Rol de enfermería en el área COVID en un hospital pediátrico de alta complejidad / The role of nurses in the COVID area in a pediatric tertiary-care hospital

Introducción: la pandemia por SARS-CoV-2 planteó un desafío para todo el equipo de salud. Fue necesario analizar y pensar en este contexto el rol de enfermería en la atención y cuidados del paciente y su familia. Los procesos asistenciales debieron adaptarse a nuevas y diversas situaciones que generaron la atención de pacientes en su mayoría con comorbilidades asociadas. El objetivo del trabajo fue describir el rol de enfermería y la implementación de diversos protocolos y procesos de atención de pacientes en salas de internación pediátrica del área COVID de un hospital de alta complejidad. Material y métodos: se realizó un estudio retrospectivo y descriptivo sobre el personal de enfermería que participó en la atención de casos sospechosos o confirmados de COVID-19 durante la pandemia y los protocolos implementados para los cuidados de enfermería. Resultados: solo el 52.5% (n 79) del personal tenía experiencia mayor a tres años, el 75% (n: 113) pertenecían al género femenino, el 47% (n: 71) eran licenciados en enfermería. Conclusiones: Los profesionales enfermeros han logrado mediante sus fortalezas disciplinares dar respuesta a las necesidades del paciente pediátrico y su familia frente a la crisis sanitaria. Las competencias desarrolladas en la administración de los recursos disponibles, la adaptación, flexibilidad a los procesos y líneas estratégicas en tiempo real, posicionan al enfermero como un valor fundamental en el cuidado asistencial (AU)

Introduction: The SARS CoV-2 pandemic posed a challenge for the entire healthcare team. It was necessary to analyze and reflect on the role of nursing in the care of patients and their families in this context. Care processes had to be adapted to new and diverse situations that were generated by the care for patients who usually had associated comorbidities. The aim of the study was to describe the nursing role and the implementation of different protocols and processes for patient care in pediatric inpatient wards in the COVID area of a tertiary-care hospital. Material and methods: a retrospective descriptive study was conducted in the nursing personnel involved in the care of suspected or confirmed cases of COVID-19 during the pandemic and the protocols implemented for nursing care. Results: only 52.5% (n: 79) of the personnel had more than three years of experience, 75% (n: 113) were female, and 47% (n: 71) had a nursing degree. Conclusions: Through their disciplinary strengths, nursing professionals have been able to respond to the needs of pediatric patients and their families in the face of the health crisis. The skills developed in the management of available resources, adaptation, and flexibility to processes and real-time strategies, have positioned nurses as a fundamental factor in healthcare (AU)

Human insulin fibrillogenesis in the presence of epigallocatechin gallate and melatonin: Structural insights from a biophysical approach.

Fibrillogenesis of monomeric human insulin in the presence or absence of (-)-epigallocatechin-3-gallate and melatonin was here investigated using a multi-technique approach. Results from Raman and Infrared spectroscopy pointed out that a high content of intermolecular ß-sheet aggregates is formed after long-term incubation. However, near UV experiments, Dynamic Light Scattering, Thioflavin-T fluorescence measurements and Atomic Force Microscopy revealed that the kinetics from native-to-fibrillar state of insulin is hampered only in the presence of (-)-epigallocatechin-3-gallate. Molecular dynamic simulations indicated that this compound binds near the B11-B18 protein segment, where hydrophobic residues responsible for the beginning of cooperative aggregation are located. Such a preferential binding region is not recognized by melatonin, a highly mobile molecule, which indeed does not affect fibril formation. The results of the present study demonstrate that (-)-epigallocatechin-3-gallate interferes with the insulin nucleation phase, giving rise to amorphous aggregates in the early stages of the aggregation process.

Role of dietary antioxidant (-)-epicatechin in the development of ß-lactoglobulin fibrils.

