Unidade de AVC : ensaio clínico randomizado

AnexosOrientadora:Rosana Hermínia ScolaDissertação (mestrado) - Universidade Federal do Paraná. Setor de Ciências da Saúde. Curso de Pós-graduação em Medicina InternaInclui bibliografiaResumo: A incidência de AVC de 156 casos / 100.000 habitantes, no ano de 1997 em Joinville, representa o dobro das incidências de vários países ocidentais. Uma estratégia alternativa para minimizar esses índices é a otimização da assistência clínica em unidades especializadas para acidentes cerebrovasculares (U-AVC). A primeira U-AVC brasileira, estruturada em Joinville em 1997, atende 200 pacientes ao ano. O objetivo deste estudo foi avaliar se o tratamento agudo em uma U-AVC reduz a morbi-mortalidade quando comparado a uma enfermaria geral convencional. No período de 1o de agosto à 31 de dezembro de 2000, os pacientes foram selecionados para um grupo experimental (U-AVC) ou para um grupo controle (enfermaria geral- EG). Foram selecionados 35 pacientes na U-AVC e 39 pacientes na EG. Incluímos no protocolo todos os pacientes internados no Hospital São José, com diagnóstico de AVC, ocorridos em até 7 dias após o início dos sintomas. Através de números randômicos gerados por computador e disponíveis no pronto socorro em envelopes selados e numerados, os pacientes foram alocados entre a U-AVC e uma enfermaria geral (EG). Os grupos foram pareados nos aspectos clínicos e demográficos. Comparou-se o tempo de internação, letalidade e o grau de dependência funcional e clínica medidas pelo índice de Barthel (IB) e pela Escala Escandinava de AVC (SSS) respectivamente, no dia da admissão, no 5o dia, e no 3o e 6o meses após o ictus. A letalidade dentro dos primeiros 10 dias nos pacientes da UAVC foi de 8.5% e 12.8% na EG (p=.41), em 30 dias foi de 14.2% na U-AVC e 28.3% na EG ( p=.24), em 3 meses 17.4% na U-AVC e 28.7% na EG.( p=.39 ) e no 6o mês, 25.7% na U-AVC e 30.7% na EG ( p=.41) . A curva de sobrevida em 30 dias evidenciou uma tendência de menor letalidade na U-AVC (logrank de 1.8 ; p-.17). Em 6 meses, o número de pacientes necessários para evitar um óbito (NNT) na UAVC foi de 20 e o NNT para se conseguir um paciente a mais independente em casa foi de 15. Não houve diferença significativa no tempo de internação e de morbidade nas escalas SSS e IB durante o seguimento. Nosso estudo mostra que não houve benefício significativo entre os pacientes tratados na U-AVC em relação a EG. Os resultados confirmam a necessidade de novos estudos com maiores amostragens. Apesar da literatura já ter definido a eficácia deste modelo de assistência clínica para pacientes com AVC, são necessários estudos nacionais cooperativos para definir o real papel das U-AVC no Brasil.tAbstract: The incidence of stroke in Joinville is very high when compared to most ocidental countries with an estimated incidence of 156 cases/100 000 habitants. Stroke units (SU) have been regarded since 1980 as an alternative to improve medical care by aggregating coordinated specialized resources. The first brazilian stroke unit has been functioning in Joinville since 1997 with nearly 200 new inpatients/ year. To assess the impact of a stroke unit on the morbidity and mortality rates when compared to a conventional general ward treatment (GW), a prospective randomized controlled study was undertaken between August and December 2000. Seventy-four consecutive patients admitted to Hospital São José with recent stroke (less than seven days) were randomly allocated at the stroke unit (n=35) or conventional general ward (n=39). Results obtained in both groups were compared regarding the lenght of hospital stay and mortality. Functional and neurological morbidity at subsequent six months period were also assessed by Barthel Index (Bl) and Scandinavian Stroke Scale (SSS), respectively. Mortality at the first ten days at SU and GW was 8.5% and 12.8% respectively (p=.41), whereas 30-days mortality rates achieved 14.2% and 28.3% (p=.12). Log-rank test for 30-days survival curve was 1.8 (p=.17). Threemonths mortality was 17.4% for SU and 28.7% for GW group (p=.19).The number necessary to treat to prevent one death (NNT) in one month was 7 and 20 in 6 months. No significant difference was found regarding the lenght of stay and morbidity Bl or SSS scales. No significant benefit was found in SU patients compared to GW group. Despite no significant difference were found among results obtained by SU and GW groups, an evident benefit in absolute numbers was observed in lethality, survival curve and NNT in thirty days period after stroke. Further collaborative studies or more samples are required to define the role of SU

Incidência do antígeno de superfície da hepatite B nos doadores de sangue do Serviço de Hemoterapia do HU -UFSC.

Trabalho de Conclusão de Curso - Universidade Federal de Santa Catarina, Centro de Ciências da Saúde, Departamento de Clínica Médica, Curso de Medicina, Florianópolis, 198

Diarréia aguda: fatores prognósticos.

