Sonication of removed breast implants for improved detection of subclinical infection.

BACKGROUND: Capsular fibrosis is a severe complication after breast implantation with an uncertain etiology. Microbial colonization of the prosthesis is hypothesized as a possible reason for the low-grade infection and subsequent capsular fibrosis. Current diagnostic tests consist of intraoperative swabs and tissue biopsies. Sonication of removed implants may improve the diagnosis of implant infection by detachment of biofilms from the implant surface. METHODS: Breast implants removed from patients with Baker grades 3 and 4 capsular contracture were analyzed by sonication, and the resulting sonication fluid was quantitatively cultured. RESULTS: This study investigated 22 breast implants (6 implants with Baker 3 and 16 implants with Baker 4 capsular fibrosis) from 13 patients. The mean age of the patients was 49 years (range, 31-76 years). The mean implant indwelling time was 10.4 years (range, 3 months to 30 years). Of the 22 implants, 12 were used for breast reconstruction and 10 for aesthetic procedures. The implants were located subglandularly (n = 12), submuscularly (n = 6), and subcutaneously (n = 4). Coagulase-negative staphylococci, Propionibacterium acnes, or both were detected in the sonication fluid cultures of nine implants (41%), eight of which grew significant numbers of microorganisms (>100 colonies/ml of sonication fluid). CONCLUSIONS: Sonication detected bacteria in 41% of removed breast implants. The identified bacteria belonged to normal skin flora. Further investigation is needed to determine any causal relation between biofilms and capsular fibrosis.

Étude de prévention de la thrombose veineuse associée au cathéter veineux central de type PICC chez les patients en oncologie recevant une chimiothérapie

Nous avons mené une étude prospective randomisée dans le but de comparer l'effet de l'irrigation du cathéter de type PICC avec deux types d'anticoagulants: Héparine standard et Tinzaparine, une héparine de faible poids moléculaire. Notre étude s'adresse aux patients de la clinique externe d'oncologie de l'hôpital Maisonneuve-Rosemont. Entre début Mai 2005 et Mars 2008, nous avons recruté 131 patients dont 70 ont été randomisés. Parmi les 61 patients exclus, 23 n'ont pas rencontré les critères d'inclusion, 30 ont refusé de participer et 8 ne sont pas inclus pour d'autres raisons. Sur les 70, 36 sujets sont randomisés dans le groupe Héparine standard et 34 dans le groupe Tinzaparine. La population en intention de traiter comprend 65 sujets dont 32 dans le groupe Héparine standard et 33 dans le groupe Tinzaparine. Le médicament a été administré pendant un mombre maximal de 30 jours et les sujets ont été suivis pendant 90 jours. La thrombose veineuse associée au cathéter (TVAC) a été objectivée par une phlébographie ou une échographie-Doppler à la fin de la période de 30 jours suivant l'installation du cathéter. L'incidence de la TVAC sur 30 jours est de 14,39 par 1000 cathéter-jours (IC à 95%:[9,0;19,79]/1000 cathéter-jours ou 41,5% (27/65). L'incidence de la thrombose veineuse profonde (TVP) symptômatique du membre supérieur sur la période de suivi de 90 jours est de 0,41 par 1000 cathéter-jours (IC à 95%:[0,08;0,81]/1000 cathéter-jours ou 3% (2/65). Nous n'avons observé aucune différence entre les deux groupes par rapport à la fréquence de la TVAC ni de la TVP. Nous ne pouvons conclure à une différence dans l'efficacité de la Tinzaparine par rapport à l'Héparine standard dans la prévention de la TVAC.