Under specific physico-chemical conditions ß-lactoglobulin is seen to form fibrils structurally highly similar to those that are formed by the amyloid-like proteins associated with neurodegenerative disorders, such as Alzheimer and Parkinson diseases. In the present study we provide insights on the possible role that the dietary flavonoid (-)-epicatechin plays on ß-lactoglobulin fibril formation. Fibril formation is induced by keeping ß-lactoglobulin solutions at pH2.0 and at a temperature of 80°C for 24h. Atomic Force Microscopy measurements suggest that, by adding (-)-epicatechin in the solution, fibrils density is visibly lowered. This last observation is confirmed by Fluorescence Correlation Spectroscopy experiments. With the use of Fourier Transform IR spectroscopy we monitored the relative abundances of the secondary structures components during the heating process. We observed that in the presence of (-)-epicatechin the spectral-weight exchange between different secondary structures is partially inhibited. Molecular Dynamics simulations have been able to provide an atomistic explanation of this experimental observation, showing that (-)-epicatechin interacts with ß-lactoglobulin mainly via the residues that, normally in the absence of (-)-epicatechin, are involved in ß-sheet formation. Unveiling this molecular mechanism is an important step in the process of identifying suitable molecules apt at finely tuning fibril formation like it is desirable to do in food industry applications.

Cytotoxic chemotherapy in the treatment of advanced renal cell carcinoma in the era of targeted therapy.

BACKGROUND: Renal cell carcinoma (RCC) is a heterogeneous disease with regards to histology, progression, and response to treatment. Cytotoxic chemotherapy has been extensively studied in metastatic RCC (mRCC). Responses in most studies are modest and the mechanisms of resistance remain poorly understood. Targeted therapies have significantly improved outcomes in mRCC; however, most patients eventually relapse and die of their disease. Early clinical data suggest that combinations of chemotherapy and targeted agents are clinically active and are well tolerated. METHODS: We reviewed the available literature for published clinical trials incorporating traditional chemotherapeutic agents in the treatment of mRCC. These papers were identified through a Medline search and were included if they employed at least one chemotherapeutic agent in the treatment of mRCC. The literature was also reviewed for information regarding mechanisms of chemotherapy resistance. RESULTS: The data regarding the use of cytotoxic chemotherapy in mRCC consist of small, non-randomized phase I and II studies. The major response proportions with single agent chemotherapies are low but combination regimens either with other cytotoxic agents, cytokines, or targeted agents have demonstrated moderate activity. Disparate trial designs and lack of head to head clinical trials make it difficult to compare the efficacy of chemotherapy with that of immunotherapy or targeted agents. Chemotherapy is particularly useful in patients with collecting duct histology and predominantly sarcomatoid differentiation. Chemotherapy resistance may be mediated by overexpression of p-glycoprotein efflux pumps and the dysregulation of the microtubule-hypoxia inducible factor signaling axis. CONCLUSIONS: The role of cytotoxic chemotherapy in the treatment for clear cell RCC remains poorly defined. Cytotoxic chemotherapy is considered a standard of care in patients with mRCC with predominantly sarcomatoid differentiation and collecting duct RCC variants (Motzer et al., 2014). Early trials combining chemotherapy with targeted therapies are generally well tolerated and show clinical activity. A better understanding of the biology of aggressive subsets of RCC and mechanisms of resistance will help elucidate the role of cytotoxic agents in the current treatment paradigm of RCC.

Programa de prevención de las bacteriemias asociadas a catéteres venosos centrales / Program for prevention of central venous catheter-related bacteremia

