Changes in Left Ventricular Torsion Early Postoperatively After Aortic Valve Replacement and at Long-Term Follow-up.

OBJECTIVE In patients with aortic stenosis, left ventricular systolic torsion (pT) is increased to overcome excessive afterload. This study assessed left ventricular torsion before and immediately after surgical valve replacement and tested the instant effect of fluid loading. DESIGN Prospective, clinical single-center study. SETTING Intensive care unit of a university hospital. PARTICIPANTS 12 patients undergoing elective aortic valve replacement for aortic stenosis. INTERVENTIONS Echocardiography was performed on the day before surgery, within 18 hours after surgery including a fluid challenge, and after 2.5 years. MEASUREMENTS AND MAIN RESULTS pT decreased early postoperatively by 21.2% (23.4° ± 5.6° to 18.4° ± 6.9°; p = 0.012) and reached preoperative values at 2.5 years follow-up (24 ± 7). Peak diastolic untwisting velocity occurred later early postoperatively (13% ± 8% to 21% ± 9.4%; p = 0.019) and returned toward preoperative values at follow-up (10.2 ± 4.7°). The fluid challenge increased central venous pressure (8 ± 4 mmHg to 11 ± 4 mmHg; p = 0.003) and reduced peak systolic torsion velocity (138.7 ± 37.6/s to 121.3 ± 32/s; p = 0.032). pT decreased in 3 and increased in 8 patients after fluid loading. Patients whose pT increased had higher early mitral inflow velocity postoperatively (p = 0.04) than those with decreasing pT. Patients with reduced pT after fluid loading received more fluids (p = 0.04) and had a higher positive fluid balance during the intensive care unit stay (p = 0.03). Torsion after fluid loading correlated with total fluid input (p = 0.001) and cumulative fluid balance (p = 0.002). CONCLUSIONS pT decreased early after aortic valve replacement but remained elevated despite elimination of aortic stenosis. After 2.5 years, torsion had returned to preoperative levels.

Nierenersatzverfahren – gestern, heute und morgen

Die Nierenersatztherapie ist eine der erfolgreichsten Geschichten eines künstlichen Organersatzes. Der vorliegende Artikel beschreibt die wichtigsten Schritte in der Evolution zur modernen Therapie mit Peritonealdialyse und Hämodialyse. Aktuelle Fragen im Bereich der Nierenersatztherapie werden diskutiert und zukünftige Entwicklungen aufgezeigt. Dem Patienten stehen heute diverse Therapiemöglichkeiten offen. Allerdings nur, wenn er mindestens ein halbes Jahr vor der Notwendigkeit eines Therapiebeginns die für ihn ideale Therapieform auswählen kann. Verspätete Zuweisungen und die Notwendigkeit eines akuten Dialysebeginns führen nicht nur zu einer erhöhten Mortalität, sondern auch dazu, dass eine präemptive Lebendnierentransplantation verunmöglicht wird. Zudem bleiben diese Patienten in der Regel im Dialysezentrum und können für eine Heimbehandlung, sei es nun in Form einer Peritonealdialyse oder Heimhämodialyse, nicht mehr motiviert werden.

