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Casado R.J.A.,Institute Medicina Integral Prof Fernando Figueira Imip | De Mello M.J.G.,Institute Medicina Integral Prof Fernando Figueira Imip | De Aragao R.C.F.,Institute Medicina Integral Prof Fernando Figueira Imip | De Aragao R.C.F.,University of Pernambuco | And 3 more authors.
Critical Care Medicine | Year: 2011

Objectives: To determine the incidence and risk factors for health care-associated pneumonia in a pediatric intensive care unit. Design: Prospective cohort study. Setting: Pediatric intensive care unit with 16 medical and surgical beds in a tertiary teaching hospital in Recife, northeast Brazil. Patients: Patients aged <18 yrs were consecutively enrolled between January 2005 and June 2006 into a cohort set to investigate health care-associated infections. Newborns and patients admitted for surveillance and those staying for <24 hrs were excluded. Patients were followed up daily throughout the stay and until 48 hrs after discharge from the unit. Interventions: None. Measurements and Main Results: This report focuses on health care-associated pneumonia, defined as pneumonia that occurs >48 hrs after admission but that was not incubating at the time of admission, as the primary outcome. Intrinsic and extrinsic variables were prospectively recorded into a standardized form. Statistical analyses, including multivariable logistic regression, were performed in Stata version 9.1. There were 765 eligible admissions. Health care-associated pneumonia occurred in 51 (6.7%) patients with an incidence density of 13.1 episodes/1,000 patient-days. There were 366 (47.8%) patients on mechanical ventilation, of whom 39 (10.7%) presented with ventilator-associated pneumonia with an incidence density of 27.1/1,000 days on ventilation. Longer stay on ventilation (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01-1.08), use of gastric tube (OR, 2.88; 95% CI, 1.41-5.87), and of sedatives/analgesics (OR, 2.45; 95% CI, 1.27-4.72) were identified as independent risk factors for healthcare-associated pneumonia. Conclusion: Identification of independent predictors of health care-associated pneumonia may inform preventive measures. Strategies to optimize use of sedatives/analgesics, reduce the use of gastric tubes, and reduce the time on ventilation should be considered for inclusion in future intervention studies. © 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.

Pacheco A.J.C.,Universidade São Francisco | Katz L.,Institute Medicina Integral Prof Fernando Figueira Imip | Souza A.S.R.,Institute Medicina Integral Prof Fernando Figueira Imip | Souza A.S.R.,Federal University of Pernambuco | And 2 more authors.
BMC Pregnancy and Childbirth | Year: 2014

Background: Maternal mortality remains a major public health issue worldwide, with persistent high rates prevailing principally in underdeveloped countries. The objective of this study was to determine the risk factors for severe maternal morbidity and near miss (SMM/NM) in pregnant and postpartum women at the maternity ward of the Dom Malan Hospital, Petrolina, in northeastern Brazil.Methods: A retrospective, cohort study was conducted to evaluate the sociodemographic and obstetric characteristics of the women. Patients who remained hospitalized at the end of the study period were excluded. Risk ratios (RR) and their respective 95% confidence intervals (95% CI) were calculated as a measure of relative risk. Hierarchical multiple logistic regression was also performed. Two-tailed p-values were used for all the tests and the significance level adopted was 5%.Results: A total of 2,291 pregnant or postpartum women receiving care between May and August, 2011 were included. The frequencies of severe maternal morbidity and near miss were 17.5% and 1.0%, respectively. Following multivariate analysis, the factors that remained significantly associated with an increased risk of SMM/NM were a Cesarean section in the current pregnancy (OR: 2.6; 95% CI: 2.0 - 3.3), clinical comorbidities (OR: 3.4; 95% CI: 2.5 - 4.4), having attended fewer than six prenatal visits (OR: 1.1; 95% CI: 1.01 - 1.69) and the presence of the third delay (i.e. delay in receiving care at the health facility) (OR: 13.3; 95% CI: 6.7 - 26.4).Conclusions: The risk of SMM/NM was greater in women who had been submitted to a Cesarean section in the current pregnancy, in the presence of clinical comorbidities, fewer prenatal visits and when the third delay was present. All these factors could be minimized by initiating a broad debate on healthcare policies, introducing preventive measures and improving the training of the professionals and services providing obstetric care. © 2014 Pacheco et al.; licensee BioMed Central Ltd.

