INTRODUÇÃO: A hipertensão pulmonar tromboembólica crônica (HPTEC) é uma doença vascular pulmonar progressiva, cuja incidência varia de 0,56% a 3,2% em indivíduos com embolia pulmonar aguda (EPA) recorrente. Apesar do avanço nas opções de tratamento para HPTEC, a tromboendarterectomia pulmonar (TEAP) continua sendo padrão ouro, levando a melhora hemodinâmica e aumento da sobrevida. OBJETIVOS: Avaliar o impacto que mudanças técnicas intraoperatórias implementadas tiveram na evolução dos pacientes submetidos à TEAP em relação à morbimortalidade imediata e tardia, e também sobre o desenvolvimento do ato operatório. MÉTODOS: Estudo retrospectivo em portadores de HPTEC, submetidos à TEAP, no período de janeiro/2007 a maio/2016, divididos em 3 grupos, de acordo com intervenções implementadas. A 1ª intervenção consistiu em mudanças na circulação extracorpórea (CEC) e no tempo de parada circulatória total (PCT), e a 2ª intervenção incluiu alterações na CEC, técnicas anestésica e cirúrgica. A avaliação dos dados incluiu análise univariada para associações entre intervenções com variáveis de morbimortalidade e técnica operatória. O modelo de regressão multivariado foi aplicado para validar se as melhorias resultaram das intervenções implementadas. A análise de sobrevida foi feita por Kaplan-Meier. RESULTADOS: Foram avaliados 102 indivíduos, 62,8% mulheres, idade média de 49,1±14,8 anos, 65,7% estavam em classe funcional III-IV (NYHA). A avaliação hemodinâmica demonstrou hipertensão pulmonar importante, com valores médios elevados de pressão média na artéria pulmonar (PmAP; G1=52,9±14,45mmHg; G2=53,2±12,4mmHg; G3=53,3±12,5mmHg, p=0,992) e resistência vascular pulmonar (RVP; G1=828,4±295,13 dynas.s.cm-5; G2=838,9±428,4 dynas.s.cm-5; G3=969±417,3 dynas.s.cm-5, p=0,313). Os pacientes submetidos à TEAP mostraram aumento do tempo total de CEC entre os grupos (G1=192,3±39,4min; G2=251,7±33,4min; G3=298,2±40,2min, p < 0,001), como resultado da padronização dos tempos de esfriamento (G1=47,9±18,5min; G2=66,9±5,9min; G3=70,6±3,7min, p < 0,001), aquecimento (G1=66,8±17,7min; G2=87,2±8,1min; G3=107,7±23,5min, p < 0,001) e reperfusão (G1=25,5±7,6min; G2=20,7±8,4 min; G3=18,6±9,4min, p=0,007). A diminuição do número de operações com mais de 2 PCT (G1= 89%; G2= 60%; G3: 55%, p=0,002) foi decorrente do aumento da duração média de cada PCT (G1=15,5±2,9min; G2=17,8±1,7min; G3=19,2±2,0min, p < 0,001). Complicações pós-operatórias foram observadas em 88,5% dos pacientes, havendo redução significativa das complicações cirúrgicas (p=0,035), infecciosas (p=0,017) e neurológicas com sintomas permanentes (p=0,048) na comparação entre os 3 grupos. No seguimento após a alta, 85% estavam em classe funcional I-II (NYHA), sem melhora hemodinâmica significativa entre os grupos. Após a análise multivariada, o G3 apresentou 4,7 menos chances de complicação cirúrgica que G1 (p=0,034) e tempo de aquecimento menor que 83 minutos aumentou 4 vezes a chance de complicação infecciosa (p=0,002). A redução da mortalidade hospitalar e da sobrevida não foi significativa entre os grupos. CONCLUSÕES: Em relação à morbimortalidade imediata e tardia, o impacto das intervenções foi evidenciado pela redução das complicações neurológicas com sintomas permanentes, complicações cirúrgicas e infecciosas. Em relação ao ato operatório, o impacto foi evidenciado pelo aumento dos tempos totais de CEC, de esfriamento, de aquecimento, tempo médio das PCT, redução nos números de PCT e no tempo total de reperfusão / INTRODUCTION: Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disease which incidence varies from 0.56% to 3.2% in individuals with recurrent acute pulmonary embolism (APE). Despite advances in treatment options for CTEPH, pulmonary endarterectomy (PE) remains a gold standard, leading to hemodynamic improvement and increased survival. OBJECTIVES: Evaluate the impact of