Evaluation of Hepatitis B Reactivation Among Patients With Chronic Myeloid Leukemia Treated With Tyrosine Kinase Inhibitors.

Hepatitis B reactivation (HBVr) in cancer patients is a well-established complication due to chemotherapy-induced immunosuppression. Studies have reported HBVr associated with immunosuppressive medications, such as rituximab, methotrexate, and high dose steroids. There are different risks for different types of chemotherapy with rituximab carrying one of the highest risks for hepatitis B reactivation. Tyrosine kinase inhibitors (TKIs) are the standard of care in patients with chronic myeloid leukemia (CML). The risk of HBVr in chronic myeloid leukemia has been reported in many studies, but to this date, there are no clear guidelines or recommendations regarding screening and monitoring of HBV in CML patients receiving TKIs. We conducted this review to identify the risk of HBVr in patients with CML who are treated with tyrosine kinase inhibitors. We recommend testing for HBV status in patients who are to be treated with TKIs and to consider giving prophylaxis in those who are positive for HBsAg at baseline. More studies are needed to assess the risk of reactivation in patients with Hepatitis B core antibody positive receiving TKIs. Currently, monitoring such patients for reactivation may be the best strategy.

Protocolo de atendimento odontológico a pacientes usuários de terapia antitrombótica / Dental care protocol for patients using antithrombotic therapy

Muitos pacientes que necessitam de intervenção odontológica, atualmente, são usuários de terapia medicamentosa antitrombótica. Essa condição se mostra prevalente, considerando que problemas cardiovasculares afetam grande parte da população. Objetivo: construir um protocolo clínico para o Serviço de Odontologia e Estomatologia do Hospital das Clínicas de Ribeirão Preto da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, a partir de evidências científicas. Revisão de literatura: foi realizada uma pesquisa bibliográfica nas bases de dados eletrônicas Scientific Eletronic Library Online (SciELO) e Public MedLine (PubMed), nos idiomas português e inglês, do período entre 2013 e 2017. Após obtenção dos periódicos, foram selecionados os que se tratavam de estudos clínicos e seguiu-se com tradução, leitura e análise dos artigos. Com base nas evidências científicas, optou-se por construir o protocolo a partir da classe de medicamento utilizada pelos usuários de terapia antitrombótica (antiagregantes plaquetários, anticoagulantes orais e novos anticoagulantes orais) e orientações (pré, intra e pós-operatórias) para cada procedimento odontológico. Considerações finais: o protocolo clínico estabeleceu parâmetros para condutas clínicas e cirúrgicas em atendimento ambulatorial e hospitalar, possibilitando o cuidado integral aos usuários de terapia antitrombótica. Futuros estudos clínicos são necessários para validação e adequação para seu uso em diferentes serviços. (AU)

Several patients who require dental intervention are current users of antithrombotic drug therapy. This condition is prevalent, considering that cardiovascular problems affect a large portion of the population. Objective: this study aimed to construct a clinical protocol for the Service of Dentistry and Stomatology of the Clinics Hospital of Ribeirão Preto from the Medical School of Ribeirão Preto of the University of São Paulo, Brazil, based on scientific evidence. Literature review: a bibliographic review was performed in the Scientific Electronic Library Online (SciELO) and Public MedLine (PubMed) electronic databases, in the Portuguese and English languages, for the period of 2013 through 2017. After obtaining the journals, the clinical studies were selected, followed by the translation, reading, and analysis of the articles. Based on the scientific evidence, we decided to build the protocol from the class of medication of the users of antithrombotic therapy (antiplatelet agents, oral anticoagulants, and new oral anticoagulants), and guidelines (pre-, intra-, and postoperative) for each dental procedure. Final considerations: the clinical protocol established parameters for clinical and surgical procedures in outpatient and hospital care, allowing comprehensive care to users of antithrombotic therapy. Further clinical studies are required to validate and adequate the use of this therapy in different services. (AU)

Sacral Neuromodulation: Standardized Electrode Placement Technique.

