Infection rate and risk factors associated with infections related to external ventricular drain

To describe incidence rates and risk factors associated with external ventricular drain (EVD)-related infections at a tertiary Brazilian teaching hospital. The patient cohort consisted of all patients at a major teaching hospital in Brazil with an EVD during the period 1 April 2007 to 30 June 2008 (15 months). Patients were followed up for 30 days after catheter removal. According to the Center for Diseases Control and Prevention criteria for meningitis/ventriculitis, all of the central nervous system (CNS) infections that occurred during this period could be considered to be meningitis or ventriculitis related to EVD placement. Infection rates were calculated using different denominators, such as (1) per patient (incidence), (2) per procedure, and (3) per 1,000 catheter-days (drain-associated infection rate). Patient demographic data, medical history of underlying diseases, antibiotic prophylaxis usage, American Society of Anesthesiologists Score classification, duration of surgery and hospitalization, length of time the EVD was in place, and overall mortality were evaluated during the study period. A logistic regression model was developed to identify factors associated with infection. A total of 119 patients, 130 EVD procedures, and 839 catheter-days were evaluated. The incidence of infection was 18.3%, the infection rate was 16.9% per procedure, and the drain-associated infection rate was 22.4 per 1,000 catheter-days; 77% of the infections were caused by Gram-negative micro-organisms. Only 75% of patients received antibiotic prophylaxis. The infection rate increased with length of the hospital stay. The length of time the catheter was in place was the only independent risk factor associated with infection (p = 0.0369). The incidence of EVD-related infections is high in our hospital, Gram-negative micro-organisms were the most frequent causal agents identified and length of time that the catheter was in place contributed to the infection rate.

Comparison of videolaparoscopic versus open surgery for benign renal diseases in children

Introduction: Laparoscopic nephrectomy in children has become a reasonable alternative to open nephrectomy and has replaced open surgery for many renal diseases. The purpose of our study is to evaluate transperitoneal videolaparoscopic procedures in renal benign diseases in comparison to an open surgery approach. Patients and methods: 34 children aged between 17 days and 15 years old (mean 6.14) were divided into two groups in order to be submitted to nephrectomy. The first one underwent transperitoneal videolaparoscopic nephrectomy and was composed by 21 patients aged from 2 months to 15 years (mean 7.42), from which 12 were females and 9 males. The second group was submitted to open nephrectomy and was composed by 13 patients aged from 17 days to 11 years (mean 3.91), 6 females and 7 males. The groups were compared regarding anesthesic time, operative time, length of hospital stay, postoperative pain and time of reintroduction of oral intake. Short and long term complications were also evaluated. Statistical analysis was performed by Student t-test with the level of significance set at P < 0.05. The study was previously approved by the Committee on Ethics in Research of our institution. Results: Significant statistical difference was observed only for the variable length of hospital stay. No laparoscopy group case was converted to open surgery. There was no immediate or late complication. Blood loss was negligible and no transfusion was required. Conclusions: In our experience, transperitoneal videolaparoscopic nephrectomy has similar results to open nephrectomy, except for time of hospitalization. (C) 2009 AEU. Published by Elsevier Espana, S.L. All rights reserved.

Declining rates of coronary heart disease in New Zealand and Australia, 1983-1993

The authors report the results of 10 years of monitoring of trends in the rates of major nonfatal and fatal coronary events and in case fatality in Auckland, New Zealand, and in Newcastle and Perth, Australia. Continuous surveillance of all suspected myocardial infarctions and coronary deaths in people aged 35-64 years was undertaken in the three centers as part of the World Health Organization's Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Project, For nonfatal definite myocardial infarction, there were statistically significant declines in rates in all centers in both men and women, with estimated average changes between 2.5% and 3.7% per year during the period 1984-1993, Rates of all coronary deaths also declined significantly in all three populations for both men and women. In absolute terms, there was, in general, a greater reduction in prehospital deaths than in deaths after hospitalization. Although 28-day case fatality remains high at between 35% and 50%, in the Australian centers it declined significantly by between 1.0% and 2.9% per year, and in Auckland there was also a small decline, However, since most deaths occur outside the hospital in people without a previous history of coronary heart disease, an increased emphasis on primary prevention is necessary.

