Clinical outcome and risk factors related to extended-spectrum beta-lactamase-producing Klebsiella spp. infection among hospitalized patients

Over the past two decades, nosocomial infections caused by extended-spectrum beta-lactamase (ESBL)-producing Klebsiella spp. have become a major problem all around the world. This situation is of concern because there are limited antimicrobial options to treat patients infected with these pathogens, and also because this kind of resistance can spread to a wide variety of Gram-negative bacilli. Our objectives wereto evaluate among in-patients at a publicuniversity tertiary-care hospital with documented infection due to Klebsiella spp., which were the risk factors (cross-sectional analysis) and the clinical impact (prospective cohort) associated with an ESBL-producing strain. Study subjects were all patients admitted at the study hospital between April 2002 and October 2003, with a clinically and microbiologically confirmed infection caused by Klebsiella spp. at any body site, except infections restricted to the urinary tract. Of the 104 patients studied, 47 were infected with an ESBL-producing strain and 57 with a non-ESBL-producing strain. Independent risk factors associated with infection with an ESBL-producing strain were young age, exposure to mechanical ventilation, central venous catheter, use of any antimicrobial agent, and particularly use of a 4th generation cephalosporin or a quinolone. Length of stay was significant longer for patients infected with ESBL-producing strains than for those infected with non-ESBL-producing strains, although fatality rate was not significantly affected by ESBL-production in this cohort. In fact, mechanical ventilation and bacteremia were the only variables withindependent association withdeath detected in this investigation.

Collection of tracheal aspirate: safety and microbiological concordance between two techniques

Objective: To evaluate the safety of the performance of the traditional and protected collection techniques of tracheal aspirate and to identify qualitative and quantitative agreement of the results of microbiological cultures between the techniques. Method: Clinical, prospective, comparative, single-blind research. The sample was composed of 54 patients of >18 years of age, undergoing invasive mechanical ventilation for a period of ≥48 hours and with suspected Ventilator Associated Pneumonia. The two techniques were implemented in the same patient, one immediately after the other, with an order of random execution, according to randomization by specialized software. Results: No significant events occurred oxygen desaturation, hemodynamic instability or tracheobronchial hemorrhage (p<0.05) and, although there were differences in some strains, there was qualitative and quantitative agreement between the techniques (p<0.001). Conclusion: Utilization of the protected technique provided no advantage over the traditional and execution of both techniques was safe for the patient.


Principal components analysis for quality evaluation of cooled banana 'Nanicão' in different packing

This work aims determinate the evaluation of the quality of 'Nanicão' banana, submitted to two conditions of storage temperature and three different kinds of package, using the technique of the Analysis of Principal Components (ACP), as a basis for an Analysis of Variance. The fruits used were 'Nanicão' bananas, at ripening degree 3, that is, more green than yellow. The packages tested were: "Torito" wood boxes, load capacity: 18 kg; "½ box" wood boxes, load capacity: 13 kg; and cardboard boxes, load capacity: 18 kg. The temperatures assessed were: room temperature (control); and (13±1ºC), with humidity controlled to 90±2,5%. Fruits were discarded when a sensory analysis determined they had become unfit for consumption. Peel coloration, percentages of imperfection, fresh mass, total acidity, pH, total soluble solids and percentages of sucrose were assessed. A completely randomized design with a 2-factorial treatment structure (packing X temperature) was used. The obtained data were analyzed through a multivariate analysis known as Principal Components Analysis, using S-plus 4.2. The conclusion was that the best packages to preserve the fruit were the ½ box ones, which proves that it is necessary to reduce the number of fruits per package to allow better ventilation and decreases mechanical injuries and ensure quality for more time.

Pulmonary interstitial emphysema: a case report and review of the literature

Pulmonary interstitial emphysema is a rare condition that generally affects low-weight preterm infants submitted to mechanical ventilation. The prognosis is variable, depending on early diagnosis and treatment. The radiologist plays a key role in this scenario. The authors report a case of persistent pulmonary interstitial emphysema, describing the main characteristics of such entity.

