Risco de Morte em Idosos com Sonolência Excessiva Diurna,Insônia e Depressão: Estudo de Coorte Prospectiva em População Urbana no Nordeste Brasileiro

BackgroundThe close relationship between sleep regulation and cardiovascular events is one of the main focuses of research in contemporary medicine. Sleep habits and characteristics interfere with the cardiac rhythm and also with life expectancy, especially in the elderly.ObjectiveTo estimate the risk of death and cardiovascular events in community-dwelling elderly individuals complaining of insomnia and excessive daytime sleepiness over eight years of follow-up.MethodA prospective cohort was designed with 160 elderly, with the first wave occurring in 2009 and the second in 2017. Follow-up groups were determined by exposure or not to complaints of primary insomnia and excessive daytime sleepiness with or without snoring. The covariates gender, marital status, depression, hypertension and diabetes were controlled. The primary outcome was death and the secondary outcome was cardio-cerebrovascular events (CCV). Outcome risks were estimated by relative risk (RR) through Poisson regression, adopting α≤0.05.ResultsThere were 40 (25.97%: 19.04-32.89) deaths over the period and 48 (30.76%: 23.52-38.01) CCV. Men had a higher risk (RR = 1.88; 1.01-3.50) of death. Depression (RR = 2.04; 1.06-3.89), insomnia severity (RR = 2.39; 1.52-4.56) and sleep latency between 16-30 minutes (RR = 3, 54; 1.26-9.94) and 31-60 minutes (RR = 2.23; 1.12-4.47) increased the risk of death independently in community-dwelling elderly. CCV were predicted only in the hypertensive and / or diabetic elderly (RR = 8.30; 1.98-34.82).ConclusionMortality in the elderly is influenced by the emotional state and difficulty in falling asleep, unlike CCVs, which are conditioned only by arterial and metabolic blood pressure conditions.     

Preditores de mortalidade intra‐hospitalar em pacientes submetidos a cirurgias não eletivas em um hospital universitário: uma coorte prospectiva

Introduction

Morbidity and mortality associated with urgent or emergency surgeries are high compared to elective procedures. Perioperative risk scores identify the non‐elective character as an independent factor of complications and death. The present study aims to characterize the population undergoing non‐elective surgeries at the Hospital de Clínicas de Porto Alegre and identify the clinical and surgical factors associated with death within 30 days postoperatively.

Maternal mortality due to arterial hypertension in São Paulo City (1995-1999)

AIM: To describe the case profile of maternal death resulting from hypertensive disorders in pregnancy and to propose measures for its reduction. METHODS: The Committee on Maternal Mortality of S?o Paulo City has identified 609 cases of obstetric maternal death between 1995 and 1999 with an underreporting rate of 52.2% and a maternal mortality rate of 56.7/100,000 live births. Arterial hypertension was the main cause of maternal death, corresponding to 142 (23.3%) cases. RESULTS: Ninety-five (66.9%) of the deaths occurred during the puerperal period and 34 (23.9%) occurred during pregnancy. The time of death was not reported in 13 (9.2%) cases. Seizures were observed in 41 cases and magnesium sulfate was used in four of them. The causes of death were ruled to be cerebrovascular accident (44.4%), acute pulmonary edema (24.6%), and coagulopathies (14.1%). Cesarean section was performed in 85 (59.9%) cases and vaginal delivery in 15 (16.0%). CONCLUSION: Complications of arterial hypertension are responsible for the high rates of pregnancy-related maternal death in S?o Paulo City. Quality prenatal care and appropriate monitoring of the hypertensive pregnant patient during and after delivery are important measures for better control of this condition and are essential to reduce disorders in pregnancy.     

The smoker's paradox in acute coronary syndrome: Is it real?

Introduction

Smoking is associated with atherosclerotic disease, but there is controversy about its protective nature after acute coronary syndrome (ACS).

Avaliação do Impacto da Implantação de um Sistema de Ambulância Pré-Hospitalar sobre Mortalidade por Infarto Agudo do Miocárdio em um País em Desenvolvimento