INTRODUCTION: Sacral neuromodulation (SNM) (sacral nerve stimulation SNS) has become an established therapy for functional disorders of the pelvic organs. Despite its overall success, the therapy fails in a proportion of patients. This may be partially due to inadequate electrode placement with suboptimal coupling of the electrode and nerve. Based on these assumptions the technique of sacral spinal neuromodulation has been redefined. All descriptions relate to the only currently available system licensed for all pelvic indications (Medtronic Interstim® ). METHOD: An international multidisciplinary working party of ten individuals highly experienced in performing SNM convened two meetings (including live operating) to standardize the implant procedure. This report addresses the main steps to optimal electrode lead placement in temporal sequence. RESULTS: Key elements of the electrode placement are radiological marking, the use of a curved stylet, the entry of the electrode into the sacral foramen and its progression through the foramen, its placement guided by a combination of a typical appearance in fluoroscopy and achieving specific motor/sensory responses with stimulation. The report describes quadripolar electrode placement and then either insertion of a connecting percutaneous extension lead or permanent implantation of the programmable device. CONCLUSION: Standardization of electrode placement may ensure close electrode proximity to the target nerve providing a higher likelihood for optimal effect with less energy consumption (better battery longevity), more programming options with more electrode contacts close to the nerve and reduced likelihood of side-effects. The potentially better clinical outcome needs to be demonstrated.

Pacientes reto: antiagregantes y nuevos anticoagulantes / No disponible

No disponible

Pre- and perioperative aspects of dermatosurgery.

Dermatosurgery occupies an exceptional position among all surgical disciplines. Above all, this includes the fact that, with very few exceptions, the vast majority of surgical interventions can be performed under local or regional anesthesia, usually in smaller procedure rooms that are spatially separated from larger operating suites. Thus, peri- and postinterventional patient monitoring is the responsibility of the dermatosurgeon and his team. Though inherently smaller, this team still has to observe numerous perioperative requirements that - in larger surgical specialties - would be attended to by a host of various specialists working in concert. Said requirements include hygienic aspects, knowledge concerning pre- and intraoperative patient monitoring, managing surgical site infections, adequate postsurgical pain management, as well as detailed pharmacological knowledge with respect to common local anesthetics and the toxic and allergic reactions associated therewith. Not only does this require interdisciplinary collaboration and shared responsibility for the patient. It also necessitates the development and implementation of quality-oriented and evidence-based guidelines that, in the dermatosurgical setting, usually extend far beyond the scope of the specialty per se. The objective of the present CME article is the condensed presentation of interdisciplinary aspects relating to the most important perioperative issues.

Adherence to European Association of Urology Guidelines on Prophylactic Antibiotics: An Important Step in Antimicrobial Stewardship.

BACKGROUND: The evolution of resistant pathogens is a worldwide health crisis and adherence to European Association of Urology (EAU) guidelines on antibiotic prophylaxis may be an important way to improve antibiotic stewardship and reduce patient harm and costs. OBJECTIVE: To evaluate the prevalence of antibiotic-resistant bacterial strains and health care costs during a period of adherence to EAU guidelines in a tertiary referral urologic institution. DESIGN, SETTING, AND PARTICIPANTS: A protocol for adherence to EAU guidelines for antibiotic prophylaxis for all urologic procedures was introduced in January 2011. Data for 3529 urologic procedures performed between January 2011 and December 2013 after protocol introduction were compared with data for 2619 procedures performed between January 2008 and December 2010 before protocol implementation. The prevalence of bacterial resistance and health care costs were compared between the two periods. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The outcome measures were the proportion of resistant uropathogens and costs related to antibiotic consumption and symptomatic postoperative infection. We used χ2 and Fisher's exact tests to test the significance of differences. RESULTS AND LIMITATIONS: The proportion of patients with symptomatic postoperative infection did not differ (180/3529 [5.1%] vs. 117/2619 [4.5%]; p=0.27). A total of 342 isolates from all patients with symptomatic postoperative infections were analysed. The rate of resistance of Escherichia coli to piperacillin/tazobactam (9.1% vs. 5.4%; p=0.03), gentamicin (18.3% vs. 11.2%; p=0.02), and ciprofloxacin (32.3% vs. 19.1%; p=0.03) decreased significantly after protocol introduction. The defined daily dose (DDD) use of ciprofloxacin fell from 4.2 to 0.2 DDD per 100 patient-days after implementation (p<0.001). Antibiotic drug costs (€76,980 vs. €36,700) and costs related to postoperative infections (€45,870 vs. €29,560) decreased following introduction of the protocol (p<0.001). CONCLUSIONS: Adherence to EAU guidelines on antibiotic prophylaxis reduced antibiotic usage without increasing post-operative infection rate and lowered the prevalence of resistant uropathogens. PATIENT SUMMARY: We analysed the impact of adherence to European Association of Urology guidelines on antibiotic prophylaxis for all surgical urologic procedures on the prevalence of infections and resistant bacterial strains and on costs. We found that adherence to the guidelines reduced the rate of bacterial resistance, in particular against piperacillin/tazobactam, gentamicin, and ciprofloxacin, and reduced costs without increasing the risk of postoperative infection after urologic procedures. We recommend adherence to the guidelines as an important part of antibiotic stewardship programmes.

