Emprego de redes complexas para modelar e analisar a disseminação de microrganismos da familia enterobacteriaceae em pacientes mantidos em unidades de terapia intensiva

Nowadays the studies of different methodologies to interfere in the growing and spread of serious infections and systemic status in institutionalized patients those kept on intensive therapy units are relevant to understanding these complex systems and bring benefits to several health areas, particularly public health. In this study, it was analyzed the clinical and microbiological data from patients hospitalized in intensive therapy units. The interaction between patients and caregivers was modeled and analyzed using dynamic system model and complex network theory, identifying outbreaks values of microorganisms of Enterobacteriaceae Family.

Effects of probiotic Lactobacillus gasseri strains of breast-fed infant in a murine model

The ingestion of probiotic lactic acid bacteria has been evaluated and noted that it has an effect on the balance of desirable microbiota in the gastrointestinal tract. Lactobacillus gasseri demonstrates good survival in the gastrointestinal tract, and it has been associated with a variety of probiotic activities and roles, including the reduction of fecal mutagenic enzymes, the production of bacteriocins and the stimulation of macrophages immunomodulation. The aim of the study was to evaluate the effects of a pool of L. gasseri strains isolated from the feces of breastfed infants added in the human milk of healthy women. The milk was both pasteurized and unpasteurized, to verify the cell cytotoxicity of macrophages and to quantify the production of immunologic mediators such as IL-4, IL-6, IFN-g, TNF-a, NO and oxygen intermediary compounds (H2O2). The administration of raw human milk and pasteurized human milk to infants is a regular, encouraged practice in units of intensive therapy (UITs) and our present investigation verified the beneficial effect of addition of a pool of L. gasseri to pasteurized human milk (PHML). Our results show that probiotic supplementation helped to maintain cell viability, reduced IL-6 and IFN-γ production and stimulated TNF-α, NO, H2O2, IL-4 production. Nevertheless, the results indicate that the addition of lactobacillus to human milk was not a determinant in the production of TNF-α. L. gasseri added to breast milk did not present a cytotoxic risk, and the addition of L. gasseri to pasteurized milk of human milk bank would benefit newborns that depend on milk banks for the colonization of more desirable microbiota.

Fisioterapia respiratória, pressão intra-abdominal e função renal de pacientes de terapia intensiva

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Evaluation of the identification protocol for newborns in a private hospital

This exploratory-descriptive quantitative study aimed to evaluate the protocol for identifying newborns admitted to the Neonatal Intensive and Semi-intensive Therapy Unit of a private hospital. The case series was made up of 540 observation opportunities, selected by simple random probability sampling. The data was collected between May and August 2010 according to a form and analyzed by descriptive statistic. The protocol's general performance had a conformity index of 82.2%. There were three stages to the protocol: identification components, the identification wristbands' condition and the number of identification wristbands. The highest percentage of conformity (93%) was attributed to the second stage and the lowest (89.3%) to the third, presenting a statistically significant difference of p=0.046. In the group of 'special' neonates, 88.5% conformity was achieved. These results will make it possible to restructure the protocol for identifying newborns and to establish care and managerial goals so as to improve the quality of care and the patients' safety.

Comparison of randomized treatments for late whiplash

BACKGROUND: To compare 4 different treatment strategies in patients with late whiplash syndrome. METHODS: Patients were randomly assigned to one of the following treatment groups: infiltration, physiotherapy, or medication. Group allocation was stratified according to gender, age, and education. Additionally, patients of each group were randomized 1:1 to cognitive-behavioral therapy (CBT) or no CBT. Patients were assessed at baseline, after an 8-week treatment period, and 3 and 6 months later. Main outcome measures were subjective outcome rating, pain intensity, and working ability. RESULTS: Of 91 enrolled patients, 73 completed the study; 62% were women. After treatment, 47 patients (64%) were subjectively improved (48%), or free of symptoms (16%), with a preponderance of women (73% vs 50%, p = 0.047). There was no difference regarding outcomes among the 3 treatment groups in men and women. The most robust difference was achieved with CBT, associated with a higher rate of recovery (23% vs 9%), and improvement (53% vs 42%) (p = 0.024), and with a gender difference (p = 0.01). All treatments significantly improved pain intensity and working ability. CONCLUSION: Intensive therapy in late whiplash syndrome can achieve improvement of different outcome measures including working ability in two-thirds of patients, more effective in women, persisting beyond 6 months in half. Additional cognitive-behavioral therapy was the most effective treatment modality. Classification of evidence: This interventional study provides Class III evidence that CBT used as an adjunct to infiltration, medication, or physiotherapy increases improvement rates in persons with late whiplash syndrome.

