13 research outputs found

    Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

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    Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

    Avaliação da taxa de comorbidades cumulativas em pacientes diagnosticados com leucemia linfóide crônica auxiliando na decisão terapêutica

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    Introdução: A Leucemia Linfoide Crônica (LLC) é a mais comum dentre o conjunto de desordens hematoproliferativas. Embora se reconheça que os tratamentos agressivos alcançam melhores taxas de resposta, eles geralmente são mal tolerados pelos pacientes mais velhos e/ou não aptos (“unfit”), levando à origem ou agravo de comorbidades pessoais. Objetivos: Avaliar as comorbidades cumulativas em pacientes em tratamento para LLC no ambulatório de Hematologia do Conjunto Hospitalar de Sorocaba (CHS), auxiliando-os na decisão terapêutica mais adequada. Metodologia: Análise de prontuários para classificação em fit e unfit e entrevista através das escalas CIRS-G, ECOG e Karnofsky. Resultados: A amostra foi de 45 pacientes, com maioria composta por homens, caucasianos e idade média de 69 anos. A Imunofenotipagem foi o método mais utilizado para diagnóstico, quando mais da metade dos pacientes se mostraram assintomáticos. Comorbidades mais ressaltadas: HAS, DM, neoplasias e cardiopatias. Pela escala CIRS-G, aproximadamente 52% da amostra foi classificada como fit e 48%, unfit. Em ambos os grupos, a maioria dos pacientes teve tratamento expectante, sendo apenas 12,9% submetido ao tratamento convencional (agressivo). Nas escalas de performance, 71% dos pacientes foram classificados com nenhuma ou pouca dificuldade para realização das atividades diárias, estando a maioria em tratamento expectante ou brando. Discussão e Conclusão: O tratamento deve ser cuidadosamente escolhido, pois, o tratamento agressivo contribui para aumento de comorbidades e queda da qualidade. Os dados são condizentes com a realidade dos pacientes e podem auxiliar os profissionais na decisão terapêutica mais adequada, com impacto positivo na qualidade de vida e na evolução do tratamento dos pacientes com LLC

    Leucemia linfoblástica aguda (LLA) durante a gravidez: um relato de caso

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    A incidência de Leucemia Linfoblástica Aguda (LLA) associada à gestação é pequena, entretanto, devido à gravidade da doença, é fundamental que o obstetra esteja capacitado a orientar a conduta médica. O tratamento deve ser iniciado logo após o diagnóstico para que não haja prejuízo do prognóstico materno. Quando diagnosticada, sabe-se que haverá prejuízos fetais frente à quimioterapia a ser empregada. O dilema ético criado pela concomitância de neoplasias com a gestação é de difícil manejo. Objetivo: relatar o caso de uma gestante no primeiro trimestre com diagnóstico de LLA. Metodologia: as informações foram obtidas por meio de revisão do prontuário e da literatura. Relato: Relatamos o caso de uma gestante, 30 anos, com dores articulares no joelho e hemograma com pancitopenia. O mielograma e a imunofenotipagem foram compatíveis com Leucemia Linfoblástica B comum, quando a paciente estava com 12 semanas de gestação (ultrassom). A paciente foi informada sobre todos os riscos do tratamento quimioterápico para o feto, bem como os riscos maternos em postergar o tratamento. A partir da discussão entre a paciente, seus familiares e equipe médica, ela decidiu por iniciar o tratamento com protocolo BFM 86 modificado, assinando um termo de consentimento. Durante a Indução 2, foi diagnosticado óbito fetal por ultra-sonografia (21 semanas de gestação). A paciente continuou o tratamento com suporte psicológico e no momento encontra-se em remissão completa, iniciando a fase de consolidação do referido protocolo. Conclusão: Pretendemos alertar sobre a difícil decisão feita por uma paciente grávida com a LLA. Tal escolha deve ser feita com o amparo de toda a equipe médica e familiares dos pacientes, além de ser firmada por meio de um termo de consentimento

    Psoríase com eosinofilia: relato de caso

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    A psoríase, doença inflamatória crônica é caracterizada por lesões dérmicas sobrepostas a áreas de lesões eritematosas ou pustulares. Ocorre pela alteração no ciclo de crescimento das células epidérmicas, levando ao espessamento epidérmico decorrente da hiperproliferação celular e vascular com presença de infiltrado linfocitário. Pode desencadear manifestações como febre, mal-estar, fraqueza e outros. Seu diagnóstico é predominantemente clínico, podendo ser complementado pela biópsia das lesões. Entretanto, alguns casos encontrados na literatura e no caso que será relatado existe a presença de eosinofilia, mesmo na ausência de fatores que justificariam o surgimento desse sinal em pacientes portadores da psoríase. Objetivo: Relatar o caso de paciente encaminhado à hematologia com quadro de psoríase concomitante à eosinofilia. Relato de Caso: Paciente de 67 anos, masculino, vem encaminhado com hipótese diagnóstica de Síndrome Hipereosinofílica. Queixa de eosinofilia persistente (>1500 por mais de seis meses) tendo realizado tratamento com Albendazol e Metronidazol, sem êxito. Concomitantemente, apresenta psoríase em acompanhamento da dermatologia sem sintomas sistêmicos. Exames laboratoriais: NR para Hepatite B ou C, HIV ou Toxocara canis. Ausência de população celular com imunofenótipo anômalo. Aumento do percentual de granulócitos eosinófilos. Coleta de JAK2 e BLC/ABR negativos. Tratamento da psoríase é realizado com shampoo indicado. Após dois meses, ainda apresenta eosinófilos = 1820. Conclusão: Recentemente, estabeleceu-se uma relação entre a eosinofilia e o aparecimento da psoríase. Não encontramos mais nenhuma causa possível que explique a eosinofilia deste paciente. Pretendemos acompanhá-lo e avaliar se o tratamento da psoríase relaciona-se com a diminuição da eosinofili