A randomized comparative study of patients undergoing myocardial revascularization with or without cardiopulmonary bypass surgery: The MASS III Trial

The MASS III Trial is a large project from a single institution, The Heart Institute of the University of Sao Paulo, Brazil (InCor), enrolling patients with coronary artery disease and preserved ventricular function. The aim of the MASS III Trial is to compare medical effectiveness, cerebral injury, quality of life, and the cost-effectiveness of coronary surgery with and without of cardiopulmonary bypass in patients with multivessel coronary disease referred for both strategies. The primary endpoint should be a composite of cardiovascular mortality, cerebrovascular accident, nonfatal myocardial infarction, and refractory angina requiring revascularization. The secondary end points in this trial include noncardiac mortality, presence and severity of angina, quality of life based on the SF-36 Questionnaire, and cost-effectiveness at discharge and at 5-year follow-up. In this scenario, we will analyze the cost of the initial procedure, hospital length of stay, resource utilization, repeat hospitalization, and repeat revascularization events during the follow-up. Exercise capacity will be assessed at 6-months, 12-months, and the end of follow-up. A neurocognitive evaluation will be assessed in a subset of subjects using the Brain Resource Center computerized neurocognitive battery. Furthermore, magnetic resonance imaging will be made to detect any cerebral injury before and after procedures in patients who undergo coronary artery surgery with and without cardiopulmonary bypass.

Hip fracture prognosis: could bioimpedance be an alternative to conventional nutritional assessment?

Background: Risk-factors for mortality in hip fractures encompass nutritional status, nominally body mass index, but not body composition. Given the difficulty of anthropometric assessment in bedridden patients a prospective study with bioimpedance analysis was designed. Methods: Elderly patients with hip fracture were consecutively recruited. Biochemical tests, primitive bioimpedance measurements (resistance, reactance and phase angle) and follow-up till one year were targeted. Results: Patients (N = 69, 81.2 +/- 8.1 years old, 72.5% females) stayed in the hospital for 15.5 +/- 17.1 days, and 18.8 %(13/69) required further hospitalization during the ensuing months. Mortality was 11.6% within 30 days, coinciding with hospital mortality, and an additional 11.6% till one year, thus reaching 23.2%. Anemia, hypoalbuminemia and low transferrin, along with elevated glucose and urea were frequent, suggesting undernutrition with metabolic derangements. Reactance, urea and creatinine were different in patients suffering both early and late demise. Resistance, white blood cell count and osteoporosis were risk factors for early mortality only, and anemia exclusively for late mortality. Conclusions: Primitive bioimpedance measurements, which had not been hitherto investigated, were prognostically related to early and late mortality. These markers of disease-related malnutrition and especially reactance should be further studied in patients unfit for anthropometric evaluation due to fracture and immobility.

Controlling the clonal spread of Pseudomonas aeruginosa infection

To evaluate nosocomial infections due to imipenem-resistant and imipenem-susceptible Pseudomonas aeruginosa, a case-control study that included genotyping was performed. Hospitalization for more than 15 days was independently associated with infection with an imipenem-resistant organism. Sixty-seven percent of the imipenem-resistant isolates analyzed and 23% of the imipenem-susceptible isolates analyzed belonged to a single clone. Intervention led to a decrease in the number of infections due to imipenem-resistant and imipenem-susceptible P. aeruginosa.