intraoperative technical changes on the evolution of patients submitted to PE related to immediate and late morbimortality, as well as on the development of the operative procedure. METHODS: Retrospective study of patients with CTEPH, submitted to PE, between January 2007 and May 2016, divided into 3 groups, according to the implemented interventions. The first intervention consisted of changes in cardiopulmonary bypass (CPB) and total circulatory arrest time (CAT), and the second intervention included changes in CPB, anaesthetic and surgical techniques. The data analysis included a univariate analysis for associations between interventions with morbidity variables and operative technique. The multivariate regression model was applied to validate whether the improvements resulted from the interventions implemented. Survival analysis was performed using Kaplan-Meier. RESULTS: We evaluated 102 individuals, 62.8% were women, mean age was 49.1 ± 14.8 years, and 65.7% were in functional class III-IV (NYHA). The hemodynamic evaluation showed significant pulmonary hypertension, with mean values of mean pulmonary artery pressure (mPAP, G1 = 52.9 ± 14.45 mmHg, G2 = 53.2 ± 12.4 mmHg, G3 = 53.3 ± 12.5 mmHg, p = 0.992) and pulmonary vascular resistance (PVR, G1 = 828.4 ± 295.13 dynas.s.cm-5, G2 = 838.9 ± 428.4 dynas.s.cm-5, G3 = 969 ± 417.3 dynas.s.cm-5, p = 0.313). The patients submitted to PE showed an increase in the total CPB time between the groups (G1 = 192.3 ± 39.4min, G2 = 251.7 ± 33.4min, G3 = 298.2 ± 40.2min, p < 0.001), as a result of the standardization of cooling times (G1 = 47.9 ± 18.5min, G2 = 66.9 ± 5.9min, G3 = 70.6 ± 3.7min, p < 0.001), heating (G1 = 66.8 ± 17.7min, G2 = 87.2 ± 8.1min, G3 = 107.7 ± 23.5min, p < 0.001) and reperfusion (G1 = 25.5 ± 7.6min, G2 = 20.7 ± 8.4 min, G3 = 18.6 ± 9.4min, p = 0.007). The decrease in the number of operations with more than 2 CAT (G1 = 89%, G2 = 60%, G3: 55%, p = 0.002) was due to the increase in the average duration of each CAT (G1 = 15.5 ± 2, 9min, G2 = 17.8 ± 1.7min, G3 = 19.2 ± 2.0min, p < 0.001). Postoperative complications were observed in 88.5% of the patients, with a significant reduction in surgical (p = 0.035), infectious (p = 0.017) and neurological complications with permanent symptoms (p = 0.048) in the comparison between the three groups. In the post-discharge follow-up, 85% were in functional class I-II (NYHA), with no significant hemodynamic improvement between groups. After the multivariate analysis, G3 presented 4.7 less chance of surgical complication than G1 (p = 0.034) and warming time less than 83 minutes increased 4 times the chance of infectious complication (p = 0.002). The reduction in hospital mortality and survival was not significant between the groups. CONCLUSIONS: Regarding immediate and late morbimortality, the impact of interventions was evidenced by the reduction of neurological complications with permanent symptoms, surgical and infectious complications. Regarding the operative event, the impact was evidenced by the increase in total CPB, cooling, heating, mean CAT time, CAT reduction and total reperfusion time

Abstract The purpose of this work was to determine on the basis of the national hospital discharge register and cause-of-death statistics the extent of the hospital treatment required for chronic obstructive pulmonary disease (COPD) in Finland over the period 1972–2001, i.e. the use made of hospital services, factors affecting the length of stay in hospital and the correlation of length of stay with the prognosis. Different intervals within this period were taken for study according to the themes of the individual papers. The results suggest that the length of stay in hospital varies both geographically and seasonally in Finland, the shortest times being recorded in Northern Finland in summer. The main explanations for this would