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Objective: Despite the existence of evidence-based guidelines forthe management of patients with severe sepsis and septic shock,there is much variation among individual treatments. Methods: Abefore-after study with prospective data collection was performedat the emergency department and intensive care unit of a 485-bed,private, tertiary, general hospital. A total of 160 patients were enrolled(94 in a “pre-protocol phase” and 66 in a “post-protocol phase”). Aresuscitation bundle for the first six hours and a management bundlefor 24 hours were used. Additional quality indicators were alsoproposed and evaluated. The outcomes analyzed included hospitalmortality, hospital and intensive care unit length of stay, compliancewith bundles and performance related to quality indicators. Results:From the “pre-protocol” to “post-protocol” phase, the diagnosismoved from the intensive care unit (52.0 to 18.2%) to the emergencydepartment (26.6 to 40.9%) and to the wards (17.0 to 36.4%).Number of blood cultures prior to antibiotics, administration ofactivated drotrecogin alfa, use of corticosteroids and compliancewith six-hour and 24-hour sepsis bundles were significantly higherafter protocol implementation. Patients in the “post-protocol” grouphad a statistically lower risk of in-hospital mortality (56.4 versus36.4%, p = 0.01). The greatest decrease in mortality rate occurredamong the most critically ill patients (67.7 to 40.7%, p = 0.004).Conclusions: Adopting an institutional protocol focused on behavioralchanges and using quality improvement tools led to reduced hospitalmortality and generated changes in healthcare team practice. Thisresult adds to the growing evidence that optimized process-of-careby implementing managed protocols for sepsis patients can reducemortality. Therefore, similar strategies should be routinely employed.

Objective: The aim of the present study was to obtain information about deaths due to sepsis in São Paulo from 2004 to 2009 and their relationship with geographical distribution. Methods: Causes of death, both main and secondary, were defined according to the codes of the International Classification of Disease version 10 (ICD-10) contained in the database. Sepsis, septic shock, multiple organ failure, pneumonia, urinary tract infection, peritonitis and other intraabdominal infections, skin and soft tissue infections (including surgical wound infection) and meningitis were considered as immediate cause of death or as the condition leading to the immediate cause of death related or associated to sepsis. Results: In the analyzed period, there was a 15.3% increase in the absolute number of deaths from sepsis in São Paulo. The mean number of deaths during this period was 28,472 ± 1566. Most deaths due to sepsis and sepsis-related diseases over the studied period occurred in a hospital or health care facility, showing that most of the patients received medical care during the event that led to death. We observed a significant concentration of deaths in the most populous regions, tending more toward the center of the city. Conclusions: Georeferencing data from death certificates or other sources can be a powerful tool to uncover regional epidemiological differences between populations. Our study revealed an even distribution of sepsis all over the inhabited areas of São Paulo. Keywords: Sepsis, Mortality, Infection, Georeferencing

OBJECTIVE: To evaluate whether the Pretransplantion Assesment of Mortality risk score is associated to transplant costs and can be used not only to predict mortality but also as a cost management tool. METHODS: We evaluated consecutively patients submitted to allogeneic (n = 27) and autologous (n = 89) hematopoietic stem cell-transplantation from 2004 to 2006 at Hospital Israelita Albert Einstein (SP), Brazil. Participants mean age at hematopoietic stem cell-transplantation was 42 (range 1 to 72) years; there were 69 males and 47 females; 30 patients had multiple myeloma; 41 had non-Hodgkin and Hodgkin's lymphomas; 22 had acute leukemia; 6 had chronic leukemia; and 17 had non-malignant disease. The Pretransplantion Assesment of Mortality risk score was applied in all patients using the available web site. RESULTS: Patients could be classified in three risk categories: high, intermediate and low, having significant difference in survival (p = 0.0162). The median cost in US dollars for each group was $ 281.000, $ 73.300 and $ 54.400 for high, intermediate and low risk, respectively. The cost of hematopoietic stem cell-transplantation significantly differed for each Pretransplantin Assesment of Mortality risk group (p = 0.008). CONCLUSION: The validation of the Pretransplantion Assesment of Mortality risk score in our patients confirmed that this system is an important tool to be used in transplantation units, being easy to apply and fully reproducible.