Da Cruz Gouveia P.A.,Federal University of Pernambuco | Da Silva G.A.P.,Institute Medicina Integral Prof Fernando Figueira Imip | De Fatima Pessoa Militao de Albuquerque M.,Aggeu Magalhaes Research Center
Tropical Medicine and International Health | Year: 2013

Objective: To identify risk factors associated with mother-to-child transmission of HIV in the Brazilian state of Pernambuco. Methods: Retrospective cohort study with 1200 HIV-exposed children born in Pernambuco, registered up to the age of 2 months in a public programme to prevent vertical transmission. Univariate and multivariate logistic regression analyses were conducted for maternal and peripartum characteristics and prophylactic interventions, to identify risk factors for mother-to-child transmission of HIV. Results: The transmission rate was 9.16% (95% CI: 7.4-10.9). The following risk factors were independently associated with transmission: non-use of antiretroviral during pregnancy (OR: 7.8; 95% CI: 4.1-15); vaginal delivery (OR: 2.02; 95% CI: 1.2-3.4); prematurity (OR: 2.5; 95% CI: 1.3-4.7); and breastfeeding (OR: 2.6; 95% CI: 1.4-4.6). Conclusions: This mother-to-child transmission rate is unacceptably high, as prophylactic interventions such as antiretroviral therapy and infant feeding formula are free of charge. Absence of antiretroviral therapy during pregnancy was the main risk factor. Therefore, early identification of exposed mothers and initiating prophylactic interventions are the main challenges for controlling transmission. © 2012 Blackwell Publishing Ltd.

Feliciano K.V.O.,Institute Medicina Integral Prof Fernando Figueira Imip
Revista Brasileira de Saude Materno Infantil | Year: 2010

This article adopts a hermeneutical and critical approach, in order to examine the importance of the conditions making possible and legitimizing communications practices aiming to evaluate the Family Health Strategy. It is the participatory nature of the strategy that enables it to establish social networks and negotiation techniques aiming to achieve coherence between the autonomous judgment of each individual and the expectation of obtaining contracts and agreements for joint projects. The shared decisionmaking process is shown to be a network of relations that are always in tension, in which the success of negotiations may be hampered by asymmetrical power relations and unfair distribution of the power to make threats. This means that is indispensable that what is said and how language is used be called into question. In order to reflect on language as a construct in a given context, the article draws on the work of Gadamer, Habermas and Ricoeur. It aims to reaffirm the importance of intersubjectivity as a condition for decision-making, thereby helping to build up the training potential of evaluation in the area of health.

Sampaio M.J.,Institute Medicina Integral Prof Fernando Figueira Imip
PLoS neglected tropical diseases | Year: 2010

Despite the major public health importance of visceral leishmaniasis (VL) in Latin America, well-designed studies to inform diagnosis, treatment and control interventions are scarce. Few observational studies address prognostic assessment in patients with VL. This study aimed to identify risk factors for death in children aged less than 15 years admitted for VL treatment in a referral center in northeast Brazil. In a retrospective cohort, we reviewed 546 records of patients younger than 15 years admitted with the diagnosis of VL at the Instituto de Medicina Integral Professor Fernando Figueira between May 1996 and June 2006. Age ranged from 4 months to 13.7 years, and 275 (50%) were male. There were 57 deaths, with a case-fatality rate of 10%. In multivariate logistic regression, the independent predictors of risk of dying from VL were (adjusted OR, 95% CI): mucosal bleeding (4.1, 1.3-13.4), jaundice (4.4, 1.7-11.2), dyspnea (2.8, 1.2-6.1), suspected or confirmed bacterial infections (2.7, 1.2-6.1), neutrophil count <500/mm 3 (3.1, 1.4-6.9) and platelet count <50,000/mm 3 (11.7, 5.4-25.1). A prognostic score was proposed and had satisfactory sensitivity (88.7%) and specificity (78.5%). Prognostic and severity markers can be useful to inform clinical decisions such as whether a child with VL can be safely treated in the local healthcare facility or would potentially benefit from transfer to referral centers where advanced life support facilities are available. High risk patients may benefit from interventions such as early use of extended-spectrum antibiotics or transfusion of blood products. These baseline risk-based supportive interventions should be assessed in clinical trials.