appear to lie in regional differences in health care resources and treatment practises and in climatic variations. The mean length of stay in hospital in the total material in 1987–1998 was nine days. The longest periods applied to cases with concurrent pneumonia or a cerebrovascular disorder. The duration of treatment for the exacerbation stage of COPD decreased by two days between 1993 and 2001, with the longest periods of treatment observed in the case of elderly women. One week of treatment with current modalities may be regarded as optimal, as this was associated with the longest interval before the next exacerbation, just over six months. About 3% of all emergency admissions ended in death, most commonly on a Friday in winter or spring. Patients admitted at a weekend died within the first 24 hours more frequently than did those admitted on a weekday. The mean duration of treatment and frequency of hospitalization increased towards the terminal stage. About one fourth of the patients had died within a year of the first admission for COPD and about a half within five years. Hospital treatment for COPD intensified in Finland during the 1990s as the numbers of hospital beds decreased. Treatment times became shorter and deaths in hospital during exacerbation became less frequent. It will be necessary from now onwards, however, to anticipate the ageing of the population and to develop treatment modalities to replace hospitalization, in order to reduce the costs accruing from this disease. Early diagnosis and outpatient rehabilitation should be developed, and special attention should be paid to appropriate treatment at the terminal stage. / Tiivistelmä Tutkimuksen tarkoituksena oli selvittää valtakunnallisen hoitoilmoitusrekisterin ja kuolemansyytilaston avulla keuhkoahtaumataudista (KAT) aiheutunutta sairaalahoitoa Suomessa 1972–2001: sairaalapalvelujen käyttöä, hoitojakson pituuteen vaikuttavia tekijöitä sekä hoitoajan yhteyttä ennusteeseen. Lähdeaineistosta valittiin erilaisia ajanjaksoja tutkimusasetelman mukaan. Tulokset viittaavat siihen, että hoitoajan pituus vaihtelee Suomessa maantieteellisesti ja vuodenaikojen mukaan: lyhyin hoitoaika on Pohjois-Suomessa kesällä. Ilmiötä selittänevät pääosin terveydenhuollon resurssien ja hoitokäytäntöjen alueelliset erot sekä ilmasto-olosuhteiden vaihtelu. Vuosina 1987–1998 keskimääräinen hoitoaika koko aineistossa oli yhdeksän vuorokautta. Jos potilaalla oli samanaikaisina sairauksina keuhkokuume tai aivoverenkiertohäiriö, nämä johtivat pisimpiin hoitoaikoihin. KAT:n pahenemisvaiheen hoitoaika lyheni kaksi vuorokautta vuodesta 1993 vuoteen 2001. Iäkkäitten naisten hoitoajat olivat pisimmät. Viikon pituinen hoitoaika nykyisillä hoitomuodoilla oli optimaalinen, sillä tällöin aika seuraavan pahenemisvaiheen hoitojakson alkuun oli pisin: vähän yli puoli vuotta. Kaikista päivystyshoitojaksoista potilaan kuolemaan päättyi kolmisen prosenttia. Yleisimmin tällainen hoitojakso päättyi potilaan kuolemaan perjantaisin ja todennäköisimmin talvella tai keväällä. Viikonloppuna sairaalaan tulleista potilaista kuoli ensimmäisen vuorokauden aikana enemmän kuin arkipäivinä tulleista. Keskimääräinen hoitoaika oli pisin ja sairaalahoito runsainta sairauden loppuvaiheessa kuoleman lähestyessä. Ensimmäisen KAT:n aiheuttaman hoitojakson jälkeen noin neljännes potilaista oli kuollut vuoden sisällä ja viiden vuoden kuluessa noin puolet. Keuhkoahtaumataudin sairaalahoito on tehostunut Suomessa 1990-luvulla sairaansijojen vähentyessä. Hoitoajat ovat lyhentyneet ja pahenemisvaiheiden sairaalakuolleisuus on vähäistä. Väestön ikääntyminen on kuitenkin ennakoitava ja sairaalaa korvaavia hoitomuotoja kehitettävä taudista aiheutuneiden kustannusten hillitsemiseksi. Varhaisdiagnostiikkaa ja avokuntoutusta on kehitettävä ja erityinen huomio kiinnitettävä sairauden loppuvaiheen asianmukaiseen hoitoon.

