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PURPOSE: Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate the clinical outcomes of a cohort of high-risk surgical patients according to high-sensitivity troponin T (hsTnT) in an LMIC setting. METHODS: We conducted a prospective cohort study of 442 high-risk patients undergoing noncardiac surgery at a Brazilian hospital between February 2019 and March 2020. High-sensitivity troponin T levels were measured preoperatively, 24 hr, and 48 hr after surgery and stratified into three groups: normal (< 20 ng·L-1); minor elevation (20-65 ng·L-1); and major elevation (> 65 ng·L-1). We performed survival analysis to determine the association between myocardial injury and one-year mortality. We described medical interventions and evaluated unplanned intensive care unit (ICU) admission and complications using multivariable models. RESULTS: Postoperative myocardial injury occurred in 45% of patients. Overall, 30-day mortality was 8%. Thirty-day and one-year mortality were higher in patients with hsTnT ≥ 20 ng·L-1. One-year mortality was 18% in the unaltered troponin group vs 31% and 41% for minor and major elevation groups, respectively. Multivariable analysis of one-year survival showed a hazard ratio (HR) of 1.94 (95% confidence interval [CI], 1.22 to 3.09) for the minor elevation group and a HR of 2.73 (95% CI, 1.67 to 4.45) for the troponin > 65 ng·L-1 group. Patients with altered troponin had more unplanned ICU admissions (13% vs 5%) and more complications (78% vs 48%). CONCLUSION: This study supports evidence that hsTnT is an important prognostic marker and a strong predictor of all-cause mortality after surgery. Troponin measurement in high-risk surgical patients could potentially be used as tool to scale-up care in LMIC settings. STUDY REGISTRATION: ClinicalTrials.gov (NCT04187664); first submitted 5 December 2019.
RéSUMé: OBJECTIF: Les lésions myocardiques après une chirurgie non cardiaque sont courantes et la plupart du temps asymptomatiques. Nous ne connaissons pas la population cible idéale qui bénéficierait de mesures régulières de la troponine dans les pays à revenu faible et intermédiaire (PRFI). Cette étude vise à évaluer les issues cliniques d'une cohorte de patient·es de chirurgie à haut risque grâce à la troponine T à haute sensibilité (hsTnT) dans un contexte de PRFI. MéTHODE: Nous avons mené une étude de cohorte prospective auprès de 442 patient·es à haut risque bénéficiant d'une chirurgie non cardiaque dans un hôpital brésilien entre février 2019 et mars 2020. Les taux de troponine T à haute sensibilité ont été mesurés avant l'opération, 24 heures et 48 heures après la chirurgie, et stratifiés en trois groupes : normaux (< 20 ng·L−1), élévation mineure (2065 ng·L−1) et élévation majeure (> 65 ng·L−1). Nous avons réalisé une analyse de survie pour déterminer l'association entre les lésions myocardiques et la mortalité à un an. Nous avons décrit les interventions médicales et évalué les admissions non planifiées à l'unité de soins intensifs (USI) ainsi que les complications à l'aide de modèles multivariables. RéSULTATS: Une lésion myocardique postopératoire est survenue chez 45 % des patient·es. La mortalité globale à 30 jours était de 8 %. La mortalité à trente jours et à un an était plus élevée chez les patient·es avec une hsTnT ≥ 20 ng·L−1. La mortalité à un an était de 18 % dans le groupe troponine inchangée vs 31 % et 41 % pour les groupes à élévation mineure et majeure de la troponine, respectivement. L'analyse multivariée de la survie à un an a montré un rapport de risque (RR) de 1,94 (intervalle de confiance [IC] à 95 %, 1,22 à 3,09) pour le groupe d'élévation mineure et un RR de 2,73 (IC 95 %, 1,67 à 4,45) pour le groupe avec une troponine > 65 ng·L−1. Les admissions non planifiées à l'USI étaient plus fréquentes chez les patient·es présentant une troponine altérée (13 % vs 5 %), tout comme les complications (78 % vs 48 %). CONCLUSION: Cette étude soutient les données probantes selon lesquelles la hsTnT est un marqueur pronostique important et un prédicteur fort de la mortalité toutes causes confondues après la chirurgie. La mesure de la troponine chez la patientèle chirurgicale à risque élevé pourrait potentiellement être utilisée comme outil pour intensifier les soins dans les PRFI. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT04187664); soumis pour la première fois le 5 décembre 2019.
