A Restructured Hospital Into a One-Building Organization for COVID-19 Patients: A Resilient and Effective Response to the Pandemic.

The COVID-19 pandemic is a unique crisis challenging healthcare institutions as it rapidly overwhelmed hospitals due to a large influx of patients. This major event forced all the components of the healthcare systems to adapt and invent new workflows. Thus, our tertiary care hospital was reorganized entirely. During the cruising phase, additional staff was allocated to a one-building organization comprising an intensive care unit (ICU), an acute care unit, a physical medicine and rehabilitation unit, and a COVID-19 screening area. The transfer of patients from a ward to another was more efficient due to these organizations and pavilion structure. The observed mortality was low in the acute care ward, except in the palliative unit. No nosocomial infection with SARS-CoV-2 was reported in any other building of the hospital since this organization was set up. This type of one-building organization, integrating all the components for comprehensive patient care, seems to be the most appropriate response to pandemics.

Mutagenicity as a parameter in surface water monitoring programs-opportunity for water quality improvement.

Effect-based analyses are being recognized as excellent tools to a comprehensive and reliable water quality evaluation to complement physical and chemical parameters. The Salmonella/microsome mutagenicity test was introduced in the São Paulo State water quality-monitoring program in 1999 and waters from 104 sites used to the production of drinking water were analyzed. Samples were tested after organic extraction, using the microsuspension version of the Salmonella/microsome assay with strains TA98 and TA100 with and without S9-mammalian metabolic system. Of the 1720 water samples analyzed in 20 years, 20% were positive; TA98 was the most sensitive strain, detecting alone 99%. Results were presented in hazard categories to facilitate water managers' understanding and general public communication. Hot spots of mutagenicity were identified, and pollution sources investigated. A flow scheme with instructions of how to proceed in case of mutagenic samples was developed and implemented in the monitoring program. Enforcement actions were taken to reduce exposure of humans and aquatic biota to mutagenic compounds. The results presented provide scientific basis for the incorporation of the Salmonella/microsome assay in a regulatory framework, and to guide water-quality managers. The inclusion of a mutagenicity assay using standardized conditions proved to be an opportunity to improve the quality of water, and the strategy presented here could be applied by any environmental agency around the world. Environ. Mol. Mutagen. 61:200-211, 2020. © 2019 Wiley Periodicals, Inc.

Feasibility and results of pull-percutaneous endoscopic gastrostomy for enteral nutrition in adults with severe cerebral palsy.

BACKGROUND & AIMS: Eating and swallowing impairments often get worse as patients with severe cerebral palsy (CP) get older, creating increased demand for percutaneous endoscopic gastrostomy (PEG) tube placement. Here we investigated the feasibility, safety, adverse events (AEs) and outcomes of PEG in adult CP. METHODS: We performed a retrospective study of 26 consecutive severe adult (age: 28 [19-48] yrs) CP patients who underwent pull-PEG tube placement under general anesthesia between 2005 and 2012 (median follow-up: 23 [6-64] months) at the same tertiary hospital centre. RESULTS: The procedure was a technical success for 19 patients (BMI: 13.8 [10.7-21.4]) with (n = 11) or without (n = 8) previous respiratory disorder. Indications were mainly swallowing disorders (n = 14) and inadequate oral intake (n = 8). Early AEs were 7 transient oxygen needs, 3 local wound infections and 2 transient ileus. Long-term AEs were 9 non-severe gastrostomy incidents. There was no significant improvement in neurological status but respiratory function was improved in 6 patients and enteral nutrition enabled a significant median weight gain of 4.2 [1-8.8] kg (P < 0.01). Quality-of-life assessed by relatives and the healthcare team was improved in 13/16 and 13/15 cases respectively. AEs and outcomes did not differ significantly with previous respiratory disorder or nutritional status. CONCLUSIONS: PEG tube placement is feasible in adult CP, although the risk of failure is increased by anatomical specificities. Previous respiratory disorders and undernourishment did not increase AE rates or modify outcomes. There were positive changes over time for nutritional status and perceived quality-of-life, but no neurological improvement.

Occurrence of adverse events in long-term intrathecal baclofen infusion: a 1-year follow-up study of 158 adults.