Use of pneumococcal vaccine in people with chronic disease in United States

Objective. The risk of complications and deaths related to pneumococcal infections is high among high risk population (i.e. those with chronic diseases such as diabetes or asthma), despite current immunization recommendations. The aim of this study is to evaluate the use of pneumonia vaccine in adults with and without diabetes or asthma by year of age and whether immunization practices conform to policy recommendations. ^ Methods. Data were drawn from 2005 Behavioral Risk Factor Surveillance Study. Age specific estimated counts and proportions of pneumonia vaccination status were computed. The association of socio-demographic factors with vaccination status was estimated from multiple logistic regression and results were presented for adults (18-64yrs) and elderly (65 or older). ^ Results. Overall 12.3% of the adults and 61.5% of elderly reported ever received pneumonia vaccine. 66.8% of diabetics and 72.6% of asthmatics received the vaccine among elderly. 33.4% of diabetics and 21.6% of asthmatics received the vaccine among adults. These numbers are far away from Healthy people 2010 objective coverage rates of 90% for elderly and 60% for high risk adults. Though diabetes was one of the recommendations for the pneumonia vaccine still the status was less than 70% even at older ages. Although asthma was not an indication for pneumonia vaccine, asthmatics still achieved 50% level by an early age of 60 and reached up to 80% at as early as 75 years. In those having both asthma and diabetes, although the curve reaches to 50% level at a very early age of 40yrs, it is not stable until the age of 55 and percentages reached to as high as 90% in older ages. Odds of receiving pneumonia vaccine were high in individuals with diabetes or asthma in both the age groups. But the odds were stronger for diabetics in adults compared to those in the elderly [2.24 CI (2.08-2.42) and 1.32 CI (1.18-1.47)]. The odds were slightly higher in adults than in elderly for asthmatics [1.92 CI (1.80-2.04) and 1.73 CI (1.50-2.00)].The likelihood of vaccination also differed by gender, ethnicity, marital status, income category, having a health insurance, current employment, physician visit in last year, reporting of good to excellent health and flu vaccine status. ^ Conclusion. There is a very high proportion of high risk adults and elderly that remain unvaccinated. Given the proven efficacy and safety of vaccine there is a need for interventions targeting the barriers for under-vaccination with more emphasis on physician knowledge and practice as well as the recipient attitudes.^

Non-staphylococcal infections of cardiac implantable electronic devices

Background. The number of infections of cardiac implantable electronic devices (CIED) continues to escalate out of proportion to the increase rate of device implantation. Staphylococcal organisms account for 70% to 90% of all CIED infections. However, little is known about non-staphylococcal infections, which have been described only in case reports, small case series or combined in larger studies with staphylococcal CIED infections, thereby diluting their individual impact. ^ Methods. A retrospective review of hospital records of patients admitted with a CIED-related infections were identified within four academic hospitals in Houston, Texas between 2002 and 2009. ^ Results. Of the 504 identified patients with CIED-related infection, 80 (16%) had a non-staphylococcal infection and were the focus of this study. Although the demographics and comorbities of subjects were comparable to other reports, our study illustrates many key points: (a) the microbiologic diversity of non-staphylococcal infections was rather extensive, as it included other Gram-positive bacteria like streptococci and enterococci, a variety of Gram-negative bacteria, atypical bacteria including Nocardia and Mycobacteria, and fungi like Candida and Aspergillus; (b) the duration of CIED insertion prior to non-staphylococcal infection was relatively prolong (mean, 109 ± 27 weeks), of these 44% had their device previously manipulated within a mean of 29.5 ± 6 weeks; (c) non-staphylococcal organisms appear to be less virulent, cause prolonged clinical symptoms prior to admission (mean, 48 ± 12.8 days), and are associated with a lower mortality (4%) than staphylococcal organisms; (d) thirteen patients (16%) presented with CIED-related endocarditis; (e) although not described in prior reports, we identified 3 definite and 2 suspected cases of secondary Gram-negative bacteremia seeding of the CIED; and (f) inappropriate antimicrobial coverage was provided in approximately 50% of patients with non-staphylococcal infections for a mean period of 2.1 days. ^ Conclusions. Non-staphylococcal CIED-related infections are prevalent and diverse with a relatively low virulence and mortality rate. Since non-staphylococcal organisms are capable of secondarily seeding the CIED, a high suspicion for CIED-related infection is warranted in patients with bloodstream infection. Additionally, in patients with suspected CIED infection, adequate Gram positive and -negative antibacterial coverage should be administered until microbiologic data become available.^

Nd isotopic composition of fossil fish teeth and debris from ODP Legs 138, 165, and 202

