Geographical information system and spatial-temporal statistics for monitoring infectious agents in hospital: a model using Klebsiella pneumoniae complex.

BACKGROUND: The emergence and spread of antimicrobial resistance and infectious agents have challenged hospitals in recent decades. Our aim was to investigate the circulation of target infectious agents using Geographic Information System (GIS) and spatial-temporal statistics to improve surveillance and control of healthcare-associated infection and of antimicrobial resistance (AMR), using Klebsiella pneumoniae complex as a model. METHODS: A retrospective study carried out in a 450-bed federal, tertiary hospital, located in Rio de Janeiro. All isolates of K. pneumoniae complex from clinical and surveillance cultures of hospitalized patients between 2014 and 2016, identified by the use of Vitek-2 system (BioMérieux), were extracted from the hospital's microbiology laboratory database. A basic scaled map of the hospital's physical structure was created in AutoCAD and converted to QGis software (version 2.18). Thereafter, bacteria according to resistance profiles and patients with carbapenem-resistant K. pneumoniae (CRKp) complex were georeferenced by intensive and nonintensive care wards. Space-time permutation probability scan tests were used for cluster signals detection. RESULTS: Of the total 759 studied isolates, a significant increase in the resistance profile of K. pneumoniae complex was detected during the studied years. We also identified two space-time clusters affecting adult and paediatric patients harbouring CRKp complex on different floors, unnoticed by regular antimicrobial resistance surveillance. CONCLUSIONS: In-hospital GIS with space-time statistical analysis can be applied in hospitals. This spatial methodology has the potential to expand and facilitate early detection of hospital outbreaks and may become a new tool in combating AMR or hospital-acquired infection.

Splenectomy in Jamaican children with sickle cell disease: Outcome of selective blood transfusion.

We reviewed the post-operative morbidity and mortality of open splenectomy undertaken in conjunction with selective blood transfusion in Jamaican children with sickle cell disease. Data were collected on 150 splenectomies performed between November 1994 and October 2017. Selective blood transfusion involved raising haemoglobin levels to approximately 100 g/L in patients with admission haemoglobin ≥10 g/L below steady state. There was no mortality. Mean post-operative stay was 3.2 days with a median of three days. Total morbidity was 19/150 cases (12.7%), with acute chest syndrome accounting for 11/19 (57.9%). Among the non-transfused, acute chest syndrome occurred in 10/117 cases (8.5%), while among transfused, acute chest syndrome occurred in 1/33 cases (2.9%). We recommend this selective blood transfusion protocol for patients with sickle cell disease to surgeons who undertake splenectomies in settings where blood bank reserves are perennially low.

Predictive factors for sepsis by carbapenem resistant Gram-negative bacilli in adult critical patients in Rio de Janeiro: a case-case-control design in a prospective cohort study.

BACKGROUND: Studies have investigated risk factors for infections by specific species of carbapenem-resistant Gram-negative bacilli (CR-GNB), but few considered the group of GNB species and most of them were performed in the setting of bacteremia or hospital infection. This study was implemented to identify risk factors for sepsis by CR- and carbapenem-susceptible (CS) GNB in intensive care unit (ICU) patients to improve management strategies for CR-GNB sepsis. METHODS: We developed a case-case-control study from a prospective cohort of patients with systemic inflammatory response syndrome (SIRS), sepsis-2 or sepsis-3 criteria in which blood and other sample cultures were collected and antimicrobial therapy was instituted, in an adult clinical-surgical ICU, at tertiary public hospital in Rio de Janeiro, from August 2015 through March 2017. RESULTS: Among the total of 629 ICU admissions followed by 7797 patient-days, after applying inclusion and exclusion criteria we identified 184 patients who developed recurrent or single hospital-acquired sepsis. More than 90% of all evaluable cases of sepsis and 87% of control group fulfilled the modified sepsis-3 definition. Non-fermenting bacilli and ventilator-associated pneumonia predominated as etiology and source of CR-GNB sepsis. While Enterobacteriaceae and intra-abdominal surgical site plus urinary-tract infections prevailed in CS-GNB than CR-GNB sepsis. Carbapenemase production was estimated in 76% of CR-GNB isolates. Multivariate logistic regression analysis revealed previous infection (mostly hospital-acquired bacterial infection or sepsis) (OR = 4.28; 95% CI 1.77-10.35), mechanical ventilation (OR = 4.21; 95% CI 1.17-15.18), carbapenem use (OR = 3.42; 95% CI 1.37-8.52) and length of hospital stay (OR = 1.03; 95% CI 1.01-1.05) as independent risk factors for sepsis by CR-GNB. While ICU readmission (OR = 6.92; 95% CI 1.72-27.78) and nosocomial diarrhea (OR = 5.32; 95% CI 1.07-26.45) were factors associated with CS-GNB sepsis. CONCLUSIONS: The investigation of recurrent and not only bacteremic episodes of sepsis was the differential of this study. The results are in agreement with the basic information in the literature. This may help improve management strategies and future studies on sepsis by CR-GNB.