Factores asociados a calidad de vida en pacientes de hemodiálisis incidentes y prevalentes

Introducción: la insuficiencia renal crónica IRC ha aumentado su prevalencia en los últimos años pasando de 44.7 pacientes por millón en 1993 a 538.46 pacientes por millón en 2010, los pacientes quienes reciben terapia de remplazo renal hemodiálisis en Colombia cada vez tienen una mayor sobrevida. El incremento de los pacientes y el incremento de la sobrevida nos enfocan a mejorar la calidad de vida de los años de diálisis. Metodología: se comparó la calidad de vida por medio del SF-36 en 154 pacientes con IRC estadio terminal en manejo con hemodiálisis, 77 pacientes incidentes y 77 pacientes prevalentes, pertenecientes a una unidad renal en Bogotá, Colombia. Resultados: se encontró una disminución de la calidad de vida en los componentes físicos (PCS) y metales (MCS) de los pacientes de hemodiálisis en ambos grupos. En el modelo de regresión logística la incapacidad laboral (p=0.05), el uso de catéter (p= 0,000), el bajo índice de masa corporal (p=0.021), la hipoalbuminemia (p=0,033) y la anemia (p=0,001) fueron factores determinantes en un 78,9% de baja calidad de vida de PCS en los pacientes incidentes con respecto a los prevalentes. En el MCS de los pacientes incidentes vs. Prevalentes se encontró la hipoalbuminemia (p=0.007), la anemia (p=0.001) y el acceso por catéter (p=0.001) como factores determinantes en un 70.6% de bajo MCS Conclusiones: la calidad de vida de los pacientes de diálisis se encuentra afectada con mayor repercusión en el grupo de los pacientes incidentes, se debe mejorar los aspectos nutricionales, hematológicos y de acceso vascular en este grupo.

Factores asociados con infección por catéter central en UCI Clínica San Pedro Claver de junio a diciembre de 2004.

La infección asociada a inserción de catéter vascular, es un problema cotidiano en las UCI a nivel mundial, a pesar del manejo de protocolos que se han implementado de manera independiente en las distintas instituciones para frenar este fenómeno. El estudio, de tipo observacional, analítico y cohorte concurrente, con 151 pacientes, a los cuales se insertó catéter en la UCI de la Clínica San Pedro Claver.Para el análisis se realizó estadística descriptiva, análisis de sobrevida, pruebas de asociación y regresión de Cox.

Osteomielitis esternal: utilidad de las pruebas de diagnóstico por imágenes con enfoque en medicina nuclear

Introducción: El diagnóstico de osteomielitis esternal post-esternotomía resulta difícil empleando síntomas clínicos o de laboratorio y las imágenes morfológicas orientan a sospecha más que al diagnóstico. Un diagnóstico precoz ofrece calidad de vida y el mejor tratamiento para reducir una mortalidad que oscila entre 14% y 47%. La gammagrafía con leucocitos marcados ofrece el mejor rendimiento diagnóstico para infecciones y se destaca como el patrón de oro diagnóstico. Objetivo: Identificar el desempeño y utilidad de la gammagrafía con leucocitos autólogos marcados con 99mTc-HMPAO en los estudios realizados para la evaluación de osteomielitis esternal. Materiales y métodos: Se realizó un estudio descriptivo, retrospectivo de prueba diagnóstica en la Fundación Cardioinfantil de Bogotá entre enero/2010 y mayo/2015 evaluando gammagrafías con leucocitos marcados ante la sospecha de osteomielitis posterior a esternotomía. Resultados: Se evaluaron 52 pacientes, en los que la gammagrafía con leucocitos mostró 23 pacientes (44,2%) con osteomielitis esternal, logrando una sensibilidad y especificidad del 88,46% y 100% respectivamente. El valor predictivo positivo fue de 100%, y el valor predictivo negativo fue de 89,66%. El impacto de una prueba negativa no modificó el manejo médico inicial en el 93% de los casos mientras que una prueba positiva lo modificó en el 83%. Conclusiones: La gammagrafía con leucocitos autólogos radiomarcados con 99mTc-HMPAO continúa siendo el patrón de oro de referencia no invasiva para el diagnóstico de osteomielitis, y en el caso de osteomielitis esternal se convierte en la prueba de elección pertinente en la selección de pacientes que ameritan una re-intervención quirúrgica.

