Bloodstream infection in patients with end-stage renal disease in a teaching hospital in central-western Brazil

Introduction Vascular access in patients undergoing hemodialysis is considered a critical determinant of bloodstream infection (BSI) and is associated with high morbidity and mortality. The purpose of this study was to investigate the occurrence of BSI in patients with end-stage renal disease using central venous catheters for hemodialysis. Methods A cohort study was conducted in a public teaching hospital in central-western Brazil from April 2010 to December 2011. For every patient, we noted the presence of hyperemia/exudation upon catheter insertion, as well as fever, shivering, and chills during hemodialysis. Results Fifty-nine patients were evaluated. Thirty-five (59.3%) patients started dialysis due to urgency, 37 (62.7%) had BSI, and 12 (20%) died. Hyperemia at the catheter insertion site (64.9%) was a significant clinical manifestation in patients with BSI. Statistical analysis revealed 1.7 times more cases of BSI in patients with hypoalbuminemia compared with patients with normal albumin levels. The principal infective agents identified in blood cultures and catheter-tip cultures were Staphylococcus species (24 cases), non-fermentative Gram-negative bacilli (7 cases of Stenotrophomonas maltophilia and 5 cases of Chryseobacterium indologenes), and Candida species (6). Among the Staphylococci identified, 77.7% were methicillin-resistant, coagulase-negative Staphylococci. Of the bacteria isolated, the most resistant were Chryseobacterium indologenes and Acinetobacter baumannii. Conclusions Blood culture was demonstrated to be an important diagnostic test and identified over 50% of positive BSI cases. The high frequency of BSI and the isolation of multiresistant bacteria were disturbing findings. Staphylococcus aureus was the most frequently isolated microorganism, although Gram-negative bacteria predominated overall. These results highlight the importance of infection prevention and control measures in dialysis units.

Predictive factors of post-discharge surgical site infections among patients from a teaching hospital

Introduction Surgical site infections (SSIs) often manifest after patients are discharged and are missed by hospital-based surveillance. Methods We conducted a case-reference study nested in a prospective cohort of patients from six surgical specialties in a teaching hospital. The factors related to SSI were compared for cases identified during the hospital stay and after discharge. Results Among 3,427 patients, 222 (6.4%) acquired an SSI. In 138 of these patients, the onset of the SSI occurred after discharge. Neurological surgery and the use of steroids were independently associated with a greater likelihood of SSI diagnosis during the hospital stay. Conclusions Our results support the idea of a specialty-based strategy for post-discharge SSI surveillance.

The use of botulinum toxin type A in the treatment of HTLV-1-associated overactive bladder refractory to conventional therapy

Urinary symptoms occur in 19% of human T-cell lymphotropic virus type 1 (HTLV-1)-infected patients who do not fulfill criteria for HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) and in almost 100% of HAM/TSP patients. Few studies have evaluated therapies for overactive bladder (OAB) caused by HTLV-1 infection. This case report describes the effect of onabotulinum toxin A on the urinary manifestations of three patients with HAM/TSP and OAB symptoms. The patients were intravesically administered 200 units of Botox®. Their incontinence episodes improved, and their OAB symptoms scores (OABSS) reduced significantly. These data indicate that Botox® should be a treatment option for OAB associated with HTLV-1 infection.

Ecological competition and the incidence of Acinetobacter baumannii bloodstream infections in a teaching hospital in Southeastern Brazil

IntroductionRecently, pathogen ecology has been recognized as an important epidemiological determinant of healthcare-associated infections (HAIs). Acinetobacter baumannii is one of the most important agents known to cause HAIs. It is widespread in healthcare settings and exhibits seasonal variations in incidence. Little is known about the impact of competition with other hospital pathogens on the incidence of A. baumannii infection.MethodsWe conducted an ecological study, enrolling patients who presented with healthcare-associated bloodstream infections (HA-BSIs) from 2005 to 2010 at a 450-bed teaching hospital in Brazil. HA-BSIs were said to be present when bacteria or fungi were recovered from blood cultures collected at least three days after admission. Monthly incidence rates were calculated for all HA-BSIs (overall or caused by specific pathogens or groups of pathogens). Multivariate Poisson regression models were used to identify the impacts of the incidence of several pathogens on the incidence of A. baumannii.ResultsThe overall incidence rate of HA-BSI caused by A. baumannii was 2.5 per 10,000 patient-days. In the multivariate analysis, the incidence of HA-BSI caused by A. baumanniiwas negatively associated with the incidence rates of HA-BSI due to Staphylococcus aureus (rate ratio [RR]=0.88; 95% confidence interval [CI]=0.80-0.97), Enterobacter spp. (RR=0.84; 95%CI=0.74-0.94) and a pool of less common gram-negative pathogens.ConclusionsOur results suggest that competition between pathogens influences the etiology of HA-BSIs. It would be beneficial to take these findings into account in infection control policies.