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Países em Desenvolvimento , Troponina , Humanos , Troponina T , Estudos Prospectivos , Medição de Risco , BiomarcadoresRESUMO
BACKGROUND: The Brief Measure of Emotional Preoperative Stress (B-MEPS) was developed to evaluate the preoperative individual vulnerability to emotional stress. To obtain a refined version of B-MEPS suitable for an app approach, this study aimed: (i) to identify items with more discriminant properties; (ii) to classify the level of preoperative emotional stress based on cut-off points; (iii) to assess concurrent validity through correlation with the Central Sensitization Inventory (CSI) score; (iv) to confirm whether the refined version of B-MEPS is an adequate predictive measure for identification of patients prone to intense postoperative pain. METHODS: We include 1016 patients who had undergone surgical procedures in a teaching hospital. The generalized partial credit model of item response theory and latent class model were employed, respectively, to reduce the number of items and to create cut-off points. We applied the CSI and assessed pain by Visual Analog Scale (0-10) and by the amount of postoperative morphine consumption. RESULTS: The refined B-MEPS shows satisfactory reliability (Cronbach's alpha 0.79). Preoperative emotional stress, according to the cut-off points, is classified into categories: low, intermediate or high stress. The refined B-MEPS exhibited a linear association with the CSI scores (r2 = 0.53, p < 0.01). Patients with higher levels of emotional stress displayed a positive association with moderate to severe pain and greater morphine consumption. CONCLUSION: The refined version of B-MEPS, along with an interface of easy applicability, assess emotional vulnerability at the bedside before surgery. This app may support studies focused on intervening with perioperative stress levels.
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Aplicativos Móveis/estatística & dados numéricos , Medição da Dor/métodos , Dor Pós-Operatória/diagnóstico , Período Pré-Operatório , Angústia Psicológica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/psicologia , Estudos Prospectivos , Psicometria , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The development of feasible preoperative risk tools is desirable, especially for low-middle income countries with limited resources and complex surgical settings. This study aimed to derive and validate a preoperative risk model (Ex-Care model) for postoperative mortality and compare its performance with current risk tools. METHODS: A multivariable logistic regression model predicting in-hospital mortality was developed using a large Brazilian surgical cohort. Patient and perioperative predictors were considered. Its performance was compared with the Charlson comorbidity index (CCI), Revised Cardiac Risk Index (RCRI), and the Surgical Outcome Risk Tool (SORT). RESULTS: The derivation cohort included 16 618 patients. In-hospital death occurred in 465 patients (2.8%). Age, with adjusted splines, degree of procedure (major vs non-major), ASA physical status, and urgency were entered in a final model. It showed high discrimination with an area under the receiver operating characteristic curve (AUROC) of 0.926 (95% confidence interval [CI], 0.91-0.93). It had superior accuracy to the RCRI (AUROC, 0.90 vs 0.76; P<0.01) and similar to the CCI (0.90 vs 0.82; P=0.06) and SORT models (0.90 vs 0.92; P=0.2) in the temporal validation cohort of 1173 patients. Calibration was adequate in both development (Hosmer-Lemeshow, 9.26; P=0.41) and temporal validation cohorts (Hosmer-Lemeshow 5.29; P=0.71). CONCLUSIONS: The Ex-Care risk model proved very efficient at identifying high-risk surgical patients. Although multicentre studies are needed, it should have particular value in low resource settings to better inform perioperative health policy and clinical decision-making.
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Técnicas de Apoio para a Decisão , Mortalidade Hospitalar , Procedimentos Cirúrgicos Operatórios/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Tomada de Decisão Clínica , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
Brazil is the fourth largest producer and exporter of pork in the world, but has never reported yet the occurrence of some economically important diseases such as porcine reproductive and respiratory syndrome (PRRS) and porcine epidemic diarrhea (PED). Most of the swine farms in Brazil are characterized by intensive production being part of large integrated companies, where biosecurity practices help to prevent the introduction and spread of disease-causing infectious agents. The assessment of biosecurity in farms is not straightforward because of the large number of practices that constitute an on-farm biosecurity program. It is therefore necessary to combine the measurement of several parameters in order to characterize the level of biosecurity on a given farm. Thus, the objective of the study was to develop a biosecurity score to estimate the biosecurity level (theta or θ) in swine farms using the item response theory (IRT) and explore the relationship between the scores and independent variables. The IRT is a latent trait method extensively used in other fields, and offers the advantage to quantify the latent trait, here the biosecurity level, and to identify the practices that discriminate the farms avoiding the use of extensive questionnaires and redundant questions. In this study, 604 farms were evaluated in the main swine production regions of the state of Rio Grande do Sul, Brazil. Thirty-five practices were considered in order to quantify the biosecurity level on a given farm. After a recursive process 14 practices were selected to compose the biosecurity score to estimate the biosecurity level (θ). The variables identified with greater capacity of distinguishing the farms as to their biosecurity level were if the farm has 'feed bin outside of the barn limit (external feed loading)', has 'perimetral fence around the farm or barn', and if 'transit of trucks inside the farm is prohibited'. The biosecurity level was associated with some independent variables, e.g. the farm operation type, the integrated company and some owner characteristics. In addition, the results demonstrated that biosecurity practices related to management (internal biosecurity) are adopted with higher frequency compared to segregation and sanitation practices (external biosecurity). The IRT model proved useful and valid to estimate the biosecurity level in swine farms. Moreover, the biosecurity score described here has a relatively low number of items, which makes the application of this tool easier and faster compared to other previously described biosecurity assessment.