Trabalho de Conclusão de Curso - Universidade Federal de Santa Catarina, Centro de Ciências da Saúde, Departamento de Pediatria, Curso de Medicina, Florianópolis, 198

Stroke incidence, mortality and case-fatality rates in 1995 and in 2005-6 in Joinville, Brazil

Introdução: Apesar do AVC persistir como a primeira causa de óbito no Brasil, estudos de mortalidade têm demonstrado queda de taxas pela doença nas últimas décadas. Comparamos a evolução das taxas de morbi-mortalidade de primeiro evento de AVC em uma mesma base populacional em quase dez anos de intervalo. Além disso, no período de 2005-6, também obtivemos a incidência de primeiro evento de subtipos de AVC, a prevalência dos fatores de risco cardiovasculares e o prognóstico funcional após seis meses do evento. Métodos: Em 2005 e 2006, utilizando metodologia proposta por Sudlow e Warlow, foram coletados prospectivamente informações sobre todos os casos de AVC, o uso de medicações pré-mórbidas e a presença de fatores de risco tradicionais. Obtivemos as taxas de incidência e de mortalidade de primeiro evento de AVC, ajustadas por idade para a população mundial e a letalidade em até 30 dias. Comparamos estes resultados com os obtidos na cidade de Joinville em 1995. As taxas de incidência e mortalidade anual foram ajustadas por idade pelo método direto. Resultados: Entre 1323 casos de AVC registrados em 2005-6, 759 foram primeiros eventos da doença. A incidência ajustada por idade por 100.000 habitantes foi de 143,7 (IC 95% 128,4-160,3) em 1995 e de 105,4 (98,0-113,2) no período de 2005-6. A mortalidade ajustada por idade foi de 37.5 (29,9-46,5) em 1995 e de 23,9 (20,4-27,8) em 2005-6. A letalidade em 30 dias foi 26,6% em 1995 e 19.1% em 2005-6. Assim, em quase dez anos, houve diminuição da incidência em 27% (p=0,01), da mortalidade em 37% (p<0,001) e da letalidade em 30 dias em 28 % (p= 0,009). As diminuições observadas na incidência ocorreram somente para pacientes com idade inferior a 75 anos. Em 2005-6, a incidência ajustada por 100.000 habitantes de infarto cerebral foi 86,0 (IC 95% 79,3-93,1), de hemorragia intracerebral foi 12,9 (10,4-15,8) e de hemorragia subaracnóide foi 7,0 (5,3-9,1). A hipertensão arterial sistêmica foi o fator de risco cardiovascular mais prevalente. Após seis meses, 25% (21,4 -29,1) tinham morrido e 61,5% (56,2-68,3) estavam independentes. Conclusões: Nossos resultados de queda de incidência, mortalidade e letalidade em quase uma década na cidade de Joinville sugerem uma provável melhora na prevenção primária e na assistência hospitalar ao paciente com AVC na cidade de Joinville. As taxas de incidência em 2005-6, agrupada e por subtipos de AVC foram similares a outros estudos de base populacional. As taxas de prevalência dos fatores de risco sugerem que a população de Joinville tenha um padrão de risco cardiovascular misto, observado tanto em populações de países desenvolvidos quanto em desenvolvimentoIntroduction: Although stroke is still the leading cause of death in Brazil, studies have shown a decrease in stroke mortality in recent decades. Besides that, in Latin America there is no prospective population data showing incidence changes along time. We compared the evolution of morbi-mortality rates of first ever stroke in the same population base at two time points, with an ten year interval between the two. In addition, in the 2005-6 period, we ascertained the incidence of first ever stroke by subtypes, the prevalence of cardiovascular risk factors and 6-month functional prognosis. Methods: In 2005-6 period, using the methodology proposed by Sudlow and Warlow, data related to all stroke cases, as well as to medications used prior to the events and prevalence of traditional risk factors, were prospectively compiled. Incidence, mortality and case-fatality rates of first-ever stroke were obtained and these results were compared to those obtained in the city of Joinville in 1995. Rates were adjusted to age by direct method. Findings: Of 1323 cases of stroke identified, 759 were incident. The incidence rates per 100.000 population was 143.7 (CI 95% 128.4-160.3) in 1995 and 105.4 (98.0-113.2) in 2005-6. The mortality rate was 37.5 (29.9-46.5) in 1995 and 23.9 (20.4-27.8) in 2005-6. The case-fatality rate at 30 days was 26.6% in 1995 and 19.1% in 2005-6. Therefore, over a span of approximately ten years, the incidence decrease by 27% (p=0.01), the mortality by 37% (p<0.001) and the case-fatality at 30 days decreased by 28 % (p= 0.009). These decreases only occurred in patients younger than 75 years old. In 2005-6 period, the adjusted incidence rate per 100.000 population for stroke subtypes were: cerebral infarction 86.0 (79.3-93.1); intracerebral hemorrhage 12.9 (10.4-15.8) and subaracnoid hemorrhage 7.0 (5.3-9.1). Arterial hypertension was the most prevalent cardiovascular risk. At 6 months, 25% (21.4-29.1) of the patients had died, whereas 61.5% (56.2-68.3) were independent. Interpretation: The observed results of decreasing in the incidence,mortality and casefatality rates over a ten-year period in Joinville suggest an improvement in primary prevention and inpatient care to stroke patients. In 2005-6, the incidence rates for all subtypes were similar to those reported in other community studies. Risk factors prevalence rates suggest that the pattern of cardiovascular risks in Joinville is mixed, presenting characteristics of developed and developing countries alik