Changes in circulation associated with the shoaling of the Isthmus of Panama and the Caribbean carbonate crash in the Miocene were investigated using Nd isotopes from fossil fish teeth and debris from two sites in the Caribbean Basin (Ocean Drilling Program Sites 998 and 999) and two sites in the eastern equatorial Pacific (Sites 846 and 1241). The total range for e-Nd values measured from 18 to 4.5 Ma in the Caribbean is -7.3 to 0. These values are higher than Atlantic water masses (~-11) and range up to values equivalent to contemporaneous Pacific water masses, confirming that flow into the Caribbean Basin was composed of a mixture of Pacific and Atlantic waters, with an upper limit of almost pure Pacific-sourced waters. Throughout the Caribbean record, particularly during the carbonate crash (10-12 Ma), low carbonate mass accumulation rates (MARs) correlate with more radiogenic e-Nd values, indicating increased flow of corrosive Pacific intermediate water into the Caribbean Basin during intervals of dissolution. This flow pattern agrees with results from general ocean circulation models designed to study the effect of the shoaling of the Central American Seaway. Low carbonate MARs and high e-Nd values also correlate with intervals of increased Northern Component Water production and, therefore, enhanced conveyor circulation, suggesting that the conveyor may respond to changes in circulation associated with shoaling of the Central American Seaway. Reduced Pacific throughflow related to shoaling of the seaway led to a gradual increase in carbonate preservation and more Atlantic-like e-Nd values following the carbonate crash.

