OTAVIO TAVARES RANZANI
Projetos de Pesquisa
Unidades Organizacionais
LIM/09 - Laboratório de Pneumologia, Hospital das Clínicas, Faculdade de Medicina
15 resultados
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- Use of dexmedetomidine for sedation in mechanically ventilated adult ICU patients: a rapid practice guideline(2022) MOLLER, Morten H.; ALHAZZANI, Waleed; LEWIS, Kimberley; BELLEY-COTE, Emilie; GRANHOLM, Anders; CENTOFANTI, John; MCINTYRE, William B.; SPENCE, Jessica; DUHAILIB, Zainab Al; NEEDHAM, Dale M.; EVANS, Laura; BLASER, Annika Reintam; PISANI, Margaret A.; D'ARAGON, Frederick; SHANKAR-HARI, Manu; ALSHAHRANI, Mohammed; CITERIO, Giuseppe; ARORA, Rakesh C.; MEHTA, Sangeeta; GIRARD, Timothy D.; RANZANI, Otavio T.; HAMMOND, Naomi; DEVLIN, John W.; SHEHABI, Yahya; PANDHARIPANDE, Pratik; OSTERMANN, MarliesPurpose The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) was to formulate evidence-based guidance for the use of dexmedetomidine for sedation in invasively mechanically ventilated adults in the intensive care unit (ICU). Methods We adhered to the methodology for trustworthy clinical practice guidelines, including use of the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence, and the Evidence-to-Decision framework to generate recommendations. The guideline panel comprised 28 international panelists, including content experts, ICU clinicians, methodologists, and patient representatives. Through teleconferences and web-based discussions, the panel provided input on the balance and magnitude of the desirable and undesirable effects, the certainty of evidence, patients' values and preferences, costs and resources, feasibility, acceptability, and research priorities. Results The ICM-RPG panel issued one weak recommendation (suggestion) based on overall moderate certainty of evidence: ""In invasively mechanically ventilated adult ICU patients, we suggest using dexmedetomidine over other sedative agents, if the desirable effects including a reduction in delirium are valued over the undesirable effects including an increase in hypotension and bradycardia"". Conclusion This ICM-RPG provides updated evidence-based guidance on the use of dexmedetomidine for sedation in mechanically ventilated adults, and outlines uncertainties and research priorities.
- Pulmonary infections complicating ARDS(2020) LUYT, Charles-Edouard; BOUADMA, Lila; MORRIS, Andrew Conway; DHANANI, Jayesh A.; KOLLEF, Marin; LIPMAN, Jeffrey; MARTIN-LOECHES, Ignacio; NSEIR, Saad; RANZANI, Otavio T.; ROQUILLY, Antoine; SCHMIDT, Matthieu; TORRES, Antoni; TIMSIT, Jean-FrancoisPulmonary infection is one of the main complications occurring in patients suffering from acute respiratory distress syndrome (ARDS). Besides traditional risk factors, dysregulation of lung immune defenses and microbiota may play an important role in ARDS patients. Prone positioning does not seem to be associated with a higher risk of pulmonary infection. Although bacteria associated with ventilator-associated pneumonia (VAP) in ARDS patients are similar to those in patients without ARDS, atypical pathogens (Aspergillus, herpes simplex virus and cytomegalovirus) may also be responsible for infection in ARDS patients. Diagnosing pulmonary infection in ARDS patients is challenging, and requires a combination of clinical, biological and microbiological criteria. The role of modern tools (e.g., molecular methods, metagenomic sequencing, etc.) remains to be evaluated in this setting. One of the challenges of antimicrobial treatment is antibiotics diffusion into the lungs. Although targeted delivery of antibiotics using nebulization may be interesting, their place in ARDS patients remains to be explored. The use of extracorporeal membrane oxygenation in the most severe patients is associated with a high rate of infection and raises several challenges, diagnostic issues and pharmacokinetics/pharmacodynamics changes being at the top. Prevention of pulmonary infection is a key issue in ARDS patients, but there is no specific measure for these high-risk patients. Reinforcing preventive measures using bundles seems to be the best option.
