Epidemiology of healthcare-associated infections among patients from a hemodialysis unit in southeastern Brazil

Patients submitted to hemodialysis are at a high risk for healthcare-associated infections (HAI). Presently there are scarce data to allow benchmarking of HAI rates in developing countries. Also, most studies focus only on bloodstream infections (BSI) or local access infections (LAI). Our study aimed to provide a wide overview of HAT epidemiology in a hemodialysis unit in southeastern Brazil. We present data from prospective surveillance carried out from March 2010 through May 2012. Rates were compared (mid-p exact test) and temporally analyzed in Shewhart control charts for Poisson distributions. The overall incidence of BSI was 1.12 per 1000 access-days. The rate was higher for patients performing dialysis through central venous catheters (CVC), either temporary (RR = 13.35, 95% CI = 6.68-26.95) or permanent (RR = 2.10,95% CI = 1.09-4.13), as compared to those with arteriovenous fistula. Control charts identified a BSI outbreak caused by Pseudomonas aeruginosa in April 2010. LAI incidence was 3.80 per 1000 access-days. Incidence rates for other HAI (per 1000 patients-day) were as follows: upper respiratory infections, 1.72; pneumonia, 1.35; urinary tract infections, 1.25; skin/soft tissues infections, 0.93. The data point out to the usefulness of applying methods commonly used in hospital-based surveillance for hemodialysis units. (C) 2013 Elsevier Editora Ltda. All rights reserved.

Intervention to reduce C-reactive protein determination requests for acute infections at an emergency department

Introduction C-reactive protein (CRP) levels rise during inflammatory processes and have been ordered for rheumatic disease follow-up since the 1950s. The number of tests ordered in the emergency setting has increased, but without evident improvement in medical care quality. Objective To determine the pattern of CRP determinations in the emergency department (ED) of a university hospital in Sao Paulo, Brazil, and to evaluate the effect of an intervention with staff and students about the best use of the test in the ED. Methods Data regarding CRP testing requests, related diagnoses and the number of monthly consultations in the hospital ED were analysed before and after the intervention. Because of an increase in CRP measurement requests from 2007 to 2009, the author started discussing the role of CRP determinations in the medical decision-making process in early 2010. Staff and faculty members openly discussed the pattern of requests in the hospital and related current medical literature. During 2010, the medical staff worked as multipliers to change the behaviour of new students and residents. The results of the first 4 months after the intervention were presented at another general meeting in July 2010. Results From 2007 to 2009, there were 11 786 CRP measurement requests with a clear exponential trend. After the intervention, during the calendar year 2010, there was a 48% reduction in adjusted annual CRP requests. Pneumonia, fever and urinary tract infections were the most common reasons for CRP requests. Discussion Inexpensive, well-directed, interactive educational interventions may affect professional behaviour and curb rates of laboratory tests.

EFFECT OF COMPETITION ON SALIVARY CORTISOL, IMMUNOGLOBULIN A, AND UPPER RESPIRATORY TRACT INFECTIONS IN ELITE YOUNG SOCCER PLAYERS

Mortatti, AL, Moreira, A, Aoki, MS, Crewther, BT, Castagna, C, de Arruda, AFS, and Filho, JM. Effect of competition on salivary cortisol, immunoglobulin A, and upper respiratory tract infections in elite young soccer players. J Strength Cond Res 26(5): 1396-1401, 2012-The present study examined the effect of a 20-day period of competition on salivary cortisol, mucosal immunity, and upper respiratory tract infections (URTI) in young male soccer players (n = 14). The players were monitored during the main under-19 Brazilian soccer championship, in which 7 matches were played in 20 days. Saliva samples were collected in the morning of each match and analyzed for cortisol and immunoglobulin A (IgA). Signs and symptoms of URTI were assessed across the study and a rating of perceived exertion (RPE) was obtained for each match. Compared with match 1, a significant increase in player RPE was observed in matches 4-7 (p < 0.05). Significant (p < 0.05) increases in the reporting of URTI occurred between matches 2 and 3, and 6 and 7, and this was accompanied by significant decreases in salivary IgA levels. Significant (p < 0.05) correlations were also seen between the individual reports of URTI and the decrease in IgA levels in match 2 (r = -0.60) and match 6 (r = -0.65). These results suggest that decrements in mucosal immunity, as measured by salivary IgA concentrations, may lead to a greater incidence of URTI in elite young soccer players. It may be speculated that the physiological and psychological stressors imposed by training and competition in a short timeframe are major contributing factors to these responses. Thus, the monitoring of salivary IgA could provide a useful and noninvasive approach for predicting URTI occurrences in young athletes during short-term competitions, especially if frequent sampling and rapid measurements are made.

Immune expression of E-cadherin and alpha, beta and gamma-Catenin adhesion molecules and prognosis for upper urinary tract urothelial carcinomas

Introduction: Cell adhesion molecules (CAM) are required for maintaining a normal epithelial phenotype, and abnormalities in CAM expression have been related to cancer progression, including bladder urothelial carcinomas. There is only one study that correlates E-cadherin and alpha-, beta- and gamma-catenin expression with prognosis of upper tract urothelial carcinomas. Our aim is to study the pattern of immune expression of these CAMs in urothelial carcinomas from the renal pelvis and ureter in patients who have been treated surgically. Our goal is to correlate these expression levels and characteristics with well-known prognostic parameters for disease-free survival. Materials and Methods: We evaluated specimens from 20 patients with urothelial carcinomas of the renal pelvis and ureter who were treated with nephroureterectomy or ureterectomy between June 1997 and January 2007. CAM expression was evaluated by immunohistochemistry in a tissue microarray and correlated with histopathological characteristics and patient outcomes after a mean follow-up of 55 months. Results: We observed a relationship between E-cadherin expression and disease recurrence. Disease recurrence occurred in 87.5% of patients with strong E-cadherin expression. Only 50.0% of patients with moderate expression and 0% of patients with weak or no expression of E-cadherin had disease recurrence (p = 0.014). There was also a difference in disease-free survival. Patients with strong E-cadherin expression had a mean disease-free survival rate of 49.1 months, compared to 83.9 months for patients with moderate expression (p = 0.011). Additionally, an absence of a-catenin expression was associated with tumors that were larger than 3 cm (p = 0.003). Conclusions: We demonstrated for the first time that immune expression of E-cadherin is related to tumor recurrence and disease-free survival rates, and the absence of a-catenin expression is related to tumor size in upper tract urothelial carcinomas.