A few studies have performed to evaluate the temperature variation influences over on the stroke rates in Brazil. METHOD: 176 medical records of inpatients were analyzed after having had a stroke between 2004 and 2006 at Hospital Israelita Albert Einstein. The temperature preceding the occurrence of the symptoms was recorded, as well as the temperature 6, 12 and 24 hours before the symptoms in 6 different weather substations, closest to their houses in São Paulo. RESULTS: Strokes occurred more frequently after a variation of 3ºC between 6 and 24 hours before the symptoms. There were most hospitalizations between 23-24ºC. CONCLUSION: Incidence of stroke on these patients was increased after a variation of 3º Celsius within 24 hours before the ictus. The temperature variations could be an important factor in the occurrence of strokes in this population.Poucos trabalhos têm estudado a variação sazonal e de temperatura em acidente vascular cerebral (AVC) no Brasil. MÉTODO: Foram analisados 176 registros de pacientes com AVC no Hospital Israelita Albert Einstein entre 2004 e 2006. Foram anotadas as temperaturas ambientes do início dos sintomas, bem como as temperaturas de 6, 12 e 24 horas antes dos sintomas, em 6 diferentes subestações metereológicas mais próximas da casa do paciente em São Paulo. RESULTADOS: Houve aumento da incidência do AVC com a variação de 3ºC entre 6 e 24 horas antes do início dos sintomas. Houve um pico de internação entre 23-24ºC. CONCLUSÃO: A variação de temperatura de 3ºC nas 24 horas que antecederam o início dos sintomas pode ter sido um fator importante na ocorrência do AVC.

Objective: To assess the impact of each measure in the six and 24-hour bundles of a Managed Care Program in the care of a cohort of hospitalized severe sepsis / septic shock patients. Methods: A prospective study was carried out with 316 consecutive patients with severe sepsis / septic shock, assessing the impact on mortality by calculating the Odds Ratio of each single action (significance level of 5%). Rresults: In the sample there were 57% males, the mean age was 65.24 years, the APACHE II score was over 25 in 39.2%; 71.8% had a diagnosis of septic shock, and 65.5% required mechanical ventilation. Furthermore, 88.9% of patients had at least two organ dysfunctions upon the initial presentation. Only the blood culture collected before starting antibiotics: OR = 0.54 (95% CI: 0.33-0.87; p < 0.009) and the introduction of antibiotics by no later than 120 minutes after the diagnosis: OR = 0.44 (95% CI: 0.23-0.87; p < 0.009) were significant. Other six-hour bundle items tended towards a worse outcome. Results were superior in the 24-hour bundles with interventions in all four items, although without statistical significance. Cconclusions: The single impact of all interventions in the bundles occurred due to only two items: collecting blood cultures before starting antibiotics and early use (by 120 minutes) of antibiotics. Future evaluations in larger databases including multivariate analysis may support these findings.

A historical review places the first registers of Epidemiology in ancient Greece, with Hippocrates, who identified environmental causes of diseases. Along the centuries, the evolution of the causation concept started to be related to changes in scientific paradigms. In London, during the 17th century, the quantitative method was introduced in Epidemiology, but it was only by the end of the 19th century that the concept of the environment and a mathematical approach to understanding Public Health issues were well established. This was a very rich period to setting new concepts and systematizations in epidemiologic methodology. The beginning of the 20th century consolidated Epidemiology as a scientific discipline and the development of computers in the post-war years brought much advance in this field. Nowadays, Epidemiology plays an important role as it integrates scientific knowledge on the health/disease process to the professional area, participating in population healthcare efforts.