Nagele: un nuevo asentamiento en un paisaje artificial

Nagele es un asentamiento urbano situado en el Noordoostpolder, territorio neerlandés ganado al mar. Fue diseñado por arquitectos de los grupos De 8 en Opbouw entre los que destacaron Rietveld, Van Eesteren, Van Eyck, Bakema, Stam y Ruys. El proyecto se desarrolló entre 1947 y 1956, un periodo de tiempo con formas de proyectar muy ricas en interpretaciones. Los arquitectos pusieron en crisis los planteamientos historicistas de las nuevas poblaciones de los pólderes. Propusieron un nuevo prototipo, una morfología compacta y concéntrica que transmitiría igualdad a una comunidad agrícola, entendida como una sociedad urbana del siglo XX. La administración apoyó la propuesta que convertiría el proyecto en un arriesgado reto por su falta de antecedentes. La vigencia de las formulaciones permanece hoy en día en la ciudad construida, aunque con alteraciones. En los dibujos del proceso se encuentran los principales enunciados teóricos que este trabajo pretende descubrir. El trabajo aborda aspectos no suficientemente explorados, como su relación con el pólder, la evolución de las estrategias proyectivas, la ordenación paisajista y los elementos urbanos. El Noordoostpolder es la culminación de una serie de experiencias multidisciplinares en el reclamo de tierras a gran escala. Se estudia su estructura urbana policéntrica, la parcelación agrícola que origina el proyecto urbano y la vinculación de la vegetación con la infraestructura, proporcionando orientación, protección climática y escala humana, conceptos que impregnan las estrategias del proyecto urbano. La primera fase de la ordenación configuró áreas monofuncionales que respondían a cada una de las cuatro necesidades básicas del método científico de la ciudad higienista. El acontecimiento que marcó el final de la primera fase fue su presentación en el séptimo CIAM de 1949, cuyo título fue Aplicación de la Carta de Atenas. El programa residencial se dividió en clusters organizados en torno a una pradera vecinal central, vinculándose el orden vecinal, urbano y territorial. La segunda fase fue un catalizador de nuevos planteamientos. El proyecto se transformó en un In-between Realm, un escenario teórico donde coexisten fenómenos tradicionalmente antagónicos que Van Eyck denominó Twin Phenomena, convirtiéndose la ciudad en una réplica formal de la ambivalencia de la mente humana. La indefinición espacial no programada en la propuesta anterior se transformó en un conjunto de espacios urbanos, con límites y dimensiones adaptados a la escala humana. El proyecto es anterior a la obra escrita de Van Eyck por lo que estimuló sus enunciados teóricos. Unas ideas también reconocidas en los tres CIAM posteriores en los que también se expuso el proyecto. El diseño paisajista se integra en el proyecto urbano desde sus orígenes. El límite se compone de una barrera boscosa que protege climáticamente, proporciona escala humana y control visual frente a las llanuras infinitas del pólder. Van Eyck sintetizó el proyecto como una habitación verde sin techo, afirmación que dilucida su equivalencia con el de un interior doméstico. Exteriormente la ciudad se convierte en una unidad autónoma del territorio. Interiormente, un sistema jerarquizado de vegetación vinculado a la arquitectura y la infraestructura constituye espacios urbanos de diferentes escalas. La propuesta fue transformada por Boer y Ruys en un nuevo espacio urbano único, no asimilando los conceptos anteriores. El proyecto y construcción de los primeros elementos urbanos consistió en un reparto de tareas a De 8 en Opbouw, hecho que estimula estudiar su relación con el proyecto urbano. La estructura policéntrica organiza las aulas de las escuelas de Van Eyck, las diferentes áreas confesionales del cementerio de Ruys y las unidades residenciales, diseñadas por Stam, Rietveld y Stam-Besse. Los Twin Phenomena alcanzan un acuerdo en el corredor comercial, diseñado por Bakema y Van der Broek. La generación de espacios dentro de otros aparece también en el cementerio, a través de una nueva barrera boscosa y en el sistema de pliegues del muro que configura la iglesia de Bakema y Van der Broek. El proyecto se vincula a un planteamiento holístico, mediante el que el diseño de cada uno de sus elementos tiene en cuenta las estrategias proyectivas del todo del cual forma parte, convirtiéndose, al igual que las obras de De Stijl, en parte de una composición infinita que acerca arte y diseño en la vida cotidiana de la sociedad. La diversidad generacional e ideológica de estos arquitectos convirtió el proyecto en un tablero de juego sobre el que se aplicaron diferentes formas de proyectar la ciudad, ubicando a Nagele en un punto de inflexión del Movimiento Moderno. ABSTRACT The research focuses on the Nagele project, a Dutch urban settlement located in the Noordoostpolder, a territory which was entirely reclaimed from the IJsselmeer lake. It was designed by a group of architects from the De 8 and Opbouw teams, the leading protagonists being Rietveld, Van Eesteren, Van Eyck, Bakema, Stam y Ruys. It was designed from 1947 to 1956, a fruitful period in urban planning. These architects questioned the traditionalist urban design applied to the new populations in the IJsselmeer polders. Facing their principles, the work group proposed a new prototype; a compact and concentric urban pattern to foster equality in a new community of farm labourers, which was recognized by the architects as a twentieth century urban society. The government supported their new proposals. The lack of implementation of the innovatory conceptual statements subjected the project into a high-risk challenge. However, in spite of these difficulties, the basic concepts remain though partially transformed, in the actual city. The project drawings reflect the principle concepts that this work aims to discover. Some approaches that have not been sufficiently studied are tackled in this thesis. Firstly, the project´s relationship with the polder. Secondly, the evolution of projective strategies during the period of urban planning, the landscape design and the design of urban elements. The Noordoostpolder is the culmination of a series of multi-disciplinary experiences in large scale land reclamation, whose polycentric urban structure and agricultural subdivision provide the framework of Nagele. Linking the vegetation to infrastructure fostered orientation, climate protection and human scale; strategies which were repeated, though on a smaller scale, in the actual city. The first phase of the project was composed of mono-functional urban areas which responded to each of the four basic human needs indicated by the scientific method of the functional city. The presentation of the project at the seventh CIAM in 1949 was the event which marked the end of the first phase of the planning. This congress was entitled Implementation of the Athens Charter. The residential program was divided into housing clusters surrounding a central prairie, a pattern which was related to its urban and territorial whole. The second phase of the plan was subjected to a new theoretical approach. The urban planning became an In-between Realm, a theoretical scenario where traditionally antagonistic concepts coexist. Van Eyck named these concepts Twin Phenomena. The city thus conceived of as a counterform of the ambivalence of the human mind where spatial indefinition in the previous proposals was transformed into a Bunch of Places with defined boundaries and dimensions, all of which reflecting human scale. The landscape design was integrated into the urban project from its inception. The limits consist of a green wind-barrier which not only provides climate protection but also provides human scale and visual control towards the unlimited plains of the polder. Van Eyck summarised the project as a green room without a roof. This statement elucidates its equivalence to a domestic interior. Outwardly, the city becomes an autonomous unit on the territory. Inwardly a hierarchical vegetation system is linked to architecture and infrastructure. Together, they configure different scales of urban spaces. The proposal was transformed by Boer and Ruys into a unique urban space without assimilating Van Eyck´s concepts. The study of the Nagele landscape project of Nagele and the writings of Van Eyck verify the fact that many of his theoretical foundations (In-between Realm, Twin Phenomena, Bunch of Places, Right Scale) can be applied not only to architecture and city but also to landscape design. The application of these principles led the Nagele project to become a counterform of Van Eyck´s thinking. The design and construction of the first urban elements involved a distribution of tasks to De 8 en Opbouw, which stimulated their relationship with the urban project. The polycentric structure organised the school classrooms outlined by Van Eyck, the different areas of the cemetery planned by Ruys and the housing clusters designed by Stam, Rietveld and Stam-Besse. The Twin Phenomena concept can be applied in Van der Broek´s shopping corridor. The concept space within another space is also implemented in the cemetery surrounded by a new green barrier, and in the church built by Van der Broek and Bakema, whose spaces are configured by a folding wall. The project takes a holistic approach, which considers the design of each element within the strategies of the whole, where they become parts of an infinite composition, as in the art works of De Stijl fostering art and design to ordinary people´s daily lives. The generational and ideological diversity of these architects turned the project into a game board on which different ways of planning the city were played, obtaining Nagele the distinction of being a turning point of Modernism.

