Background and Purpose-Little information exists on the epidemiology and patterns of treatment of patients admitted to Brazilian hospitals with stroke. Our objective was to describe the frequency of risk factors, patterns of management, and outcome of patients admitted with stroke in Fortaleza, the fifth largest city in Brazil. Methods-Data were prospectively collected from consecutive patients admitted to 19 hospitals in Fortaleza with a diagnosis of stroke or transient ischemic attack from June 2009 to October 2010. Results-We evaluated 2407 consecutive patients (mean age, 67.7Ϯ14.4 years; 51.8% females). Ischemic stroke was the most frequent subtype (72.9%) followed by intraparenchymal hemorrhage (15.2%), subarachnoid hemorrhage (6.0%), transient ischemic attack (3%), and undetermined stroke (2.9%). The median time from symptoms onset to hospital admission was 12.9 (3.8 -32.5) hours. Hypertension was the most common risk factor. Only 1.1% of the patients with ischemic stroke received thrombolysis. The median time from hospital admission to neuroimaging was 3.4 (1.2-26.5) hours. In-hospital mortality was 20.9% and the frequency of modified Rankin Scale score Յ2 at discharge was less than 30%. Older age, prestroke disability, and having a depressed level of consciousness at admission were independent predictors of poor outcome; conversely, male gender was a predictor of good outcome. Conclusions-The prevalence of stroke risk factors and clinical presentation in our cohort were similar to previous series.Treatment with thrombolysis and functional independency after a stroke admission were infrequent. We also found long delays in hospital admission and in evaluation with neuroimaging and high in-hospital mortality. (Stroke. 2011;42:3341-3346.)

Objective To describe the impact of the telemedicine application on the clinical process of care and its different effects on hospital culture and healthcare practice.Methods The concept of telemedicine through real time audio-visual coverage was implemented at two different hospitals in São Paulo: a secondary and public hospital, Hospital Municipal Dr. Moysés Deutsch, and a tertiary and private hospital, Hospital Israelita Albert Einstein.Results Data were obtained from 257 teleconsultations records over a 12-month period and were compared to a similar period before telemedicine implementation. For 18 patients (7.1%) telemedicine consultation influenced in diagnosis conclusion, and for 239 patients (92.9%), the consultation contributed to clinical management. After telemedicine implementation, stroke thrombolysis protocol was applied in 11% of ischemic stroke patients. Telemedicine approach reduced the need to transfer the patient to another hospital in 25.9% regarding neurological evaluation. Sepsis protocol were adopted and lead to a 30.4% reduction mortality regarding severe sepsis.Conclusion The application is associated with differences in the use of health services: emergency transfers, mortality, implementation of protocols and patient management decisions, especially regarding thrombolysis. These results highlight the role of telemedicine as a vector for transformation of hospital culture impacting on the safety and quality of care.

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OBJECTIVE:To assess expenditures and the profi le of benefi ciaries of a private health plan and the impact of these expenditures on the fi nances of both the plan and of benefi ciaries. METHODS:Descriptive study including 64,219 costumers of a health insurance plan of the State of São Paulo in the year of 2003. The characteristics of high spenders were assessed according to age group, gender, type of expenditure, and related diseases. RESULTS:Among all customers, 642 benefi ciaries (1%) were the highest spender in the year, accounting for 36% of the total. Among these benefi ciaries, 45% were elderly, over 60 years old. Greatest expenditure was with medical supplies and drugs. Circulatory diseases, cancer, musculoskeletal diseases, respiratory tract diseases and the external causes were most frequently associated with these expenditures. CONCLUSIONS:Age is an important factor associated with high expenditures, being closely connected with chronic degenerative diseases. Thus, ageing of the population points out to the need for strategic changes in the management of private health care plans.

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On January 12, 2010 an earthquake of 7.0 on the Richter scale struck Haiti, the poorest country in America. The quake's epicenter was in Leogane with extension to almost all the country also hitting Portau-Prince, the country's capital. This disaster caused a huge destruction and devastated more than 250,000 of houses and commercial buildings and left more than a million of homeless people. In the aftermath, this catastrophe caused 230,000 deaths and more than 30,000 wounded people (1). (Figures 1 A and B) After the disaster medical institutions, government and non-governmental organizations from around the world geared up to help. Many volunteer health professionals from different areas came together to perform this task. Previous studies described the severity and epidemiology of injuries post-earthquakes (2-3). The Wenchuan 2008 earthquake in China presented, based on the Injury Severity Score (ISS), 45% of cases with less than eight injuries (minor injuries), 41% between 9 and 14 (moderate injuries) and 13.9% over 15 (severe injuries) (2). Of the injuries of the Kashemir 2005 earthquake in Pakistan, 64.9% were superficial lacerations, 22.2% were fractures and 5.9% were contusions and sprains (3). These studies pointed out the need of a coordinated action and a well equipped hospital to take care of the victims. We believe that huge disasters are the greatest threat facing mankind. On account of Haiti limited resources and the great number of patients who needed care, a multi-professional action after the earthquake became

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