- A Comparison of Mortality From Sepsis in Brazil and England: The Impact of Heterogeneity in General and Sepsis-Specific Patient Characteristics(2019) RANZANI, Otavio T.; SHANKAR-HARI, Manu; HARRISON, David A.; RABELLO, Ligia S.; SALLUH, Jorge I. F.; ROWAN, Kathryn M.; SOARES, MarcioObjectives: To test whether differences in both general and sepsis-specific patient characteristics explain the observed differences in sepsis mortality between countries, using two national critical care (ICU) databases. Design: Cohort study. Setting: We analyzed 62 and 164 ICUs in Brazil and England, respectively. Patients: Twenty-two-thousand four-hundred twenty-six adult ICU admissions from January 2013 to December 2013. Interventions: None. Measurements and Main Results: After harmonizing relevant variables, we merged the first ICU episode of adult medical admissions from Brazil (ORganizational CHaractEeriSTics in cRitical cAre study) and England (Intensive Care National Audit & Research Centre Case Mix Programme). Sepsis-3 definition was used, and the primary outcome was hospital mortality. We used multilevel logistic regression models to evaluate the impact of country (Brazil vs England) on mortality, after adjustment for general (age, sex, comorbidities, functional status, admission source, time to admission) and sepsis-specific (site of infection, organ dysfunction type and number) patient characteristics. Of medical ICU admissions, 13.2% (4,505/34,150) in Brazil and 30.7% (17,921/58,316) in England met the sepsis definition. The Brazil cohort was older, had greater prevalence of severe comorbidities and dependency compared with England. Respiratory was the most common infection site in both countries. The most common organ dysfunction was cardiovascular in Brazil (41.2%) and respiratory in England (85.8%). Crude hospital mortality was similar (Brazil 41.4% vs England 39.3%; odds ratio, 1.12 [0.98-1.30]). After adjusting for general patient characteristics, there was an important change in the point-estimate of the odds ratio (0.88 [0.75-1.02]). However, after adjusting for sepsis-specific patient characteristics, the direction of effect reversed again with Brazil having higher risk-adjusted mortality (odds ratio, 1.22 [1.05-1.43]). Conclusions: Patients with sepsis admitted to ICUs in Brazil and England have important differences in general and sepsis-specific characteristics, from source of admission to organ dysfunctions. We show that comparing crude mortality from sepsis patients admitted to the ICU between countries, as currently performed, is not reliable and that the adjustment for both general and sepsis-specific patient characteristics is essential for valid international comparisons of mortality amongst sepsis patients admitted to critical care units.
- Lessons From the COVID-19 Pandemic in Latin America: Vulnerability Leading to More Vulnerability(2022) HALPERN, Bruno; RANZANI, Otavio T.
- Vaccine coverage and effectiveness against laboratory-confirmed symptomatic and severe Covid-19 in indigenous people in Brazil: a cohort study(2023) PESCARINI, Julia M.; CARDOSO, Andrey M.; SANTOS, Ricardo Ventura; SCAFF, Priscila F.; PAIXAO, Enny S.; RANZANI, Otavio T.; CERQUEIRA-SILVA, Thiago; BOAVENTURA, Viviane S.; BERTOLDO-JUNIOR, Juracy; OLIVEIRA, Vinicius A. de; WERNECK, Guilherme L.; BARRETO, Mauricio L.; BARRAL-NETTO, ManoelBackgroundIndigenous people have historically suffered devastating impacts from epidemics and continue to have lower access to healthcare and be especially vulnerable to respiratory infections. We estimated the coverage and effectiveness of Covid-19 vaccines against laboratory-confirmed Covid-19 cases among indigenous people in Brazil.MethodsWe linked nationwide Covid-19 vaccination data with flu-like surveillance records and studied a cohort of vaccinated indigenous people aged & GE; 5 years between 18th January 2021 and 1st March 2022. We considered individuals unexposed from the date they received the first dose of vaccine until the 13th day of vaccination, partially vaccinated from the 14th day after the first dose until the 13th day after receiving the second dose, and fully vaccinated onwards. We estimated the Covid-19 vaccination coverage and used Poisson regression to calculate the relative risks (RR) and vaccine effectiveness (VE) of CoronaVac, ChAdOx1, and BNT162b2 against Covid-19 laboratory-confirmed cases incidence, mortality, hospitalisation, and hospital-progression to Intensive Care Unit (ICU) or death. VE was