul, Porto Alegre, Brazil[Baqueiro Freitas, Luiz Fernando] Hosp Santa Lydia, Ribeirao Preto, Brazil[Martins, Ianick Souto] Hosp Canc Inst Nacl Canc, Rio De Janeiro, Brazil[Casi, Daiane] Hosp Samaritano, Sao Paulo, Brazil[Maretti Da Silva, Maria Angela; Blecher, Sergio; Villins, Margarete; Salomao, Reinaldo] Hosp Santa Marcelina, Sao Paulo, Brazil[Oliveira Castro, Solange Regina; Da Silva Escudero, Daniela V.; Oliveira Reis, Mariana Andrade] Hosp Sao Paulo Escola Paulista Medicina Unifesp, Sao Paulo, Brazil[Mendonca, Marcelo; Furlan, Valter; do Amaral Baruzzi, Antonio Claudio] Totalcor, Sao Paulo, Brazil[Sanchez, Tarquino Eristidesg] Hosp Anchieta Ltda, Taguatinga, Brazil[Moreira, Marina] Hosp Universidade de Taubaté (Unitau)[de Freitas, Wania Vasconcelos; de Souza, Leonardo Passos] Hosp Casa Portugal, Rio de Janeiro, Brazil[Velinova, Velmira Angelova; Hadjieva, Nassya; Petrov, Michael M.; Karadimov, Dimitar Georgiev; Kostadinov, Emil D.; Dicheva, Violeta Jivkova] Queen Giovanna Isul, Sofia, Bulgaria[Wang, Chaohua; Guo, Xiuqin; Geng, Xihua; Wang, Shufang; Zhang, Jinzhi; Zhu, Ling; Zhuo, Shufang; Guo, Chunli] Dong E Peoples Hosp, Liaocheng Shi, Shandong, Peoples R China[Tao, Lili] First Hosp Shanxi Med Univ, Taiyuan, Peoples R China[Li, Ruisheng] Beijing Chao Yang Hosp, Beijing, Peoples R Chin