Introducción: Las infecciones son las complicaciones más importantes asociadas al uso de los Catéteres Venosos Centrales (CVC), representan un riesgo 20 veces mayor de bacteriemias que los catéteres venosos periféricos. El objetivo de este estudio fue evaluar el efecto de la implementación de un paquete de medidas o "bundle" en las infecciones asociadas a catéteres venosos centrales (BACT- CVC) en la Unidad de Cuidados Intensivos del Hospital Garrahan (UCI). Métodos: El Programa de Intervención para disminuir las bacteriemias asociadas a catéteres venosos centrales requirió de la aplicación de cuatro paquetes de medidas y un subprograma para aumentar la adherencia a la higiene de manos. Se aplicó en todas las UCI, pero en el presente estudio se presenta como modelo de referencia el que se llevó a cabo en una de ellas. Período del estudio: se compararon 2 períodos: basal (1º Agosto de 2008 - 31 de Diciembre de 2009) y intervención (1º de Enero 2010 al 31 de Diciembre de 2011). La tasa de BACT - CVC se calculó en concordancia con los protocolos utilizados por el sistema NHSN - CDC de los Estados Unidos y el sistema nacional VIHDA. La base de datos utilizada para el estudio fue el software provisto por el programa VIHDA. Se compararon las tasas de BACT - CVC en el período previo y posterior a las intervenciones realizadas. Para el análisis estadístico se utilizó el programa EPIINFO. Se consideró estadísticamente significativo un valor de p < 0.05. Resultados: en el primer período (Agosto 2008 - Diciembre 2009) se produjeron un total de 44 BACT - CVC, con una tasa promedio de 9.64 BACT-CVC por 1000 días-catéter versus 17 BACT - CVC, tasa promedio de 4.41 BACT-CVC por 1000 días-catéter en el período en que se desarrolla el programa de intervención. Esta disminución resulta estadísticamente significativa (Chi cuadrado; valor P= 0,0048; RR 0,46; IC 95%: 0,26 - 0,80). Conclusiones: La aplicación de los combos y el subprograma para mejorar la adherencia a la higiene de manos según orientación de la OMS y aplicando Estrategias Multimodales, resultaron en una mejora significativa en la tasa de BACT- CVC (AU)

Introduction: Infections are the main complication associated with the use of central venous catheters (CVC), accounting for an infection risk about 20 times that of peripheral venous catheters. The aim of this study was to assess the effect of the implementation of sets of measures or "bundle" for the prevention of CVC-associated bacteremia (CVC-BACT) in the ICU. Methods: The intervention program for the reduction of CVC-BACT consisted of four sets of measures and a sub-program to increase adherence to hand hygiene. Bundle use was started in all PICUs, however, in this study implementation of the program in one of them was used as a reference model. Study period: Two periods were compared: Baseline (August 1, 2008 ­ December 31, 2009) and intervention (January 1, 2010 ­ December 31, 2011). The CVC-BACT rate was calculated according to the NHSN-CDC protocols of the United States and the Argentine VIHDA system. For the data base of the study software provided by the VIHDA program was used. CVC-BACT rates before and after the intervention period were calculated. For statistical analysis the EPIINFO program was used. A p < 0.05 was considered significant. Results: In the first period (August 2008 - December 2009) 44 CVC-BACT occurred, with a mean CVC-BACT rate of 9.64 per 1000 catheter days versus 17 CVC-BACT, mean CVC-BACT rate of 4.41 per 1000 catheter days, in the intervention period. This decrease was statistically significant (Chi square 7.94; p = 0.0048; RR 0.46; 95% CI: 0.26 ­ 0.80). Conclusions: Bundle use and the subprogram for better adherence to hand hygiene, according to WHO guidelines and applying multimodal strategies, resulted in a significantly lower CVC-BACT rate (AU)

Brote de Ralstonia mannitolilytica a partir de bacteriemias asociadas a catéteres implantables y semiimplantables en un hospital pediátrico / Outbreak of Raistonia mannitolilytica by implantable and semi-implantable catheter-related bacteremia in a pediatric hospital