A novel paradigm for patient-cooperative control of upper-limb rehabilitation robots

Early intervention and intensive therapy improve the outcome of neuromuscular rehabilitation. There are indications that where a patient is motivated and premeditates their movement, the recovery is more effective. Therefore, a strategy for patient-cooperative control of rehabilitation devices for upper extremities is proposed and evaluated. The strategy is based on the minimal intervention principle allowing an efficient exploitation of task space redundancies and resulting in user-driven movement trajectories. The patient's effort is taken into consideration by enabling the machine to comply with forces exerted by the user. The interaction is enhanced through a multimodal display and a virtually generated environment that includes haptic, visual and sound modalities.

Transient Fanconi syndrome with severe polyuria and polydipsia in a 4-year old Shih Tzu fed chicken jerky treats.

Acquired Fanconi syndrome is characterized by inappropriate urinary loss of amino acids, bicarbonate, electrolytes, and water. It has recently been described in dogs fed chicken jerky treats from China, a new differential diagnosis to the classical inciting infectious diseases (e.g. leptospirosis, pyelonephritis) and toxins. A dog fed exclusively chicken jerky treats purchased in Switzerland was presented to our clinic with severe polyuria, polydipsia and profound electrolyte and acid base disturbances. Other inciting causes of Fanconi syndrome were ruled out. The requirement of a very intensive supportive treatment in this dog stands in contrast to treatment of chronic forms of Fanconi syndrome as described in the Basenji. This intensive therapy and the associated monitoring can be a real challenge and a limiting factor for the prognosis of acquired Fanconi syndrome. Veterinarians should be aware of the risk of excessive feeding of chicken jerky treats.

Bloodstream infection in paediatric cancer centres--leukaemia and relapsed malignancies are independent risk factors.

UNLABELLED In a prospective multicentre study of bloodstream infection (BSI) from November 01, 2007 to July 31, 2010, seven paediatric cancer centres (PCC) from Germany and one from Switzerland included 770 paediatric cancer patients (58% males; median age 8.3 years, interquartile range (IQR) 3.8-14.8 years) comprising 153,193 individual days of surveillance (in- and outpatient days during intensive treatment). Broviac catheters were used in 63% of all patients and Ports in 20%. One hundred forty-two patients (18%; 95% CI 16 to 21%) experienced at least one BSI (179 BSIs in total; bacteraemia 70%, bacterial sepsis 27%, candidaemia 2%). In 57%, the BSI occurred in inpatients, in 79% after conventional chemotherapy. Only 56 % of the patients showed neutropenia at BSI onset. Eventually, patients with acute lymphoblastic leukaemia (ALL) or acute myeloblastic leukaemia (AML), relapsed malignancy and patients with a Broviac faced an increased risk of BSI in the multivariate analysis. Relapsed malignancy (16%) was an independent risk factor for all BSI and for Gram-positive BSI. CONCLUSION This study confirms relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. On a unit level, data on BSIs in this high-risk population derived from prospective surveillance are not only mandatory to decide on empiric antimicrobial treatment but also beneficial in planning and evaluating preventive bundles. WHAT IS KNOWN • Paediatric cancer patients face an increased risk of nosocomial bloodstream infections (BSIs). • In most cases, these BSIs are associated with the use of a long-term central venous catheter (Broviac, Port), severe and prolonged immunosuppression (e.g. neutropenia) and other chemotherapy-induced alterations of host defence mechanisms (e.g. mucositis). What is New: • This study is the first multicentre study confirming relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. • It describes the epidemiology of nosocomial BSI in paediatric cancer patients mainly outside the stem cell transplantation setting during conventional intensive therapy and argues for prospective surveillance programmes to target and evaluate preventive bundle interventions.