OBJECTIVE: To assess the frequency and types of adverse events (AEs) related to intrathecal baclofen (ITB) therapy in adults, and associated risk factors. DESIGN: A prospective, observational cohort study of adults followed up from January 1 to December 31, 2010. SETTING: A neurologic rehabilitation department in a university hospital. PARTICIPANTS: All consecutive adult subjects (N=158) receiving ITB via a pump, either implanted or followed up during the study period. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Frequency and type of AEs. RESULTS: In 2010, 158 subjects were followed up for ITB therapy, of whom 128 were implanted before 2010 (nonsurgical subjects), and 30 underwent implantation in 2010 (surgical subjects). Of these 30 subjects, 20 were "newly implanted" and 10 were "replacements." The most frequent pathologic disorders were spinal cord injury (42%) and multiple sclerosis (28%). Twenty-eight subjects (18%) experienced a total of 38 AEs. The rate of AEs was .023 per month of ITB treatment. AEs were related to the surgical procedure in 53% of cases, to the device in 29% (predominantly catheter dysfunctions), and to adverse effects of baclofen in 18%. AEs related to the surgical incision (scar complications and collections) were more frequent in replacement than newly implanted subjects (P=.009). No significant association between occurrence of an AE and subject characteristics (age, gait capacity, spinal vs cerebral spasticity, duration of ITB therapy follow-up) was found. Nearly half of the AEs were serious, extending admission time by a mean of 16 days. No AE induced long-term morbidity or death. CONCLUSIONS: The AE rate was relatively low in this cohort. This has to be balanced against the clinical, functional, and quality-of-life improvements, which are expected from ITB therapy.

Intrathecal baclofen pump: a foreign-body reaction case report and its solution.

CASE REPORT: A 43-year-old woman with cerebral palsy and disabling spasticity underwent a series of 4 implantations of intrathecal baclofen pumps, performed by two teams. A history of 3 aseptic local skin reactions over the site of insertion started 4 months after the first insertion, once with partial pump exposure. There were no clinical or biological signs of infection. Skin patch tests were negative. Relocation of the system was followed by a relapse, while removal of the pump was followed each time by complete resolution of the symptoms. Histological findings showed slight mononuclear dermal infiltration without epidermal lesions, which excluded contact dermatitis. Pump intolerance with a foreign-body reaction was diagnosed. A pump wrapped with polyethylene terephthalate was reimplanted. No recurrence of symptoms occurred after a 3-year follow-up period, with improvement in impairment, activity and satisfaction due to intrathecal baclofen therapy. CONCLUSION: A foreign-body reaction after intrathecal baclofen pump implantation is a rare complication, which has not been reported previously, and which is associated with negative skin patch tests. In cases with no signs of infection, skin intolerance must be suspected and dermatological assessments should be carried out. Replacement with a pump wrapped in an inert coating is an effective and available solution.

Cervical myelopathy in athetoid and dystonic cerebral palsy: retrospective study and literature review.

The early onset of degenerative cervical lesions has been well described in patients suffering from athetoid or dystonic cerebral palsy. Myelopathy can occur and aggravate of their unstable neurological status. Diagnosis and treatment are delayed and disrupted by the abnormal movements. This retrospective study was implemented to evaluate the symptoms, the anatomical findings, and the surgical management of seven patients from 20 to 56 years old suffering from cervical myelopathy and athetoid or dystonic cerebral palsy. The mean delay in diagnosis was 15 months and the mean follow-up was 33 months. The initial symptoms were spasticity, limbs weakness, paresthesias and vesico-sphinteric dysfunction. In addition to abnormal movements, imaging demonstrated disc herniation, spinal stenosis and instability. All patients were managed surgically by performing simultaneous spinal cord decompression and fusion. Two patients benefited from preoperative botulinum toxin injections, which facilitated postoperative care and immobilization. Strict postoperative immobilization was achieved for 3 months by a Philadelphia collar or a cervico-thoracic orthosis. All patients improved functionally with a mean Japanese Orthopaedic Association score gain of 1.5 points, in spite of the permanent disabilities of the myelopathy. Complications occurred with wound infection, metal failure and relapse of cervical myelopathy at an adjacent level in one case each. All the previous authors advised against isolated laminectomy but no consensus emerged from the literature analysis. Spinal fusion is usually recommended but can be complicated by degenerative adjacent deterioration. Surgical management provides good outcomes but requires a long-term follow-up.