Radial and tangential dispersion patterns in the mouse retina are cell-class specific.

The retina is derived from a pseudostratified germinal zone in which the relative position of a progenitor cell is believed to determine the position of the progeny aligned in the radial axis. Such a developmental mechanism would ensure that radial arrays of cells which comprise functional units in the mature central nervous system are also clonally related. The present study has tested this hypothesis by using X chromosome-inactivation transgenic mosaic mice. We report that the retina shows a conspicuous distinction for clonally related neuroblasts of different laminar and functional fates: the rod photoreceptor, Müller, and bipolar cells are aligned in the radial axis, whereas the cone photoreceptor, horizontal, amacrine, and ganglion cells are tangentially displaced with respect to them. These results indicate that the dispersion of cell classes across the retinal surface is differentially constrained. Some classes of retinal neuroblast exhibit a significant tangential, as well as radial, component in their dispersion from the germinal zone, whereas others disperse only in the radial dimension. Consequently, the majority of radial columns within the mature retina must be derived from multiple progenitors. Because the cone photoreceptor, horizontal, amacrine, and ganglion cells establish nonrandom matrices in their cellular distributions within the respective retinal layers, tangential dispersion may be the means by which these matrices are constructed.

Intervenções em centros urbanos e conflitos distributivos: modelos regulatórios, circuitos de valorização e estratégias discursivas

Este trabalho discute as transformações no modo de intervenção do Estado na produção do espaço urbano no capitalismo contemporâneo a partir de uma reflexão sobre as políticas de revitalização de centros urbanos e os conflitos de natureza distributiva relacionados a esses projetos. Situando-se no campo do direito econômico, o trabalho explora as relações entre a acumulação capitalista e os padrões de intervenção do Estado sobre o espaço urbano a partir de diferentes níveis de análise, articulando elementos teóricos, jurídico-institucionais e empíricos. O processo de reestruturação do capitalismo que se iniciou nos anos 1970 teve desdobramentos relevantes no campo da regulação urbanística, desencadeando mudanças que atingiram suas funções e formas, e que perpassam diversas escalas geográficas. A ordem social e econômica que se configurou no capitalismo contemporâneo, marcada pela difusão de uma agenda política neoliberal e pela emergência de um regime de acumulação com dominância financeira, tem seus desdobramentos específicos na escala das cidades. Nesse contexto, as políticas urbanas passaram a ser progressivamente norteadas por uma racionalidade pragmática e empresarial, fechando-se à influência de esferas democráticas e desviando-se da institucionalização de compromissos redistributivos. Essa mudança qualitativa é mediada por formas institucionais e arranjos regulatórios que não se limitam à escala urbana e ao direito urbanístico propriamente dito, perpassando normas que regulam o regime jurídico da propriedade imobiliária e suas conexões com a esfera financeira, os padrões de financiamento das políticas urbanas, entre outras. A partir de um estudo sobre o Projeto Porto Maravilha uma intervenção urbanística de grande porte, e amplamente conectada a fluxos econômicos globais, que está sendo implementada na cidade do Rio de Janeiro desde 2009 , desenvolvemos uma reflexão sobre alguns vetores de mudança no papel exercido pelo Estado nos processos de urbanização. Este trabalho apresenta duas hipóteses articuladas. A primeira é a de que os padrões de regulação urbanística que emergiram no capitalismo contemporâneo não são meros reflexos de transformações mais abrangentes, mas sim fatores constitutivos dessas mudanças. A segunda a é de que as políticas de revitalização de centros urbanos agem como vetores de aprofundamento das conexões entre dinâmicas locais e processos globais, e também como incubadoras de novos padrões de regulação urbanística.