<p>Veno-arterijski gradijent ugljen-dioksida (Pv-aCO2) se smatra pokazateljem adekvatnosti microcirculatornog venskog protoka. U stanjima usporenog protoka dolazi do povećavanja Pv-aCO2 zbog fenomena zadržavanja CO2. Vrednost Pv-aCO2 predložena je kao dodatni cilj rane usmerene terapije kod pacijenata sa septičnim &scaron;okom. Cilj rada bilo je utvrditi postojanje korelacije promene Pv-aCO2 s promenom SOFA (&ldquo;Sequential Organ Failure Assessment&rdquo;) skora (delta SOFA) nakon primene rane ciljane terapije, kao i korelacije vrednosti različitih pokazatelja krvnog protoka unutar prvih 12 sati od početka lečenja pacijenata sa sepsom. Sekundarni cilj bilo je utvrditi postojanje korelacije Pv-aCO2 6 sati nakon početka rane ciljane terapije (T6) s dužinom boravka u intenzivnoj jedinici i ishodom lečenja. Prospektivnim, neintervencijskim ispitivanjem obuhvaćeno je 150 pacijenata sa sepsom ili septičnim &scaron;okom. Merenja serumskog laktata, saturacije kiseonikom me&scaron;ane venske krvi (ScvO2) i Pv-aCO2 vr&scaron;ena su na početku rane ciljane terapije (T0), posle 6 i 12 sati (T6, T12). Pv-aCO2 se računao kao razlika između parcijalnog pritiska ugljen dioksida arterijske i me&scaron;ane venske krvi. Vrednost SOFA skora određivana je u vremenu T0 i nakon 48 časova (T48). Pacijenti su za potrebe analize podeljeni u dve grupe na osnovu promene SOFA skora [(1) pacijenti kod kojih je do&scaron;lo do smanjenja SOFA skora (delta SOFA &lt; 0); (2) pacijenti kod kojih je smanjenje SOFA skora izostalo (delta SOFA &ge; 0)] i na osnovu vrednosti Pv-aCO2 u vremenu T6 [(1) pacijenti sa visokim Pv-aCO2 (&ge; 0.8 kPa); (2) pacijenti sa normalnim Pv-aCO2 (&lt; 0.8 kPa)]. Između dve grupe pacijenata, sa normalnim i visokim Pv-aCO2, statistički značajne razlike uočene su samo u odnosu na najvi&scaron;u vrednost respiratorne komponente SOFA skora (p=0.01). Uočena je statistički značajna korelacija između vrednosti Pv-aCO2 i laktata u vremenu T6 (r=0.2), Pv-aCO2 i ScvO2 u vremenu T0 (r=-0.4) i T12 (r=-0.24) kao i laktata i ScvO2 u vremenu T0 (r=-0.26) i T12 (r=-0.18). Analizom ponavljanih merenja nije utvrđena statistički značajna korelacija između promene vrednosti Pv-aCO2 unutar prvih 6 sati s promenom SOFA skora unutar prvih 48 sati nakon početka rane ciljane terapije (p=0.12). Utvrđeno je da su vrednosti Pv-aCO2 u vremenu T6 bile lo&scaron; prediktor smrtnog ishoda. Nisu utvrđene statistički značajne razlike u dužini boravka u intenzivnoj jedinici i ishodu lečenja u zavisnosti od vrednosti Pv-aCO2.</p> / <p>Central venous-arterial CO2 difference (Pv-aCO2) reflects adequacy of microcirculatory venous flow. Widening of Pv-aCO2 due to CO2-stagnant phenomenon is described in the low flow states. Pv-aCO2 was proposed as an additional resuscitation target for patients with septic shock.The aim of this study was to examine correlation between changes in Pv-aCO2 and SOFA score as well as different blood flow indices (lactate, mixed venous oxygen saturation) 12 hours after onset of resuscitation in patients with sepsis or septic shock. Secondary aim was to evaluate association of delta CO2 6 hours after onset of resuscitation and patient outcomes (length of stay in the ICU, mortality). Prospective observational study included 150 patients with sepsis. Simultaneous measurements of lactate, mixed venous oxygen saturation (ScvO2) and delta PCO2 were performed at onset of resuscitation (T0) and after 6 hours (T6). Delta PCO2 was calculated as a difference between arterial PCO2 and PCO2 from mixed venous blood. Organ dysfunction was evaluated with the Sequential Organ Failure Assessment (SOFA) score at T0 and after 48 hours (T48). Mortality was assessed after 28 days. For data analysis purposes two groups were created based on delta SOFA [(1) patients with SOFA score decrease (delta SOFA &lt;0); (2) patients without SOFA score decrease (delta SOFA &ge; 0)] and based on Pv-aCO2 [(1) patients with high Pv-aCO2 (&ge;0.8 kPa); (2) patients with normal Pv-aCO2 (&lt;0.8 kPa). Patients with high and normal Pv-aCO2 differed only with respect to highest respiratory SOFA score (p=0.01) Change in Pv-aCO2 between T0 and T6 was not in correlation with change in SOFA score between T0 and T48 (p=0.12). Moderate statistically significant correlation was found between Pv-aCO2 and lactate at T6 (r=0.2), and moderate inverse correlation between Pv-aCO2 and ScvO2 at T0 (r=-0.4) and T12 (r=-0.25) and ScvO2 and lactate at T0 (r=-0.27) and T12 (r=-0.18). Pv-aCO2 at T6 was not associated with 28-day mortality and length of stay in the ICU.</p>

No description available.