Seven-year trend analysis of nosocomial candidemia and antifungal (fluconazole and caspofungin) use in Intensive Care Units at a Brazilian University Hospital

Candidemia is associated with high morbidity and mortality resulting in significant increases in the length of patients` hospitalization and in healthcare costs. Critically ill patients are at particular risk for candidemia because of their debilitated condition and frequent need for invasive procedures. The aim of this study was to characterize the incidence and epidemiology of candidemia over a seven-year period in intensive care units (ICUs) and the use of fluconazole and caspofungin in a large university-affiliated hospital. All cases of candidemia were identified by surveillance, using the Centers for Diseases Control and Prevention criteria. Demographic variables, use of antifungal (fluconazole and caspofungin) and patient outcomes were evaluated. The 2 test for linear trend was employed to evaluate the distribution of Candida spp. and the use of fluconazole and caspofungin by defined daily dose (DDD) per 1,000 patients-days during the study period. One hundred and eight episodes of candidemia were identified. The overall incidence of candidemia (P=0.20) and incidence of non-Candida albicans Candida infections (P=0.32) remained stable over the study period and ranged from 0.3-0.9 episodes per 1,000 catheter-days and 0.39-0.83 episodes per 1,000 patients-days. However, the use of fluconazole and caspofungin increased significantly (P0.001). While there were no reports of the use of fluconazole for prophylaxis in 1999, its use for this purpose increased from 3% in 2000 to 7.0% (P=0.07) in 2006. C. albicans was the most frequent specie isolated and burns and cancer were the most frequent underlying conditions. The overall mortality was 76%. There was no difference between C. albicans and non-C. albicans Candida infections when the crude and 14-day mortality rates were compared. Our data demonstrated that C. albicans is still the most frequent species causing candidemia in our intensive care units. Our rates of candidemia are lower than those reported from the region and similar to American and European hospitals. Although the incidence of blood stream infections (BSI) and candidemia remained stable, the use of fluconazole and caspofungin increased significantly over the years included in this study but had no impact on the incidence of infections caused by non-C. albicans Candida species.

Randomized Study of Surgical Prophylaxis in Immunocompromised Hosts

Although prophylaxis is current practice, there are no randomized controlled studies evaluating preoperative antimicrobial prophylaxis in dental procedures in patients immunocompromised by chemotherapy or organ transplants. To evaluate prophylaxis in dental-invasive procedures in patients with cancer or solid organ transplants, 414 patients were randomized to receive one oral 500-mg dose 2 hours before the procedure (1-dose group) or a 500-mg dose 2 hours before the procedure and an additional dose 8 hours later (2-dose group). Procedures were exodontia or periodontal scaling/root planing. Follow-up was 4 weeks. No deaths or surgical site infections occurred. Six patients (1.4%) presented with use of pain medication > 3 days or hospitalization during follow-up: 4 of 207 (2%) in the 1-dose group and 2 of 207 (1%) in the 2-dose group (relative risk, 2.02; 95% confidence interval, 0.37-11.15). In conclusion, no statistically significant difference occurred in outcome using 1 or 2 doses of prophylactic amoxicillin for invasive dental procedures in immunocompromised patients.

Five-year evaluation of bloodstream yeast infections in a tertiary hospital: the predominance of non-C. albicans Candida species

This is a retrospective observational study of clinical and epidemiologic data from bloodstream yeast infections over 5 years (2004-2008) in a tertiary-care hospital. During this period, there were 52 such infections, at a rate of 2.4 per 1,000 hospital admissions. Non-C. albicans Candida species and other genera were responsible for 82% of infections, with C. tropicalis and C. parapsilosis being the most common. In 2008 no C. albicans infections occurred. Several uncommon fungal pathogens were observed, including Trichosporon asahii, Rhodotorula spp. and Candida zeylanoides. Of 16 isolates tested, 3 (19%) were resistant to fluconazole, including one C. zeylanoides (MIC 8 mu g/ml) and one C. tropicalis (MIC 16 mu g/ml) isolate, as well as intrinsically resistant C. krusei. All isolates tested were susceptible to itraconazole (n = 7) and amphotericin B (n = 8). Yeast infections were associated with severe underlying diseases, mainly hematological/solid cancers (71%), hospitalization in the ICU (41%), central venous catheters (80%), and use of antimicrobials (94%). The overall mortality rate was 50%. Our finding of a predominance of non-C. albicans Candida species infection with uncommon yeasts, and fluconazole resistance, suggests the need for continuous surveillance of fungemia and of antibiotic susceptibility trends, in order to adopt treatment strategies applicable to particular healthcare institutions.

