What risk do Brucella vaccines pose to humans? A systematic review of the scientific literature on occupational exposure.

BACKGROUND: Currently, vaccination of livestock with attenuated strains of Brucella remains an essential measure for controlling brucellosis, although these vaccines may be dangerous to humans. The aim of this study was to review the risk posed to humans by occupational exposure to vaccine strains and the measures that should be implemented to minimize this risk. METHODS: This article reviewed the scientific literature indexed in PubMed up to September 30, 2023, following "the PRISMA guidelines". Special emphasis was placed on the vaccine strain used and the route of exposure. Non-occupational exposure to vaccine strains, intentional human inoculation, publications on exposure to wild strains, and secondary scientific sources were excluded from the study. RESULTS: Nineteen primary reports were found and classified in three subgroups: safety accidents in vaccine factories that led to an outbreak (n = 2), survellaince studies on vaccine manufacturing workers with a serologic diagnosis of Brucella infection (n = 3), and publications of infection by vaccine strains during their administration, including case reports, records of occupational accidents and investigations of outbreaks in vaccination campaigns (n = 14). Although accidental exposure during vaccine manufacturing were uncommon, they could provoke large outbreaks through airborne spread with risk of spread to the neighboring population. Besides, despite strict protection measures, a percentage of vaccine manufacturing workers developed positive Brucella serology without clinical infection. The most frequent type of exposure with symptomatic infection was needle injury during vaccine administration. Prolonged contact with the pathogen, lack of information and a low adherence to personal protective equipment (PPE) use in the work environment were commonly associated with infection. CONCLUSIONS: Brucella vaccines pose occupational risk of contagion to humans from their production to their administration to livestock, although morbidity is low and deaths were not reported. Recommended protective measures and active surveillance of exposed workers appeared to reduce this risk. It would be advisable to carry out observational studies and/or systematic registries using solid diagnostic criteria.

Prevalence of diabetes, prediabetes, and stress hyperglycemia: insulin therapy and metabolic control in patients on total parenteral nutrition (prospective multicenter study).

OBJECTIVE: The prevalence of carbohydrate metabolism disorders in patients who receive total parenteral nutrition (TPN) is not well known. These disorders can affect the treatment, metabolic control, and prognosis of affected patients. The aims of this study were to determine the prevalence in noncritically ill patients on TPN of diabetes, prediabetes, and stress hyperglycemia; the factors affecting hyperglycemia during TPN; and the insulin therapy provided and the metabolic control achieved. METHODS: We undertook a prospective multicenter study involving 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included, and data were collected on demographic, clinical, and laboratory variables (glycated hemoglobin, C-reactive protein [CRP], capillary blood glucose) as well as insulin treatment. RESULTS: The study included 605 patients. Before initiation of TPN, the prevalence of known diabetes was 17.4%, unknown diabetes 4.3%, stress hyperglycemia 7.1%, and prediabetes 27.8%. During TPN therapy, 50.9% of patients had at least one capillary blood glucose of >180 mg/dL. Predisposing factors were age, levels of CRP and glycated hemoglobin, the presence of diabetes, infectious complications, the number of grams of carbohydrates infused, and the administration of glucose-elevating drugs. Most (71.6%) patients were treated with insulin. The mean capillary blood glucose levels during TPN were: known diabetes (178.6 ± 46.5 mg/dL), unknown diabetes (173.9 ± 51.9), prediabetes (136.0 ± 25.4), stress hyperglycemia (146.0 ± 29.3), and normal (123.2 ± 19.9) (P<.001). CONCLUSION: The prevalence of carbohydrate metabolism disorders is very high in noncritically ill patients on TPN. These disorders affect insulin treatment and the degree of metabolic control achieved.

Attitudes of oncologists towards palliative care and the Edmonton Symptom Assessment System (ESAS) at an Ontario cancer center in Canada.