Oliveira J.B.,Institute Medicina Integral Prof Fernando Figueira Imip
Current Opinion in Pediatrics | Year: 2013

PURPOSE OF REVIEW: Several autoimmune lymphoproliferative syndromes have been described lately. We review here the main clinical and laboratory findings of these new disorders. RECENT FINDINGS: The prototypical autoimmune lymphoproliferative syndrome (ALPS) has had its diagnostic criteria modified, somatic mutations in RAS genes were found to cause an ALPS-like syndrome in humans, and mutations in a gene encoding a protein kinase C (PRKCD) were discovered to cause a syndrome of lymphoproliferation, autoimmunity and natural killer cell defect. SUMMARY: The recent discoveries shed light on the molecular pathways governing lymphocyte death, proliferation and immune tolerance in humans. Copyright © 2013 Lippincott Williams & Wilkins.

Scavuzzi A.,Institute Medicina Integral Prof Fernando Figueira Imip | Souza A.S.R.,Institute Medicina Integral Prof Fernando Figueira Imip | Costa A.A.R.,Institute Medicina Integral Prof Fernando Figueira Imip | Amorim M.M.R.,Institute Medicina Integral Prof Fernando Figueira Imip | Amorim M.M.R.,Federal University of Campina Grande
Human Reproduction | Year: 2013

STUDY QUESTIONHow effective is the vaginal administration of misoprostol in dilating the cervix prior to inserting an intrauterine device (IUD) in nulligravidas?SUMMARY ANSWERThe use of misoprostol at a dose of 400 μg administered vaginally 4 h prior to IUD insertion increased the ease of insertion and reduced the incidence of pain during the procedure, although the frequency of cramps increased following misoprostol use.WHAT IS KNOWN AND WHAT THIS PAPER ADDSMisoprostol has been widely used in Obstetrics and Gynecology; however, its usefulness and efficacy in facilitating IUD insertion in nulligravidas have yet to be established. The present study shows that the benefits of misoprostol use prior to IUD insertion include facilitating insertion and reducing pain during the procedure; therefore, weighing up the benefits encountered against the only negative side effect (cramps prior to insertion), these results suggest that misoprostol use should become standard practice to facilitate IUD insertion in nulligravidas.STUDY DESIGN, SIZE DURATIONA randomized, double-blind clinical trial was conducted.PARTICIPANTS/ MATERIALS, SETTING METHODSNulligravid women of reproductive age were submitted to IUD insertion between July 2009 and November 2011 at the Instituto de Medicina Integral Prof. Fernando Figueira in Recife, Pernambuco, Brazil. A total of 179 women were randomly allocated to two groups: 86 to receive 400 μg of misoprostol vaginally 4 h prior to IUD insertion and 93 to receive placebo. Risk ratios (RRs) were calculated as measures of relative risk, together with their 95% confidence intervals (95% CI). The number needed to treat (NNT) and the number needed to harm (NNH) were also calculated.MAIN RESULTS AND THE ROLE OF CHANCESignificant differences were found between the groups for all the immediate end points studied, with less difficulty in inserting the IUD [RR = 0.49 (23/86 versus 51/93); 95% CI: 0.33-0.72; P = 0.00005], a lower risk of dilatation <4 mm [RR = 0.48 (24/86 versus 54/93); 95% CI: 0.33-0.70; P = 0.0001], a reduction in moderate-to-severe pain at IUD insertion [RR = 0.56 (32/86 versus 62/93]; 95% CI: 0.41-0.76; P = 0.00008), as well as a lesser likelihood of experiencing a disagreeable or very disagreeable sensation [RR = 0.49(29/86 versus 64/93); 95% CI: 0.35-0.68; P = 0.000004] in the group that was given misoprostol compared with the group that received placebo. There was no significant difference between the groups in relation to complications during IUD insertion. There were no cases of uterine perforation in either group. The frequency of cramps was 40% higher in the misoprostol group.LIMITATIONS, REASONS FOR CAUTIONThe present study showed a positive balance between the benefits and risks of the use of misoprostol; however, it is not feasible to conclude that its use is imperative prior to IUD insertion in nulligravidas and IUD insertion should not be canceled when the medication is unavailable.WINDER IMPLICATIONS OF THE FINDINGSIn view of its effect in promoting cervical dilatation, misoprostol may be used prior to IUD insertion both in nulligravidas and in any women with cervical stenosis irrespective of parity.STUDY FUNDINGThis study was funded by the Instituto de Medicina Integral Prof Fernando Figueira.COMPETING INTERESTSNone. © The Author 2013.

