RESUMO Objetivo Descrever as características microbiológicas e avaliar os fatores de risco para mortalidade na traqueobronquite associada à ventilação mecânica em um estudo caso-controle de pacientes de terapia intensiva. Métodos Estudo realizado ao longo de 6 anos em uma unidade de terapia intensiva médico-cirúrgica de 40 leitos, em um hospital privado e de nível terciário em São Paulo, Brasil. O Grupo Caso foi identificado usando o banco de dados da Comissão de Controle de Infecção Hospitalar. O Grupo Controle foi pareado na proporção de 1:8,8 entre janeiro de 2006 e dezembro de 2011. Resultados Quarenta episódios de traqueobronquites associadas à ventilação foram avaliados em 40 pacientes na unidade de terapia intensiva, e 354 pacientes não apresentaram traqueobronquite Grupo Controle. Foram identificados 42 microrganismos (dos quais 5% foram infecções polimicrobianas), sendo que 88,2% de todos os microrganismos eram bactérias Gram-negativas. Usando um modelo de regressão logística, encontramos os seguintes fatores de risco independentes para mortalidade em pacientes com traqueobronquites associadas à ventilação: pontuação da Acute Physiology and Chronic Health Evaluation I (odds ratio 1,18 por uma unidade de pontuação; IC95%: 1,05-1,38; p=0,01) e duração da ventilação mecânica (odds ratio 1,09 por dia de ventilação mecânica; IC95%: 1,03-1,17; p=0,004). Conclusão Nosso estudo forneceu informações sobre os fatores de risco para mortalidade e características microbiológicas da traqueobronquite associada à ventilação mecânica.

ABSTRACT Objective To describe the microbiological characteristics and to assess the risk factors for mortality of ventilator-associated tracheobronchitis in a case-control study of intensive care patients. Methods This case-control study was conducted over a 6-year period in a 40-bed medical-surgical intensive care unit in a tertiary care, private hospital in São Paulo, Brazil. Case patients were identified using the Nosocomial Infection Control Committee database. For the analysis of risk factors, matched control subjects were selected from the same institution at a 1:8.8 ratio, between January 2006 and December 2011. Results A total of 40 episodes of ventilator-associated tracheobronchitis were evaluated in 40 patients in the intensive care unit, and 354 intensive care patients who did not experience tracheobronchitis were included as the Control Group. During the 6-year study period, a total of 42 organisms were identified (polymicrobial infections were 5%) and 88.2% of all the microorganisms identified were Gram-negative. Using a logistic regression model, we found the following independent risk factors for mortality in ventilator-associated tracheobronchitis patients: Acute Physiology and Chronic Health Evaluation I score (odds ratio 1.18 per unit of score; 95%CI: 1.05-1.38; p=0.01), and duration of mechanical ventilation (odds ratio 1.09 per day of mechanical ventilation; 95%CI: 1.03-1.17; p=0.004). Conclusion Our study provided insight into the risk factors for mortality and microbiological characteristics of ventilator-associated tracheobronchitis.

Delirium usually hardens care during hospitalization and increases morbidity during hospital stay and after discharge. The objective of this study was to describe the prevalence of delirium in elderly inpatients in a Buenos Aires hospital, its morbidity and mortality during hospital stay and the next 18 month follow-up. Patients aged 70 or older admitted to internal medicine unit between September 2005 and May 2006 were enrolled. Delirium was assessed with the Spanish version of Confusion Assessment Method. Demographic data, cause of admition and length of stay, destination after discharge and mortality were registered. A new evaluation was made 18 months after discharge. We evaluated 194 patients and 74 were excluded. Of the 120 included, 52 (43.3%) presented delirium. We found significant differences between patients with and without delirium in previous placement in nursing home (17.3% vs. 1.5%; p < 0.002), dementia (40.4% vs. 8.8%; p < 0.001), median activity of daily living (5 vs. 6; p < 0.001), length-of-stay (7 vs. 5; p = 0.04) and mortality rate (21.2% vs. 1.5%; p < 0.001). Evaluation 18 months later showed differences between patients with and without delirium in median of activity of daily living (1/6 vs. 5/6), patients living in nursing homes (27.5% vs. 7.9%), estimated survival 35.3% (CI 95%: 24-49%) at day 569 and 49% (CI 95%: 32.9-65.4%) at day 644. The difference between survival curves was statistically significant (p = 0.027). Delirium increases morbidity and mortality during hospital stay. Elderly with delirium are at risk of worsening disability and of becoming dependent after discharge and it is a risk factor for higher mortality during the following months after discharge.