No / To assess the validity of case mix adjustment methods used to derive standardised mortality ratios for hospitals, by examining the consistency of relations between risk factors and mortality across hospitals. DESIGN: Retrospective analysis of routinely collected hospital data comparing observed deaths with deaths predicted by the Dr Foster Unit case mix method. SETTING: Four acute National Health Service hospitals in the West Midlands (England) with case mix adjusted standardised mortality ratios ranging from 88 to 140. PARTICIPANTS: 96 948 (April 2005 to March 2006), 126 695 (April 2006 to March 2007), and 62 639 (April to October 2007) admissions to the four hospitals. MAIN OUTCOME MEASURES: Presence of large interaction effects between case mix variable and hospital in a logistic regression model indicating non-constant risk relations, and plausible mechanisms that could give rise to these effects. RESULTS: Large significant (P<or=0.0001) interaction effects were seen with several case mix adjustment variables. For two of these variables-the Charlson (comorbidity) index and emergency admission-interaction effects could be explained credibly by differences in clinical coding and admission practices across hospitals. CONCLUSIONS: The Dr Foster Unit hospital standardised mortality ratio is derived from an internationally adopted/adapted method, which uses at least two variables (the Charlson comorbidity index and emergency admission) that are unsafe for case mix adjustment because their inclusion may actually increase the very bias that case mix adjustment is intended to reduce. Claims that variations in hospital standardised mortality ratios from Dr Foster Unit reflect differences in quality of care are less than credible.

No / To build an early warning score (EWS) based exclusively on routinely undertaken laboratory tests that might provide early discrimination of in-hospital death and could be easily implemented on paper. Using a database of combined haematology and biochemistry results for 86,472 discharged adult patients for whom the admission specialty was Medicine, we used decision tree (DT) analysis to generate a laboratory decision tree early warning score (LDT-EWS) for each gender. LDT-EWS was developed for a single set (n=3496) (Q1) and validated in 22 other discrete sets each of three months long (Q2, Q3...Q23) (total n=82,976; range of n=3428 to 4093) by testing its ability to discriminate in-hospital death using the area under the receiver-operating characteristic (AUROC) curve. The data generated slightly different models for male and female patients. The ranges of AUROC values (95% CI) for LDT-EWS with in-hospital death as the outcome for the validation sets Q2-Q23 were: 0.755 (0.727-0.783) (Q16) to 0.801 (0.776-0.826) [all patients combined, n=82,976]; 0.744 (0.704-0.784, Q16) to 0.824 (0.792-0.856, Q2) [39,591 males]; and 0.742 (0.707-0.777, Q10) to 0.826 (0.796-0.856, Q12) [43,385 females]. CONCLUSIONS: This study provides evidence that the results of commonly measured laboratory tests collected soon after hospital admission can be represented in a simple, paper-based EWS (LDT-EWS) to discriminate in-hospital mortality. We hypothesise that, with appropriate modification, it might be possible to extend the use of LDT-EWS throughout the patient's hospital stay.