Effects of thoracic epidural analgesia on lower urinary tract function in women

The need for an indwelling transurethral catheter in patients with postoperative thoracic epidural analgesia (TEA) is a matter of controversy. Subjective observations are ambivalent and the literature addressing this issue is scarce. As segmental blockade can be achieved with epidural analgesia, we hypothesized that analgesia within segments T4-T11 has no or minimal influence on lower urinary tract function. Thus, we evaluated the effect of TEA on lower urinary tract function by urodynamic studies.

Mapping of a new locus for congenital anomalies of the kidney and urinary tract on chromosome 8q24

Congenital anomalies of the kidney and urinary tract (CAKUT) account for the majority of end-stage renal disease in children (50%). Previous studies have mapped autosomal dominant loci for CAKUT. We here report a genome-wide search for linkage in a large pedigree of Somalian descent containing eight affected individuals with a non-syndromic form of CAKUT.

Sacral neuromodulation for neurogenic lower urinary tract dysfunction: systematic review and meta-analysis

Context Treatment of neurogenic lower urinary tract dysfunction (LUTD) is a challenge, because conventional therapies often fail. Sacral neuromodulation (SNM) has become a well-established therapy for refractory non-neurogenic LUTD, but its value in patients with a neurologic cause is unclear. Objective To assess the efficacy and safety of SNM for neurogenic LUTD. Evidence acquisition Studies were identified by electronic search of PubMed, EMBASE, and ScienceDirect (on 15 April 2010) and hand search of reference lists and review articles. SNM articles were included if they reported on efficacy and/or safety of tested and/or permanently implanted patients suffering from neurogenic LUTD. Two reviewers independently selected studies and extracted data. Study estimates were pooled using Bayesian random-effects meta-analysis. Evidence synthesis Of the 26 independent studies (357 patients) included, the evidence level ranged from 2b to 4 according to the Oxford Centre for Evidence-Based Medicine. Half (n = 13) of the included studies reported data on both test phase and permanent SNM; the remaining studies were confined to test phase (n = 4) or permanent SNM (n = 9). The pooled success rate was 68% for the test phase (95% credibility interval [CrI], 50–87) and 92% (95% CrI, 81–98%) for permanent SNM, with a mean follow-up of 26 mo. The pooled adverse event rate was 0% (95% CrI, 0–2%) for the test phase and 24% (95% CrI, 6–48%) for permanent SNM. Conclusions There is evidence indicating that SNM may be effective and safe for the treatment of patients with neurogenic LUTD. However, the number of investigated patients is low with high between-study heterogeneity, and there is a lack of randomised, controlled trials. Thus, well-designed, adequately powered studies are urgently needed before more widespread use of SNM for neurogenic LUTD can be recommended.

Antegrade perfusion with bacillus Calmette-Guérin in patients with non-muscle-invasive urothelial carcinoma of the upper urinary tract: who may benefit?

There is paucity of data on bacillus Calmette-Guérin (BCG) perfusion in patients with non-muscle-invasive urothelial carcinoma (NMIUC) of the upper urinary tract (UUT).

CHD1L: a new candidate gene for congenital anomalies of the kidneys and urinary tract (CAKUT)

Recently, we identified a microduplication in chromosomal band 1q21.1 encompassing the CHD1L/ALC1 gene encoding a chromatin-remodelling enzyme in congenital anomalies of the kidneys and urinary tract (CAKUT) patient.

Sacral Neuromodulation for Refractory Lower Urinary Tract Dysfunction: Results of a Nationwide Registry in Switzerland

OBJECTIVE: To assess the efficacy and safety of sacral neuromodulation (SNM) in patients with refractory lower urinary tract dysfunction in Switzerland based on a nationwide registry. PATIENTS AND METHODS: A total of 209 patients (181 females, 28 males) underwent SNM testing between July 2000 and December 2005 in Switzerland. Subjective symptom improvement, bladder/pain diary variables, adverse events, and their management were prospectively registered. RESULTS: SNM testing was successful (defined as improvement of more than 50% in bladder/pain diary variables) in 102 of 209 patients (49%). An implantable pulse generator (IPG) was placed in 91 patients (89% of all successfully tested and 44% of all tested patients). Of the IPG-implanted patients, 71 had urge incontinence, 13 nonobstructive chronic urinary retention, and 7 chronic pelvic pain syndrome. After a median follow-up of 24 mo, SNM was successful in 64 of the 91 IPG-implanted patients (70%) but failed in 27 patients. SNM was continued in 15 of the 27 patients considered failures, because following troubleshooting SNM response improved subjectively and the patients were satisfied. However, improvement in bladder/pain diary variables remained less than 50%. In the other 12 patients both the leads and the IPG were explanted. During the test phase and during/following IPG implantation, 6% (12 of 209) and 11% (10 of 91) adverse event rates and 1% (3 of 209) and 7% (6 of 91) surgical revision rates were reported, respectively. CONCLUSIONS: SNM is an effective and safe treatment for refractory lower urinary tract dysfunction. Adverse events are usually transient and can be treated effectively.