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OBJECTIVE: The objective of this study was to evaluate the efficacy of the surgical technique using the quadriceps tendon as a graft in static reconstruction of the medial patellofemoral ligament. METHODS: This was a prospective case series study in which the participants were 22 patients with a diagnosis of recurrent patellar dislocation without any other anatomical alterations that required surgical treatment. The functional results from the technique were evaluated using clinical data and the Lysholm questionnaire, one year after the operation. RESULTS: It was observed that the patients were predominantly female (86%) and under 21 years of age (73%), just like in the literature. At the first annual return after the surgery, there was no significant pain on medium efforts, no loss of range of motion and a positive apprehension test. According to the questionnaire used, the results were graded as good. The patients who reported having severe pain on greater effort were involved in employment-related legal disputes. CONCLUSION: This technique showed low morbidity and good functional results over the short term.

ABSTRACT Objective: The purpose of this survey was to reduce the use of human albumin 20% in non-supported indications at Hospital Israelita Albert Einstein. Methods: During a 30-day period, in December 2006, a preliminary prospective analysis of medical prescriptions of human albumin 20% and therapeutic indications according to ANVISA RDC 115 guidelines was performed. Based on this analysis, a project was developed. In January 2007, a daily routine to follow up albumin prescriptions by the Hospital pharmacists was established. Results: From January to October 2007, 14,799 vials of albumin 20% were used, out of which 4,191 had non-supported indications, resulting in a R$ 1.36 million loss. In 2008 (from January to October), 13,519 vials of albumin 20% were prescribed, and 1,648 of them had non-supported indications, causing a R$ 535 thousand loss. The ratio between loss risk and consumed amount was 91.99 between January and October 2007. During the same period in 2008, this ratio was 39.60. Between January and October 2007, the average percentage of albumin prescribed for non-supported indications was 28%, whereas this percentage dropped to 13%, i.e., a decrease by 54%, during the same period of 2008. Conclusions: The inclusion of a pharmacist in the process of verifying medicine indications and justification of use was translated into safer processes to patients, ensuring that they received the correct medication for the correct indication, therefore reducing the chance of adverse events and contributing to reduce red-tape procedures and unnecessary expenditures by the institution.

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: 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.

Sepsis and septic shock are prevalent in the intensive care setting,accounting for more than 40% of mortality in this scenario. Theappropriate management and recognition of sepsis-inducedmyocardial dysfunction are paramount for its proper treatmentand probably impact mortality rates. The objective of this articleis to review its definition, pathophysiologic mechanisms, possibletreatments and current research on the subject according to acritical view.Cellular signaling involved in myocardial depression is not fullyunderstood. Disturbances in calcium homeostasis,cardiodepressant circulating factors, inflammatory mediators,nitric oxide and apoptosis act as synergistic pathways that leadto severely depressed cardiac function. The diagnosis ofmyocardial dysfunction during sepsis carries a worse prognosisand increased mortality.Myocardial dysfunction plays an important role in morbidity andmortality rate of critically ill patients. Current research in thisarea will continue to evolve; we will, therefore, soon have moreinsights into potential novel therapies that can change its mortalityrates.

Os autores desenvolveram um novo implante para osteotomia proximal de tíbia como alternativa para tratamento da osteoartrose do joelho com deformidade em varo . O objetivo do trabalho foi desenvolver uma placa para fixação simples, de fácil manejo, e menor custo, propiciando baixa morbidade em relação aos métodos existentes, e compará-la com o método idealizado por BRUNNER e WEBER (1982)² que utilizaram a placa semitubular. Os testes mecânicos foram realizados em máquina universal de ensaios do Laboratório de Bioengenharia da Faculdade de Medicina de Ribeirão Preto, Campus Universitário, Universidade de São Paulo. Nos parâmetros analisados como limite de proporcionalidade, módulo de elasticidade observaram-se valores diferentes entre as duas placas mostrando que o novo implante apresentou resistência e estabilidade superior à placa semitubular quando submetidos a testes de flexão.The author compares this new plate with other type of fixation described by Weber that employed a semitubular plate based on tension band principle. The mecanical tests were perfomed in a universal test machine of the "Laboratório de Bioengenharia da Faculdade de Medicina de Ribeirão Preto, Campus Universitário, Universidade de São Paulo". A three-point-flexion test established was employed dislocation.The weak point in the semitubular plate model ocurred mainly where it was bent at is external hole, displaying hole enlargement at loads of less than 30 N.m. The author choosed the 3-points flexion test, which provides a qualitative indication of the material resistivity. The conclusion was that the new implant showed stability and resistance superior to the semitubular plate when submitted to flexion tests.

BACKGROUND AND OBJECTIVES: Morphine and petidine are the most commonly used opioids to treat pain in hospitalized patients. Morphine is recommended by the World Health Organization (WHO) and by the International Association for the Study of Pain because it is less toxic than petidine, which is still largely used in Brazil and in other developing countries. This study aimed at evaluating the decreased use of petidine after the implementation of an educative program to decrease its consumption. METHOD: Intervention, quantitative and prospective study using as information source the pharmacy database. Petidine prescriptions were monitored with educative interventions on prescribers, orienting about drug effects and suggesting the change to a different opioid, according to criteria established by WHO and the International Association for the Study of Pain. Opioids prescription data were collected from 2005 to 2009 and were analyzed by descriptive and inferential statistics and linear regression. RESULTS: There has been significant decrease (r =0.96, beta = 0.12, p = 0.003) in the use of petidine, as well as a significant increase in the use of morphine (r = 0.96, beta = 0.47, p = 0.02) during the period. CONCLUSION: The implementation of a multidisciplinary and educational protocol to decrease petidine prescription has significantly contributed to decrease its consumption, showing the efficacy of an educative program.