BACKGROUND: Cancer Care Ontario promotes the Edmonton Symptom Assessment System (ESAS) for standardized systematic screening and assessment of symptoms across cancer centers in Ontario, Canada. Attitudes of medical oncologists (MOs), radiation oncologists (ROs), and general practitioners in oncology (GPOs) toward palliative care, and the ESAS were surveyed in Ottawa. METHODS: A four-part questionnaire was developed, drawing on items from similar studies. RESULTS: Forty respondents (17 MOs, 16 ROs, and 7 GPOs) were interviewed. Attitudes to palliative care: regarding coordination of care across the illness trajectory including end of life by MOs, all ROs disagreed while 71.4 % of GPOs and 41.2 % of MOs agreed that this was the MO's role. Most respondents supported palliative care alongside concurrent anti-tumor therapies (82.4 % MOs, 62.5 % ROs, and 100 % GPOs). Attitudes to ESAS: respondents agreed that the ESAS enhances care and assessment of symptom severity. ROs felt that reviewing the ESAS histogram was less useful than did MOs (42.9 versus 76.5 %, respectively); 56.3 % of ROs and 88.2 % of MOs agreed that the ESAS is useful for follow-up (p < 0.08); 64.7 % of MOs, 88.3 % of GPOs, and 6.3 % of ROs agreed with ESAS completion at every visit (p < 0.00). Frequency of use of the ESAS: 62.5 % of respondents reported inspecting the ESAS "most of the time or always," while 17.5 % reported "never" or "rarely." CONCLUSIONS: MOs and GPOs appear more positive than ROs toward regular use of ESAS. There is discordance between what is perceived to be a useful beneficial instrument versus actual use of the instrument in daily practice. The reasons for this gap need to be better understood in future studies.

Hypoglycemia in noncritically ill patients receiving total parenteral nutrition: a multicenter study. (Study group on the problem of hyperglycemia in parenteral nutrition; Nutrition area of the Spanish Society of Endocrinology and Nutrition).

OBJECTIVE: Hypoglycemia is a common problem among hospitalized patients. Treatment of hyperglycemia with insulin is potentially associated with an increased risk for hypoglycemia. The aim of this study was to determine the prevalence and predictors of hypoglycemia (capillary blood glucose <70 mg/dL) in hospitalized patients receiving total parenteral nutrition (TPN). METHODS: This prospective multicenter study involved 19 Spanish hospitals. Noncritically ill adults who were prescribed TPN were included, thus enabling us to collect data on capillary blood glucose and insulin dosage. RESULTS: The study included 605 patients of whom 6.8% (n = 41) had at least one capillary blood glucose <70 mg/dL and 2.6% (n = 16) had symptomatic hypoglycemia. The total number of hypoglycemic episodes per 100 d of TPN was 0.82. In univariate analysis, hypoglycemia was significantly associated with the presence of diabetes, a lower body mass index (BMI), and treatment with intravenous (IV) insulin. Patients with hypoglycemia also had a significantly longer hospital length of stay, PN duration, higher blood glucose variability, and a higher insulin dose. Multiple logistic regression analysis showed that a lower BMI, high blood glucose variability, and TPN duration were risk factors for hypoglycemia. Use of IV insulin and blood glucose variability were predictors of symptomatic hypoglycemia. CONCLUSIONS: The occurrence of hypoglycemia in noncritically ill patients receiving PN is low. A lower BMI and a greater blood glucose variability and TPN duration are factors associated with the risk for hypoglycemia. IV insulin and glucose variability were predictors of symptomatic hypoglycemia.

Nutrition-related risk indexes and long-term mortality in noncritically ill inpatients who receive total parenteral nutrition (prospective multicenter study).

BACKGROUND: Malnutrition in hospitalized patients is associated with an increased risk of death, in both the short and the long term. AIMS: The purpose of this study was to determine which nutrition-related risk index predicts long-term mortality better (three years) in patients who receive total parenteral nutrition (TPN). METHODS: This prospective, multicenter study involved noncritically ill patients who were prescribed TPN during hospitalization. Data were collected on Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Geriatric Nutritional Risk Index (GNRI), body mass index, albumin and prealbumin, as well as long-term mortality. RESULTS: Over the 1- and 3-year follow-up periods, 174 and 244 study subjects (28.8% and 40.3%) respectively, died. Based on the Cox proportional hazards survival model, the nutrition-related risk indexes most strongly associated with mortality were SGA and albumin (<2.5 g/dL) (after adjustment for age, gender, C-reactive protein levels, prior comorbidity, mean capillary blood glucose during TPN infusion, diabetes status prior to TPN, diagnosis, and infectious complications during hospitalization). CONCLUSIONS: The SGA and very low albumin levels are simple tools that predict the risk of long-term mortality better than other tools in noncritically ill patients who receive TPN during hospitalization.

