Effectiveness of Heterologous Coronavirus Disease 2019 (COVID-19) Vaccine Booster Dosing in Brazilian Healthcare Workers, 2021.

BACKGROUND: Little is currently known about vaccine effectiveness (VE) for either 2 doses of Oxford-AstraZeneca (ChAdOx1) viral vector vaccine or CoronaVac (Instituto Butantan) inactivated viral vaccine followed by a third dose of mRNA vaccine (Pfizer/BioNTech) among healthcare workers (HCWs). METHODS: We conducted a retrospective cohort study among HCWs (aged ≥18 years) working in a private healthcare system in Brazil from January to December 2021. VE was defined as 1 - incidence rate ratio (IRR), with IRR determined using Poisson models with the occurrence of laboratory-confirmed coronavirus disease 2019 (COVID-19) infection as the outcome, adjusting for age, sex, and job type. We compared those receiving viral vector or inactivated viral primary series (2 doses) with those who received an mRNA booster. RESULTS: A total of 11 427 HCWs met the inclusion criteria. COVID-19 was confirmed in 31.5% of HCWs receiving 2 doses of CoronaVac vaccine versus 0.9% of HCWs receiving 2 doses of CoronaVac vaccine with mRNA booster (P < .001) and 9.8% of HCWs receiving 2 doses of ChAdOx1 vaccine versus 1% among HCWs receiving 2 doses of ChAdOx1 vaccine with mRNA booster (P < .001). In the adjusted analyses, the estimated VE was 92.0% for 2 CoronaVac vaccines plus mRNA booster and 60.2% for 2 ChAdOx1 vaccines plus mRNA booster, when compared with those with no mRNA booster. Of 246 samples screened for mutations, 191 (77.6%) were Delta variants. CONCLUSIONS: While 2 doses of ChAdOx1 or CoronaVac vaccines prevent COVID-19, the addition of a Pfizer/BioNTech booster provided significantly more protection.

Time to blood culture positivity as a predictor of clinical outcome in patients with Candida albicans bloodstream infection.

BACKGROUND: Few studies have assessed the time to blood culture positivity as a predictor of clinical outcome in fungal bloodstream infections (BSIs). The purpose of this study was to evaluate the time to positivity (TTP) of blood cultures in patients with Candida albicans BSIs and to assess its impact on clinical outcome. METHODS: A historical cohort study with 89 adults patients with C. albicans BSIs. TTP was defined as the time between the start of incubation and the time that the automated alert signal indicating growth in the culture bottle sounded. RESULTS: Patients with BSIs and TTPs of culture of ≤ 36 h (n=39) and >36 h (n=50) were compared. Septic shock occurred in 46.2% of patients with TTPs of ≤ 36 h and in 40.0% of patients with TTP of >36 h (p=0.56). A central venous catheter source was more common with a BSI TTP of ≤ 36 h (p=0.04). Univariate analysis revealed that APACHE II score ≥ 20 at BSI onset, the development of at least one organ system failure (respiratory, cardiovascular, renal, hematologic, or hepatic), SOFA at BSI onset, SAPS II at BSI onset, and time to positivity were associated with death. By using logistic regression analysis, the only independent predictor of death was time to positivity (1.04; 95% CI, 1.0-1.1, p=0.035), with the chance of the patient with C. albicans BSI dying increasing 4.0% every hour prior to culture positivity. CONCLUSION: A longer time to positivity was associated with a higher mortality for Candida albicans BSIs; therefore, initiating empiric treatment with antifungals may improve outcomes.

Nature Photographs as Complementary Care in Chemotherapy: A Randomized Clinical Trial.

The incidence of cancer cases is increasing worldwide, and chemotherapy is often necessary as part of the treatment for many of these cases. Nature-based interventions have been shown to offer potential benefits for human well-being. OBJECTIVE: This study aims to investigate the outcome of nature images on clinical symptom management related to chemotherapy. METHODS: A randomized clinical trial was conducted in an outpatient cancer unit of a private hospital in Brazil, with 173 participants over the age of 18 who were undergoing chemotherapy and had signed an informed consent form. The intervention consisted of the presentation of a 12-min video featuring nature images categorized under the themes of Tranquility, Beauty, Emotions Up, or Miscellany. Images were sourced from the e-Nature Positive Emotions Photography Database (e-NatPOEM), a publicly available collection of affectively rated images. Sociodemographic and clinical data, as well as the participants' connection to nature, were investigated. The Positive Affect/Negative Affect Scale (PANAS) and the Edmonton Symptom Assessment System (ESAS) were applied pre- and post-intervention. RESULTS: Data showed very strong evidence of a reduction in negative affect for the intervention group (p < 0.001) and moderate evidence for the control group (p = 0.034). There was also a significant reduction in the intervention group for pain (p < 0.001), tiredness (p = 0.002), sadness (p < 0.001), anxiety (p < 0.001), and appetite (p = 0.001). The Beauty video had the best performance, while the Tranquility video showed no significant improvement in any of the symptoms evaluated. These findings suggest that images of nature may be a valuable tool to help control clinical and psychological symptoms in cancer patients undergoing chemotherapy.