Comparison of the Salmonella/microsome microsuspension assay with the new microplate fluctuation protocol for testing the mutagenicity of environmental samples.

The objective of this study was to compare the responses of the Salmonella/microsome microsuspension assay with the new microplate fluctuation protocol (MPF) for the evaluation of the mutagenic activity of environmental samples. Organic extracts of total particulate atmospheric air samples, surface waters, and effluents were tested in dose-response experiments. The assays were performed with strain TA98 in the absence and presence of S9 mix. Both protocols produced similar results, despite the fact that the maximum score of the MPF is limited to 48 wells, whereas in the regular plate assay it is possible to count up to 1,500 colonies using an automatic counter. Similar sensitivities based on the lowest dose that resulted in a positive response were obtained for both assays. The MPF procedure is less laborious (e.g., all-liquid format, use of multichannel pipettors) and allows for automation of the pipetting and dispensing steps, thus, reducing time of the analysis which is particularly important in environmental quality monitoring programs or in effect-directed analysis. The results show that the MPF procedure is a promising tool to test environmental samples for mutagenic activity.

A preliminary characterization of the mutagenicity of atmospheric particulate matter collected during sugar cane harvesting using the Salmonella/microsome microsuspension assay.

During sugar cane harvesting season, which occurs from May to November of each year, the crops are burnt, cut, and transported to the mills. There are reports showing that mutagenic activity and PAH content increase during harvesting season in some areas of São Paulo State in comparison with nonharvesting periods. The objective of this work was to preliminarily characterize the mutagenic activity of the total organic extracts as well as corresponding organic fractions of airborne particulate matter (PM) collected twice from two cities, Araraquara (ARQ) and Piracicaba (PRB), during sugar cane harvesting season using the Salmonella/microsome microssuspension assay. One sample collected in São Paulo metropolitan area was also included. The mutagenicity of the total extracts ranged from 55 to 320 revertants per cubic meter without the addition of S9 and from not detected to 57 revertants per cubic meter in the presence of S9 in areas with sugar cane plantations. Of the three fractions analyzed, the most polar ones (nitro and oxy) were the most potent. A comparison of the response of TA98 with YG1041 and the increased potencies without S9 indicated that nitro compounds are causing the observed effect. More studies are necessary to verify the sources of the mutagenic activity such as burning of vegetal biomass and combustion of heavy duty vehicles used to transport the sugar cane to the mills. The Salmonella/microsome assay can be an important tool to monitor the atmosphere for mutagenicity during sugar cane harvesting season.

Mutagenic and carcinogenic potential of a textile azo dye processing plant effluent that impacts a drinking water source.

Recently a textile azo dye processing plant effluent was identified as one of the sources of mutagenic activity detected in the Cristais River, a drinking water source in Brazil [G.A. Umbuzeiro, D.A. Roubicek, C.M. Rech, M.I.Z. Sato, L.D. Claxton, Investigating the sources of the mutagenic activity found in a river using the Salmonella assay and different water extraction procedures, Chemosphere 54 (2004) 1589-1597]. Besides presenting high mutagenic activity in the Salmonella/microsome assay, the mutagenic nitro-aminoazobenzenes dyes CI Disperse Blue 373, CI Disperse Violet 93, and CI Disperse Orange 37 [G.A. Umbuzeiro, H.S. Freeman, S.H. Warren, D.P. Oliveira, Y. Terao, T. Watanabe, L.D. Claxton, The contribution of azo dyes in the mutagenic activity of the Cristais river, Chemosphere 60 (2005) 55-64] as well as benzidine, a known carcinogenic compound [T.M. Mazzo, A.A. Saczk, G.A. Umbuzeiro, M.V.B. Zanoni, Analysis of aromatic amines in surface waters receiving wastewater from textile industry by liquid chromatographic with eletrochemical detection, Anal. Lett., in press] were found in this effluent. After approximately 6 km from the discharge of this effluent, a drinking water treatment plant treats and distributes the water to a population of approximate 60,000. As shown previously, the mutagens in the DWTP intake water are not completely removed by the treatment. The water used for human consumption presented mutagenic activity related to nitro-aromatics and aromatic amines compounds probably derived from the cited textile processing plant effluent discharge [G.A. Umbuzeiro, D.A. Roubicek, C.M. Rech, M.I.Z. Sato, L.D. Claxton, Investigating the sources of the mutagenic activity found in a river using the Salmonella assay and different water extraction procedures, Chemosphere 54 (2004) 1589-1597; G.A. Umbuzeiro, H.S. Freeman, S.H. Warren, D.P. Oliveira, Y. Terao, T. Watanabe, L.D. Claxton, The contribution of azo dyes in the mutagenic activity of the Cristais river, Chemosphere 60 (2005) 55-64]. Therefore, it is important to evaluate the possible risks involved in the human consumption of this contaminated water. With that objective, one sample of the cited industrial effluent was tested for carcinogenicity in the aberrant crypt foci medium-term assay in colon of Wistar rats. The rats received the effluent in natura through drinking water at concentrations of 0.1%, 1%, and 10%. The effluent mutagenicity was also confirmed in the Salmonella/microsome assay with the strains TA98 and YG1041. There was an increased number of preneoplastic lesions in the colon of rats exposed to concentrations of 1% and 10% of the effluent, and a positive response for both Salmonella strains tested. These results indicate that the discharge of the effluent should be avoided in waters used for human consumption and show the sensitivity of the ACF crypt foci assay as an important tool to evaluate the carcinogenic potential of environmental complex mixtures.