O suporte à família em cuidados paliativos / Family support in palliative care

Não faz sentido falar de cuidados paliativos sem referenciar uma equipa multidisciplinar e interdisciplinar que comporta diferentes profissionais, de diferentes áreas, que apoiem o doente e a família (TWYCROSS, 2003). Este é o desafio que o artigo apresenta, o de poder passar a visão psicossocial que envolve o mundo do doente paliativo e suas famílias, onde os cuidados de saúde considerados ativos estão centrados na dolência do ser humano. Pretende-se aqui contribuir para o conhecimento sobre as famílias no contexto de doença terminal recorrendo à investigação efetuada nesta área sistêmica e ao conhecimento empírico, enquanto investigadores e profissionais no trabalho diário com doentes e famílias em intenso sofrimento.

It makes no sense to talk about palliative care without referencing a multidisciplinary and interdisciplinary team approach comprising different professionals from different fields, supporting the patient and family (TWYCROSS, 2003). This is our challenge: the challenge to study the psychosocial world of palliative patients and their families, where health care are considered active and centered on the human being. We intend in this paper to contribute to the knowledge of the families in the context of terminal illness using the systemic research done in this area and our empirical knowledge, while researchers and practitioners in their daily work with patients and families in higher distress.

Single-port Roux-en-Y gastric bypass: toward a less invasive procedure with the same surgical results and a better cosmesis.

BACKGROUND: The current tendency to use increasingly less aggressive procedures has facilitated the development of new minimally invasive techniques. In this context, single-port (SP) access procedures can become an alternative to the conventional laparoscopic approach. METHODS: A total of 22 morbidly obese patients were submitted to pure SP Roux-en-Y gastric bypass without additional ports. Selection for this approach was based on distance from the xiphoid to the umbilicus less than 28 cm, body mass index (BMI) lower than 50 kg/m(2), and preferably peripheral obesity. Access to the cavity was obtained through a single transverse, transumbilical incision, with placement of a SILS Port device. RESULTS: The mean age of the patients was 41 ± 8.98 years, and 95 % of the patients were women. The mean BMI of the series was 42.68 ± 2.28 kg/m(2), and the mean body weight was 111.34 ± 10.66 kg. Surgery was performed successfully in all cases through a transumbilical incision with a mean length of 26.68 ± 5.27 mm. The mean surgical time was 114.05 ± 21 min, and the mean hospital stay was 3.27 ± 1.01 days. No intraoperative or immediate postoperative deaths or complications occurred. The median postoperative BMI during a mean follow-up period of 12 months was 28 kg/m(2) (range, 18-35 kg/m(2)). The median weight loss was 39 kg, and the percentage loss of excess body weight was 86 %. In relation to improvement of the comorbidities, two of the three patients with arterial hypertension showed normalization of their blood pressure values. Likewise, the blood glucose levels were corrected in two of the three diabetic patients, as well as in the patient with altered fasting blood glucose. CONCLUSIONS: Single-port Roux-en-Y gastric bypass surgery seems to be a safe, viable, and reproducible technique, but randomized studies involving larger patient series and longer follow-up periods are needed to compare the SP access and the multiple-port laparoscopic approach.

Parenteral nutrition-associated hyperglycemia in non-critically ill inpatients increases the risk of in-hospital mortality (multicenter study).

OBJECTIVE: Hyperglycemia may increase mortality in patients who receive total parenteral nutrition (TPN). However, this has not been well studied in noncritically ill patients (i.e., patients in the nonintensive care unit setting). The aim of this study was to determine whether mean blood glucose level during TPN infusion is associated with increased mortality in noncritically ill hospitalized patients. RESEARCH DESIGN AND METHODS: This prospective multicenter study involved 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included prospectively, and data were collected on demographic, clinical, and laboratory variables as well as on in-hospital mortality. RESULTS: The study included 605 patients (mean age 63.2 ± 15.7 years). The daily mean TPN values were 1.630 ± 323 kcal, 3.2 ± 0.7 g carbohydrates/kg, 1.26 ± 0.3 g amino acids/kg, and 0.9 ± 0.2 g lipids/kg. Multiple logistic regression analysis showed that the patients who had mean blood glucose levels >180 mg/dL during the TPN infusion had a risk of mortality that was 5.6 times greater than those with mean blood glucose levels <140 mg/dL (95% CI 1.47-21.4 mg/dL) after adjusting for age, sex, nutritional state, presence of diabetes or hyperglycemia before starting TPN, diagnosis, prior comorbidity, carbohydrates infused, use of steroid therapy, SD of blood glucose level, insulin units supplied, infectious complications, albumin, C-reactive protein, and HbA1c levels. CONCLUSIONS: Hyperglycemia (mean blood glucose level >180 mg/dL) in noncritically ill patients who receive TPN is associated with a higher risk of in-hospital mortality.