estimated as (1-RR)*100, comparing unexposed to partially or fully vaccinated.ResultsBy 1st March 2022, 48.7% (35.0-62.3) of eligible indigenous people vs. 74.8% (57.9-91.8) overall Brazilians had been fully vaccinated for Covid-19. Among fully vaccinated indigenous people, we found a lower risk of symptomatic cases (RR: 0.47, 95%CI: 0.40-0.56) and mortality (RR: 0.47, 95%CI: 0.14-1.56) after the 14th day of the second dose. VE for the three Covid-19 vaccines combined was 53% (95%CI:44-60%) for symptomatic cases, 53% (95%CI:-56-86%) for mortality and 41% (95%CI:-35-75%) for hospitalisation. In our sample, we found that vaccination did not reduce Covid-19 related hospitalisation. However, among hospitalised patients, we found a lower risk of progression to ICU (RR: 0.14, 95%CI: 0.02-0.81; VE: 87%, 95%CI:27-98%) and Covid-19 death (RR: 0.04, 95%CI:0.01-0.10; VE: 96%, 95%CI: 90-99%) after the 14th day of the second dose.ConclusionsLower coverage but similar Covid-19 VE among indigenous people than overall Brazilians suggest the need to expand access, timely vaccination, and urgently offer booster doses to achieve a great level of protection among this group.
- Effectiveness of CoronaVac, ChAdOx1 nCoV-19, BNT162b2, and Ad26.COV2.S among individuals with previous SARS-CoV-2 infection in Brazil: a test-negative, case-control study(2022) CERQUEIRA-SILVA, Thiago; ANDREWS, Jason R.; BOAVENTURA, Viviane S.; RANZANI, Otavio T.; OLIVEIRA, Vinicius de Araujo; PAIXAO, Enny S.; BERTOLDO JUNIOR, Juracy; MACHADO, Tales Mota; HITCHINGS, Matt D. T.; DORION, Murilo; LIND, Margaret L.; PENNA, Gerson O.; CUMMINGS, Derek A. T.; DEAN, Natalie E.; WERNECK, Guilherme Loureiro; PEARCE, Neil; BARRETO, Mauricio L.; I, Albert Ko; CRODA, Julio; BARRAL-NETTO, ManoelBackground COVID-19 vaccines have proven highly effective among individuals without a previous SARS-CoV-2 infection, but their effectiveness in preventing symptomatic infection and severe outcomes among individuals with previous infection is less clear. We aimed to estimate the effectiveness of four COVID-19 vaccines against symptomatic infection, hospitalisation, and death for individuals with laboratory-confirmed previous SARS-CoV-2 infection. Methods Using national COVID-19 notification, hospitalisation, and vaccination datasets from Brazil, we did a testnegative, case-control study to assess the effectiveness of four vaccines (CoronaVac [Sinovac], ChAdOx1 nCoV-19 [AstraZeneca], Ad26.COV2.S [Janssen], and BNT162b2 [Pfizer- BioNtech]) for individuals with laboratory-confirmed previous SARS-CoV-2 infection. We matched cases with RT-PCR positive, symptomatic COVID-19 with up to ten controls with negative RT-PCR tests who presented with symptomatic illnesses, restricting both groups to tests done at least 90 days after an initial infection. We used multivariable conditional logistic regression to compare the odds of test positivity and the odds of hospitalisation or death due to COVID-19, according to vaccination status and time since first or second dose of vaccines. Findings Between Feb 24,2020, and Nov 11,2021, we identified 213 457 individuals who had a subsequent, symptomatic illness with RT-PCR testing done at least 90 days after their initial SARS-CoV-2 infection and after the vaccination programme started. Among these, 30910 (14.5%) had a positive RT-PCR test consistent with reinfection, and we matched 22566 of these cases with 145 055 negative RT-PCR tests from 68426 individuals as controls. Among individuals with previous SARS-CoV-2 infection, vaccine effectiveness against symptomatic infection 14 or more days from vaccine series completion was 39.4% (95% CI 364-42.6) for CoronaVac, 56.0% (51.4-60.2) for ChAdOxi nCoV-19, 44.0% (31.5-54.2) for Ad26.COV2.S, and 64.8% (54.9-72.4) for BNT162b2. For the two-dose vaccine series (CoronaVac, ChAdOx1 nCoV-19, and BNT162b2), effectiveness against symptomatic infection was significantly greater after the second dose than after the first dose. Effectiveness against hospitalisation or death 14 or more days from vaccine series completion was 81.3% (75.3-85.8) for CoronaVac, 89.9% (83.5-93.8) for ChAdOx1 nCo'V-19, 57.7% (-2.6 to 82.5) for Ad26.COV2.S, and 89.7% (54.3-97.7) for BNT162b2. Interpretation All four vaccines conferred additional protection against symptomatic infections and severe outcomes among individuals with previous SARS-CoV-2 infection. The provision of a full vaccine series to individuals after recovery from COVID-19 might reduce morbidity and mortality.