Trombosis asociada a cateter venoso central en pediatría de la Fundación Cardioinfantil julio 2013 a julio 2015

La trombosis relacionada al uso del catéter es un problema que cobra cada vez mayor importancia. Se han descrito factores de riesgo para su presentación en la población pediátrica pero aún no se han realizado estudios en nuestro medio. Objetivo: Determinar los factores de riesgo y la prevalencia de la trombosis asociada a catéter venoso central en los pacientes pediátricos de la Fundación Cardioinfantil hospitalizados durante el periodo comprendido entre Julio 2013 a Julio 2015. Metodología: Se realizó un estudio de corte transversal de asociación. Se incluyeron pacientes clasificados en 4 grupos: trombosis y catéter, trombosis sin catéter, catéter sin trombosis y sin trombosis ni catéter. Se estimaron OR como medidas de asociación utilizando el estadístico mantel haenszel. Resultados: En total se incluyeron 221 pacientes. La prevalencia de la trombosis y uso del catéter fue del 22%. La edad inferior a los 36 meses (OR 2,27 IC95% 1,16-4,44,p<0.001), profilaxis antitrombótica (OR 34,4 IC95% 4,18-282,92, p<0.01), hospitalización en la UCI (OR 3,82, IC95% 1,69-8,65, p<0.001) y el tiempo de hospitalización (OR 16,83 IC95% 7,8-36,27, p<0.001) están asociadas con un mayor riesgo de presentación de la trombosis. Conclusión: La edad, hospitalización en UCI, uso de profilaxis antitrombótica y el tiempo de hospitalización son factores de riesgo que estan relacionados con la presentación de la trombosis en pacientes con cateter.

Enhanced classification of Chagas serologic results and epidemiologic characteristics of seropositive donors at three large blood centers in Brazil

BACKGROUND: A major problem in Chagas disease donor screening is the high frequency of samples with inconclusive results. The objective of this study was to describe patterns of serologic results among donors to the three Brazilian REDS-II blood centers and correlate with epidemiologic characteristics. STUDY DESIGN AND METHODS: The centers screened donor samples with one Trypanosoma cruzi lysate enzyme immunoassay (EIA). EIA-reactive samples were tested with a second lysate EIA, a recombinant-antigen based EIA, and an immunfluorescence assay. Based on the serologic results, samples were classified as confirmed positive (CP), probable positive (PP), possible other parasitic infection (POPI), and false positive (FP). RESULTS: In 2007 to 2008, a total of 877 of 615,433 donations were discarded due to Chagas assay reactivity. The prevalences (95% confidence intervals [CIs]) among first-time donors for CP, PP, POPI, and FP patterns were 114 (99-129), 26 (19-34), 10 (5-14), and 96 (82-110) per 100,000 donations, respectively. CP and PP had similar patterns of prevalence when analyzed by age, sex, education, and location, suggesting that PP cases represent true T. cruzi infections; in contrast the demographics of donors with POPI were distinct and likely unrelated to Chagas disease. No CP cases were detected among 218,514 repeat donors followed for a total of 718,187 person-years. CONCLUSION: We have proposed a classification algorithm that may have practical importance for donor counseling and epidemiologic analyses of T. cruzi-seroreactive donors. The absence of incident T. cruzi infections is reassuring with respect to risk of window phase infections within Brazil and travel-related infections in nonendemic countries such as the United States.