Branchial vascular pathways in two species of Tetraodontiformes and the concept of secondary vessels and nutrient arteries

The vascular organisation of the branchial basket was examined in two Tetraodontiform fishes; the three-barred porcupinefish, Dicotylichthys punctulatus and the banded toadfish, Marylina pleurosticta by scanning electron microscopy of vascular casts and standard histological approaches. In D. punctulatus, interarterial anastomoses (iaas) originated at high densities from the efferent filamental and branchial arteries, subsequently re-anastomosing to form progressively larger secondary vessels. Small branches of this system entered the filament body, where it was interspersed between the intrafilamental vessels. Large-bore secondary vessels ran parallel with the efferent branchial arteries, and were found to constitute an additional arterio-arterial pathway, in that these vessels exited the branchial basket in company with the mandibular, the carotid and the afferent and efferent branchial arteries, from where they gave rise to capillary beds after exit. Secondary vessels were not found to supply filament muscle; rather these tissues were supplied by single specialised vessels running in parallel between the efferent and afferent branchial arteries in both species examined. Although the branchial vascular anatomy was generally fairly similar for the two species examined, iaas were not found to originate from any branchial component in the banded toadfish, M. pleurosticta, which instead showed a moderate frequency of iaas on other vessels in the cephalic region. It is proposed that four independent vascular pathways may be present within the teleostean gill filament, the conventional arterio-arterial pathway across the respiratory lamellae; an arterio-arterial system of secondary vessels supplying the filament and non-branchial tissues; a system of vessels supplying the filament musculature; and the intrafilamental vessels (central venous sinus). The present study demonstrates that phylogenetic differences in the arrangement of the branchial vascular system occur between species of the same taxon.

Fluid resuscitation practice patterns in intensive care units of the USA: a cross-sectional survey of critical care physicians.

BACKGROUND: Fluid resuscitation is a cornerstone of intensive care treatment, yet there is a lack of agreement on how various types of fluids should be used in critically ill patients with different disease states. Therefore, our goal was to investigate the practice patterns of fluid utilization for resuscitation of adult patients in intensive care units (ICUs) within the USA. METHODS: We conducted a cross-sectional online survey of 502 physicians practicing in medical and surgical ICUs. Survey questions were designed to assess clinical decision-making processes for 3 types of patients who need volume expansion: (1) not bleeding and not septic, (2) bleeding but not septic, (3) requiring resuscitation for sepsis. First-choice fluid used in fluid boluses for these 3 patient types was requested from the respondents. Descriptive statistics were performed using a Kruskal-Wallis test to evaluate differences among the physician groups. Follow-up tests, including t tests, were conducted to evaluate differences between ICU types, hospital settings, and bolus volume. RESULTS: Fluid resuscitation varied with respect to preferences for the factors to determine volume status and preferences for fluid types. The 3 most frequently preferred volume indicators were blood pressure, urine output, and central venous pressure. Regardless of the patient type, the most preferred fluid type was crystalloid, followed by 5 % albumin and then 6 % hydroxyethyl starches (HES) 450/0.70 and 6 % HES 600/0.75. Surprisingly, up to 10 % of physicians still chose HES as the first choice of fluid for resuscitation in sepsis. The clinical specialty and the practice setting of the treating physicians also influenced fluid choices. CONCLUSIONS: Practice patterns of fluid resuscitation varied in the USA, depending on patient characteristics, clinical specialties, and practice settings of the treating physicians.

