Infecções por enterobacteriaceae resistente aos carbapenêmicos em hospital de ensino: epidemiologia e caracterização molecular

Introduction: The production of KPC (Klebsiella pneumoniae carbapenemase) has become an important mechanism of carbapenem-resistance among Enterobacteriaceae strains. In Brazil, KPC is already widespread and its incidence has increased significantly, reducing treatment options. The “perfect storm” combination of the absence of new drug developmentand the emergence of multidrug-resistant strains resulted in the need for the use of older drugs, with greater toxicity, such as polymyxins. Aims: To determine the occurrence of carbapenemase-producing strains in carbapenem-resistant Enterobacteriaceae isolated from patients with nosocomial infection/colonization during September/2014 to August/2015, to determine the risk factors associated with 30-day- mortality and the impact of inappropriate therapy. Materials and Methods: We performed a case control study to assess the risk factors (comorbidities, invasive procedures and inappropriate antimicrobial therapy) associated with 30-day-mortality, considering the first episode of infection in 111 patients. The resistance genes blaKPC, blaIMP, blaVIM and blaNDM-1 were detected by polymerase chain reaction technique. Molecular typing of the strains involved in the outbreak was performed by pulsed field gel electrophoresis technique. The polymyxin resistance was confirmed by the microdilution broth method. Results: 188 episodes of carbapenem-resistant Enterobacteriaceae infections/colonizations were detected; of these, 122 strains were recovered from the hospital laboratory. The presence of blaKPC gene were confirmed in the majority (74.59%) of these isolates. It was not found the presence of blaIMP , blaVIM and blaNDM-1 genes. K. pneumoniae was the most frequent microorganism (77,13%), primarily responsible for urinary tract infections (21,38%) and infections from patients of the Intensive Care Unit (ICU) (61,38%). Multivariate statistical analysis showed as predictors independently associated with mortality: dialysis and bloodstream infection. The Kaplan-Meier curve showed a lower probability of survival in the group of patients receiving antibiotic therapy inappropriately. Antimicrobial use in adult ICU varied during the study period, but positive correlation between increased incidence of strains and the consumption was not observed. In May and July 2015, the occurrence rates of carbapenem-resistant Enterobacteriaceae KPC-producing per 1000 patient-days were higher than the control limit established, confirming two outbreaks, the first caused by colistin-susceptible KPC-producing K. pneumoniae isolates, with a polyclonal profile and the second by a dominant clone of colistin-resistant (≥ 32 μg/mL) KPC-producing K. pneumoniae. The cross transmission between patients became clear by the temporal and spatial relationships observed in the second outbreak, since some patients occupied the same bed, showing problems in hand hygiene adherence among healthcare workers and inadequate terminal disinfection of environment. The outbreak was contained when the ICU was closed to new admissions. Conclusions: The study showed an endemicity of K. pneumoniae KPC-producing in adult ICU, progressing to an epidemic monoclonal expansion, resulted by a very high antibiotic consumption of carbapenems and polymyxins and facilitated by failures in control measures the unit.

Internacionalização de empresas e o fechamento do capital : um estudo sobre a deslistagem no mercado brasileiro

This work contributes to the finance literature proposing to analyze the relationship between the degree of internationalization of Brazilian companies and the likelihood of delisting. Therefore, even though the internationalization as a differential, in the formulation of hypotheses and analysis of the relationship between the variables dealt with concepts and theories within the Corporate Governance, which is already established in theory when it comes to delisting. First, with a view to the theory of internalization, which gives competitive advantages to the company due the adoption internationalization strategy and in parallel to the positive effects that this strategy generates on firms performance, it was formulated an hypothesis that the degree of internationalization would be adversely related to the probability of delisting, mainly due to such benefits generated to the organization. In turn, as an alternative hypothesis of the research, it proposed a positive relationship between these variables, based on agency theory, according to which internationalization would contribute to delisting by increasing geographical separation between shareholders and managers and, consequently, agency conflicts and the difficulty of monitoring. For the achievement of objectives, as well as being included economic and financial variables and GC, it was proposed the analysis of periods of crisis, as the events of recent past of the Brazilian economy. Starting from a base model initially developed by Pour and Lasfer (2013), which later, the proxies of internationalization and crisis have been added also contemplating adjustments to the Brazilian context. The data collected include the period from 2006 to 2014 and information on active and inactive companies at Bovespa. As results, it was found negative significance between the degree of internationalization and the delisting decision, confirming the first hypothesis of the research and stating that the benefits generated by internationalization in the company generate it spreads and results that reduce the probability of delisting. By analyzing the results of control variables was still possible to observe that, even internationalization reducing the likelihood of delisting, by particular aspects of corporate governance in Brazil, such as the high ownership concentration, the benefits it generates contribute to delisting. Regarding the analysis in crisis, the consequences of the crisis of the US subprime in general market were more relevant that the occurrence of itself, unlike the Brazilian internal crisis of 2014, which was statistically significant for the analyzed event. For future researches it is suggested the expansion of database and individual treatment of the reasons adopted by a company when delisting decision.

Escala diagramática e influência de sistemas de produção na ocorrência do crestamento gomoso da melancia

CHAPTER 1 - The gummy stem blight, caused by the fungus D. bryoniae, is a disease commonly found in watermelon cultivated in several countries. In Brazil, there are numerous studies related to the disease, but there are not uniform methods for quantifying of disease severity in the field. Thus, we developed a diagrammatic scale based on scanned photos of watermelon leaves infected with D. bryoniae. The scale developed showed levels of 0; 10; 20; 45; 65 and 90% of severity. The scale validation was divided into two parts: initially, 10 evaluators (half with experienced and other half without experience) estimated the disease severity based on the initial observation of 100 photos of watermelon leaves with symptoms of the disease at different severity levels. Before, the same evaluators estimated the disease severity with the support of the scale prepared from the Quant program. Data were analyzed using linear regression and were obtained angular, linear, and correlation coefficients. Based on these data, we determined the accuracy and precision of the evaluations. The correlation coefficients (R2) ranged from 0.88 - 0.97 for the experienced evaluators and from 0.55 - 0.95 for the inexperienced evaluators. The average angular coefficient (A) for inexperienced evaluators was 20.42 and 8.61 with and without the support of diagrammatic scale, respectively. Experienced evaluators showed values of average linear coefficient of 5.30 and 1.68 with and without the support of diagrammatic scale, respectively. The absolute errors analysis indicated that the use of diagrammatic scale contributed to minimize the flaws in the severity levels estimation. The diagrammatic scale proposed shown adequate for gummy stem blight severity evaluation in watermelon. CHAPTER 2 - The gummy stem blight (Didymella bryoniae) is a disease that affects the productivity of watermelon leading to losses over 40%. This study aimed to evaluate the efficiency of different production systems in control of gummy stem blight in watermelon for to establish efficient methods to combat the disease. There were applied the following treatments: conventional tillage (T1), integrated management (T2) and organic management (T3). In T1 and T2 were applied mineral fertilization and T3 was used bovine manure. There was application of fungicides and insecticides in commercial dose in T1 and T2, being after soil chemical analysis in T2. Disease severity was assessed by grading scale. The experimental design was randomized blocks. The severity of gummy stem blight has increased substantially during the fruit formation. Watermelon plants grown with integrated management (T2) showed lower levels of disease severity, while plants in organic management (T3) exhibited higher levels of severity. We conclude that management based on judicious accompaniments in field represents best way to achieve the phytosanitary aspect adequate for cultivation of watermelon in Tocantins.