Frequency of the toxic shock syndrome toxin-1 gene in methicillin-susceptible and -resistant Staphylococcus aureus isolates from teaching hospitals in Shiraz, Iran

INTRODUCTION: Staphylococcus aureus produces a range of virulence factors such as toxic shock syndrome toxin-1. METHODS: In this cross-sectional study of 345 clinical S. aureus isolates, the presence of the tst gene was assessed by polymerase chain reaction (PCR). RESULTS: The study revealed 53/345 (15.4%) isolates were positive for the tst gene. The tst gene was present in 18.1% of methicillin-susceptible S. aureus (MSSA) isolates and 11.6% of methicillin-resistant S. aureus (MRSA) isolates (p = 0.136). CONCLUSIONS: These results reveal the remarkable risk of S. aureus infections in hospitals, regardless of methicillin-resistance status.

Opportunistic infections among individuals with HIV-1/AIDS in the highly active antiretroviral therapy era at a Quaternary Level Care Teaching Hospital

INTRODUCTION : In this study, clinical-laboratory and epidemiological characteristics are described for a group of 700 individuals with HIV (human immunodeficiency virus)/AIDS (acquired immunodeficiency syndrome) in the ART (antiretroviral therapy) era at a teaching hospital that provides a quaternary level of care, with an emphasis on opportunistic infections (OIs), co-infections and immune profile. METHODS : A retrospective cross-sectional study of AIDS cases was conducted from 1998 to 2008 by reviewing medical records from the Base Hospital/FUNFARME (Fundação Faculdade Regional de Medicina), São José do Rio Preto, São Paulo, Brazil. RESULTS: The individuals were 14 to 75 years of age, and 458 were males. Heterosexuals accounted for 31.1% of all patients. Eighty-three percent were on ART, and 33.8% of those presented difficulties with treatment adherence. OIs were analyzed from medical records, and Pneumocystis jiroveci pneumonia was the most prevalent, regardless of the LTCD4+ (TCD4+ Lymphocytes) levels. Individuals whose viral loads were ≥10,000 showed a 90% greater chance of neurotoxoplasmosis. For P. jiroveci pneumonia, neurotoxoplasmosis, esophageal candidiasis, pulmonary tuberculosis and neurocryptococcosis, the chances of infection were higher among patients with LTCD4+ levels below 200 cells/mm3. HIV/hepatitis C virus (HCV) and HIV/hepatitis B virus (HBV) co-infections were significantly associated with death. CONCLUSIONS : OIs remain frequent in the ART era even in populations where the access to medical care is considered satisfactory.

Pharmacokinetic/pharmacodynamic target attainment of intravenous β-lactam regimens against Gram-negative bacteria isolated in a Brazilian teaching hospital

ABSTRACTINTRODUCTION: Monte Carlo simulations have been used for selecting optimal antibiotic regimens for treatment of bacterial infections. The aim of this study was to assess the pharmacokinetic and pharmacodynamic target attainment of intravenous β-lactam regimens commonly used to treat bloodstream infections (BSIs) caused by Gram-negative rod-shaped organisms in a Brazilian teaching hospital.METHODS: In total, 5,000 patients were included in the Monte Carlo simulations of distinct antimicrobial regimens to estimate the likelihood of achieving free drug concentrations above the minimum inhibitory concentration (MIC; fT > MIC) for the requisite periods to clear distinct target organisms. Microbiological data were obtained from blood culture isolates harvested in our hospital from 2008 to 2010.RESULTS: In total, 614 bacterial isolates, including Escherichia coli, Enterobacterspp., Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa, were analyzed Piperacillin/tazobactam failed to achieve a cumulative fraction of response (CFR) > 90% for any of the isolates. While standard dosing (short infusion) of β-lactams achieved target attainment for BSIs caused by E. coliand Enterobacterspp., pharmacodynamic target attainment against K. pneumoniaeisolates was only achieved with ceftazidime and meropenem (prolonged infusion). Lastly, only prolonged infusion of high-dose meropenem approached an ideal CFR against P. aeruginosa; however, no antimicrobial regimen achieved an ideal CFR against A. baumannii.CONCLUSIONS:These data reinforce the use of prolonged infusions of high-dose β-lactam antimicrobials as a reasonable strategy for the treatment of BSIs caused by multidrug resistant Gram-negative bacteria in Brazil.