Effectiveness of two coronavirus disease 2019 (COVID-19) vaccines (viral vector and inactivated viral vaccine) against severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection in a cohort of healthcare workers.

OBJECTIVE: We investigated real-world vaccine effectiveness for Oxford-AstraZeneca (ChAdOx1) and CoronaVac against laboratory-confirmed severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among healthcare workers (HCWs). METHODS: We conducted a retrospective cohort study among HCWs (aged ≥18 years) working in a private healthcare system in Brazil between January 1, 2021 and August 3, 2021, to assess vaccine effectiveness. We calculated vaccine effectiveness as 1 - rate ratio (RR), with RR determined by adjusting Poisson models with the occurrence of SARS-CoV-2 infection as the outcome and the vaccination status as the main variable. We used the logarithmic link function and simple models adjusting for sex, age, and job types. RESULTS: In total, 13,813 HCWs met the inclusion criteria for this analysis. Among them, 6,385 (46.2%) received the CoronaVac vaccine, 5,916 (42.8%) received the ChAdOx1 vaccine, and 1,512 (11.0%) were not vaccinated. Overall, COVID-19 occurred in 6% of unvaccinated HCWs, 3% of HCWs who received 2 doses of CoronaVac vaccine, and 0.7% of HCWs who received 2 doses of ChAdOx1 vaccine (P < .001). In the adjusted analyses, the estimated vaccine effectiveness rates were 51.3% for CoronaVac, and 88.1% for ChAdOx1 vaccine. Both vaccines reduced the number of hospitalizations, the length of hospital stay, and the need for mechanical ventilation. In addition, 19 SARS-CoV-2 samples from 19 HCWs were screened for mutations of interest. Of 19 samples, 18 were the γ (gamma) variant. CONCLUSIONS: Although both COVID-19 vaccines (viral vector and inactivated virus) can significantly prevent COVID-19 among HCWs, CoronaVac was much less effective. The COVID-19 vaccines were also effective against the dominant γ variant.

Comparison of two electronic hand hygiene systems using real-time feedback via wireless technology to improve hand hygiene compliance in an intensive care unit.

Background: Most hand hygiene (HH) intervention studies use a quasi-experimental design, are primarily uncontrolled before-and-after studies, or are controlled before-and-after studies with a nonequivalent control group. Well-funded studies with improved designs and HH interventions are needed. Objectives: To evaluate healthcare worker (HCW) HH compliance with alcohol-based hand rub (ABHR) through direct observation (human observer), 2 electronic technologies, a radio frequency identification (RFID) badge system, and an invasive device sensor. Methods: In our controlled experimental study, 2,269 observations were made over a 6-month period from July 1 to December 30, 2020, in a 4-bed intensive care unit. We compared HH compliance between a basic feedback loop system with RFID badges and an enhanced feedback loop system that utilized sensors on invasive devices. Results: Real-time feedback by wireless technology connected to a patient's invasive device (enhanced feedback loop) resulted in a significant increase in HH compliance (69.5% in the enhanced group vs 59.1% in the basic group; P = .0001). Conclusion: An enhanced feedback loop system connected to invasive devices, providing real-time alerts to HCWs, is effective in improving HH compliance.

Pain in Brazilian people experiencing homelessness.