L'objectiu d'aquest treball era avaluar la mortalitat hospitalària de la cirurgia coronaria en malalts de la sanitat pública operats en centres de gestió pública i privada de Catalunya, mitjançant l'ús de dues escales de risc (l'EuroSCORE i un model d'àmbit local). S'analitzà també la validesa dels mètodes d'avaluació i es comparà el resultat de la cirurgia sense circulació extracorpòria respecte de la cirurgia amb circulació extracorpòria. Es van incloure tots els malalts consecutius (1.605) sotmesos a una primera intervenció d'empelt coronari aïllat durant dos anys en cinc hospitals. Els resultats indiquen que a Catalunya: 1) La gestió privada del centre s'associa marginalment amb una millor supervivència. 2) L'efectivitat de la cirurgia coronària a millorat en els últims anys. 3) Ambdós instruments d'ajust del risc son útils per a l'avaluació d'aquests resultats. 4) La cirurgia sense circulació extracorpòria s'associa a millors resultats, sobre tot en els pacients amb risc preoperatori baix. / El objetivo de este trabajo era evaluar la mortalidad hospitalaria de la cirugía coronaria de los pacientes de la sanidad pública operados en centros de gestión pública y privada de Cataluña, mediante dos escalas de riesgo (el EuroSCORE y una de ámbito local). Se analizó también la validez de los métodos de evaluación y se comparó el resultado de la cirugía sin circulación extracorporea con el de la cirugía con circulación extracorporea.Se incluyeron los pacientes (1.605) sometidos a una primera intervención de implante aortocoronario aislado durante dos años en cinco centros.Los resultados indican que en Cataluña: La gestión privada se asocia marginalmente a mejor supervivencia. La efectividad de la cirugía coronaria ha mejorado en los últimos años. Ambos instrumentos de ajuste del riesgo resultan útiles para la evaluación de estos resultados. La cirugía sin circulación extracorporea se asocia a mejores resultados, sobre todo en pacientes de riesgo bajo. / The objective of the present study was to evaluate hospital mortality after coronary surgery in patients from the public health system operated on in public and private centers, using two risk scores (the EuroSCORE and a locally derived model). In addition, validity of such evaluating methods was assessed and the results of off-pump and on-pump coronary surgery were compared.All consecutive patients (1.605) undergoing a first isolated coronary by-pass procedure during two years were recruited in five hospitals.The results show that in Catalonia: 1) Private hospital management is associated to a maginal increase in hospital survival. 2) Effectiveness of coronary by-pass surgery has increased compared to previous evaluations. 3) Both risk scores showed complementary properties fort he evaluation of results. 4) Off-pump coronary surgery is associated to better results and the association is grater in low risk patients.

Made available in DSpace on 2011-05-04T12:36:23Z (GMT). No. of bitstreams: 0 Previous issue date: 2009 / OBJETIVO: Avaliar a efetividade do tratamento hospitalar do Acidente Vascular Cerebral Agudo no Sistema Único de Saúde SUS, comparando a mortalidade hospitalar ajustada entre pacientes que realizaram ou não a tomografia computadorizada. MÉTODO: A fonte de informação utilizada foi o Sistema de Informação Hospitalar do SUS (SIH-SUS). Foram selecionadas 328.087 internações ocorridas no SUS em todo o território nacional entre abril de 2006 e dezembro de 2007. As internações foram reunidas e estudadas em 4 grupos: Acidente Isquêmico Transitório (CID-10: G459); Acidente Vascular Cerebral Hemorrágico (CID-10: I60; I61 e I62); Acidente Vascular Isquêmico (CID-10: I63) e Acidente Vascular Cerebral não especificado (CID-10: I64). Foram utilizadas as mortalidades hospitalares até o sétimo e até o trigésimo dias, como medidas de resultado para comparar pacientes que realizaram e não realizaram tomografia computadorizada. RESULTADOS: Em geral os pacientes que realizaram a tomografia computadorizada apresentaram menores taxas de mortalidade hospitalar em relação àqueles que não realizaram o exame, sendo essa diferença em favor da realização do exame observada principalmente até o segundo dia de internação em todos os 4 grupos. A diferença entre os que realizaram e os que não realizaram o exame foi acentuada no grupo do Acidente Vascular Isquêmico (OR: 0,325; p>0,000), sendo que no primeiro dia o odds ratio foi de 0,021(p>0,000), em favor dos que realizaram o exame. CONCLUSÕES: Os exames de tomografia computadorizada no SUS, em geral, são realizados mais tardiamente que o recomendado pela literatura. Apesar das limitações ainda existentes na qualidade da informação diagnóstica disponível no SIH-SUS que restringiram a estratégia de ajuste de risco empregada nesse estudo, sugere-se o uso da tomografia computadorizada, o mais cedo possível, como tecnologia auxiliar no diagnóstico e tratamento do AVC. Além disso, sugere-se o emprego mais amplo de medidas de desempenho, tais como a mortalidade hospitalar aqui empregada, para o monitoramento da qualidade do cuidado prestado no âmbito do SUS. / OBJECTIVE: To evaluate the effectiveness of hospital care of the Stroke in the Brazilian Health System by comparing adjusted hospital mortality rate between patients who had done or not CT scanning. METHOD: Brazilian hospital information systems was the data source used. Three hundred twenty eight thousand and eighty seven inpatients were included in this study, covering all the Brazilian territory between April of 2006 and December of 2007. The inpatients had been grouped in 4 groups: Transient cerebral ischaemic attack, unspecified (ICD-10: G45.9); Haemorrhage Stroke (ICD -10: I60; I61 and I62); Cerebral infaction (ICD -10: I63) and Stroke not specified as haemorrhage or infarction (ICD -10: I64). Hospital mortality until seventh and the thirtieth day was used as a result measure to compare patients who had been submitted or not to Computerized tomography (CT) scanning. RESULTS: In general the patients who submitted to TC scanning presented lower hospital mortality rates in relation to those who had not done CT scanning, being this difference for the accomplishment of the examination observed until the second day of in-hospital all stroke group. The group of the ischemic stroke presented the higher difference among those who were submitted or not to Computerized tomography (CT) scanning (OR: 0.325; p>0.000). In the first in-hospital day for the stroke group the odds ratio 0.021 (p>0.000) in favor of the group who had done the CT. CONCLUSIONS: The TC scans in the Brazilian health system, in general, are used with a greater delay than the recommended in literature. This leads to a reduction of the benefits of the examination. Although the limitations in the data quality of Brazilian hospital, the use of the TC scanning, as soon as possible, is suggested as auxiliary technology in the diagnosis and treatment of the stroke. Furthermore, it is also suggested a more frequent employment of performance indicator, such as hospital mortality rate, to monitoring quality of care in Brazil.