El objetivo de este trabajo fue describir la prevalencia de síndrome confusional agudo en ancianos hospitalizados, la evolución durante la internación y a los 18 meses. Se evaluó en forma prospectiva a pacientes de 70 años de edad o mayores, internados en el Servicio de Clínica Médica de nuestro hospital, entre septiembre de 2005 y mayo de 2006. Se utilizó una versión validada en español del Confussion Assessment Method para diagnosticar delirium. A los 18 meses se evaluó el estado vital, lugar de residencia, actividades de la vida diaria, dependencia de cuidadores y reinternaciones. Se evaluaron 194 pacientes y 74 fueron excluidos. De los 120 casos incluidos, 52 (43.3%) presentaron delirium. La edad media fue de 82.6 años (DS: 7.4) en el grupo de pacientes con síndrome confusional agudo y de 80.4 años (DS: 5.6) en el grupo de pacientes sin delirium. Al comparar estos dos grupos encontramos diferencias significativas en las características, siendo más frecuentes en el grupo con delirium la residencia previa en un centro de tercer nivel (17.3% vs. 1.5%; p < 0.002), la demencia (40.4% vs. 8.8%; p < 0.001), menor puntaje en la evaluación de las actividades de la vida diaria (5 vs. 6; p < 0.001), más días de internación (7 vs. 5; p = 0.04) y mayor mortalidad intrahospitalaria (21.2% vs. 1.5%; p < 0.001). A los 18 meses de seguimiento después del alta, el desarrollo de delirium durante la internación se asoció a mayor grado de dependencia evidenciado por el peor puntaje en las actividades de la vida diaria (mediana 1/6 vs. 5/6) y a menor sobrevida actuarial 35.3% (CI 95%: 24-49%) a los 569 días y 49% (CI 95%: 32.9-65.4%) a los 644 días (p=0.027).

Although the introduction of alcohol based products have increased compliance with hand hygiene in intensive care units (ICU), no comparative studies with other products in the same unit and in the same period have been conducted. We performed a two-month-observational prospective study comparing three units in an adult ICU, according to hand hygiene practices (chlorhexidine alone-unit A, both chlorhexidine and alcohol gel-unit B, and alcohol gel alone-unit C, respectively). Opportunities for hand hygiene were considered according to an institutional guideline. Patients were randomly allocated in the 3 units and data on hand hygiene compliance was collected without the knowledge of the health care staff. TISS score (used for measuring patient complexity) was similar between the three different units. Overall compliance with hand hygiene was 46.7% (659/1410). Compliance was significantly higher after patient care in unit A when compared to units B and C. On the other hand, compliance was significantly higher only between units A (32.1%) and C (23.1%) before patient care (p=0.02). Higher compliance rates were observed for general opportunities for hand hygiene (patient bathing, vital sign controls, etc), while very low compliance rates were observed for opportunities related to skin and gastroenteral care. One of the reasons for not using alcohol gel according to health care workers was the necessity for water contact (35.3%, 12/20). Although the use of alcohol based products is now the standard practice for hand hygiene the abrupt abolition of hand hygiene with traditional products may not be recommended for specific services.

For decades strategies for marketing of breast milk substitutes (BMS) have discouraged the practice of breastfeeding. With the sanction of the International Code of Marketing of Breast-milk Substitutes (ICMBS) from the World Health Organization in 1981, sector's companies reacting for not loosing "clients". BMS advertisements and related products which appeared in the two most important pediatric journals in Argentina published between 1977 and 2006, were evaluated. This research found product advertising and not "scientific and objective" information as the ICMBS requires; only 2,7% of these advertisements had references, while images and commercial messages were frequently used, being the code compliance of 24,1%. Regarding the variety of products advertised, it went from two types of formulas before 1981 to nine, while were generated 17 new indications for its use. We emphasize the process of medicalization suffered, the link between scientific journals and companies of BMS, the lack of scientific rigor in the information provided to health care professionals and the need to legitimize legal standards sanctioned.

Las estrategias de comercialización de los sucedáneos de la leche materna (SLM) han desalentado por décadas la práctica del amamantamiento. Con la sanción del Código Internacional de Comercialización de Sucedáneos de la Leche Materna (CICSLM) por parte de la Organización Mundial de la Salud en 1981, las compañías del sector respondieron tratando de no perder su "clientela". Fueron evaluadas las publicidades de SLM aparecidas en las dos colecciones pediátricas argentinas más relevantes publicadas entre 1977 y 2006. La investigación verificó el hallazgo de publicidad y no la publicación de información "científica y objetiva" tal como el CICSLM exige; solamente el 2,7% de ellas poseían referencias bibliográficas utilizándose imágenes y mensajes promocionales, siendo el cumplimiento del código del 24,1%. Con relación a la variedad de productos publicitados, esta pasó de dos tipos de fórmulas antes de 1981 a nueve con posterioridad, mientras que se generaron 17 nuevas indicaciones para su uso. Resaltamos el proceso de medicalización sufrido, el vínculo revistas científicas-empresas de SLM, la carencia de rigor científico en la información brindada y la necesidad de construir legitimidad alrededor de las normas legales.