Ralstonia mannitolilytica junto con Ralstonia pickettii han sido asociadas con brotes hospitalarios relacionados con la contaminación de algún dispositivo o fluido. El objetivo de este trabajo fue describir un brote por R. mannitolilytica a partir de bacteriemias asociadas a catéteres implantables y semiimplantables ocurrido en un hospital pediátrico de alta complejidad y evaluar la utilidad del empleo de métodos moleculares para su investigación.Se detectó la presencia de bacilos gram negativos no fermentadores, con igual antibiotipo, en hemocultivos y retrocultivos a partir de dos pacientes que tenían catéteres implantables y estaban atendidos en una misma área del hospital. Se realizaron estudios microbiológicos de muestras de frascos de heparina, soluciones de dextrosa y soluciones antisépticas con resultado negativo. Algunos pacientes tuvieron signos y/o síntomas clínicos de bacteriemia al habilitar los catéteres para su uso. Se citaron para su estudio a todos los pacientes que habían tenido un procedimiento de apertura y cierre de catéter durante las fechas cercanas a los hallazgos en hemocultivos (N expuestos = 45). Ocurrieron 17 casos (infectados), a partir de los cuales se analizaron 23 aislamientos, en los que se pudo documentar la presencia de R. mannitolilytica (23 aislamientos). Por métodos moleculares se determinó que los aislamientos provenientes de muestras de pacientes involucrados en el brote se encontraban estrechamente relacionados y podrían representar una misma cepa o clon. Por evidencia circunstancial se consideró a la "solución heparínica de cierre" como fuente posible del brote (AU)

Both Ralstonia mannitolilytica and Ralstonia pickettii have been associated with hospital outbreaks due to device or fluid contamination. The aim of this study was to describe an implantable- or semi-implantable-catheter-related bacteremia outbreak by R. mannitolilytica in a tertiary-care hospital and to assess the usefulness of molecular analysis for the identification of the organism. Non-fermenting gram-negative bacilli, with identical antibiotypes, were detected in hemocultures of two patients with implantable catheters in the same hospital area. Microbiological studies of heparin and dextrose and antiseptic solution vials were negative. Some of the patients had clinical signs and/or symptoms of bacteremia when the catheter was prepared for use. All patients who underwent a procedure of accessing or locking the port of the catheter around the time of the positive hemoculture findings were contacted (N exposed = 45). Seventeen infections were detected, of which 23 isolates were analyzed. The presence of R. mannitolilytica was recorded in 23 isolates. Molecular analysis showed that the isolates from the samples of the patients involved in the outbreak were closely related and might represent the same strain or clone. Circumstantial evidence suggested that the heparin-lock solution may have been the source of the outbreak (AU)

Programa de prevención de infecciones respiratorias virales en niños hospitalizados / Prevention program for viral respiratory infections in hospitalized children

Las infecciones respiratorias virales (IRV) son una causa importante de morbilidad en la infancia. El objetivo de este estudio fue analizar el programa de prevención de infecciones respiratorias virales relizado en los niños internados en el Hospital de Pediatría Juan P. Garrahan. La tasa global de episodios IH fue 12,7 por ciento. Cuando se analiza según microorganismo, podemos obserbar que en el caso de VSR la tasa global fue de 11,3 por ciento, mientras que en influenza fue 12 por ciento y en adenovirus 23 por ciento. El análisis comprativo de los episodios muestra que en el período 2000 - 2001 la tasa de infecciones IH fue de 17,8 por ciento, mientras que en el período 2006 -2007 la tsa de IH documentada fue de 10,7 por ciento (p=0.004). Cuando se analiza según agente dicha diferencia se mantiene cuando se trata de VSR, el virus más frecuene OR:1.76(1,25-2,49;p=0.001). Las recomendaciones para la prevención se basan en el modo de transmisión del agente e incluyen la implementación de medidas de contacto y en algunos casos, el aislamiento respiratorio por gotitas. La medida fundamental es la antisepsia de las manos, ya sea a través del lavado o el uso de gel alcohólico y el uso de guantes con el contacto del paciente.