Two-stage transvaginal cervical length screening for preterm birth in twin pregnancies

Aim: To compare cervical length (CL) at 18-21 and 22-25 weeks` gestation in twin pregnancies in prediction of spontaneous preterm delivery and to examine cervical shortening. Methods: Retrospective cohort study of CL measured at 18-21 and 22-25 weeks` gestation in twin pregnancies. Results: Receiver operating characteristics (ROC) curve revealed area of 0.64 (95% CI 0.53-0.75) and 0.80 (95% CI 0.72-0.88) for measurements at 18-21 and 22-25 weeks, respectively (P <= 0.001). Sensitivities of 33.3% and 23% and negative predicting value (NPV) of 97.3% and 86.8% for delivery at <28 and <34 weeks gestation were reached for measurements at 18-21 weeks. Sensitivities of 71.4% and 38.2% and NPV of 99.1% and 91.4% for delivery at <28 and <34 weeks` gestation were reached for measurements at 22-25 weeks. Cervical length shortening analysis showed an area under ROC curve of 0.81 (95% CI 0.73-0.89) and best cut-off was at >= 2 mm/week. Sensitivities of 80% and 60.8% and NPV of 98.9% and 90.6% for delivery at <28 and <34 weeks gestation were reached. Conclusions: In twin gestations, assessment of CL at 22-25 weeks is better than assessment at 18-21 weeks to predict preterm delivery before 34 weeks. Cervical shortening at a rate of >= 2 mm/weeks between 18 and 25 weeks gestation was a good predictor of spontaneous preterm birth in this high-risk population.

Genitoperineal Injuries Associated With the Use of an Orthopedic Table With a Perineal Posttraction

Background: Surgical treatment of lower extremity fractures commonly involves the use of orthopedic table with perineal post for countertraction. However, prolonged application of the perineal post has been associated with significant complications. We describe our experience in the management of genitoperineal cutaneous injuries associated with the use of a traction table. Methods: Six patients with genitoperineal complications attributed to the use of a traction table were treated at our institution over a period of 2 years. The patient`s median age was 25 (range, 2028) years and all had fractures caused by motor vehicle collision. We evaluated the clinical presentation of these perineal injuries, operative time, therapeutic approach, clinical outcomes, and hospitalization time. Results. The mean operative time of the orthopedic surgery was 318 minutes 128 minutes (range, 185-540). All patients developed a partial-thickness necrotic area involving the perineum and scrotum in 2 days to 15 days (mean, 7 +/- 5.4) after the surgery. Three patients developed infection of the necrotic tissue. All patients underwent surgical debridement 16.5 days +/- 6.5 days (range, 13-29) after the orthopedic surgery and only one debridement procedure was nec-sure was possible in one case, and in the other cases the wound healed completely by second intention. The mean hospitalization time was 26.3 days +/- 9.7 days (range, 19-44). conclusion: Genitoperineal skin necrosis induced by perineal traction posttable is a morbid complication that demands surgical debridement and prolonged hospitalization for your treatment. There are many procedures available to reduce the risk of this complication that should be used more liberally by the orthopedic surgeons.