Carneiro Gomes Ferreira A.L.,Institute Medicina Integral Prof Fernando Figueira Imip | Impieri Souza A.,Institute Medicina Integral Prof Fernando Figueira Imip | Evangelista Pessoa R.,Institute Medicina Integral Prof Fernando Figueira Imip | Braga C.,Institute Medicina Integral Prof Fernando Figueira Imip
Contraception | Year: 2011

Background: Brazilian women who have undergone abortion use contraceptive methods; however, their use of contraceptive methods is inconsistent and/or inappropriate. Study Design: This randomized trial evaluated the effectiveness of a personalized counseling on contraceptive acceptability and its use for postabortion women in the northeast of Brazil. It was conducted in July 2008 to September 2009, enrolling 246 women randomly distributed in intervention (n=123) and control (n=123) groups. An intention-to-treat analysis was performed. Results: In the follow-up, 98.4% women in the intervention group were using contraceptive methods compared with 70.6% women in the control group (p<.001). The probability of adherence and of the use of any kind of contraceptive method 6 months after the abortion was 41% greater in the intervention group. Conclusions: The strategy on individualized contraceptive counseling increased the acceptance and the use of contraceptive methods and increased the adequate use of the methods. © 2011 Elsevier Inc.

Souza J.P.,World Health Organization | Cecatti J.G.,University of Campinas | Haddad S.M.,University of Campinas | Parpinelli M.A.,University of Campinas | And 3 more authors.
PLoS ONE | Year: 2012

Objectives: To validate the WHO maternal near-miss criteria and develop a benchmark tool for severe maternal morbidity assessments. Methods: In a multicenter cross-sectional study implemented in 27 referral maternity hospitals in Brazil, a one-year prospective surveillance on severe maternal morbidity and data collection was carried out. Diagnostic accuracy tests were used to assess the validity of the WHO maternal near-miss criteria. Binary logistic regression was used to model the death probability among women with severe maternal complications and benchmark the management of severe maternal morbidity. Results: Of the 82,388 women having deliveries in the participating health facilities, 9,555 women presented pregnancy-related complications, including 140 maternal deaths and 770 maternal near misses. The WHO maternal near-miss criteria were found to be accurate and highly associated with maternal deaths (Positive likelihood ratio 106.8 (95% CI 99.56-114.6)). The maternal severity index (MSI) model was developed and found to able to describe the relationship between life-threatening conditions and mortality (Area under the ROC curve: 0.951 (95% CI 0.909-0.993)). Conclusion: The identification of maternal near-miss cases using the WHO list of pregnancy-related life-threatening conditions was validated. The MSI model can be used as a tool for benchmarking the performance of health services managing women with severe maternal complications and provide case-mix adjustment. © 2012 Souza et al.

Meneses J.,Institute Medicina Integral Prof Fernando Figueira IMIP | Bhandari V.,Yale University | Alves J.G.,Institute Medicina Integral Prof Fernando Figueira IMIP | Herrmann D.,University of Alagoas
Pediatrics | Year: 2011

CONTEXT: Strategies for reducing exposure to endotracheal ventilation through the use of early noninvasive ventilation has proven to be safe and effective, but the option with the greatest benefits needs to be determined. OBJECTIVE: To determine, in infants with respiratory distress syndrome, if early nasal intermittent positive-pressure ventilation (NIPPV) compared with nasal continuous positive airway pressure (NCPAP) decreases the need for mechanical ventilation. PATIENTS AND METHODS: In this single-center, randomized controlled trial, infants (gestational ages 26 to 33 6/7 weeks) with respiratory distress syndrome were randomly assigned to receive early NIPPV or NCPAP. Surfactant was administered as rescue therapy. The primary outcome was the need for mechanical ventilation within the first 72 hours of life. RESULTS: A total of 200 infants, 100 in each arm, were randomly assigned. Rates of the primary outcome did not differ significantly between the NIPPV (25%) and NCPAP (34%) groups (relative risk [RR]: 0.71 [95% confidence interval (CI): 0.48-1.14]). In posthoc analysis, from 24 to 72 hours of life, significantly more infants in the NIPPV group remained extubated compared with those in the NCPAP groups (10 vs 22%; RR: 0.45 [95% CI: 0.22-0.91]). This difference was also noted in the group of infants who received surfactant therapy, NIPPV (10.9%), and NCPAP (27.1%) (RR: 0.40 [95% CI: 0.18-0.86]). CONCLUSIONS: Early NIPPV did not decrease the need for mechanical ventilation compared with NCPAP, overall, in the first 72 hours of life. However, further studies to assess the potential benefits of noninvasive ventilation are warranted, especially for the most vulnerable or preterm infants. Copyright © 2011 by the American Academy of Pediatrics.

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