Outdoor/indoor air quality in primary schools in Lisbon: a preliminary study

Simultaneous measurements of outdoor and indoor pollution were performed at three schools in Lisbon. Volatile organic compounds (VOCs), formaldehyde and NO2 were passively monitored over a two-week period. Bacterial and fungal colony-forming units and comfort parameters were also monitored at classrooms and playgrounds. The highest indoor levels of CO2 (2666 μg/m³), NO2 (40.3 μg/m³), VOCs (10.3 μg/m³), formaldehyde (1.03 μg/m³) and bioaerosols (1634 CFU/m³), and some indoor/outdoor ratios greater than unity, suggest that indoor sources and building conditions might have negative effects on air indoors. Increasing ventilation rates and use of low-emission materials would contribute towards improving indoor air quality.

The impact of evaporative cooling on the thermoregulation and sensible heat loss of sows during farrowing

Pigs are more sensitive to high environmental temperatures explained by the inability of sweating and panting properly when compared to other species of farmed livestock. The evaporative cooling system might favor the thermal comfort of animals during exposure to extreme environmental heat and reduce the harmful effects of heat stress. The purpose of this study was to assess the sensible heat loss and thermoregulation parameters from lactating sows during summer submitted to two different acclimatization systems: natural and evaporative cooling. The experiment was carried out in a commercial farm with 72 lactating sows. The ambient variables (temperature, relative humidity and air velocity) and sows physiological parameters (rectal temperature, surface temperature and respiratory rate) were monitored and then the sensible heat loss at 21days lactation was calculated. The results of rectal temperature did not differ between treatments. However, the evaporative cooling led to a significant reduction in surface temperature and respiratory rate and a significant increase in the sow's sensible heat loss. It was concluded that the use of evaporative cooling system was essential to increase sensible heat loss; thus, it should reduce the negative effects of heat on the sows' thermoregulation during summer.

The use of infrared thermography in the identification of pododermatitis in broilers

ABSTRACT International trade in broiler’ feet, mainly to Asian markets, has demanded better quality control. The objective of this research was to study the suitability of using chicken footpad surface temperature to determine early lesions of pododermatitis. The project was conducted in two houses A1 and A2) in a commercial farm during one production flock. A1 had reused litter of wood shavings and rice hulls, and A2 had a new litter of sawdust. Both houses had positive pressure ventilation. The inner area of the poultry was virtually divided into three quadrants. The footpads were checked for the feet quality, and a degree of pododermatitis was awarded. Thermal images were made to test the surface temperature of the foot and identify inflammation in a total of 30 birds per house, at ages 5, 19, 29, 28 and 40 days of grow-out. Conditions of the rearing environment as well as the surface temperature of the litter, litter moisture, and degree of compression, were recorded. The environment within the houses did not differ. The surface temperatures of the footpad did not differ between the groups. The minimum footpad surface temperatures within the scores were similar, except for the score 3, which did not occur in A1. There was a prevalence of severe injury in the house with a new litter.

Edema pulmonar de reexpansão tratado com ventilação não invasiva: relato de caso

The authors report a case of Reexpansion Pulmonary Edema (RPE) seen at Hospital de Pronto Socorro de Porto Alegre 3 hours after drainage of spontaneous pneumothorax. The patient presented a unilateral pneumothorax with one-week duration. After pleural drainage respiratory failure occured being managed at the Intensive Care Unit with non-invasive positive pressure ventilation through facial mask. The patient had favorable outcome and was discharged asymtomatic after 72 hours.