Mutagenic compounds generated from the chlorination of disperse azo-dyes and their presence in drinking water.

The water produced by the Cristais River Drinking Water Treatment Plant (CR-DWTP) repeatedly produced mutagenic responses that could not be explained by the presence of disinfection byproducts (DBPs) generated by the reaction of humic acids and chlorine. In order to determine the possible role of chlorinated dye products in this mutagenic activity, solutions of a black dye commercial product (BDCP) composed of C.I. Disperse Blue 373, C.I. Disperse Orange 37, C.I. Disperse Violet 93, and chemically reduced BDCP (R-BDCP) were chlorinated in a manner similar to that used by the CR-DWTP. The resulting solutions were extracted with XAD-4 along with one drinking water sample collected from the CR-DWTP. All extracts showed mutagenic activity in the Salmonella/microsome assay. Dye components of the BDCP as well as its reduced chlorinated (CI-R-BDCP) derivative were detected in the drinking water sample by analysis with a high performance liquid chromatography/diode array detector (HPLC/DAD). The mutagenicity results of these products suggest that they are, at least in part, accounting for the mutagenic activity detected in the drinking water samples from the Cristais River. The data obtained in this study have environmental and health implications because the chlorination of the BDCP and the R-BDCP leads to the formation of mutagenic compounds (CI-BDCP and CI-R-BDCP), which are potentially important disinfection byproducts that can contaminate the drinking water as well as the environment.

Blue rayon-anchored technique/Salmonella microsome microsuspension assay as a tool to monitor for genotoxic polycyclic compounds in Santos estuary.

The most important harbor of Brazil is located in Santos Estuary. In the 1970s, this area was one of the major examples of coastal degradation and although the quality of the environment has improved, the sediment is still contaminated with polycyclic aromatic hydrocarbons (PAHs) and mutagenic activity. Because of sediment dredging and consequently contaminants resuspension, it is useful to have reliable methods to monitor the water quality. Considering that blue rayon (BR) has been successfully used in evaluation of mutagenicity and PAHs content the objective of this work was to verify the applicability and adapt the methodology to monitor the water for mutagenic activity using the BR associated with the Salmonella assay. Analysis of three sites with different levels of contamination was performed using a modification of the BR hanging method denominated in this work BR anchored technique. The microsuspension protocol of the Salmonella/microsome assay was employed with the strain YG1041. The water from the site 1 the most contaminated and under influence of the steel mill discharge presented the highest potency reaching 36,000 revertants/g of BR with S9. Sites 2 and 3 showed less mutagenicity than site 1 with values approximately 1000 revertants/g of BR. We conclude that the BR anchored technique associated with Salmonella assay using YG1041 is a reliable alternative to monitor estuarine waters, especially in regions where sediment resuspension or acute pollution episodes can occur.