BACKGROUND: Previous studies conducted in developed countries have shown that homeless people experience a high rate of pain. In this population, pain is not only underdiagnosed but is also undertreated. In Brazil, the pain of people experiencing homelessness is unknown and this is the first study on this subject in the country. OBJECTIVE: To assess and characterize the prevalence of pain in homeless people living on the streets in the center of São Paulo, Brazil, and to understand its implications to general activities according to the Brief Pain Inventory (BPI) questionnaire. METHOD: This is a descriptive-exploratory cross-sectional study with a quantitative approach conducted with 69 homeless people from the central region of São Paulo, Brazil. The data were captured as protected health information and analyzed with a sociodemographic form, the BPI questionnaire, the McGill Pain Questionnaire (MPQ), and the Wong-Baker Face Scale. RESULTS: The sample consisted mainly of men who spend the night on the streets, of black and miscegenated Brazilian people, with a mean age of 51 years. This population lived an average of 12 years on the streets, presented low levels of education, and used psychoactive substances. We observed a prevalence of severe musculoskeletal pain in the spine, with intermittent activity and duration of several days. The most common self-reported worsening factor was body movement and the most common factor of improvement was use of medication, but only 15% reported pain relief. Pain greatly interfered with all BPI's Activities of Daily Living, in particular with sleep (87.2%). The MPQ was difficult for the subjects to understand. There was no evidence of an association between pain and sex. Our results suggest that the longer the time living on the street, the less pain symptoms are acknowledged by the subjects, due to the accommodation phenomenon.

Sustainability of a program for continuous reduction of catheter-associated urinary tract infection.

BACKGROUND: Urinary tract infections account for 8%-21% of health care-associated infections; of these, 80% are associated with the use of a urinary catheter. METHODS: A quasi-experimental study was conducted in 2 medical-surgical intensive care units (ICUs) with 48 beds and 3 step-down units (SDUs) with 95 beds in a private tertiary care hospital in Sao Paulo, Brazil. The study had 3 phases over a 9-year period to determine the sustainability of a program for continuous reduction of catheter-associated urinary tract infection (CAUTI). RESULTS: Over the 3 phases of the study, rates of CAUTI in the ICUs fell from 7.0 to 3.5 to 0.9 infections per 1,000 catheter days. In the SDUs, CAUTI rates decreased from 14.9 to 6.6 to 1.0 per 1,000 catheter days. Comparisons of CAUTI rates in the 3 study phases, both in the ICUs and SDUs, showed significant reductions both between the 3 periods and in all possible combinations of analysis phases (all P < .001). CONCLUSIONS: These results suggest that it is possible to reduce CAUTI rates to near zero and sustain these rates, but it requires a multidisciplinary team with different strategies that require continuous monitoring.

MiR-9 and miR-21 as prognostic biomarkers for recurrence in papillary thyroid cancer.

Despite low mortality rates, nodal recurrence in papillary thyroid carcinoma occurs in up to 20 % of patients. Emerging evidences indicate that dysregulated microRNAs are implicated in the process of metastasis. In the present study, we investigated whether miR-9, miR-10b, miR-21 and miR-146b levels are predictive of papillary thyroid carcinoma recurrence. Using macro-dissection followed by quantitative real-time PCR, we measured miR-9, miR-10b, miR-21 and miR-146b expression levels in formalin-fixed, paraffin-embedded samples of 66 patients with papillary thyroid carcinoma categorized into two groups: the recurrent group (n = 19) and the non-recurrent group (n = 47). All patients underwent total thyroidectomy and were followed for at least 120 months after surgery to be considered recurrence-free. Univariate and multivariate analysis were performed using the Cox proportional hazard model in order to identify associations between multiple clinical variables and microRNA expression levels and papillary thyroid carcinoma recurrence. MiR-9 and miR-21 expression levels were found to be significant prognostic factors for recurrence in patients with papillary thyroid carcinoma (HR = 1.48; 95 % CI 1.24-1.77, p < 0.001; and HR = 1.52; 95 % CI 1.18-1.94, p = 0.001; respectively). Multivariate analysis involving the expression level of miR-9 and miR-21 and various clinical parameters identified the expression of these microRNAs as independent prognostic factors for papillary thyroid cancer patients. In conclusion, our results support the potential clinical value of miR-9 and miR-21 as prognostic biomarkers for recurrence in papillary thyroid carcinoma.

Comparison of human and electronic observation for the measurement of compliance with hand hygiene.

BACKGROUND: Monitoring of hand hygiene is an important part of the improvement of hospital quality indicators. METHODS: This study was prospectively performed over a 14-week (electronic observer) period from December 3, 2013-March 9, 2014, to evaluate hand hygiene compliance in an adult step-down unit. We compared electronic handwash counters with the application of radiofrequency identification (RFID - ZigBee; i-Healthsys, São Carlos, Brazil) (electronic observer), which counts each activation of the alcohol gel dispenser to direct observation (human observer) using the iScrub application. RESULTS: For the overall time period of simultaneous electronic and human observation, we found that the electronic observer identified 414 hand hygiene episodes, whereas the human observers identified 448 episodes. Therefore, we found 92% (95% confidence interval [CI], 90%-95%) overall concordance (414/448), with an intraclass correlation coefficient of .87 (95% CI, 0.77-0.92). CONCLUSION: Our RFID (ZigBee) system showed good accuracy (92%) and is a useful method to monitor hand hygiene compliance.

