BACKGROUNDThe aim of this study was to determine the occurrence rate, demographics, clinical characteristics, and outcomes of patients with severe sepsis admitted to the emergency department.METHODSA prospective study evaluating all patients admitted to the emergency department unit in a public hospital of tertiary complexity in a six-month period was conducted. During this period, the emergency team was trained to diagnose sepsis. Patients who met the diagnostic criteria for severe sepsis were followed until their discharge from the hospital.RESULTSA total of 5,332 patients were admitted to the emergency department, and 342 met the criteria for severe sepsis/septic shock. The median (interquartile range) age of patients was 74 (65–84) years, and 52.1% were male. The median APACHE II and SOFA scores at diagnosis were 19 (15–25) and 5 (3–7), respectively. The median number of dysfunctional organ systems per patient was 2 (1–3). The median hospital length of stay was 10 (4.7–17) days, and the hospital mortality rate was 64%. Only 31% of the patients were diagnosed by the emergency department team as septic. About 33.5% of the 342 severe sepsis patients admitted to the emergency department were referred to an ICU, with a median time delay of 24 (12–48) hours. Training improved diagnosis and decreased the time delay for septic patients in arriving at the ICU.CONCLUSIONSThe occurrence rate of severe sepsis in the emergency department was 6.4%, and the rate of sepsis diagnosed by the emergency department team as well as the number of patients transferred to the ICU was very low. Educational campaigns are important to improve diagnosis and, hence, treatment of severe sepsis.

GRADE (Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study) is a 36-center unmasked, parallel treatment group, randomized controlled trial evaluating four diabetes medications added to metformin in people with type 2 diabetes (T2DM). We report baseline characteristics and compare GRADE participants to a National Health and Nutrition Examination Survey (NHANES) cohort. RESEARCH DESIGN AND METHODS Participants were age ‡30 years at the time of diagnosis, with duration of T2DM <10 years, HbA 1c 6.8-8.5% (51-69 mmol/mol), prescribed metformin monotherapy, and randomized to glimepiride, sitagliptin, liraglutide, or insulin glargine. RESULTS At baseline, GRADE's 5,047 randomized participants were 57.2 6 10.0 years of age, 63.6% male, with racial/ethnic breakdown of 65.7% white, 19.8% African American, 3.6% Asian, 2.7% Native American, 7.6% other or unknown, and 18.4% Hispanic/ Latino. Duration of diabetes was 4.2 6 2.8 years, with mean HbA 1c of 7.5 6 0.5% (58 6 5.3 mmol/mol), BMI of 34.3 6 6.8 kg/m 2 , and metformin dose of 1,944 6 204 mg/day. Among the cohort, 67% reported a history of hypertension, 72% a history of hyperlipidemia, and 6.5% a history of heart attack or stroke. Applying GRADE inclusion criteria to NHANES indicates enrollment of a representative cohort with T2DM on metformin monotherapy (NHANES cohort average age, 57.9 years; mean HbA 1c , 7.4% [57 mmol/mol]; BMI, 33.2 kg/m 2 ; duration, 4.2 6 2.5 years; and 7.2% with a history of cardiovascular disease). CONCLUSIONS The GRADE cohort represents patients with T2DM treated with metformin requiring a second diabetes medication. GRADE will inform decisions about the clinical effectiveness of the addition of four classes of diabetes medications to metformin. The optimal medication management of hyperglycemia in type 2 diabetes (T2DM) is not established. In addition to lifestyle intervention, metformin is the recommended initial medication in T2DM due to its glycemic effectiveness, lack of associated hypoglycemia or weight gain, low cost, and evidence of long-term benefit and safety

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RESUMO JUSTIFICATIVA E OBJETIVOS: Um dos maiores desafios dos médicos intensivistas é o controle da hipoperfusão tecidual, sendo o lactato sérico classicamente aceito como indicador de hipóxia tecidual. Deste modo, estudos demonstraram boa correlação entre o lactato e o prognóstico no choque e durante a reanimação. O objetivo deste estudo foi avaliar a utilidade clínica do lactato arterial à admissão na UTI como indicador de morbimortalidade em pacientes críticos no pós-operatório de intervenções cirúrgicas não cardíacas de alto risco. MÉTODO: Estudo de coorte prospectivo observacional, realizado em UTI de hospital terciário no período

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JUSTIFICATIVA E OBJETIVOS: A doença oncológica per se é uma condição que muitas vezes influencia no tratamento dispensado ao paciente. O objetivo do presente estudo foi comparar o desfecho hospitalar de pacientes oncológicos e não oncológicos submetidos à procedimentos cirúrgicos eletivos com alto risco de óbito. MÉTODO: Estudo de coorte prospectivo observacional, realizado em UTI de hospital terciário no período de 01 de abril a 31 de julho de 2005. Foram coletados dados demográficos, escore APACHE II, MODS,

Introduction: Failure to accurately estimate energy requirements may result in an impaired recovery. Overfeeding has been associated with increased carbon dioxide production, respiratory failure, hyperglycemia and fat deposits in the liver, while underfeeding can lead to malnutrition, muscle weakness and impaired immunity. Objective: This study aimed to determine the metabolic profile of infant and preschool children submitted to mechanical ventilation in the ICU. Methods: A prospective study was carried out in a pediatric ICU in Rio de Janeiro that included children aged from 1 month to 6 years submitted to mechanical ventilation from June 2013 to May 2015. Indirect calorimetry was used to obtain resting energy expenditure (REE) and oxygen consumption (VO 2) in the first 48 hours of admission. The predicted basal metabolic rate (PBMR) was calculated using the Schofield equation. The metabolic state of each patient was assigned as hypermetabolic (REE/PBMR >110%), hypometabolic (REE/PBMR <90%) or normal (REE/PBMR 90-110%). The ratio of caloric intake to REE was also calculated and ratios of >1.5 and <0.5 were classified as overfeeding and underfeeding respectively. Results: A total of 35 infants and 17 preschool children were included. The male/female ratio was 34/18. In respect of severity of sepsis, 19 patients had septic shock, 24 had sepsis, five had severe sepsis and four had systemic inflammatory response syndrome. We observed a high incidence of hypometabolism (88.5%) and a low incidence of normal metabolism (7.7%) and hypermetabolism (3.8%). A low value of VO 2 was observed in 46.1% of the patients (VO 2 ≤120 ml/minute/m 2), a normal value in 40.4% (VO 2 >120 to ≤160 ml/minute/m 2) and a high value in only 13.5% of the patients (VO 2 > 160 ml/minute/m 2). Among the 52 included patients, 18 were fasting at the moment of the examination. The ratio of caloric intake to REE for the remaining 34 patients showed 38.2% overfeeding, 11.8% underfeeding and 50.0% normal feeding. Conclusion: Predictive equations do not accurately predict REE in critically ill infants and preschool children, resulting in inadequate feeding. Although hypermetabolism and enhanced energy expenditure are the main clinical features of critical illness in adults, the majority of our patients were found to be hypometabolic which reinforces the need for a different approach between adult and pediatric critically ill patients.

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