Páncreas artificial basado en un controlador Smith paramétrico

La diabetes mellitus es una enfermedad que se caracteriza por la nula o insuficiente producción de insulina, o la resistencia del organismo a la misma. La insulina es una hormona que ayuda a que la glucosa llegue a los tejidos periféricos y al sistema nervioso para suministrar energía. Actualmente existen dos tipos de terapias aplicada en tejido subcutáneo: mediante inyección múltiple realizada con plumas, y la otra es mediante infusión continua de insulina por bomba (CSII). El mayor problema de esta terapia son los retardos por la absorción, tanto de los carbohidratos como de la insulina, y los retardos introducidos por el sensor subcutáneo de glucosa que mide la glucosa del líquido intersticial, lo deseable es controlar la glucosa en sangre. Para intentar independizar al paciente de su enfermedad se está trabajando en el desarrollo del páncreas endocrino artificial (PEA) que dotaría al paciente de una bomba de insulina, un sensor de glucosa y un controlador, el cual se encargaría de la toma de decisiones de las infusiones de insulina. Este proyecto persigue el diseño de un regulador en modo de funcionamiento en CL, con el objetivo de conseguir una regulación óptima del nivel de glucosa en sangre. El diseño de dicho regulador va a ser acometido utilizando la teoría del control por modelo interno (IMC). Esta teoría se basa en la idea de que es necesario realimentar la respuesta de un modelo aproximado del proceso que se quiere controlar. La salida del modelo, comparada con la del proceso real nos da la incertidumbre del modelo de la planta, frente a la planta real. Dado que según la teoría del modelo interno, estas diferencias se dan en las altas frecuencias, la teoría IMC propone un filtro paso bajo como regulador en serie con la inversa del modelo de la planta para conseguir el comportamiento deseado. Además se pretende implementar un Predictor Smith para minimizar los efectos del retardo de la medida del sensor. En el proyecto para conseguir la viabilidad del PEA se ha adaptado el controlador IMC clásico utilizando las ganancias estáticas de un modelo de glucosa, a partir de la ruta subcutánea de infusión y la vía subcutánea de medida. El modo de funcionamiento del controlador en SCL mejora el rango de normoglucemia, necesitando la intervención del paciente indicando anticipadamente el momento de las ingestas al controlador. El uso de un control SCL con el Predictor de Smith mejora los resultados pues se añade al controlador una variable sobre las ingestas con la participación del paciente. ABSTRACT. Diabetes mellitus is a group of metabolic diseases in which a person has high blood sugar, due to the body does not produce enough insulin, or because cells do not respond to the insulin produced. The insulin is a hormone that helps the glucose to reach to outlying tissues and the nervous system to supply energy. There are currently two types of therapies applied in subcutaneous tissue: the first one consists in using the intensive therapy with an insulin pen, and the other one is by continuous subcutaneous insulin infusion (CSII). The biggest problems of this therapy are the delays caused by the absorption of carbohydrates and insulin, and the delays introduced by the subcutaneous glucose sensor that measures glucose from interstitial fluid, it is suitable to control glucose blood. To try to improve these patients quality of life, work is being done on the development of an artificial endocrine pancreas (PEA) consisting of a subcutaneous insulin pump, a subcutaneous glucose sensor and an algorithm of glucose control, which would calculate the bolus that the pump would infuse to patient. This project aims to design a controller for closed-loop therapy, with the objective of obtain an optimal regulation of blood glucose level. The design of this controller will be formed using the theory of internal model control (IMC). This theory is based on the uncertainties given by a model to feedback the system control. Output model, in comparison with the actual process gives the uncertainty of the plant model, compared to the real plant. Since the theory of the internal model, these differences occur at high frequencies, the theory proposes IMC as a low pass filter regulator in series with the inverse model of the plant to get the required behavior. In addition, it will implement a Smith Predictor to minimize the effects of the delay measurement sensor. The project for the viability of PEA has adapted the classic IMC controller using the gains static of glucose model from the subcutaneous infusion and subcutaneous measuring. In simulation the SemiClosed-Loop controller get on the normoglycemia range, requiring patient intervention announce the bolus priming connected to intakes. Using an SCL control with the Smith Predictor improves the outcome because a variable about intakes is added to the controller through patient intervention.