Using economic data to reduce healthcare-acquired infection

In this issue Burns et al. report an estimate of the economic loss to Auckland City Hospital from cases of healthcare-associated bloodstream infection. They show that patients with infection stay longer in hospital and this must impose an opportunity cost because beds are blocked. Harder to measure costs fall on patients, their families and non-acute health services. Patients face some risk of dying from the infection.

Cost-effectiveness of hospital infection control interventions in resource-limited settings

The aim of this project was to evaluate the cost-effectiveness of hand hygiene interventions in resource-limited hospital settings. Using data from north-east Thailand, the research found that such interventions are likely to be very cost-effective in intensive care unit settings as a result of reduced incidence of methicillin-resistant Staphylococcus aureus bloodstream infection alone. This study also found evidence showing that the World Health Organization's (WHO) multimodal intervention is effective and when adding either goal-setting, reward incentives, or accountability strategies to the WHO intervention, compliance could be further improved.

Staphylococcus epidermidis as a cause of bacteremia

Staphylococcus epidermidis is a biofilm-producing commensal organism found ubiquitously on human skin and mucous membranes, as well as on animals and in the environment. Biofilm formation enables this organism to evade the host immune system. Colonization of percutaneous devices or implanted medical devices allows bacteria access to the bloodstream. Isolation of this organism from blood cultures may represent either contamination during the blood collection procedure or true bacteremia. S. epidermidis bloodstream infections may be indolent compared with other bacteria. Isolation of S. epidermidis from a blood culture may present a management quandary for clinicians. Over-treatment may lead to patient harm and increases in healthcare costs. There are numerous reports indicating the difficulty of predicting clinical infection in patients with positive blood cultures with this organism. No reliable phenotypic or genotypic algorithms currently exist to predict the pathogenicity of a S. epidermidis bloodstream infection. This review will discuss the latest advances in identification methods, global population structure, pathogenicity, biofilm formation, antimicrobial resistance and clinical significance of the detection of S. epidermidis in blood cultures. Previous studies that have attempted to discriminate between invasive and contaminating strains of S. epidermidis in blood cultures will be analyzed.

Controlled exposure as a management tool for Glasser's disease.

In this study, nasal swabs taken from multiparous sows at weaning time or from sick pigs displaying symptoms of Glasser's disease from farms in Australia [date not given] were cultured and analysed by polymerase chain reaction (PCR). Within each genotype detected on a farm, representative isolates were serotyped by gel diffusion (GD) testing or indirect haemagglutination (IHA) test. Isolates which did not react in any of the tests were regarded as non-typable and were termed serovar NT. Serovars 1, 5, 12, 13 and 14 were classified as highly pathogenic; serovars 2, 4 and 15 being moderately pathogenic; serovar 8 being slightly pathogenic and serovars 3, 6, 7, 9 and 11 being non-pathogenic. Sows were inoculated with the strain of Haemophilus parasuis (serovars 4, 6 and 9 from Farms 1, 2 and 4, respectively) used for controlled challenge 3 and 5 weeks before farrowing. Before farrowing the sows were divided into control and treatment groups. Five to seven days after birth, the piglets of the treatment group were challenged with a strain from the farm which had were used to vaccinate the sows. The effectiveness of the controlled exposure was evaluated by number of piglets displaying clinical signs possibly related to infection, number of antibiotic treatments and pig mortality. Nasal swabs of sick pigs were taken twice a week to find a correlation to infection. A subsample of pigs was weighed after leaving the weaning sheds. The specificity of a realtime PCR amplifying the infB gene was evaluated with 68 H. parasuis isolates and 36 strains of closely related species. 239 samples of DNA from tissues and fluids of 16 experimentally challenged animals were also tested with the realtime PCR, and the results compared with culture and a conventional PCR. The farm experiments showed that none of the controlled challenge pigs showed any signs of illness due to Glasser's disease, although the treatment groups required more antibiotics than the controls. A total of 556 H. parasuis isolates were genotyped, while 150 isolates were serotyped. H. parasuis was detected on 19 of 20 farms, including 2 farms with an extensive history of freedom from Glasser's disease. Isolates belonging to serovars regarded as potentially pathogenic were obtained from healthy pigs at weaning on 8 of the 10 farms with a history of Glasser's disease outbreaks. Sampling 213 sick pigs yielded 115 isolates, 99 of which belonged to serovars that were either potentially pathogenic or of unknown pathogenicity. Only 16 isolates from these sick pigs were of a serovar known to be non-pathogenic. Healthy pigs also had H. parasuis, even on farms free of Glasser's disease. The realtime PCR gave positive results for all 68 H. parasuis isolates and negative results for all 36 non-target bacteria. When used on the clinical material from experimental infections, the realtime PCR produced significantly more positive results than the conventional PCR (165 compared to 86).