Measuring hand hygiene compliance in a hematology-oncology unit: a comparative study of methodologies.

BACKGROUND: In managing hematology-oncology patients, there is a great opportunity for performing hand hygiene (HH). METHODS: Over a 4-month period, we compared HH compliance measurement by 3 different methods: direct observation, electronic handwash counter for alcohol gel, and measuring the volume of product used (alcohol gel) in a 40-bed hematology-oncology unit at a tertiary care, private hospital. RESULTS: There were 388 directly observed opportunities for HH, and the overall HH compliance rate was 84.5%. A total of 235,923 HH episodes was recorded by the electronic devices. The mean HH episodes per patient-day was 77.7. There were 91.1 mL of alcohol gel used per patient-day in the unit. The correlation and P value between the percentage of HH compliance and HH episodes per 1,000 patient-days were ρ = 0.442 and P = .076, respectively. The correlation and P value between HH episodes per patient-days and alcohol gel consumption in milliliters per patient-days were ρ = 0.142 and P = .586. CONCLUSION: HH compliance was high in this unit. Direct observation, although useful, has many drawbacks. Other measures must be considered, such as electronic devices and measurement of volume use per patient-day to stimulate health care workers to increase and sustain HH compliance.

A multicenter study using positive deviance for improving hand hygiene compliance.

BACKGROUND: Positive deviance (PD) can be a strategy for the improvement of hand hygiene (HH) compliance. METHODS: This study was conducted in 8 intensive care units and 1 ward at 7 tertiary care, private, and public hospitals. Phase 1 was a 3-month baseline period (from August to October 2011) in which HH counts were performed by observers using iPods (iScrub program). From November 2011 to July 2012, phase 2, a PD intervention was performed in all the participating centers. We evaluated the consumption of HH products (alcohol gel and chlorhexidine) and the incidence density of health care-associated infections. RESULTS: There was a total of 5,791 HH observations in the preintervention phase and 11,724 HH observations in the intervention phase (PD). A statistically significant difference was found in overall HH compliance with 46.5% in the preintervention phase and 62.0% in the PD phase (P < .001). There was a statistically significant reduction in the incidence of density of device-associated infections per 1,000 patient-days and also in the median of length of stay between the preintervention phase and the PD phase (13.2 vs 7.5 per 1,000 patient-days, respectively, P = .039; and 11.0 vs 6.8 days, respectively, P < .001, respectively). CONCLUSION: PD demonstrated great promise for improving HH in multiple inpatient settings and was associated with a decrease in the median length of stay and the incidence of device-associated HAIs.

Preventing catheter-associated urinary tract infection in the zero-tolerance era.

BACKGROUND: Catheter-associated urinary tract infection (CAUTI) is one of the most common health care‒associated infections in the critical care setting. METHODS: A quasi-experimental study involving multiple interventions to reduce the incidence of CAUTI was conducted in a medical-surgical intensive care unit (ICU) and in 2 step-down units (SDUs). Between June 2005 and December 2007 (phase 1), we implemented some Centers for Disease Control and Prevention‒recommended evidence-based practices. Between January 2008 and July 2010 (phase 2), we intervened to improve compliance with these practices at the same time that performance monitoring was being done at the bedside, and we implemented the Institute for Healthcare Improvement's bladder bundle for all ICU and SDU patients requiring urinary catheters. RESULTS: There was a statistically significant reduction in the rate of CAUTI in the ICU, from 7.6 per 1,000 catheter-days (95% confidence interval [CI], 6.6-8.6) before the intervention to 5.0 per 1,000 catheter-days (95% CI, 4.2-5.8; P < .001) after the intervention. There also was a statistically significant reduction in the rate of CAUTI in the SDUs, from 15.3 per 1,000 catheter-days (95% CI, 13.9-16.6) before the intervention to 12.9 per 1,000 catheter-days (95% CI, 11.6-14.2) after the intervention (P = .014). CONCLUSION: Our findings suggest that reducing CAUTI rates in the ICU setting is a complex process that involves multiple performance measures and interventions that can be applied to SDU settings as well.