Identification and antimicrobial susceptibility of Staphylococcus from home-treated peritoneal dialysis patients

Staphylococcus aureus is the main agent of infections during peritoneal dialysis (PD). The presence of S. aureus in the nasal cavity has been extensively studied and suggested as a risk factor of dialysis-related infections, whereas coagulase-negative Staphylococcus (CNS) species are frequently considered part of the normal human microbiota. The aim of this study was to identify Staphylococcus in the nasal cavity, pericatheter skin and peritoneal effluent from PD patients, as well as to evaluate the antimicrobial activity evolution in vitro. Thirty-two chronic PD patients were observed during 12 months and had nasal and pericatheter skin samples collected for culture. When peritonitis was detected, samples were also collected from the peritoneal effluent for culture. The activity of several antimicrobial drugs (penicillin G, oxacillin, cephalothin, ofloxacin, netilmicin and vancomycin) against different Staphylococcus species was measured by using the agar drug diffusion assay (Kirby-Bauer method). Staphylococcus was separated into S. aureus, S. epidermidis and other CNS species in order to determine the in vitro resistance level. S. epidermidis resistance to oxacillin progressively increased during the study period (p < 0.05). Resistance to ofloxacin was inexpressive, whereas resistance to netilmicin and vancomycin was not detected. of the oxacillin-resistant species (n = 74), 83% were S. epidermidis, 13% other CNS and 4% S. aureus (p < 0.05). Regarding multidrug resistant strains (n = 45), 82% were S. epidermidis, 13% other CNS, and 5% S. aureus (p < 0.05). This study shows the relevance of resistance to oxacillin and CNS multi-drug resistance, particularly concerning S. epidermidis, in PD patients.

Fondaparinux em intervenção coronária percutânea no tratamento da síndrome coronária aguda

Background: Fondaparinux is considered an agent with a well-established safety and efficacy profile in the treatment of non-ST segment elevation acute coronary syndromes, but when used alone, is associated to a higher incidence of thrombotic complications during invasive coronary procedures, requiring the supplementation of an anti-IIa agent. This study aimed to evaluate the efficacy and safety of percutaneous coronary intervention (PCI) in patients with non-ST segment elevation acute coronary syndromes previously treated with fondaparinux. Methods: Prospective, controlled registry enrolling 127 consecutive patients submitted to an early invasive stratification during treatment with fondaparinux, with supplementation of intravenous unfractionated heparin at a dose of 85 U/kg at the time of PCI. Results: The rate of the composite primary endpoint including death, acute myocardial infarction, stroke, stent thrombosis or emergency myocardial revascularization was 3.2%. The cumulative incidence of major bleeding and vascular complications was 3.2%. There were no cases of guidecatheter thrombosis or abrupt vessel closure. Conclusions: PCI in patients with acute coronary syndromes receiving fondaparinux is associated with a low rate of major adverse cardiovascular ischemic events and severe hemorrhagic complications. Supplementation of unfractionated heparin during the invasive procedures eliminates the risk of catheter-related thrombosis.

Caracterização venosa central em crianças internadas em Unidades de Terapia Intensiva pediátrica

Pós-graduação em Pediatria - FMB

Percepções de profissionais que atuam em unidade de terapia intensiva sobre a ocorrência de infecções relacionadas à assistência

Pós-graduação em Enfermagem (mestrado profissional) - FMB

Investigação dos polimorfismos no éxon 1 do gene MBL (Mannose-Binding Lectin) e sua associação com a síndrome da imunodeficiência adquirida (AIDS)

No presente estudo foram investigadas as freqüências das mutações no éxon 1 do gene MBL em um grupo de 128 pacientes com Aids, 116 portadores assintomáticos da infecção pelo HIV-1, 84 mulheres soronegativas profissionais do sexo, com comportamentos de alto risco e 99 indivíduos controles soronegativos, com o objetivo de avaliar a ocorrência de uma possível associação entre os polimorfismos neste gene e a infecção pelo HIV-1. A identificação dos alelos MBL *A, *B, *C e *D foi realizada por meio da reação em cadeia mediada pela polimerase, utilizando sequências de iniciadores específicos e posterior digestão enzimática (RFLP). As análises das frequências alélicas e genotípicas do éxon 1 não mostraram qualquer diferença significativa entre pacientes soropositivos (assintomáticos e Aids) e soronegativos (controle e controle de alto risco) (p>0,05). Não foram observadas associações significativas entre a presença de co-infecções e as variantes alélicas. Entretanto, tuberculose, neurotoxoplasmose, candidíase, neurocriptococose e pneumonia foram as co-infecções com maior prevalência. As associações entre o número de linfócitos TCD4+, a carga viral plasmática e os polimorfismos no éxon 1 do gene MBL nos pacientes com Aids e portadores assintomáticos não foram estatisticamente significante. Desse modo, pode-se sugerir a ausência de associação entre estes polimorfismos e a susceptibilidade à infecção pelo HIV-1, destacando a necessidade de estudos adicionais para determinar se estes polimorfismos apresentam qualquer impacto associado à infecção ou a progressão para a Aids.