Aflatoxigenic fungi and aflatoxin in cocoa.

This paper reports the occurrence of aflatoxigenic fungi and the presence of aflatoxins in 226 cocoa samples collected on Brazilian farms. The samples were taken at various stages of fermentation, drying and storage. A total of 819 potentially aflatoxigenic fungi were isolated using Dichloran 18% Glycerol agar after surface disinfection, and identified by standard techniques. The ability of the fungi to produce aflatoxins was determined using the agar plug technique and TLC. The presence of aflatoxins in cocoa samples was determined by HPLC using post-column derivatization with bromide after immunoaffinity column clean up. The aflatoxigenic fungi isolated were Aspergillus flavus, A. parasiticus and A. nomius. A considerable increase in numbers of these species was observed during drying and storage. In spite of the high prevalence of aflatoxigenic fungi, only low levels of aflatoxin were found in the cocoa samples, suggesting the existence of limiting factors to the accumulation of aflatoxins in the beans.

Consensus recommendations for the management of constipation in patients with advanced, progressive illness.

Constipation is a highly prevalent and distressing symptom in patients with advanced, progressive illnesses. Although opioids are one of the most common causes of constipation in patients with advanced, progressive illness, it is important to note that there are many other potential etiologies and combinations of causes that should be taken into consideration when making treatment decisions. Management approaches involve a combination of good assessment techniques, preventive regimens, appropriate pharmacological treatment of established constipation, and frequent monitoring. In this vulnerable patient population, maintenance of comfort and respect for individual preferences and sensitivities should be overriding considerations when making clinical decisions. This consensus document was developed by a multidisciplinary group of leading Canadian palliative care specialists in an effort to define best practices in palliative constipation management that will be relevant and useful to health care professionals. Although a wide range of options exists to help treat constipation and prevent its development or recurrence, there is a limited body of evidence evaluating pharmacological interventions. These recommendations are, therefore, based on the best of the available evidence, combined with expert opinion derived from experience in clinical practice. This underscores the need for further clinical evaluation of the available agents to create a robust, evidence-based foundation for treatment decisions in the management of constipation in patients with advanced, progressive illness.

Ochratoxigenic fungi and ochratoxin A in cocoa during farm processing.

This study investigated the occurrence of fungi with the potential to produce ochratoxin A (OTA), and the occurrence of OTA, in Brazilian cocoa beans. Two hundred and twenty two samples of cocoa were evaluated, taken at various stages of fermentation, drying and storage. Samples were collected from Bahia, the main cocoa producing region in Brazil. Fungi with the potential to produce OTA were isolated by direct plating of cocoa beans on Dichloran 18% Glycerol agar after surface disinfection, and identified by standard techniques. The ability of the fungi to produce OTA was estimated using the agar plug technique and TLC. The presence of OTA in cocoa samples was determined by HPLC after immunoaffinity column clean up. The most common ochratoxigenic species found were Aspergillus carbonarius and A. niger aggregate, with lower numbers of A. melleus, A. westerdijkiae and Av. ochraceus. A considerable increase in the numbers of these species was observed during drying and storage. OTA was found at all stages of cocoa processing, with the major incidence during drying and storage. The OTA levels found were in general low and there was a strong positive correlation between the presence of A. carbonarius and OTA contamination in the beans.

Contaminación y desastre ambiental Zona de Kara Kara / Pollution and environmental disaster zone Kara Kara

Tengo el honor de presentarles un trabajo de investigación fonográfico un contenido que apunta al cambio de una sociedad, con respecto a la preservación de nuestro medio ambiente y tomar conciencia de lo importante que presenta cuidarla, para que otras generaciones puedan vivir mucho mejor respirando un aire limpio y puro, el contenido está dividido en tres capítulos. La cual al principio enfoca un análisis actual sobre la contaminación y el desastre ambiental que provoca el botadero de Kara Kara, más de 22 años se vierte la basura de nuestra ciudad sin níngun tipo de consideración ni respeto al medio ambiente.

Contaminación y desastre ambiental Zona de Kara Kara / Pollution and environmental disaster zone Kara Kara

Tengo el honor de presentarles un trabajo de investigación fonográfico un contenido que apunta al cambio de una sociedad, con respecto a la preservación de nuestro medio ambiente y tomar conciencia de lo importante que presenta cuidarla, para que otras generaciones puedan vivir mucho mejor respirando un aire limpio y puro, el contenido está dividido en tres capítulos. La cual al principio enfoca un análisis actual sobre la contaminación y el desastre ambiental que provoca el botadero de Kara Kara, más de 22 años se vierte la basura de nuestra ciudad sin níngun tipo de consideración ni respeto al medio ambiente.