The impact of acute kidney injury on fatality of ischemic stroke from a hospital-based population in Joinville, Brazil

Abstract Introduction: The occurrence of acute kidney injury (AKI) after ischemic stroke has been associated to a worse prognosis. There is a lack of Brazilian studies evaluating this issue. This study aimed to describe the impact of AKI after a first-ever ischemic stroke in relation to fatality rate in 30 days. Methods: This was a retrospective hospital-based cohort. We included patients who had their first ischemic stroke between January to December 2015. AKI was defined by an increase of serum creatinine in relation to baseline value at admission ≥ 0.3 mg/dL or a rise in serum creatinine level by 1.5 times the baseline value at any point in the first week after admission. We performed a univariate and multivariate analysis to evaluate the presence of AKI with fatality in 30 days. Results: The final study population (n=214) had mean age of 66.46 ± 13.73 years, 48.1% were men, the mean NIHSS was 6.33 ± 6.27 and 20 (9.3%) presented AKI. Patients with AKI were older, had a higher score on the NIHSS, and had higher creatinine values on hospital discharge. The 30-day mortality was higher in the AKI subgroup compared to non-AKI (35% vs. 6.2%, p < 0.001). AKI was an independent predictor of fatality after an ischemic stroke but limited by severity of stroke (NIHSS). Conclusion: The presence of AKI is an important complication after ischemic stroke. Despite its impact on 30-day fatality, the predictive strength of AKI was limited by the severity of stroke

Prevalence of obesity among stroke patients in five Brazilian cities: a cross-sectional study

ABSTRACT Objective There is gap in knowledge about obesity prevalence in stroke patients from low- and middle-income countries. Therefore, we aimed to measure the prevalence of overweight and obesity status among patients with incident stroke in Brazil. Methods In a cross-sectional study, we measured the body mass index (BMI) of ischemic and hemorrhagic stroke patients. The sample was extracted in 2016, from the cities of Sobral (CE), Sertãozinho (SP), Campo Grande (MS), Joinville (SC) and Canoas (RS). Results In 1,255 patients with first-ever strokes, 64% (95% CI, 62–67) were overweight and 26% (95%CI, 24–29) were obese. The obesity prevalence ranged from 15% (95%CI, 9–23) in Sobral to 31% (95%CI, 18–45) in Sertãozinho. Physical inactivity ranged from 53% (95%CI, 43-63) in Sobral to 80% (95%CI, 73–85) in Canoas. Conclusions The number of overweight patients with incident stroke is higher than the number of patients with stroke and normal BMI. Although similar to other findings in high-income countries, we urgently need better policies for obesity prevention

How Many Patients Become Functionally Dependent after a Stroke? A 3-Year Population-Based Study in Joinville, Brazil

<div><p>The decrease in stroke mortality will increase the burden of survivors with functional dependence (FD). The aim of this study was to evaluate how many patients become functionally dependent over 3 years after an incident event in Joinville, Brazil. The proportion of FD (defined as a modified Rankin score 3 to 5) among stroke survivors from the Joinville Stroke Registry was assessed using a validated telephone interview. Incidence of FD after stroke in Joinville in one year was 23.24 per 100,000 population. The overall proportion of FD among stroke survivors at discharge was 32.7%. Of 303 patients with first-ever ischaemic stroke (IS), one-third were FD at discharge, and 12%, 9% and 8%, respectively at 1, 2 and 3 years. Among 37 patients with haemorrhagic stroke (HS), 38% were dependent at discharge, 16% after 1 and 2 years and 14% after 3. Among 27 patients with subarachnoid haemorrhage (SAH), 19% were dependent at discharge and 4% from 1 to 3 years. Among IS subtypes, cardioembolic ones had the worst risk of FD. (RR 19.8; 95% CI: 2.2 to 175.9). Our results showed that one-third of stroke survivors have FD during the first year after stroke in Brazil. Therefore, a city with half a million people might expect 120 new stroke patients with FD each year.</p></div

Modified Rankin Scale (mRS) scores of 37 first-ever haemorrhagic stroke patients.

<p>Proportions of patients after hospital admission, 30 days and 1 to 3 years in Joinville, 2008 to 2010; Rankin score 0 to 2: functional Independence, 3 to 5:functional dependence and 6:death.</p

Modified Rankin Scale (mRS) scores of 27 first-ever sub-arachnoid haemorrages stroke patients.

<p>Proportions of patients after hospital admission, 30 days and 1 to 3 years in Joinville, 2008 to 2010; Rankin score 0 to 2: functional Independence, 3 to 5:functional dependence and 6:death.</p