- Long-term survival and cause-specific mortality of patients newly diagnosed with tuberculosis in Sao Paulo state, Brazil, 2010-15: a population-based, longitudinal study(2020) RANZANI, Otavio T.; RODRIGUES, Laura C.; BOMBARDA, Sidney; MINTO, Catia M.; WALDMAN, Eliseu A.; CARVALHO, Carlos R. R.Background Long-term survival and cause-specific mortality of patients who start tuberculosis treatment is rarely described. We aimed to assess the long-term survival of these patients and evaluate the association between vulnerable conditions (social, health behaviours, and comorbidities) and cause-specific mortality in a country with a high burden of tuberculosis. Methods In this population-based, longitudinal study in Sao Paulo state, Brazil, we described the 5-year survival of patients who were newly diagnosed with tuberculosis in 2010. We included patients with newly-diagnosed tuberculosis, aged 15 years or older, and notified to the Sao Paulo State Tuberculosis Program in 2010. We excluded patients whose diagnosis had changed during follow-up (ie, they did not have tuberculosis) and patients who had multidnig-resistant (MDR) tuberculosis. We selected our population with tuberculosis from the dedicated electronic system TBweb. Our primary objective was to estimate the excess mortality over 5 years and within the group who survived the first year, compared with the general Sao Paulo state population. We also estimated the association between social vulnerability (imprisonment and homelessness), health behaviours (alcohol and drug use), and comorbidities (diabetes and mental disorders) with all-cause and cause-specific mortality. We used the competing risk analysis framework, estimating cause-specific hazard ratios (HRs) adjusted for potential confounding factors. Findings In 2010, there were 19 252 notifications of tuberculosis cases. We excluded 550 cases as patients were younger than 15 years, 556 cases that were not tuberculosis, 2597 retreatments, and 48 cases of MDR tuberculosis, resulting in a final cohort of 15 501 patients with tuberculosis. Over a period of 5 years from tuberculosis diagnosis, 2660 (17%) of 15 501 patients died. Compared with the source population, matched by age, sex, and calendar year, the standardised mortality ratio was 6.47 (95% CI 6.22-6.73) over 5 years and 3.93 (3. 71-4.17) among those who survived the first year. 1197 (45%) of 2660 deaths were due to infection. Homelessness and alcohol and drug use were associated with death from infection (adjusted cause-specific HR 1.60, 95% CI 1.39-1.85), cardiovascular (1.43, 1. 06-1. 95), and external or ill-defined causes of death (1.80, 1.37-2. 36). Diabetes was associated with deaths from cardiovascular causes (1.70, 1. 23-2.35). Interpretation Patients newly diagnosed with tuberculosis were at a higher risk of death than were the source population, even after tuberculosis treatment. Post-tuberculosis sequelae and vulnerability are associated with excess mortality and must be addressed to mitigate the tuberculosis burden worldwide.