Predictive factors for Leishmania infantum infection in dogs examined at a veterinary teaching hospital in Teresina, State of Piauí, Brazil

Abstract: INTRODUCTION: In Brazil, culling of seropositive dogs is one of the recommended strategies to control visceral leishmaniasis. Since infectiousness is correlated with clinical signs, control measures targeting symptomatic dogs could be more effective. METHODS: A cross-sectional study was carried out among 1,410 dogs, predictive models were developed based on clinical signs and an indirect immunofluorescence antibody test. RESULTS: The validated predictive model showed sensitivity and specificity of 86.5% and 70.0%, respectively. CONCLUSIONS: Predictive models could be used as tools to aid control programs in focusing on a smaller fraction of dogs contributing more to infection dissemination.

Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial

OBJECTIVE: The aims of this study were to evaluate the safety and efficacy of laparoscopic abdominoperineal resection compared to conventional approach for surgical treatment of patients with distal rectal cancer presenting with incomplete response after chemoradiation. METHOD: Twenty eight patients with distal rectal adenocarcinoma were randomized to undergo surgical treatment by laparoscopic abdominoperineal resection or conventional approach and evaluated prospectively. Thirteen underwent laparoscopic abdominoperineal resection and 15 conventional approach. RESULTS: There was no significant difference (p<0,05) between the two studied groups regarding: gender, age, body mass index, patients with previous abdominal surgeries, intra and post operative complications, need for blood transfusion, hospital stay after surgery, length of resected segment and pathological staging. Mean operation time was 228 minutes for the laparoscopic abdominoperineal resection versus 284 minutes for the conventional approach (p=0.04). Mean anesthesia duration was shorter (p=0.03) for laparoscopic abdominoperineal resection when compared to conventional approach : 304 and 362 minutes, respectively. There was no need for conversion to open approach in this series. After a mean follow-up of 47.2 months and with the exclusion of two patients in the conventional abdominoperineal resection who presented with unsuspected synchronic metastasis during surgery, local recurrence was observed in two patients in the conventional group and in none in the laparoscopic group. CONCLUSIONS: We conclude that laparoscopic abdominoperineal resection is feasible, similar to conventional approach concerning surgery duration, intra operative morbidity, blood requirements and post operative morbidity. Larger number of cases and an extended follow-up are required to adequate evaluation of oncological results for patients undergoing laparoscopic abdominoperineal resection after chemoradiation for radical treatment of distal rectal cancer.

Prevalence rates of infection in intensive care units of a tertiary teaching hospital

OBJECTIVE: To determine the prevalence rates of infections among intensive care unit patients, the predominant infecting organisms, and their resistance patterns. To identify the related factors for intensive care unit-acquired infection and mortality rates. DESIGN: A 1-day point-prevalence study. SETTING:A total of 19 intensive care units at the Hospital das Clínicas - University of São Paulo, School of Medicine (HC-FMUSP), a teaching and tertiary hospital, were eligible to participate in the study. PATIENTS: All patients over 16 years old occupying an intensive care unit bed over a 24-hour period. The 19 intensive care unit s provided 126 patient case reports. MAIN OUTCOME MEASURES: Rates of infection, antimicrobial use, microbiological isolates resistance patterns, potential related factors for intensive care unit-acquired infection, and death rates. RESULTS: A total of 126 patients were studied. Eighty-seven patients (69%) received antimicrobials on the day of study, 72 (57%) for treatment, and 15 (12%) for prophylaxis. Community-acquired infection occurred in 15 patients (20.8%), non- intensive care unit nosocomial infection in 24 (33.3%), and intensive care unit-acquired infection in 22 patients (30.6%). Eleven patients (15.3%) had no defined type. The most frequently reported infections were respiratory (58.5%). The most frequently isolated bacteria were Enterobacteriaceae (33.8%), Pseudomonas aeruginosa (26.4%), and Staphylococcus aureus (16.9%; [100% resistant to methicillin]). Multivariate regression analysis revealed 3 risk factors for intensive care unit-acquired infection: age > 60 years (p = 0.007), use of a nasogastric tube (p = 0.017), and postoperative status (p = 0.017). At the end of 4 weeks, overall mortality was 28.8%. Patients with infection had a mortality rate of 34.7%. There was no difference between mortality rates for infected and noninfected patients (p=0.088). CONCLUSION: The rate of nosocomial infection is high in intensive care unit patients, especially for respiratory infections. The predominant bacteria were Enterobacteriaceae, Pseudomonas aeruginosa, and Staphylococcus aureus (resistant organisms). Factors such as nasogastric intubation, postoperative status, and age ³60 years were significantly associated with infection. This study documents the clinical impression that prevalence rates of intensive care unit-acquired infections are high and suggests that preventive measures are important for reducing the occurrence of infection in critically ill patients.