    Quadro de condicionamento aversivo a situações relacionadas à quimioterapia em paciente com Doença de Hodgkin

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    Introdução: A doença de Hodgkin é de origem unicêntrica capaz de crescer descontroladamente e disseminar-se através da produção de cópias idênticas das células malignas. Atualmente recomenda-se para tratamento a utilização de terapêutica combinada com ciclos de quimioterapia (QT), cujo esquema standard é o ABVD (doxorrubicina, bleomicina, vinblastina, dacarbazina), associado à radioterapia. Este esquema tem como um de seus efeitos colaterais a ocorrência de náuseas e vômitos que são variáveis para cada paciente, envolvendo, inclusive, aspectos psicológicos. Objetivos: relatar o caso de um paciente que apresentou quadro aversivo às situações associadas à quimioterapia. Metodologia: as informações foram obtidas por meio de revisão do prontuário, entrevista com o paciente, registro fotográfico de exames e revisão da literatura. Relato de caso: Relatamos o caso de um paciente de 43 anos, portador de Linfoma de Hodgkin de Celularidade Mista, estádio IIB, tratado com ABVD por quatro ciclos mais radioterapia. Logo após o primeiro ciclo, o paciente começou a apresentar quadros de aversão às situações associadas à quimioterapia, como cheiros e pessoas que atuavam no setor. Neste, predominava o cheiro de café e cappuccino. Chegou ao extremo de não poder pronunciar tais palavras (cappuccino, quimioterapia, café). O paciente foi encaminhado ao Serviço de Psiquiatria sendo considerado um condicionamento aversivo Pavloviano e tratado com dessensibilização e antidepressivos. Conclusão: Consideramos importante que o ambiente onde é realizada a quimioterapia seja o mais agradável possível a fim de se evitar situações que possam ocasionar este tipo de aversão

    Leucemia mielóide aguda (LMA) secundária à trombocitemia essencial (TE): um relato de caso

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    Introdução: A trombocitemia essencial é classificada como pertencente ao grupo de distúrbios mieloproliferativos clássicos BCR/ABL negativos. A progressão para leucemia aguda é rara (<2%) e é considerada, na maioria das vezes, no contexto da terapia leucemogênica. A transformação em leucemia pode demorar de 1,7 a 16 anos. Relato de caso: Paciente de 56 anos, do sexo feminino. Apresentou plaquetose de 655.000/mm3. Foram afastadas causas reacionais de plaquetose e solicitados exames como mutação da JAK2 (V617F presente), biópsia de medula óssea e cariótipo (Ph1 negativo), que mostraram-se compatíveis com diagnóstico de Trombocitemia Essencial. Em 2008 foi iniciado tratamento com Hidroxiureia mas a pedido da paciente houve mudança para Anagrelide. Como o controle com esse medicamento foi inadequado (plaquetose chegando a 1.000.000/mm3), foi reiniciando tratamento com Hidroxiureia, obtendo-se boa resposta, apesar do uso irregular.Em Maio de 2015 retornou ao serviço com hemograma de Março apresentando anemia (11,5g/dl), neutrófilos no limite inferior (1617/mm3) e plaquetas de 285.000/mm3. Apesar da suspensão da hydroxiureia por 1 semana, evoluiu com piora do hemograma, passando a apresentar pancitopenia. Foi solicitada avaliação de medula, resultando em diagnóstico de Leucemia Mielóide Aguda do tipo M6 com características de Síndrome Mieloproliferativa Crônica e de Síndrome Mielodisplasica e 20% de blastos Paciente veio a óbito por sangramentos e sepse após o primeiro ciclo. Conclusão: Apesar de pouco frequente, a transformação da Trombocitemia Essencial pode ocorrer e a observação constante desses pacientes deve sempre procurar alterações que possam sugerir esta complicação

    Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

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    Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

    Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

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    Background: This study assessed the potential cost-effectiveness of high (80–100%) vs low (21–35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ().Results:HighFiO2maybecosteffective(cheaperandeffective).InNigeria,theaveragecostforhighFiO2was). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was 216 compared with 222forlowFiO2leadingtoa 222 for low FiO2 leading to a −6 (95% confidence interval [CI]: −13to 13 to −1) difference in costs. In India, the average cost for high FiO2 was 184comparedwith184 compared with 195 for low FiO2 leading to a −11(9511 (95% CI: −15 to −6)differenceincosts.InSouthAfrica,theaveragecostforhighFiO2was6) difference in costs. In South Africa, the average cost for high FiO2 was 1164 compared with 1257forlowFiO2leadingtoa 1257 for low FiO2 leading to a −93 (95% CI: −132to 132 to −65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a −1.05 (95% CI: −1.14 to −0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this

    Treating MERS-CoV during an outbreak

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    Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication. Funding: DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant

    Use of Telemedicine for Post-discharge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review with Meta-analysis

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    Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardised assessment tools are needed. Summary background data: Surgical site infection is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. Methods: The primary outcome of this study was surgical site infection reported up to 30-days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analysed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30-days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs. 11.1%, P&lt;0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval 0.63-0.84, P&lt;0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In nine eligible non-randomised studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47-0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. Conclusions: Use of telemedicine to assess the surgical wound post-discharge is feasible, but risks underreporting of SSI. Standardised tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally
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