- Urban-rural differences in hypertension prevalence in low-income and middle-income countries, 1990-2020: A systematic review and meta-analysis(2022) RANZANI, Otavio T.; KALRA, Anjani; GIROLAMO, Chiara Di; CURTO, Ariadna; VALERIO, Fernanda; HALONEN, Jaana I.; BASAGANA, Xavier; TONNE, CathrynBackground The influence of urbanicity on hypertension prevalence remains poorly understood. We conducted a systematic review and meta-analysis to assess the difference in hypertension prevalence between urban and rural areas in low-income and middle-income countries (LMICs), where the most pronounced urbanisation is underway. Methods and findings We searched PubMed, Web of Science, Scopus, and Embase, from 01/01/1990 to 10/03/ 2022. We included population-based studies with >= 400 participants 15 years and older, selected by using a valid sampling technique, from LMICs that reported the urban-rural difference in hypertension prevalence using similar blood pressure measurements. We excluded abstracts, reviews, non-English studies, and those with exclusively self-reported hypertension prevalence. Study selection, quality assessment, and data extraction were performed by 2 independent reviewers following a standardised protocol. Our primary outcome was the urban minus rural prevalence of hypertension. Hypertension was defined as systolic blood pressure >= 140 mm Hg and/or diastolic blood pressure as >= 90 mm Hg and could include use of antihypertensive medication, self-reported diagnosis, or both. We investigated heterogeneity using study-level and socioeconomic country-level indicators. We conducted meta-analysis and meta-regression using random-effects models. This systematic review and meta-analysis has been registered with PROSPERO (CRD42018091671). We included 299 surveys from 66 LMICs, including 19,770,946 participants (mean age 45.4 +/- SD = 9 years, 53.0% females and 63.1% from rural areas). The pooled prevalence of PLOS hypertension was 30.5% (95% CI, 28.9, 32.0) in urban areas and 27.9% (95% CI, 26.3, 29.6) in rural areas, resulting in a pooled urban-rural difference of 2.45% (95% CI, 1.57, 3.33, I-square: 99.71%, tau-square: 0.00524, P-heterogeneity < 0.001). Hypertension prevalence increased over time and the rate of change was greater in rural compared to urban areas, resulting in a pooled urban-rural difference of 5.75% (95% CI, 4.02, 7.48) in the period 1990 to 2004 and 1.38% (95% CI, 0.40, 2.37) in the period 2005 to 2020, p < 0.001 for time period. We observed substantial heterogeneity in the urban-rural difference of hypertension, which was partially explained by urban-rural definition, probably high risk of bias in sampling, country income status, region, and socioeconomic indicators. The urbanrural difference was 5.67% (95% CI, 4.22, 7.13) in low, 2.74% (95% CI, 1.41, 4.07) in lowermiddle and -1.22% (95% CI, -2.73, 0.28) in upper-middle-income countries in the period 1990 to 2020, p< 0.001 for country income. The urban-rural difference was highest for South Asia (7.50%, 95% CI, 5.73, 9.26), followed by sub-Saharan Africa (4.24%, 95% CI, 2.62, 5.86) and reversed for Europe and Central Asia (-6.04%, 95% CI, -9.06, -3.01), in the period 1990 to 2020, p < 0.001 for region. Finally, the urban-rural difference in hypertension prevalence decreased nonlinearly with improvements in Human Development Index and infant mortality rate. Limitations included lack of data available from all LMICs and variability in urban and rural definitions in the literature. Conclusions The prevalence of hypertension in LMICs increased between 1990 and 2020 in both urban and rural areas, but with a stronger trend in rural areas. The urban minus rural hypertension difference decreased with time, and with country-level socioeconomic development. Focused action, particularly in rural areas, is needed to tackle the burden of hypertension in LMICs.