Form tutors in the joint teaching of music: perspectives and experiences

In the Portuguese school system, form tutors (FTs) are an intermediate education management structure. The form tutor is responsible for a position of coordination and orientation with a «threefold function»: a relationship with students, relationship with the student’s family and relationship with other class teachers. The joint teaching of music is a part of the educational system in basic education. It is optional and provides musical and instrumental training to students who are interested in taking it. In order to achieve this, there is a system, subject to protocols, between general education schools and schools specializing in teaching music. There is also the position of FT in specialized schools and it also includes a «threefold function». However, these FTs have the additional role of representing music teachers at the class council, which is held at the general education school. Thus, in these cases, both FTs have a fourth joint area, between the music school and the general education school, which makes the relationship between them even more complex. This paper is based on the analysis of empirical data obtained from the testimonies of FTs regarding their representations and experiences in leadership and the coordination of teachers among schools in which there is a joint teaching system. The aim of collecting narratives is to look into some of the main challenges and confrontations related to leadership issues, which we assume to be the focus of those who have the role of form tutor in that specific context.

Self-compacting concrete and conventional concrete in the arena Pernambuco: comparative study of durability indicators and economic feasibility

This study addressed the application, strength and durability of self-compacting concrete (SCC) in a large-scale construction site, comparing its performance with vibrated conventional concrete (CC) with similar characteristics, assessing its economic feasibility. The studies were undertaken in the Arena Pernambuco project and involved the concreting during May, June and July 2012, for data collection, accompanying the routine concrete control tests and performing specific strength and durability tests. The SCC compressive strength was on average 4.5% higher than the CC one, and its formwork reinforced to withstand greater lateral pressure of the fresh concrete. The durability indicators results were in favour of SCC, which cost was 13.5% higher than CC.

A aula de orquestra como laboratório para a criatividade

Relatório de estágio de mestrado em Ensino da Música

The Need for Pedagogical Qualifications for Teaching Cardiology to Undergraduate Students

OBJECTIVE: To report a training program in cardiology emphasizing changes in its pedagogical practice. These changes were put into practice by some teachers at the Medical School of Porto Alegre of the University of Rio Grande do Sul (FAMED/UFRGS) aiming to make faculty and student activities more dynamic and to promote more efficacious learning. The training program is directed at 5th semester medical students and aims at a behavioral change in teachers and students to promote more interaction, to favor exchanges, and to make the teaching-learning process easier, always maintaining the patient in the center of the medical activity. METHODS: The program emphasizes the definition of general and specific objectives for each activity to be developed by the students, with training in the area of admission to the cardiology service, with special emphasis on behavioral change in the cognitive, motor, affective, and attitudinal areas. Knowledge was developed by means of interactive seminars with initial and final assessment tests to identify students' and teachers' performance. The students were evaluated in an immediate, continuous, and progressive way in their daily activities and through comparison of the results of 2 tests, one applied at the beginning of the training and the other at its end. These 2 tests contained the same questions. RESULTS: We systematically assessed 560 students over 4 years. The mean grades of the tests performed prior to and after the 244 seminars were 7.38±1.66 and 9.17± 0.82, respectively (p<0.0001). For the tests applied at the beginning and at the end of the training, the mean grades were 5.61±1.61 and 9.37±0.90, respectively (p<0.0001). CONCLUSION: The program proved to be efficient both for the students' learning and for assessing their performance in a systematic and objective way.

Biographical narratives in teaching: a study of rofessors on postgraduate courses

Literature and research have shown that professional development constitutes an essential dimension in constructing both work and professional identity. An important aspect in such development is training. In the field of adult education, different authors (Pratt, 1993; Mezirow, 1985; Schön, 1996; Silva, 2007) emphasize the importance of placing trainees at the center of the learning and cognitive processes and within their corresponding social and historical contexts. Training is supported by a comprehensive adult learning theory. Therefore, the acquired knowledge is not only the result of an external and objective reality but also of a complex construction in which the appropriation of experience plays a relevant role. This paper reveals the findings obtained through biographical narratives in a five-year work program with teachers at different levels (from pre-school to higher education) on postgraduate courses. The core issue is the importance of biographical narratives, as an identification strategy for personal experience, knowledge construction and professional identity. This strategy provided the opportunity for recognition of practical experience, as a provider of learning, as well as his/her own authorship, which are important conditions in the understanding of professional identity.