Modified method for bronchial suture by Ramirez Gama compared to separate stitches suture: experimental study

OBJECTIVE: To experimentally compare two classic techniques described for manual suture of the bronchial stump.METHODS: We used organs of pigs, with isolated trachea and lungs, preserved by refrigeration. We dissected 30 bronchi, which were divided into three groups of ten bronchi each, of 3mm, 5mm, and 7mm, respectively. In each, we performed the suture with simple, separated, extramucosal stitches in five other bronchi, and the technique proposed by Ramirez and modified by Santos et al in the other five. Once the sutures were finished, the anastomoses were tested using compressed air ventilation, applying an endotracheal pressure of 20mmHg.RESULTS: the Ramirez Gama suture was more effective in the bronchi of 3, 5 and 7 mm, and there was no air leak even after subjecting them to a tracheal pressure of 20mmHg. The simple interrupted sutures were less effective, with extravasation in six of the 15 tested bronchi, especially in the angles of the sutures. These figures were not significant (p = 0.08).CONCLUSION: manual sutures of the bronchial stumps were more effective when the modified Ramirez Gama suture was used in the caliber bronchi arms when tested with increased endotracheal pressure.

Pulmonar recruitment in acute respiratory distress syndrome. What is the best strategy?

Supporting patients with acute respiratory distress syndrome (ARDS), using a protective mechanical ventilation strategy characterized by low tidal volume and limitation of positive end-expiratory pressure (PEEP) is a standard practice in the intensive care unit. However, these strategies can promote lung de-recruitment, leading to the cyclic closing and reopening of collapsed alveoli and small airways. Recruitment maneuvers (RM) can be used to augment other methods, like positive end-expiratory pressure and positioning, to improve aerated lung volume. Clinical practice varies widely, and the optimal method and patient selection for recruitment maneuvers have not been determined, considerable uncertainty remaining regarding the appropriateness of RM. This review aims to discuss recent findings about the available types of RM, and compare the effectiveness, indications and adverse effects among them, as well as their impact on morbidity and mortality in ARDS patients. Recent developments include experimental and clinical evidence that a stepwise extended recruitment maneuver may cause an improvement in aerated lung volume and decrease the biological impact seen with the traditionally used sustained inflation, with less adverse effects. Prone positioning can reduce mortality in severe ARDS patients and may be an useful adjunct to recruitment maneuvers and advanced ventilatory strategies, such noisy ventilation and BIVENT, which have been useful in providing lung recruitment.

Total intravenous anaesthesia with propofol-racemic ketamine and propofol-S-ketamine: a comparative study and haemodynamic evaluation in dogs undergoing ovariohysterectomy

Total intravenous anaesthesia (TIVA) with propofol and ketamine proved to be very satisfactory from a clinical point of view. This blind randomised controlled trial was designed to compare induction and maintenance of anaesthesia under continuous infusion of propofol-racemic ketamine (PRK) with that of propofol-S-ketamine (PSK) and evaluate their haemodynamic, metabolic and ventilatory effects. Seven female dogs undergoing ovariohysterectomy were involved in each group. Anaesthesia was induced: in Group PRK, with propofol (4.0mg kg-1) and racemic ketamine (2.0mg kg-1) intravenous (i.v.), followed by i.v. infusion of propofol (initial dose of 0.5mg kg-1 min-1) and racemic ketamine (0.2mg kg-1 min-1); in Group PSK, with propofol (4.0mg kg-1) and S-ketamine (1.0 mg kg¹) i.v., followed by i.v. infusion of propofol (initial dose of 0.5mg kg-1 min-1) and S-ketamine (0.1mg kg-1 min-1). Parameters were assessed before anaesthesia and in 6 time points after induction. In both groups, heart rate increased significantly at all time points. There was a slight decrease in systemic blood pressure, cardiac output and cardiac index in both groups. The systolic index decrease significantly and intense respiratory depression was observed in all groups, making assisted ventilation necessary.

Petri Net approach for modelling system integration in intelligent buildings

In this paper, a Petri Net approach is introduced for modelling and simulation of control strategies in Intelligent Building. In this context, it is claimed that integration with other building systems can be achieved in a more systematic way considering a mechatronic approach (i.e. multidisciplinary concepts applied to the development of systems). The case study is the Ambulatory Building of Medical School Hospital of University of São Paulo. Particularly, the developed methodology is applied to the elevator system and to the HVAC (Heating, Ventilation and Air Conditioning) system. It is shown that using this approach, the control systems could be integrated, improving performance.