Impacto de 10 años de vigilancia de colonización con enterococos resistentes a vancomicina (ERV) en un hospital pediátrico de alta complejidad / 10 year impact of monotoring colozation with vancomycin resistant enterococci (VRE) in a tertiary care pediatric hospital

Se demostro que la vigilancia activa de colonización con enterococos resistentes a vancomicina (ERV) resulta costo-efectiva y que es capaz de limitar la presencia de esos patógenos en los hospitales. El objetivo de este trabajo fue evaluar el impacto de una forma de vigilancia menos estricta a través de los resultados de los estudios de prevalencia de un día y del número anual de pacientes infectados con ERV. En los cortes de prevalencia, se estudiaron todos los pacientes hospitalizados en días determinados, a través de hisopados rectales cultivados en medio BEAA con 6 ug/ml de vancomicina (VAN). También se estudiaron todos los aislamientos de enterococos provenientes de materiales clinicamente significativos a lo largo de los años. La resistencia a VAN fue confirmada por difusión, Etest y PCR especifica para lo genes vanA, vanB, o van C. La relación clonal fue establecida por electroforesis en campos pulsados cor cortes con la enzima Smal. El porcentaje de colonización rectal de ERV en los cortes de prevanlencia no registró un aumento significativo entre 2002 y 2007 (p > 0.05). La diversidad clonal mostró una baja tendencia hacia la diseminación intrahospitalaria de los ERV. El número de bacteriemias por ERV se mantuvo en niveles aceptables y la mayoria de las infecciones estuvieron localizadas en el tracto urinario. Concluyendo, el número de pacientes colonizados aumentó en forma sostenida pero sin diferencias significativas entre los distintos años. El número de pacientes severamente infectados con ERV hasta el momento ha sido escaso. Esto pareceria indicar que la estrategia elegida ha resultado efectiva.

Analisis del costo beneficio de la prevención de bacteriemias relacionadas con cateteres vasculares / Cost/Benefit analysis in the prevention of vascular catheter-related bacteremia

Introducción: el impacto que generan las bacteriemias asociadas a cvc es muy importante. Como parte de un programa de prevención de las bacteriemias asociadas a CVC se evaluó el exceso de costo atribuible a dichas infecciones y el costo beneficio del programa. Métodos: Se compararon las tasas de BI asociadas a CVC ocurridas en el período previo (PreI)y posterior a las intervenciones (PostI). Se utilizaron las definiciones desarrolladas por el NNIS. Se calculó el costo atribuible a través de la diferencia casos y controles. Se analizó el costo por infección y el total del período. Resultados: la tasa global anual de BI asociadas a CVC fue de 7.6 por 1000 pacientes días. La tasa de BI se redujo en Post I en forma significativa con una tasa de 5.7 BI/1000 pacientes día versus 10,2 BI/1000 en el período previo (p=0.03; RR 0.56 IC 95 por ciento 0.33, 0.95). La fracción prevenible es de 44 por ciento. IC 95 por ciento 5.44, 67.3. El numero de BI estimativamente evitadas en el Post I fue de 14. El exceso de costo promedio atribuible a las BI asociadas a CVC fue de U$S 5180. Conclusión: un programa de BI puede reducir las tasas de infección y dichas actividades son cruciales para reducir los costos extra asociados.Palabras clave: Bacteriemias asociadas, prevención

Evaluation of polyphenol bioavailability in rat small intestine.