[Hysterectomy for benign pathology: Guidelines for clinical practice]. / Hystérectomie pour pathologie bénigne: recommandations pour la pratique clinique.

OBJECTIVE: The objective of the study was to provide guidelines for clinical practice from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, concerning hysterectomy for benign pathology. METHODS: Each recommendation for practice was allocated a grade which depends on the level of evidence (guidelines for clinical practice method). RESULTS: Hysterectomy should be performed by a high volume surgeon (>10 procedures of hysterectomy per year) (grade C). Rectal enema stimulant laxatives are not recommended prior to hysterectomy (grade C). It is recommended to carry out vaginal disinfection using povidone iodine solution prior to an hysterectomy (grade B). Antibioprophylaxis is recommended during a hysterectomy, regardless of the surgical route (grade B). The vaginal or the laparoscopic routes are recommended for hysterectomy for benign pathology (grade B), even if the uterus is large and/or the patient is obese (grade C). The choice between these two surgical approaches depends on others parameters, such as the surgeon's experience, the mode of anesthesia and organizational constraints (operative duration and medico economic factors). Hysterectomy by vaginal route is not contraindicated in nulliparous women (grade C) or in women with previous c-section (grade C). No specific technique to achieve hemostasis is recommended with a view to avoid urinary tract injuries (grade C). In the absence of ovarian pathology and personal or family history of breast/ovarian carcinoma, it is recommended to conserve ovaries in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended in order to diminish the risk of per- or postoperative complications (grade B). CONCLUSION: The application of these recommendations should minimize risks associated with hysterectomy.

[Guidelines from the Infectious Disease Committee of the French Association of Urology and The Neuro-Urology Committee of the AFU: antibiotic prophylaxis for sacral neuromodulation]. / Recommandations de bonnes pratiques cliniques : antibioprophylaxie et neuromodulation des racines sacrées par le Comité d'infectiologie de l'Association française d'urologie (CIAFU) et le Comité de neuro-urologie de l'AFU.

INTRODUCTION: In urology, antibiotic prophylaxis is advised by the French Association of anesthesiology (SFAR) and the Infectious Disease Committee of the French Association of urology guidelines published in 2010. No guideline exists concerning the implantation of neuromodulation implants. MATERIAL AND METHOD: A literature analysis was performed on sacral modulation and antibiotic prophylaxis. Then guidelines were discussed by reviewers. Items that showed no consensus were then discussed again to arrive at recommendations. RESULTS: Antibiotic prophylaxis is recommended during the test phase as well as in the case of installation of sacral neuromodulation (Grade C). Antibiotic recommended (Grade B) are: cefotetan or cefoxitin, 2g dose by slow intravenous injection or amoxicillin-clavulanic acid at a dose of 2 g, intravenously or, in the case of allergy vancomycin at a dose of 15 mg/kg or the clindamycin has 600 mg intravenously. CONCLUSIONS: Despite the lack of high level of evidence, antibiotic prophylaxis seems necessary when setting up of electrode case of sacral neuromodulation.

Osteoradionecrosis prevention myths.

PURPOSE: To critically analyze controversial osteoradionecrosis (ORN) prevention techniques, including preradiation extractions of healthy or restorable teeth and the use of prophylactic antibiotics or hyperbaric oxygen (HBO) treatments for preradiation and postradiation extractions. METHODS: The author reviewed ORN studies found on PubMed and in other article references, including studies on overall ORN incidence and pre- and postradiation incidence, with and without prophylactic HBO or antibiotics. RESULTS: Owing in part to more efficient radiation techniques, the incidence of ORN has been declining in radiation patients over the last 2 decades, but the prevention of ORN remains controversial. A review of the available literature does not support the preradiation extraction of restorable or healthy teeth. There is also insufficient evidence to support the use of prophylactic HBO treatments or prophylactic antibiotics before extractions or other oral surgical procedures in radiation patients. CONCLUSIONS: To prevent ORN, irradiated dental patients should maintain a high level of oral health. A preradiation referral for a dental evaluation and close collaboration by a multidisciplinary team can be invaluable for radiation patients. As with most other dental patients, restorable and healthy teeth should be retained in irradiated patients. The use of prophylactic HBO or antibiotics should be reconsidered for preradiation and postradiation extractions.