Susceptibility to chlorhexidine amongst multidrug-resistant clinical isolates of Staphylococcus epidermidis from bloodstream infections

We thank the staff of the Aberdeen Clinical Diagnostic Laboratory and the Centre for Genome-Enabled Biology and Medicine of the University of Aberdeen for their dedicated support to this study.

Benefit of antiretroviral therapy on survival of human immunodeficiency virus-infected patients admitted to an intensive care unit

Objective: To evaluate the impact of antiretroviral therapy (ART) and the prognostic factors for in-intensive care unit (ICU) and 6-month mortality in human immunodeficiency virus (HIV)-infected patients. Design: A retrospective cohort study was conducted in patients admitted to the ICU from 1996 through 2006. The follow-up period extended for 6 months after ICU admission. Setting: The ICU of a tertiary-care teaching hospital at the Universidade de Sao Paulo, Brazil. Participants: A total of 278 HIV-infected patients admitted to the ICU were selected. We excluded ICU readmissions (37), ICU admissions who stayed less than 24 hours (44), and patients with unavailable medical charts (36). Outcome Measure: In-ICU and 6-month mortality. Main Results: Multivariate logistic regression analysis and Cox proportional hazards models demonstrated that the variables associated with in-ICU and 6-month mortality were sepsis as the cause of admission (odds ratio [OR] = 3.16 [95% confidence interval [CI] 1.65-6.06]); hazards ratio [HR] = 1.37 [95% Cl 1.01-1.88)), an Acute Physiology and Chronic Health Evaluation 11 score >19 [OR = 2.81 (95% CI 1.57-5.04); HR = 2.18 (95% CI 1.62-2.94)], mechanical ventilation during the first 24 hours [OR = 3.92 (95% CI 2.20-6.96); HR = 2.25 (95% CI 1.65-3.07)], and year of ICU admission [OR = 0.90 (95% CI 0.81-0.99); HR = 0.92 [95% CI 0.87-0.97)]. CD4 T-cell count <50 cells/mm(3) Was only associated with ICU mortality [OR = 2.10 (95% Cl 1.17-3.76)]. The use of ART in the ICU was negatively predictive of 6-month mortality in the Cox model [HR = 0.50 (95% CI 0.35-0.71)], especially if this therapy was introduced during the first 4 days of admission to the ICU [HR = 0.58 (95% CI 0.41-0.83)]. Regarding HIV-infected patients admitted to ICU without using ART, those who have started this treatment during ICU, stay presented a better prognosis when time and potential confounding factors were adjusted for [HR 0.55 (95% CI 0.31-0.98)]. Conclusions: The ICU outcome of HIV-infected patients seems to be dependent not only on acute illness severity, but also on the administration of antiretroviral treatment. (Crit Care Med 2009; 37: 1605-1611)

alpha 1-acid glycoprotein and alpha 1-antitrypsin as early markers of treatment response in patients receiving the intensive phase of tuberculosis therapy

The identification of early markers that predict the response to anti-tuberculosis treatment would facilitate evaluation of new drugs and improve patient management. This study aimed to determine whether selected acute phase proteins and micronutrients measured at the time of diagnosis and during the first weeks of treatment could predict treatment responses during the 2-month standard intensive phase of therapy. For this purpose, alpha 1-antitrypsin, alpha 1-acid gtycoprotein, alpha 2-macroglobutin, C-reactive protein, C3, C4, zinc, copper and selenium concentrations were measured in Brazilian patients with smear-positive tuberculosis at the time of diagnosis and 1, 3, 5 and 8 weeks after initiation of therapy. Patients were classified into fast (n = 29), intermediate (n = 18) and slow responders (n = 10) if they were smear-negative at 3, 5 or 8 weeks of treatment. alpha 1-acid gtycoprotein on enrolment and 1 week of treatment, alpha 1-antitrypsin at week 1 and C-reactive protein and C3 after 3 weeks of therapy were higher in slow responders than in fast responders. alpha 1-antitrypsin and alpha 1-acid glycoprotein may be helpful in predicting treatment response at the time of initiation of therapy, and could be used as early markers to identify patients with an increased likelihood of treatment failure. (C) 2008 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.