- Association between sepsis at ICU admission and mortality in patients with ICU-acquired pneumonia: An infectious second-hit model(2020) ESPERATTI, Mariano; FUENTES, Nora; FERRER, Miquel; RANZANI, Otavio T.; BASSI, Gianluigi Li; SINGER, Mervyn; GONZALEZ, Maria Eugenia; PERAITA, Georgina; URBANO, Maria Soledad; TORRES, AntoniPurpose: We explore the hypothesis that critically ill patients developing ICU-acquired pneumonia (ICU-AP) have worse outcomes and an altered inflammatory response if their ICU admission was sepsis-related. Methods: Prospective cohort study in two centers. Patients with ICU-AP were evaluated according to their previous exposure to sepsis at ICU-admission. Demographic variables, comorbidities, severity scores at admission and at the time of acquisition of ICU-AP, and serum biomarkers of the inflammatory response were evaluated. Primary outcome: 90-day mortality. Secondary outcomes: ICU and hospital length of stay, mortality at days 28 and 180, in-hospital mortality, ventilator-free days (day-28), and inflammatory response. Propensity scoring weighted the risk of previously-acquired sepsis. Multivariate analysis evaluated the risk of mortality by day-90. Sensitivity analyses evaluated the primary outcome in different subgroups. Results: Of 341 patients enrolled, 147 had sepsis on ICU-admission. Adjusted risk of mortality at 90 days did not differ overall [hazard ratio (HR) = 0.94(0:0.65-137)], nor in subpopulations with a confirmed etiology of pneumonia [HR = 0.93(CI:0.57-1.53)] or sepsis [HR = 0.91(0.54-1.55)], ventilator-associated pneumonia (VAP) [HR = 1.01(CI:0.61-1.68)], nor non-VAP ICU-AP [HR = 0.83(CI:0.40-1.71)]. No differences were found in clinical secondary outcomes, the inflammatory response was similar. Conclusions: Previous sepsis does not appear to predispose to higher mortality nor worse outcomes in patients who develop ICU-acquired pneumonia. (C) 2020 Published by Elsevier Inc.
- The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in Sao Paulo State, Brazil(2016) RANZANI, Otavio T.; CARVALHO, Carlos R. R.; WALDMAN, Eliseu A.; RODRIGUES, Laura C.Background: Tuberculosis (TB) is a major public health problem requiring complex treatment, the success of which depends on biological, social, and institutional factors. Sao Paulo State (SPS), in Brazil, has a high TB burden. Because of high socioeconomic heterogeneity and chaotic urbanisation, homelessness might play an important role in the TB burden in SPS. Our aim was to determine the association between homelessness and outcome of treatment of pulmonary TB (PTB) in SPS. Methods: A historical cohort from the routine SPS TB database for 2009-2013 was analysed. The study population was newly diagnosed adult patients with PTB. Homelessness was ascertained at notification or when treatment started. Our outcome was unsuccessful outcome of treatment. We used logistic regression to adjust for potential confounders and multiple imputation for missing data. Results: We analysed 61,817 patients; 1 726 (2.8 %, 95% CI 2.7-2.9 %) were homeless. Homeless patients were concentrated in bigger cities, were more frequently middle-aged males, had black/brown skin colour, and had received less education (P < 0.001, for all). Alcohol and drug use was three times more frequent in homeless patients (43.2 % vs 14.4 %, 30.2 % vs. 9.4 %, P < 0.001, respectively). HIV testing was less common among the homeless, of whom 17.3 % were HIV positive compared with 8.5 % among the not homeless population (P < 0.001). Microbiologic confirmation was more frequent among the homeless (91.6 % vs. 84.8 %, P < 0.001). Unsuccessful outcome of treatment was 57.3 % among the homeless and 17.5 % among the not homeless (OR = 6.32, 95% CI 5.73-6.97, P < 0.001), mainly due to loss to follow-up (39 %) and death (10.5 %). After full-adjustment for potential confounders, homelessness remained strongly associated with lower treatment success (aOR = 4.96, 95 % CI 4.27-5.76, P < 0.001). HIV status interacted with homelessness: among HIV-infected patients, the aOR was 2.45 (95% CI 1.90-3.16, Pinteraction < 0.001). The population attributable fraction for the joint effect of homelessness, alcohol and drug use was almost 20 %. Conclusions: Confirming our hypothesis, homelessness led to a marked reduction in the successful treatment of newly diagnosed pulmonary tuberculosis. Homelessness and associated conditions were important contributors to lack of treatment success in pulmonary tuberculosis in Sao Paulo. A multifaceted intervention must be implemented to target this vulnerable population.