Cardiovascular and respiratory changes during slow-wave sleep in rats are associated with electrocorticogram desynchronization

In awake rats a single recurrent larger tidal volume (deep breaths) occurs at regular intervals, followed by oscillations in arterial pressure and heart rate. In the present study we recorded the changes in blood pressure, heart rate and ventilation during the wakefulness-sleep cycle identified by electrocorticographic records in order to determine whether the deep breaths and cardiovascular oscillations were associated with changes in the electrocorticogram. During several episodes of slow-wave sleep (SWS) in 7 rats the deep breaths and oscillations in arterial pressure and heart rate were preceded by SWS desynchronization. The interval between deep breaths during SWS was 71 ± 4 s, the period between initial desynchronization and the generation of deep breaths was 3.98 ± 0.45 s and the duration of SWS desynchronization was 11 ± 0.65 s. Hypotension (-16 ± 1 mmHg) and tachycardia (+15 ± 5 bpm) were observed during deep breaths in the SWS state. These data indicate that the oscillations in arterial pressure and heart rate during SWS are associated with deep breaths, which in turn are preceded by desynchronization of the electrocorticogram in this state of sleep

Paraquat poisoning: an experimental model of dose-dependent acute lung injury due to surfactant dysfunction

Since the most characteristic feature of paraquat poisoning is lung damage, a prospective controlled study was performed on excised rat lungs in order to estimate the intensity of lesion after different doses. Twenty-five male, 2-3-month-old non-SPF Wistar rats, divided into 5 groups, received paraquat dichloride in a single intraperitoneal injection (0, 1, 5, 25, or 50 mg/kg body weight) 24 h before the experiment. Static pressure-volume (PV) curves were performed in air- and saline-filled lungs; an estimator of surface tension and tissue works was computed by integrating the area of both curves and reported as work/ml of volume displacement. Paraquat induced a dose-dependent increase of inspiratory surface tension work that reached a significant two-fold order of magnitude for 25 and 50 mg/kg body weight (P<0.05, ANOVA), sparing lung tissue. This kind of lesion was probably due to functional abnormalities of the surfactant system, as was shown by the increase in the hysteresis of the paraquat groups at the highest doses. Hence, paraquat poisoning provides a suitable model of acute lung injury with alveolar instability that can be easily used in experimental protocols of mechanical ventilation

Chemoreceptors and cardiovascular control in acute and chronic systemic hypoxia

This review describes the ways in which the primary bradycardia and peripheral vasoconstriction evoked by selective stimulation of peripheral chemoreceptors can be modified by the secondary effects of a chemoreceptor-induced increase in ventilation. The evidence that strong stimulation of peripheral chemoreceptors can evoke the behavioural and cardiovascular components of the alerting or defence response which is characteristically evoked by novel or noxious stimuli is considered. The functional significance of all these influences in systemic hypoxia is then discussed with emphasis on the fact that these reflex changes can be overcome by the local effects of hypoxia: central neural hypoxia depresses ventilation, hypoxia acting on the heart causes bradycardia and local hypoxia of skeletal muscle and brain induces vasodilatation. Further, it is proposed that these local influences can become interdependent, so generating a positive feedback loop that may explain sudden infant death syndrome (SIDS). It is also argued that a major contributor to these local influences is adenosine. The role of adenosine in determining the distribution of O2 in skeletal muscle microcirculation in hypoxia is discussed, together with its possible cellular mechanisms of action. Finally, evidence is presented that in chronic systemic hypoxia, the reflex vasoconstrictor influences of the sympathetic nervous system are reduced and/or the local dilator influences of hypoxia are enhanced. In vitro and in vivo findings suggest this is partly explained by upregulation of nitric oxide (NO) synthesis by the vascular endothelium which facilitates vasodilatation induced by adenosine and other NO-dependent dilators and attenuates noradrenaline-evoked vasoconstriction.