Azitromicina: un macrólido diferente: Perfil terapéutico en infecciones odontogénicas / Azithromycin: a different macrolide. Therapeutic profile in odontogenic infections

Las diferentes patologías de la cavidad bucal, en un gran número, son de origen infeccioso. Tanto el odontólogo general como los diferentes especialistas utilizan antibióticos para el tratamiento coadyuvante de éstas. Es importante conocer los aspectos farmacocinéticos de los antibióticos para poder realizar un uso racional en las infecciones odontogénicas. Los B-lactámicos son los antibióticos de primera elección en las patologías infecciosas de la cavidad bucal; sin embargo, la aparición de cepas multirresistentes, así como del alto número de pacientes que reportan sensibilidad cruzada a este grupo de antibióticos, confieren a los macrólidos una alternativa terapéutica en el manejo de las infecciones bucales. El primer macrólido fue la eritromicina, durante su evolución se han realizado modificaciones a la estructura química original, creando nuevas moléculas como la azitromicina y claritromicina que majoran la estabilidad en medio ácido. La azitromicina tiene distribución tisular amplia y gran concentración del medicamento en el interior de tejidos o secreciones, comparada con la concentración; tiene características peculiares que le confieren una alta confiabilidad, aportando a los odontólogos generales y especialistas un antimicrobiano seguro, confiable y con un gran rango antibacteriano

Impact of local guidelines and an integrated dispensing system on antibiotic prophylaxis quality in a surgical centre.

Surgical antibiotic prophylaxis is effective in preventing postoperative wound infections. Guidelines are designed to optimize antimicrobial use in this setting. The aim of this study was to assess antibiotic use in surgical prophylaxis in a surgical hospital before and after the implementation of both local antibiotic prophylaxis guidelines and a specific medication set for various surgical procedures. The appropriateness of surgical antibiotic prophylaxis increased from 50.9% in the pre-implementation stage to 94.9% in the postimplementation stage (P<0.001). The implementation of a multidisciplinary protocol and design of medication sets helped to improve the practice of surgical antibiotic prophylaxis.

Prevention of gram-negative translocation reduces the severity of hepatopulmonary syndrome.

Hepatopulmonary syndrome (HPS) is characterized by intrapulmonary vascular dilatations and an increased alveoloarterial oxygen difference (AaPO(2)). These abnormalities are related to augmented pulmonary nitric oxide (NO) production, dependent primarily on increases in the expression and activity of inducible NO-synthase (iNOS) within pulmonary intravascular macrophages and, to a lesser extent, of endothelial NOS (eNOS). Production of iNOS by pulmonary intravascular macrophages might be related to translocated gut bacteria present in the pulmonary circulation. To test this hypothesis, we determined whether macrophage sequestration, lung iNOS expression and activity, and HPS severity were decreased after norfloxacin was given for 5 weeks to prevent Gram-negative bacterial translocation in rats with common bile duct ligation-induced cirrhosis. Norfloxacin decreased the incidence of Gram-negative translocation from 70 to 0% and the percentage of pulmonary microvessels containing more than 10 macrophages from 52 +/- 7 to 21 +/- 8% (p < 0.01). AaPO(2) and cerebral uptake of intravenous (99m)Tc-labeled albumin macroaggregates (reflecting intrapulmonary vascular dilatations) were intermediate to those of untreated cirrhotic and sham-operated rats. The activity and expression of lung iNOS, but not eNOS, were reduced to normal. Norfloxacin may reduce HPS severity by inhibiting Gram-negative bacterial translocation, thereby decreasing NO production by pulmonary intravascular macrophages. Bacterial translocation may be the key to the pathogenesis of HPS.

Pharmacokinetics of antibiotic prophylaxis in major orthopedic surgery and blood-saving techniques.

The pharmacokinetics of cefuroxime, cefotiam, cefamandole, and ampicillin/sulbactam were randomly measured in 40 patients undergoing major orthopedic surgery associated with high blood and volume turnover and intraoperative blood salvage. Serum and bone concentrations and the pharmacokinetics occurring in the context of these procedures were measured. No changes in elimination half-life relative to a normal population occurred with cefuroxime, cefotiam, and ampicillin. Serum and tissue concentrations were slightly lower with cefamandole and sulbactam, but reapplication of the initial dose was required with all antibiotics 4 hours after the first application.