Caracterização de amostras de sedimento hídrico do estuário de Santos utilizando análises de toxicidade aguda e genotoxicidade e quantificação de bactérias dos ciclos bioquímicos / Characterization of Hydric Sediment Samples from the Santos Estuary Using Acute Toxicity and Genotoxicity Analyses and Quantification of Bacteria of the Biochemical Cycles

Com o objetivo de complementar a caracterização da quantidade dos sedimentos do estuário de Santos, que nos locais mais contaminados pode conter até 2000 mg/g de benzo(a)pireno, 2600 mg/g de zinco e 567 mg/g chumbo, foram analisados três pontos de coleta. Um, no estuário, próximo a siderúrgica (ponto A), mais contamindado por HPAs e metais, outro no rio Piaçaguera (Ponto B), impactado por diferentes atividades industriais e no rio Queiroz (Ponto C), considerado neste estudo como controle. Diferentes análises foram realizadas em amostas de sedimento dos pontos citados. Para avaliação da toxicidade aguda foi utilizado o ensaio com bactérias luminescentes (V. fischeri), e para avaliação da mutagenicidade empregou-se o teste com Salmonella/microsoma (teste de Ames). Foram também realizadas análises microbiológicas para isolamento e quantificação de bactérias redutoras do sulfato (BRS), oxidantes do enxofre (BOS), bactérias metagênias (IBM) e heterotróficas (BH). As amostras do ponto de impacto pela siderúrgica, mostraram efeito tóxico agudo e os dados mostram que tanto os metais como os orgânicos poderiam ser a causa do efeito observado. As amostras deste ponto também mostraram atividade mutagência (10³ a 10 revertentes/g), sendo que a adição de S9 aumentou a atividade mutagência sugerindo a predominância de HPAs não substiuídos. O ponto do rio Piaçaguera não apresentou toxicidade aguda e a mutagenicidade foi aproximadamente 10 vezes menor que amostras do ponto A. O ponto C apresentou resultados negativos para ambos os testes realizados. Elevadas contagens de BRS e BM foram observadas nos três pontos avaliadaos. Bactérias do grupo das oxidantes do enxofre (BOS), especialmente do grupo neutrofílicas, foram também isoladas, apesar do caráter anóxico desta matriz. Podemos concluir que o ponto coleta localizado no estuário (Ponto A) é mais impactado que o ponto do rio Piaçaguera (Ponto B), e que o Rio Queiroz monstrou-se adequado como controle.

Investigating the sources of the mutagenic activity found in a river using the Salmonella assay and different water extraction procedures.

In the routine São Paulo state (Brazil) surface water quality-monitoring program, which includes the Salmonella microsome mutagenicity assay as one of its parameters, a river where water is taken and treated for drinking water purposes has repeatedly shown mutagenic activity. A textile dyeing facility employing azo-type dyes was the only identifiable source of mutagenic compounds. We extracted the river and drinking water samples with XAD4 at neutral and acidic pH and with blue rayon, which selectively adsorbs polycyclic compounds. We tested the industrial effluent, raw, and treated water and sediment samples with YG1041 and YG1042 and compared the results with the TA98 and TA100 strains. The elevated mutagenicity detected with YG-strains suggested that nitroaromatics and/or aromatic amines were causing the mutagenicity detected in the samples analyzed. Positive responses for the blue rayon extracts indicated that mutagenic polycyclic compounds were present in the water samples analyzed. The mutagen or mixture of mutagens present in the effluent and water samples cause mainly frameshift mutations and are positive with and without metabolic activation. The Salmonella assay combined with different extraction procedures proved to be very useful in the identification of the origin of the pollution and in the identification of the classes of chemical compounds causing the mutagenic activity in the river analyzed.

Comparison of the mutagenic activity of XAD4 and blue rayon extracts of surface water and related drinking water samples.