No / Hospitals are under pressure to reduce waiting times and costs. One strategy that may be effective focuses on optimising the flow of emergency patients. We undertook a patient flow analysis of older emergency patients to identify and address delays in ensuring timely care, without additional resources. Prospective systems redesign study over 2 years. The Geriatric Medicine Directorate in an acute hospital (Sheffield Teaching Hospitals NHS Foundation Trust) with 1920 beds. Older patients admitted as emergencies. Diagnostic patient flow analysis followed by a series of Plan Do Study Act cycles to test and implement changes by a multidisciplinary team using time series run charts. 60% of patients aged 75+ years arrived in the Emergency Department during office hours, but two-thirds of the admissions to GM wards were outside office hours highlighting a major delay. Three changes were undertaken to address this, Discharge to Assess, Seven Day Working and the establishment of a Frailty Unit. Average bed occupancy fell by 20.4 beds (95% confidence interval (CI) -39.6 to -1.2, P = 0.037) for similar demand. The risk of hospital mortality also fell by 2.25% (before 11.4% (95% CI 10.4-12.4%), after 9.15% (95% CI 7.6-10.7%) which equates to a number needed to treat of 45 and a 19.7% reduction in relative risk of mortality. The risk of re-admission remained unchanged. Redesigning the system of care for older emergency patients led to reductions in bed occupancy and mortality without affecting re-admission rates or requiring additional resources.

Introdução: Estima-se que ocorram 2,5 milhões de mortes por ano relacionadas a cirurgias não cardíacas e cinco vezes este valor para morbidade, com limitações funcionais e redução na sobrevida em longo prazo. Pacientes que deverão ser submetidos à cirurgia vascular são considerados de risco aumentado para eventos adversos cardiovasculares no pós-operatório. Há, ainda, muitas dúvidas em como fazer uma avaliação pré-operatória mais acurada desses pacientes. Objetivo: Em pacientes submetidos à cirurgia vascular arterial eletiva, avaliar a incidência e preditores de complicações cardiovasculares e/ou óbito total, e calcular a performance dos modelos de estratificação de risco mais utilizados. Métodos: Em pacientes adultos, consecutivos, operados em hospital terciário, determinou-se a incidência de complicações cardiovasculares e óbitos, em 30 dias e em um ano. Comparações univariadas e regressão logística avaliaram os fatores de risco associados com os desfechos e a curva ROC (receiver operating characteristic) examinou a capacidade discriminatória do Índice de Risco Cardíaco Revisado (RCRI) e do Índice de Risco Cardíaco do Grupo de Cirurgia Vascular da New England (VSG-CRI). Resultados: Um total de 141 pacientes (idade média 66 anos, 65% homens) realizou cirurgia de: carótida 15 (10,6%), membros inferiores 65 (46,1%), aorta abdominal 56 (39,7%) e outras (3,5%). Complicações cardiovasculares e óbito ocorreram, respectivamente, em 28 (19,9%) e em 20 (14,2%), em até 30 dias, e em 20 (16,8%) e 10 (8,4%), de 30 dias a um ano. Complicações combinadas ocorreram em 39 (27,7%) pacientes em até 30 dias e em 21 (17,6%) de 30 dias a um ano da cirurgia. Para eventos em até 30 dias, os preditores de risco encontrados foram: idade, obesidade, acidente vascular cerebral, capacidade funcional ruim, cintilografia com hipocaptação transitória, cirurgia aberta, cirurgia de aorta e troponina alterada. Os escores Índice de Risco Cardíaco Revisado (RCRI) e Índice de Risco Cardíaco do Grupo de Estudo Vascular da New England (VSG-CRI) obtiveram AUC (area under curve) de 0,635 e 0,639 para complicações cardiovasculares precoces e 0,562 e 0,610 para óbito em 30 dias, respectivamente. Com base nas variáveis preditoras aqui encontradas, testou-se um novo escore pré-operatório que obteve AUC de 0,747, para complicações cardiovasculares precoces, e um escore intraoperatório que apresentou AUC de 0,840, para óbito em até 30 dias. Para eventos tardios (de 30 dias a 1 ano), os preditores encontrados foram: capacidade funcional ruim, pressão arterial sistólica, cintilografia com hipocaptação transitória, ASA (American Society of Anesthesiologists Physical Status) classe > II, RCRI (AUC 0,726) e troponina alterada. Conclusões: Nesse grupo pequeno e selecionado de pacientes de elevada complexidade clínica, submetidos à cirurgia vascular arterial, a incidência de eventos adversos foi elevada. Para complicações em até 30 dias, mostramos que os índices de avaliação de risco mais utilizados até o momento (RCRI e VSG-CRI) não apresentaram boa performance em nossa amostra. A capacidade preditiva de um escore mais amplo pré-operatório, e uma análise de risco em dois tempos: no pré-operatório e no pós-operatório imediato, como o que simulamos, poderá ser mais efetiva em estimar o risco de complicações / Introduction: Approximately 2.5 million deaths are caused by non-cardiac surgeries per year, while morbidity, represented by functional impairment and a decline in long-term survival, accounts for five times this value. Patients who require a vascular surgery are considered at an increased risk for adverse cardiovascular events in the postoperative period. However, the method for obtaining a more accurate preoperative evaluation in these patients has not yet been determined. Objective: In patients undergoing elective arterial vascular surgery, the incidence and predictors of cardiovascular complications and/or total death were determined and the performance of risk stratification models was assessed. Methods: The incidence of cardiovascular complications and death within 30 days and 1 year after vascular surgery was determined in consecutive adult patients operated in a tertiary hospital. Univariate comparison and logistic regression analysis were used to evaluate risk factors associated with the outcome, and the receiver operating characteristic (ROC) curve determined the discriminatory capacity of the Revised Cardiac Risk Index (RCRI) and the Cardiac Risk Index of the New England Vascular Surgery Group (VSG-CRI). Results: In all, 141 patients (mean age, 66 years; 65% men) underwent vascular surgery, namely for the carotid arteries (15 [10.6%]), inferior limbs (65 [46.1%]), abdominal aorta (56 [39.7%]), and others (5 [3.5%]). Cardiovascular complications and death occurred in 28 (19.9%) and 20 (14.2%) patients, respectively, within 30 days after surgery, and in 20 (16.8%) and 10 (8.4%) patients, respectively, between 30 days and 1 year after the surgical procedure. Combined complications occurred in 39 patients (27.7%) within 30 days and in 21 patients (17.6%) between 30 days and 1 year after surgery. The risk predictors for cardiovascular events that occurred within 30 days were age, obesity, stroke, poor functional capacity, transitory myocardial hypocaptation on scintigraphy, open surgery, aortic surgery, and abnormal troponin levels. The RCRI and VSG-CRI showed an under the curve area of 0.635 and 0.639 for early cardiovascular complications as well as of 0.562 and 0.610 for death within 30 days, respectively. Based on the predictors found in this study, a new preoperative score was proposed, based on an AUC of 0.747 obtained for early cardiovascular complications and an intraoperative score that presented an AUC of 0.840 for death within 30 days. For late events (between 30 days and 1 year), the predictors were poor functional capacity, systolic blood pressure, presence of transitory myocardial hypocaptation on scintigraphy, class > II American Society of Anesthesiologists Physical Status score, RCRI (AUC= 0.726), and abnormal troponin levels. Conclusions: In this small group of patients with increased clinical complexity who underwent arterial surgery, the incidence of adverse events was high. In our series, we found that RCRI and VSG-CRI do not reasonably predict the risk of cardiovascular complications. The predictive capacity of a modified preoperative score and evaluating the risk preoperatively and early postoperatively, such as that simulated in this study, may be more effective in determining the risk of complications