Low serum potassium levels increase the infectious-caused mortality in peritoneal dialysis patients: a propensity-matched score study

Background and ObjectivesHypokalemia has been consistently associated with high mortality rate in peritoneal dialysis. However, studies investigating if hypokalemia is acting as a surrogate marker of comorbidities or has a direct effect in the risk for mortality have not been studied. Thus, the aim of this study was to analyze the effect of hypokalemia on overall and cause-specific mortality.Design, Setting, Participants and MeasurementsThis is an analysis of BRAZPD II, a nationwide prospective cohort study. All patients on PD for longer than 90 days with measured serum potassium levels were used to verify the association of hypokalemia with overall and cause-specific mortality using a propensity match score to reduce selection bias. In addition, competing risks were also taken into account for the analysis of cause-specific mortality.ResultsThere was a U-shaped relationship between time-averaged serum potassium and all-cause mortality of PD patients. Cardiovascular disease was the main cause of death in the normokalemic group with 133 events (41.8%) followed by PD-non related infections, n=105 (33.0%). Hypokalemia was associated with a 49% increased risk for CV mortality after adjustments for covariates and the presence of competing risks (SHR 1.49; CI95% 1.01-2.21). In contrast, in the group of patients with K < 3.5mEq/L, PD-non related infections were the main cause of death with 43 events (44.3%) followed by cardiovascular disease (n=36; 37.1%). For PD-non related infections the SHR was 2.19 (CI95% 1.52-3.14) while for peritonitis was SHR 1.09 (CI95% 0.47-2.49).ConclusionsHypokalemia had a significant impact on overall, cardiovascular and infectious mortality even after adjustments for competing risks. The causative nature of this association suggested by our study raises the need for intervention studies looking at the effect of potassium supplementation on clinical outcomes of PD patients.

Systemic lupus erythematous and clinical outcomes in peritoneal dialysis

Background: The prevalence of systemic lupus erythematous (SLE) patients requiring renal replacement therapy (RRT) is increasing but data on clinical outcomes are scarce. Interestingly, data on technique failure and peritoneal-dialysis (PD)-related infections are rarer, despite SLE patients being considered at high risk for infections. The aim of our study is to compare clinical outcomes of SLE patients on PD in a large PD cohort. Methods: We conducted a nationwide prospective observational study from the BRAZPD II cohort. For this study we identified all patients on PD for greater than 90 days. Within that subset, all those with SLE as primary renal disease were matched with PD patients without SLE for comparison of clinical outcomes, namely: patient mortality, technique survival and time to first peritonitis, then were analyzed taking into account the presence of competing risks. Results: Out of a total of 9907 patients, we identified 102 SLE patients incident in PD and with more than 90 days on PD. After matching the groups consisted of 92 patients with SLE and 340 matched controls. Mean age was 46.9 +/- 16.8 years, 77.3% were females and 58.1% were Caucasians. After adjustments SLE sub-hazard distribution ratio for mortality was 1.06 (CI 95% 0.55-2.05), for technique failure was 1.01 (CI 95% 0.54-1.91) and for time to first peritonitis episode was 1.40 (CI 95% 0.92-2.11). The probability for occurrence of competing risks in all three outcomes was similar between groups. Conclusion: PD therapy was shown to be a safe and equally successful therapy for SLE patients compared to matched non-SLE patients.