The combination of mutagenicity tests and selective extraction methodologies can be useful to indicate the possible classes of genotoxic organic contaminants in water samples. Treated and source water samples from two sites were analyzed: a river under the influence of an azo dye-processing plant discharge and a reservoir not directly impacted with industrial discharges, but contaminated with untreated domestic sewage. Organic extraction was performed in columns packed with XAD4 resin, that adsorbs a broad class of mutagenic compounds like polycyclic aromatic hydrocarbons (PAHs), arylamines, nitrocompounds, quinolines, antraquinones, etc., including the halogenated disinfection by-products; and with blue rayon that selectively adsorbs polycyclic planar structures. The organic extracts were tested for mutagenicity with the Salmonella assay using TA98 and TA100 strains and the potencies were compared. A protocol for cleaning the blue rayon fibers was developed and the efficiency of the reused fibers was analyzed with spiked samples. For the river water samples under the influence of the azo-type dye-processing plant, the mutagenicity was much higher for both blue rayon and XAD4 extracts when compared to the water from the reservoir not directly impacted with industrial discharges. For the drinking water samples, although both sites showed mutagenic responses with XAD4, only samples from the site under the influence of the industrial discharge showed mutagenic activity with the blue rayon extraction, suggesting the presence of polycyclic compounds in those samples. As expected, negative results were found with the blue rayon extracts of the drinking water collected from the reservoir not contaminated with industrial discharges. In this case, it appears that using the blue rayon to extract drinking water samples and comparing the results with the XAD resin extracts we were able to distinguish the mutagenicity caused by industrial contaminants from the halogenated disinfection by-products generated during water treatment.

Breathlessness associated with abdominal spastic contraction in a patient with C4 tetraplegia: a case report.

A tetraplegic patient with C4 cervical cord injury reported breathlessness during episodes of spastic contraction of the abdominal muscles. To determine the mechanism, we performed electrophysiologic testing of the phrenic nerves. We measured abdominal pressure, esophageal pressure, and transdiaphragmatic pressure (Pdi) during a maximal inspiratory effort (Pdi max), a maximal sniff maneuver (sniff Pdi) during resting breathing, and during the episodes of breathlessness. Electrophysiologic testing of the phrenic nerves showed axonal neuropathy on the left. Sniff Pdi and Pdi max were 38cmH(2)O and 42cmH(2)O, respectively. Transient spastic contractions of abdominal muscles were associated with an increase in abdominal pressure greater than 30cmH(2)O, with a decrease in abdominal volume; this rise in abdominal pressure was transmitted to the esophageal pressure. Inspiration became effective only when esophageal pressure fell below the resting baseline value. Achieving this decrease required an increase in inspiratory effort, characterized by swings in esophageal pressure and Pdi of 30cmH(2)O and 40cmH(2)O (approximately 100% of Pdi max), respectively. During these periods, minute ventilation was markedly reduced. This is the first report that spastic abdominal muscle contractions can impose a significant load on the diaphragm, uncovering moderate diaphragmatic weakness. This has important clinical implications; abolition of the spastic abdominal muscle contraction in this patient completely resolved her intermittent respiratory symptoms.

Genotoxicity of 5-aminolevulinic and 4,5-dioxovaleric acids in the salmonella/microsuspension mutagenicity assay and SOS chromotest.

5-Aminolevulinic acid (ALA) is a heme precursor that accumulates in some porphyric disorders and in lead poisoning which can undergo metal-catalyzed oxidation producing reactive oxygen species and the keto-aldehyde, 4,5-dioxovaleric acid (DOVA). Evidence in vitro of ALA-induced DNA lesions suggests that ALA and DOVA have mutagenic potential that could possibly contribute to an increased frequency of hepatocellular carcinoma (HCC) in patients with acute intermittent porphyria (AIP). In this study, we evaluated the genotoxic potential of ALA and DOVA. In the absence of exogenous metabolic activation, ALA and DOVA were mutagenic in Salmonella typhimurium tester strain TA104. ALA was also mutagenic in S. typhimurium TA102, but not in TA98, TA100, or TA1535, indicating an oxidative mechanism. Removal of H(2)O(2) with catalase gave only partial protection, suggesting generation of other mutagenic species. Both ALA and DOVA damaged the DNA of Escherichia coli PQ37, inducing the SOS response detected by an increase in beta-galactosidase activity. These results verified the potential mutagenic activity of ALA and DOVA and reinforce the hypothesis that DNA damage induced by ALA may be associated with the development of HCC in individuals suffering from AIP.

A simple method for storage of methanogenic bacteria in liquid nitrogen

Säo descritos métodos e procedimentos de preservaçäo de bactérias anaeróbias estritas produtoras de metano. Duas técnicas diferentes foram adotadas: uma para manutençäo de baixo potencial de oxireduçäo em frascos de cultivo e outra para conservaçäo das células bacterianas em nitrogênio líquido