For decades strategies for marketing of breast milk substitutes (BMS) have discouraged the practice of breastfeeding. With the sanction of the International Code of Marketing of Breast-milk Substitutes (ICMBS) from the World Health Organization in 1981, sector's companies reacting for not loosing "clients". BMS advertisements and related products which appeared in the two most important pediatric journals in Argentina published between 1977 and 2006, were evaluated. This research found product advertising and not "scientific and objective" information as the ICMBS requires; only 2,7% of these advertisements had references, while images and commercial messages were frequently used, being the code compliance of 24,1%. Regarding the variety of products advertised, it went from two types of formulas before 1981 to nine, while were generated 17 new indications for its use. We emphasize the process of medicalization suffered, the link between scientific journals and companies of BMS, the lack of scientific rigor in the information provided to health care professionals and the need to legitimize legal standards sanctioned.

Las estrategias de comercialización de los sucedáneos de la leche materna (SLM) han desalentado por décadas la práctica del amamantamiento. Con la sanción del Código Internacional de Comercialización de Sucedáneos de la Leche Materna (CICSLM) por parte de la Organización Mundial de la Salud en 1981, las compañías del sector respondieron tratando de no perder su "clientela". Fueron evaluadas las publicidades de SLM aparecidas en las dos colecciones pediátricas argentinas más relevantes publicadas entre 1977 y 2006. La investigación verificó el hallazgo de publicidad y no la publicación de información "científica y objetiva" tal como el CICSLM exige; solamente el 2,7% de ellas poseían referencias bibliográficas utilizándose imágenes y mensajes promocionales, siendo el cumplimiento del código del 24,1%. Con relación a la variedad de productos publicitados, esta pasó de dos tipos de fórmulas antes de 1981 a nueve con posterioridad, mientras que se generaron 17 nuevas indicaciones para su uso. Resaltamos el proceso de medicalización sufrido, el vínculo revistas científicas-empresas de SLM, la carencia de rigor científico en la información brindada y la necesidad de construir legitimidad alrededor de las normas legales.

Fetal thoracic masses may cause hydrops and intrauterine death or pulmonary hypoplasia and neonatal ventilatory failure. We present a male fetus with two cystic masses which were detected at the 26º week of gestation. The huge unilocular right thoracic cystic mass measured 6 x 6 cm and caused a severe displacement of both lungs and the mediastinum. The abdominal cystic mass in the right flank was 4 x 4 cm. in size and had no communication with the former. Other associated anomalies were ruled out through a fetal MRI. Weekly sonographic follow-up until term did not show hydrops fetalis. Threfore a multidisciplinary perinatal reception was arranged at term, with a cesarean section, to immediately solve the expected neonatal hypoxia. The thoracic cyst was decompressed under US guidance with a 10 French trocar, and 200cc of fluid were evacuated before both lungs could expand. After 48 hours of ventilatory support, the thoracic intestinal duplication was resected through videothoracoscopy using 3 mm instruments. After an uneventful recovery, the abdominal jejunal cystic duplication, which had then expanded up to 8 x 8 cms., was also resected, through a mini-invasive laparoscopically assisted procedure at 18 days of age. The baby was discharged home with full breast feeding at 24 days of age.

Las masas expansivas en el tórax fetal pueden producir insuficiencia cardíaca y muerte. Si el feto sobrevive, pueden causar insuficiencia respiratoria neonatal por hipoplasia pulmonar. Presentamos el caso de un feto con dos duplicaciones intestinales quísticas detectadas en la 26ª semana de gestación. Una de ellas, de 6 x 6 cm, se ubicaba en el hemitórax derecho, desplazando los pulmones y el mediastino. La otra masa quística, de 4 x 4 cm, era subhepática e independiente de la anterior. Con RNM se descartaron otras anomalías. No presentó hidropesía fetal y se planificó el manejo perinatal multidisciplinario al término para resolver la probable incapacidad ventilatoria. Inmediatamente después del nacimiento se drenó la masa torácica con guía ecográfica, permitiendo la expansión pulmonar y a las 48 horas se la resecó por videotoracoscopia. Al 18° día de vida se extirpó por una minilaparotomía video-asistida, una duplicación yeyunal que medía 8 x 8 cm. Fue dado de alta al 24º día. El diagnóstico prenatal y el manejo perinatal inmediato evitaron la hipoxia neonatal.