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Criação de Animais Domésticos/métodos , Doenças dos Suínos/prevenção & controle , Animais , Brasil/epidemiologia , Controle de Doenças Transmissíveis/métodos , Controle de Doenças Transmissíveis/normas , Fazendas , Fatores de Risco , Suínos , Doenças dos Suínos/epidemiologiaRESUMO
OBJECTIVE: To evaluate the degree of knowledge about pain management and opioids use by professionals working at three pediatric units. DESIGN: This is a cross-sectional study. SETTING: This study was carried out at three pediatric units (pediatrics, intensive care unit, and oncology) of Hospital de Clínicas de Porto Alegre, which is a university hospital located in southern Brazil. SUBJECT: The subjects of this study include physicians, pharmacists, physiotherapists, nurses, nursing technicians, and nursing assistants. METHODS: Cross-sectional study carried out in a university hospital in southern Brazil. A self-applicable semi-structured questionnaire was handed out to 182 professionals from December 2011 to March 2012. RESULTS: The response rate was 67% (122); the average percentage of correct answers was 63.2 ± 1.4%. The most frequent errors were: an opioid must not be used if the cause of pain is unknown (47%; 54/115); patients often develop respiratory depression (42.3%; 22/52); and confusion about symptoms of withdrawal, tolerance, and dependency syndromes (81.9%; 95/116). Only 8.8% (10/114) reported the use of pain scales to identify pain in children. The most often cited hindrance to control pain was the difficulty to measure and spot pain in pediatric patients. Finally, 50.8% (62/122) of them did not have any previous training in pain management. CONCLUSIONS: Problems in the processes of pain identification, measurement, and treatment have been found. Results suggest that there is a need for both an investment in continuing education of professionals and the development of protocols to optimize the analgesic therapy, thus preventing increased child suffering.
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Dor Aguda/tratamento farmacológico , Analgésicos Opioides/uso terapêutico , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/normas , Manejo da Dor/normas , Adulto , Atitude do Pessoal de Saúde , Brasil , Criança , Cuidados Críticos/normas , Estudos Transversais , Feminino , Humanos , Masculino , Oncologia/normas , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem Hospitalar/normas , Medição da Dor , Pediatria/normas , Farmacêuticos/normas , Fisioterapeutas/normas , Médicos/psicologia , Adulto JovemRESUMO
UNLABELLED: We present the performance of a new instrument developed to measure the height of patients in bed (Luft Ruler). METHODS: Standing height was the gold standard measured in 116 hospitalized adults with a stadiometer, compared with measurements from the Luft Ruler and calculated estimates. RESULTS: Using the Luft Ruler in women, men, <60 years old, and >60 years old, the mean difference from the gold standard was, respectively, 1.5 cm (P= .02), 1.3 cm (P= .06), 1.2 cm (P= .07), and 1.6 cm (P= .02); total arm span: 6.7 cm, 7.7 cm, 5.4 cm, and 9.0 cm (P< .01 for all strata); 2x half arm span: 7.8 cm, 10.2 cm, 7.7 cm, and 10.3 cm (P< .01 for all); World Health Organization (WHO) equation: 5.5 cm, 6.2 cm, 4.7 cm, and 6.9 cm (P< .01 for all); and the Hospital de Clínicas de Porto Alegre equation: 1.9 cm (P< .01), 2.5 cm (P< .01), 1.1 cm (P= .12), and 3.3 cm (P< .01). The proportion of differences >5 cm was 0.9% (n=1) using the Luft Ruler, 62.9% using total arm span, 71.6% using 2x half arm span, 64.7% using the WHO equation, and 27.6% using the Hospital de Clínicas de Porto Alegre equation. CONCLUSIONS: The Luft Ruler was the only method that presented minor mean differences in relation to the gold standard in both gender and age strata. The other estimates are not recommended because of high frequency of relevant errors.