Patologia ed epidemiologia molecolare delle infezioni associate all'impianto

Staphylococcus aureus and Staphylococcus epidermidis are leading pathogens of implant-related infections. This study aimed at investigating the diverse distribution of different bacterial pathogen factors in most prevalent S. aureus and S. epidermidis strain types causing orthopaedic implant infections. In this study the presence both of the ica genes, encoding for biofilm exopolysaccharide production, and the insertion sequence IS256, a mobile element frequently associated to transposons, was investigated in relationship with the prevalence of antibiotic resistance among Staphylococcus epidermidis strains. The investigation was conducted on 70 clinical isolates derived from orthopaedic implant infections. Among the clinical isolates investigated a dramatic high level of association was found between the presence of ica genes as well as of IS256 and multiple resistance to all the antibiotics tested. Noteworthy, a striking full association between the presence of IS256 and resistance to gentamicin was found, being none of the IS256-negative strain resistant to this antibiotic. This association is probably because of the link of the corresponding aminoglycoside-resistance genes, and IS256, often co-existing within the same staphylococcal transposon. Moreover we investigated the prevalence of aac(6’)-Ie-aph(2’’), aph (3’) IIIa, and ant(4’) genes, encoding for the three forms of aminoglycoside-modifying enzymes (AME), responsible for resistance to aminoglycoside antibiotics. All isolates were characterized by automated ribotyping, so that the presence of antibiotic resistance determinants was investigated in strains exhibiting different ribopatterns. Interestingly, combinations of coexisting AME genes appeared to be typical of specific ribopatterns. 200 S. aureus isolates, categorized into ribogroups by automated ribotyping, i.e. rDNA restriction fragment length polymorphism analysis, were screened for the presence of a panel of adhesins genes, accessory gene regulatory (agr) polymorphisms and toxins. For many ribogroups, characteristic tandem genes arrangements could be identified. Surprisingly, the isolates of the most prevalent cluster, enlisting 27 isolates, were susceptible to almost all antibiotics and never possessed the lukD/lukE gene, thus suggesting the role of factors other than antibiotic resistance and the here investigated toxins in driving the major epidemic clone to the larger success. Afterwards, .in the predominant S. aureus cluster, the bbp gene encoding bone sialoprotein-binding protein appeared a typical virulence trait, found in 93% of the isolates. Conversely, the bbp gene was identified in just 10% of the remaining isolates of the collection. In this cluster, co-presence of bbp with the cna gene encoding collagen adhesin was a pattern consistently observed. These findings indicate a crucial role of both these adhesins, able to bind the most abundant bone proteins, in the pathogenesis of orthopaedic implant infections, there where biomaterials interface bone tissues. Moreover a PCR screening for the ebpS gene, conducted on over two hundred S. aureus clinical isolates from implant related infections revealed the detection of six strains exhibiting an altered amplicon size, shorter than expected. In order to elucidate the sequence changes present in these gene variants, the trait comprised between the primers was analyzed in all six isolates bearing the modification and in four isolates exhibiting the regular amplicon size. From nucleotide translation, the corresponding encoded protein was found to lack an entire peptide segment of 60 amino acids. These variants, missing an entire hydrophobic region, could actually facilitate current structural studies, helping to assess whether the absent domain is strictly necessary for a functional adhesin conformation and its contribution to the topology of the protein. This study suggests that epidemic clones appear to pursue different survival strategies, where adhesins, when present, exhibit diverse importance as virulence factors. A practical message arising from the present study is that strategies for the prevention and treatment of implant orthopaedic infections should target adhesins conjointly present in epidemic clones. Furthermore, the choice of reference strains for testing the anti-infective properties of biomaterials should focus on a selection of the most prevalent clones as they exhibit distinct profiles of adhesins.