Nutrition Therapy in a Pediatric Intensive Care Unit: Indications, Monitoring, and Complications

Background: Nutrition therapy (NT) is essential for the care of critically ill children. Inadequate feeding leads to malnutrition and may increase the patient`s risk of morbidity and mortality. The aim of this study was to describe the NT used in a tertiary pediatric intensive care unit (PICU). Methods: The authors evaluated NT administered to 90 consecutive patients who were hospitalized for 7 days in the PICU of Instituto da Crianca, Hospital das Clinicas, Universidade de Sao Paulo, Brazil. NT was established according to the protocol provided by the institution`s NT team. NT provided a balance of fluids and nutrients and was monitored with a weekly anthropometric nutrition assessment and an evaluation of complications. Results: NT was initiated, on average, within 72 hours of hospitalization. Most children (80%) received enteral nutrition (EN) therapy; of these, 35% were fed orally and the rest via nasogastric or postpyloric tube. There were gastrointestinal complications in patients (5%) who needed a postpyloric tube. Parenteral nutrition (PN) was used in only 10% of the cases, and the remaining 10% received mixed NT (EN + PN). The average calorie and protein intake was 82 kcal/kg and 2.7 g/kg per day. Arm circumference and triceps skinfold thickness decreased. Conclusions: The use of EN was prevalent in the tertiary PICU, and few clinical complications occurred. There was no statistically significant change in most anthropometric indicators evaluated during hospitalization, which suggests that NT probably helped patients maintain their nutrition status. (JPEN J Parenter Enteral Nutr. 2011;35:523-529)

A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study.

PURPOSE: An optimal target for glucose control in ICU patients remains unclear. This prospective randomized controlled trial compared the effects on ICU mortality of intensive insulin therapy (IIT) with an intermediate glucose control. METHODS: Adult patients admitted to the 21 participating medico-surgical ICUs were randomized to group 1 (target BG 7.8-10.0 mmol/L) or to group 2 (target BG 4.4-6.1 mmol/L). RESULTS: While the required sample size was 1,750 per group, the trial was stopped early due to a high rate of unintended protocol violations. From 1,101 admissions, the outcomes of 542 patients assigned to group 1 and 536 of group 2 were analysed. The groups were well balanced. BG levels averaged in group 1 8.0 mmol/L (IQR 7.1-9.0) (median of all values) and 7.7 mmol/L (IQR 6.7-8.8) (median of morning BG) versus 6.5 mmol/L (IQR 6.0-7.2) and 6.1 mmol/L (IQR 5.5-6.8) for group 2 (p < 0.0001 for both comparisons). The percentage of patients treated with insulin averaged 66.2 and 96.3%, respectively. Proportion of time spent in target BG was similar, averaging 39.5% and 45.1% (median (IQR) 34.3 (18.5-50.0) and 39.3 (26.2-53.6)%) in the groups 1 and 2, respectively. The rate of hypoglycaemia was higher in the group 2 (8.7%) than in group 1 (2.7%, p < 0.0001). ICU mortality was similar in the two groups (15.3 vs. 17.2%). CONCLUSIONS: In this prematurely stopped and therefore underpowered study, there was a lack of clinical benefit of intensive insulin therapy (target 4.4-6.1 mmol/L), associated with an increased incidence of hypoglycaemia, as compared to a 7.8-10.0 mmol/L target. (ClinicalTrials.gov # NCT00107601, EUDRA-CT Number: 200400391440).