Acinetobacter spp.: resistência a antimicrobianos, genotipagem e dinâmica da colonização em CTI de um Hospital Universitário um ano de estudo

As espécies do gênero Acinetobacter são freqüentes no ambiente, mas nas últimas décadas vêm se destacando como patógenos hospitalares, especialmente Acinetobacter baumannii e as genoespécies 3 e 13TU, que formam o Complexo A. baumannii e cuja diferenciação só é possível pela utilização de metodologias moleculares. São associadas a diferentes apresentações clínicas, principalmente em pacientes internados em unidades de tratamento intensivo. Freqüentemente apresentam resistência a uma ampla variedade de antimicrobianos, incluindo os carbapenêmicos. Nestes casos as opções de tratamento podem, algumas vezes, limitar-se à polimixina. Esse trabalho objetivou avaliar a susceptibilidade a antimicrobianos, a diversidade genética e a dinâmica de colonização de Acinetobacter spp. isolados de pacientes internados no Centro de Tratamento Intensivo do Hospital Universitário Pedro Ernesto em um ano de estudo. Durante o ano de 2009 foram estudadas 76 amostras de Acinetobacter spp. isoladas de 34 pacientes, sendo a maioria obtida do trato respiratório (42,1 %), seguido de sangue (19,7%). Do total, 96,1% (73) foram identificadas como A. baumannii através da detecção do gene intrínseco blaOXA-51-like. Todas as amostras de A. baumannii foram produtoras da carbapenemase OXA-23 e apresentaram perfil de multirresistência, enquanto as três espécies não-baumannii foram sensíveis a todos os antimicrobianos testados. Não houve produto de amplificação para os genes blaOXA-24-like, blaOXA-58-like e blaOXA-143 pela técnica de PCR multiplex. As amostras apresentaram taxa de resistência maior que 70% para oito dos onze antimicrobianos testados: piperacilina-tazobactam, ceftazidima, cefotaxima, cefepime, amicacina, ciprofloxacina, imipenem e meropenem. A droga com melhor atividade in vitro foi a polimixina B. Quatro amostras foram resistentes com CIM determinada pelo E-test variando de 6 g/mL a 32 g/mL. Observou-se uma grande diversidade genética dentre as amostras, com dez grupos clonais identificados pelo PFGE. O grupo clonal B foi prevalente e persistente na unidade, representado por 32 (42,1%) amostras. Esse foi o mesmo clone descrito como o mais freqüente no Rio de Janeiro em estudo prévio. O clone associado a um surto ocorrido na mesma instituição entre 2007 e 2008 esteve presente em apenas sete (9,2%) amostras, tendo sido substituído pelo genótipo B. A análise prospectiva dos pacientes que permaneceram internados por pelo menos um mês mostrou casos de substituição clonal após terapia antimicrobiana, indicando a existência de reservatório ambiental dos genótipos circulantes. A colonização do trato respiratório por A. baumannii foi bastante comum, mas também foram observados casos de substituição de uma espécie não-baumannii por A. baumannii, além de infecção de corrente sanguínea por um genótipo diferente daquele responsável pela colonização. A presença de cepas resistentes à polimixina é preocupante, pois representa uma ameaça à terapia com a droga. A existência de um clone multirresistente disseminado no Rio de Janeiro, possivelmente pela transferência de pacientes e por profissionais que trabalham em mais de um hospital, aponta a necessidade de se adotar medidas de controle de infecção mais eficazes a fim de reduzir as taxas de morbidade e mortalidade. Além disso, a identificação de focos ambientais de dispersão das cepas epidêmicas parece essencial para garantir a eficácia das demais medidas de contenção de surtos