BACKGROUND: Dietary polyphenols, which are contained in several foods of plant origin, have been reported to be effective protective agents against cardiovascular diseases and cancer. However, data on their absorption from the gastrointestinal tract are still scarce and, often, contradictory. AIM OF THE STUDY: In this report, evaluation of polyphenol bioavailability was carried out by using segments of the small intestine from rat. The extent of absorption throughout the small intestine of rat was evaluated with two model compounds, tannic acid and catechin, as representatives of high and low molecular weight polyphenols, respectively. The consequence of the binding of tannic acid to BSA on both tannic acid absorption and in vivo protein digestibility was also examined. METHODS: Polyphenol solutions of different concentrations were injected into the lumen of ligated segments (6 cm) of the small intestine and the segments incubated in buffer for 5 min. The residual amount of polyphenol in the lumen of each segment was assayed by maximum absorption in the UV/VIS optical spectrum as was the amount of compound that had crossed the gut wall into the incubation buffer. Digestibility of BSA and of a BSA- tannic acid complex was assayed with rats. RESULTS: The results indicated a significant, concentration-dependent, disappearance of both polyphenols from the small intestine of the rat, with higher uptake levels being evident for tannic acid (50%) than catechin (30%). However, complete transfer through the gut wall was not observed with tannic acid whilst low but significant amounts (10%) were detected in incubation buffers with catechin. Partial binding of polyphenols by endogenous proteins in the intestinal lumen was also demonstrated. Complexing tannic acid with BSA (1:10 mol/mol) was not found to affect either the extent of interaction of tannic acid with the small intestine or the in vivo digestibility of the protein. CONCLUSIONS: Our experiments show that tannic acid and catechin both interact with the gut but only catechin appears able to traverse the gut. In addition, they provide evidence for binding of tannic acid and catechin by endogenous proteins in the intestinal lumen. This may limit their absorption from the small intestine. BSA complexed with tannic acid was as readily digested as BSA alone. This may suggest that tannic acid exerts anti-nutritional effects by binding to proteins of the gut wall and interfering with gut function rather than by inhibition of dietary protein digestion.

Investigation of the mechanisms affecting Cu and Fe bioavailability from legumes: role of seed protein and antinutritional (nonprotein) factors.

Chemical composition and content in polyphenols, phytic acid, and dietary fiber of whole cooked common bean (Phaseolus vulgaris L.) and faba bean (Vicia faba L.) and of soluble and insoluble fractions separated from them were determined. Simultaneous determination of Cu, Fe, and protein bioavailability in the small intestine of rat was carried out in single-dose, short-term (1 h) experiments. After cooking, about 80% of seed components (on a weight basis) of either legume was recovered in the precipitate (insoluble fraction) after extraction with water. Protein, lipid, starch, dietary fiber, and polyphenols underwent the most severe insolubilization, together with more than 70% of total Cu and Fe. Cu, Fe, and protein bioavailability showed a similar trend (i.e., the lower the protein, the lower the Cu and Fe availability). Availability of proteins, Cu, and Fe in the insoluble fractions were the lowest, but Cu bioavailability was higher than that of Fe in all fractions. The results provide evidence that the heat-induced insolubilization process adversely affects not only protein but also Cu and Fe bioavailability from legumes and that polyphenols are likely to be a major inhibitor on absorption.

Perspectives into factors limiting in vivo digestion of legume proteins: antinutritional compounds or storage proteins?

The in vivo protein digestibility of raw and cooked common bean (Phaseolus vulgaris L.) and faba bean (Vicia faba L.) and of protein fractions extracted from them was determined with growing rats. Overnight-fasted rats were intubated with a protein suspension or fed the same amount of protein added to a basal diet. The rats were killed 1 h later, the contents of stomach and small intestine were washed out, and their protein contents were measured. The in vivo digestibility of proteins of raw common bean flour was 72.4% and not significantly improved after cooking. In contrast, the digestibility of faba bean proteins was decreased from 86.5 to 60.6% by the thermal treatment. Globulins from either species had similar digestibilities (approximately 70%). Proteins in the soluble fraction of cooked beans were more digestible than those in the insoluble fraction, which contained the bulk of the proteins. Hemagglutination assay and trypsin inhibitor determination indicated that after the thermal treatment only very low, nonharmful, levels of both lectin and inhibitor remained. Faba bean contained more polyphenols than common bean samples, with most of the polyphenols being bound to globulins. However, protein-bound polyphenols were markedly decreased after cooking. SDS-PAGE characterization of the gastrointestinal digesta of globulins and amino acid analysis of undigested proteins of whole cooked common bean and faba bean suggested that it is mainly the structural properties of the storage proteins and not their binding of polyphenols, which determines the extent of protein aggregation on autoclaving and may therefore be responsible for their low digestibility.