Intragastric balloon-induced satiety is not mediated by modification in fasting or postprandial plasma ghrelin levels in morbid obesity.

BACKGROUND: The BioEnterics Intragastric Balloon (BIB) has been proposed as an adjuvant therapy for the short-term treatment of obesity. The temporal pattern of BIB-induced satiety and whether this effect is mediated by modification of ghrelin levels is unknown. METHODS: Patients with treatment-resistant morbid obesity were invited to participate in a randomized, double-blind, sham-controlled trial of 4-month duration. Anthropometric and biochemical parameters, estimation of energy intake, and pre- and postprandial evaluation of satiety were required monthly. Ghrelin response after a standard mixed meal was scheduled prior to and 4 weeks after the endoscopic procedure. RESULTS: 21 out of 22 enrolled patients completed the study (17 women, 5 men; 35.9 +/- 9.9 years; BMI 50.4 +/- 7.8 kg/m2). Pre-intervention weight decreased from 143.8 +/- 31.2 kg to 131.1 +/- 32.6 kg in Group Balloon (P < 0.001) and from 138.8 +/- 24.5 kg to 129.9 +/- 25.6 kg in Group Sham (P < 0.01) at the end of the study. Weight loss was not significantly different in Group Balloon and Group Sham at any time-point of the follow-up. Only patients from Group Balloon showed a temporary increased pre- and postprandial satiety, which was maximal at 4 weeks after the intervention. Total area under the curve, fasting and postprandial plasma ghrelin were not significantly different between groups at inclusion or 4 weeks after follow-up. No correlation was found between any of the satiety scores at any time-point with their comparable ghrelin levels. CONCLUSION: BIB induces a temporary sense of satiety in morbidly obese patients which is not mediated by modification of fasting or postprandial levels of plasma ghrelin.

[Study of heart valve function on obese patients treated with sibutramine]. / Estudio de la función valvular cardíaca en pacientes obesos tratados con sibutramina.

BACKGROUND: Some anorectic drugs have been related with he development of heart valve lesions. Sibutramine is a new anorectic drug used for the treatment of obesity. Although data reported to date suggest that sibutramine does not induce heart valve lesions, there are no published reports performing longitudinal echocardiographic studies before and after treatment with sibutramine. PATIENTS AND METHODS: Consecutive series of 16 obese patients who underwent Doppler-echocardiography before and after treatment with sibutramine. RESULTS: After 6 months of treatment, at 10 mg/day dose, sibutramine does noe appear to induce heart valve lesions. CONCLUSIONS: Sibutramine does not induce heart valve lesions when it is used in short-term treatment courses.

Intervençäo primária da fisioterapia na síndrome de Rett / Primary intervention of physioterapy in Rett's syndrome

Pesquisa realizada no período de 1922 a 1993 com seis (06) pacientes portadoras da Síndrome de Rett, visando a atuaçäo fisioterápica no tratamento destas crianças, para melhorar ou amenizar os sintomas resultantes desta síndrome

Amigdalite crônica: estudo imunohistoquímico e histológico / Cronic tonsilitis: inmunohistochemical and histologic study

Um estudo histológico e imunohistoquímico, foi realizado em 35 amígadas, provenientes de cirurgias em crianças de ambos os sexos com idade de 2 a 12 anos. Em todos os 35 pacientes havia indicaçäo histológico deu-se importância a presença de folículos linfóides, centros germinativos, presença ou näo de fibrose, necrose e presença ou näo de neutrófilos nas criptas. Segundo estes padröes e de acordo com a classificaçäo proposta por Lopes e Mimica em 1982, foram encontradas 22 classificáveis no grupo I e 13 no tipo II. Do ponto de vista imunológico, fez-se a análise imunohistoquímica do tecido amigdaliano, obedecendo-se a uma avaliaçäo quantitativa em campos histológicos e quantificadas as imunoglobulinas segundo a sua positividade em 100 células por campo, de uma cruz (+) a quatro cruzes. Em todas amígdalas estudadas houve um predomínio no encontro de IgG sobre a IgA, confirmando achados anteriores de Fioretti (1974). Nossos achados sugerem a existência de um quadro histológico e imunohistoquímico característico, na amigdalite crônica infantil