BackgroundThe effective management of patients with acute myocardial infarction (AMI) is time-dependent.ObjectivesTo assess the impacts of the implementation of prehospital care on admission rates and mortality associated with AMI.MethodsRetrospective, ecological study, which assessed data from the Brazilian Universal Health System, from all 853 municipalities of Minas Gerais, from 2008 to 2016. Excessive skewness of general and in-hospital mortality rates was smoothed using the empirical Bayes method. This study assessed the relationship between Mobile Emergency Care Service (SAMU) in each municipality and the following 3 outcomes: mortality rate due to AMI, AMI in-hospital mortality, and AMI hospitalization rate, using the Poisson hierarchical model. Rates were corrected by age structure and detrended by seasonality and temporal influences. A confidence interval of 95% was adopted.ResultsAMI mortality rates decreased throughout the study, on average 2% per year, with seasonal variation. AMI in-hospital mortality also showed a decreasing trend, from 13.81% in 2008 to 11.43% in 2016. SAMU implementation was associated with decreased AMI mortality (odds ratio [OR] = 0.967, 95% confidence interval [CI] 0.936 to 0.998) and AMI in-hospital mortality (OR = 0.914, 95% CI 0.845 to 0.986), with no relation with hospitalizations (OR = 1.003, 95% CI 0.927 to 1.083).ConclusionSAMU implementation was associated with a modest but significant decrease in AMI in-hospital mortality. This finding reinforces the key role of prehospital care in AMI care and the need for investments on this service to improve clinical outcomes in low- and middle-income countries.     

IDH,Recursos Tecnológicos e Humanos para Diagnóstico e Tratamento das Malformações do Aparelho Circulatório no Brasil

Background In 2015, the number of infants with congenital malformations (CMs) per 100 000 live births (LBs) was 2368 (7.6%) worldwide, of whom 10.6% died in the first year of life, 43% due to malformations of the circulatory system (MCSs), a scenario similar to what occurs in Brazil.Objective To assess, per Brazilian macroregion, whether diagnosis of MCS at birth and death due to MCS in the first year of life associate with human development index (HDI) and with technological and human resources.Methods Ecological study including data available in 2000–2015. Data of LBs, deaths and availability of echocardiography devices were obtained from the DATASUS website. The HDI was obtained from the Atlas of Human Development in Brazil, while other variables were obtained from medical demographic data. Correlation measures between the variables were performed using the Kendall index.Results The CM rate was 660.8/100 000 LBs, of which 18 444 were due to MCS (diagnosis rate, 38.55/100 000 LBs). Of all Brazilian macroregions, the Southern and Southeastern regions, with the highest HDI values and resources, had the highest MCS diagnosis rates (56.94/100 000 and 62.83/100 000 LBs, respectively). The Northern and Northeastern regions, with the lowest HDI values and resources, had the lowest MCS diagnosis rates (9.77/100 000 and 13.43/100 000 LBs, respectively). The MCS diagnosis rate was 6.4-fold higher in the Southeastern region as compared to the Northern region, but mortality rates were similar in both regions.Conclusion Of the CMs, the MCS accounted for the highest number of deaths in children under the age of 1 year in Brazil.     

Mortality in adolescents and young adults with chronic diseases during 16 years: a study in a Latin American tertiary hospital

ObjectivesTo evaluate mortality in adolescents and young adult patients with chronic diseases followed in a Latin American tertiary hospital.MethodsA cross-sectional retrospective study was performed in a tertiary/academic hospital in the state of São Paulo, Brazil. Death occurred in 529/2850 (18.5%) adolescents and young adult patients with chronic diseases, and 25/529 (4.7%) were excluded due to incomplete medical charts. Therefore, 504 deaths were evaluated.ResultsDeaths occurred in 316/504 (63%) of early adolescent patients and in 188/504 (37%) of late adolescent/young adult patients. Further comparisons between early adolescents (n = 316) and late adolescent/young adult patients (n = 188) with pediatric chronic diseases at the last hospitalization showed that the median disease duration (22.0 [0–173] vs. 43.0 [0–227] months, p < 0.001) was significantly lower in early adolescents vs. late adolescent/young adult patients. The median number of previous hospitalizations was significantly lower in the former group (4.0 [1–45] vs. 6.0 [1–52], p < 0.001), whereas the last hospitalization in intensive care unit was significantly higher (60% vs. 47%, p = 0.003). Regarding supportive measures, palliative care was significantly lower in the younger group compared to the older group (33% vs. 43%, p = 0.02). The frequencies of renal replacement therapy (22% vs. 13%, p = 0.02), vasoactive agents (65% vs. 54%, p = 0.01), and transfusion of blood products (75% vs. 66%, p = 0.03) were significantly higher in the younger group. The five most important etiologies of pediatric chronic diseases were: neoplasias (54.2%), hepatic diseases/transplantation (10%), human immunodeficiency virus (5.9%), and childhood-onset systemic lupus erythematosus and juvenile idiopathic arthritis (4.9%). Autopsy was performed in 58/504 (11%), and discordance between clinical and postmortem diagnoses was evidenced in 24/58 (41.3%).ConclusionsAlmost 20% of deaths occurred in adolescents and young adults with distinct supportive care and severe disease patterns. Discordance between clinical diagnosis and autopsy was frequently observed.