Rotavirus morbidity and mortality in children in Brazil

Objective. To study the epidemiology of rotavirus and estimate rotavirus- associated morbidity and mortality in children <= 5 years of age in Brazil in 2004 before introducing the rotavirus vaccine in Brazil`s National Immunization Program ( Programa Nacional de Imunizacoes, PNI). Methods. To estimate rotavirus morbidity, published studies ( 1999 - 2006) addressing incidence of acute diarrhea among children <= 5 years of age and frequency of rotavirus infection among children with diarrhea in Brazil were reviewed. Diarrhea episodes were divided into three categories of severity by level of care: mild cases requiring only home- based care; moderate cases requiring a visit to an outpatient healthcare facility; and severe cases requiring hospitalization. To estimate rotavirus mortality, information on the number of registered deaths from diarrhea in children <= 5 years of age was obtained from the Mortality Information System ( Sistema de Informacao, sobre Mortalidade, SIM) of Brazil`s public healthcare system ( Sistema Unico de Sa de, SUS) and the proportion of deaths due to rotavirus was calculated. Results. Rotavirus infections were estimated to cause 3 525 053 episodes of diarrhea, 655 853 visits to outpatient healthcare facilities, 92 453 hospitalizations, and 850 deaths of children <= 5 years of age each year in Brazil. Conclusion. Rotavirus infections are an important cause of child morbidity and mortality in Brazil.

Dual candidemia detected by nested polymerase chain reaction in two critically ill children

The use of improved microbiological procedures associated with molecular techniques has increased the identification of Candida bloodstream infections, even if the isolation of more than one species by culture methods remains uncommon. We report the cases of two children presenting with severe gastrointestinal disorders and other risk factors that contribute to Candida infections. In the first patient, C. albicans DNA was initially detected by a nested-amplification and C. tropicalis was found later during hospitalization, while blood cultures were persistently negative. In the second child, there was amplification of C. albicans and C. glabrata DNA in the same samples, but blood cultures yielded only C. albicans. Both patients received antifungal therapy but had unfavorable outcomes. These two cases illustrate that PCR was more successful than culture methods in detecting Candida in the bloodstream of high risk children, and was also able to detect the presence of more than one species in the same patient that might impact therapy when the fungi are resistant to azole compounds.</.

An optimization model for antibiotic use

There is a positive correlation between the intensity of use of a given antibiotic and the prevalence of resistant strains. The more you treat, more patients infected with resistant strains appears and, as a consequence, the higher the mortality due to the infection and the longer the hospitalization time. In contrast, the less you treat, the higher the mortality rates and the longer the hospitalization time of patients infected with sensitive strains that could be successfully treated. The hypothesis proposed in this paper is an attempt to solve such a conflict: there must be an optimum treatment intensity that minimizes both the additional mortality and hospitalization time due to the infection by both sensitive and resistant bacteria strains. In order to test this hypothesis we applied a simple mathematical model that allowed us to estimate the optimum proportion of patients to be treated in order to minimize the total number of deaths and hospitalization time due to the infection in a hospital setting. (C) 2007 Elsevier Inc. All rights reserved.

Adverse Drug Reactions and Drug Interactions as Causes of Hospital Admission in Oncology

Context. Although several studies have evaluated the frequency of adverse drug reactions (ADRs) and drug-drug interactions (DDIs) in general medicine, few studies have looked at the epidemiology of adverse drug events (ADEs) in oncology. Objectives. We sought to investigate how many hospital admissions in oncology are related to a DDI or an ADR. Methods. All cancer patients admitted to an oncology ward during an eight-month period had their charts retrospectively evaluated for reasons of hospitalization, using a 4-point scale (definitely, probably, possibly, or unlikely associated) to classify admissions by their probability of being associated with either a DDI or an ADR. Results. From September 2007 to May 2008, there were 550 hospital admissions and 458 were eligible. Among unplanned admissions (n = 298), 39 (13.0%, 95% confidence interval [CI] 9.4%-17.4%) were considered to be associated with an ADE, 33 (11.0%, 95% CI 7.7%-15.2%) with an ADR, and six (2.0%, 95% CI 0.7%-4.3%) with a DDI. The most common DDIs involved warfarin, captopril, and anti-inflammatory agents, and the most frequent ADR was neutropenic fever post-chemotherapy. Most patients were discharged completely recovered, but two patients died. Conclusion. Approximately one in 10 unplanned hospitalizations of cancer patients is associated with an ADE. Prospective and population-based studies are warranted to evaluate their magnitude in oncology. J Pain Symptom Manage 2011;42:342-353. (C) 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.