Efficacy of a Novel Surgical Manikin for Simulating Emergency Surgical Procedures.

The practical component of the Advanced Trauma Life Support (ATLS®) course typically includes a TraumaMan® manikin. This manikin is expensive; hence, a low-cost alternative (SurgeMan®) was developed in Brazil. Our primary objective was to compare user satisfaction among SurgeMan, TraumaMan, and porcine models during the course. Our secondary objective was to determine the user satisfaction scores for SurgeMan. This study included 36 ATLS students and nine instructors (4:1 ratio). Tube thoracostomy, cricothyroidotomy, pericardiocentesis, and diagnostic peritoneal lavage were performed on all the three models. The participants then rated their satisfaction both after each activity and after the course. The porcine and TraumaMan models fared better than SurgeMan for all skills except pericardiocentesis. In the absence of ethical or financial constraints, 58 per cent of the students and 66 per cent of the instructors indicated preference for the porcine model. When ethical and financial factors were considered, no preference was evident among the students, whereas 66 per cent of instructors preferred SurgeMan over the others. The students gave all three models an overall adequacy rating of >80 per cent; the instructors gave only the animal models an adequacy rating of <80 per cent. Although the users were more satisfied with TraumaMan than with SurgeMan, both were considered acceptable for the ATLS course.

Quantification of anti-nutritional factors and their correlations with protein and oil in soybeans.

Soybeans contain about 30% carbohydrate, mainly consisting of non-starch polysaccharides (NSP) and oligosaccharides. NSP are not hydrolyzed in the gastrointestinal tract of monogastric animals. These NSP negatively affect the development of these animals, especially the soluble fraction. This work aimed to establish a method to quantify NSP in soybeans, using high performance liquid chromatography (HPLC), and to estimate correlations between NSP, oligosaccharides, protein and oil. Sucrose, raffinose + stachyose, soluble and insoluble NSP contents were determined by HPLC. Oil and protein contents were determined by near-infrared spectroscopy (NIRS). The soluble PNAs content showed no significant correlation with protein, oil, sucrose and raffinose + stachyose contents, but oligosaccharides showed a negative correlation with protein content. These findings open up the possibility of developing cultivars with low soluble NSP content, aiming to develop feed for monogastric animals.

Quantification of anti-nutritional factors and their correlations with protein and oil in soybeans

ABSTRACT Soybeans contain about 30% carbohydrate, mainly consisting of non-starch polysaccharides (NSP) and oligosaccharides. NSP are not hydrolyzed in the gastrointestinal tract of monogastric animals. These NSP negatively affect the development of these animals, especially the soluble fraction. This work aimed to establish a method to quantify NSP in soybeans, using high performance liquid chromatography (HPLC), and to estimate correlations between NSP, oligosaccharides, protein and oil. Sucrose, raffinose + stachyose, soluble and insoluble NSP contents were determined by HPLC. Oil and protein contents were determined by near-infrared spectroscopy (NIRS). The soluble PNAs content showed no significant correlation with protein, oil, sucrose and raffinose + stachyose contents, but oligosaccharides showed a negative correlation with protein content. These findings open up the possibility of developing cultivars with low soluble NSP content, aiming to develop feed for monogastric animals.

Penetrating anorectal injuries in Jamaican children.

PURPOSE: To discuss the presentation, management and outcomes of penetrating anorectal injuries at the Bustamante Hospital for Children. METHODS: A retrospective review over an 11-year period (January 2001-December 2011) was undertaken. The data analysed were extracted from patients' case notes which were pulled based on the hospital's admission database. RESULTS: Over the study period a total of 14 children presented with penetrating anorectal injuries. The medical records for one child were missing. The mean age at presentation was 6 years. Impalement by a metal spike was the mechanism of injury in 12 children, with one case of sexual assault. Three of the children had associated urogenital injuries. Ten rectal injuries were extraperitoneal. Five of the 13 cases (38 %) were managed with a colostomy-average time to closure was 6 months. There was one case of perineal wound infection and dehiscence. There was no mortality. CONCLUSION: Selective fecal diversion in the form of a sigmoid loop colostomy is a safe and acceptable management option for children with penetrating anorectal injuries. The perineal wound itself can be closed primarily except in cases of delayed presentation.

Pentavalent rotavirus vaccine in developing countries: safety and health care resource utilization.

OBJECTIVE: In the international, placebo-controlled, Rotavirus Efficacy and Safety Trial, the pentavalent rotavirus vaccine reduced the rate of rotavirus-attributable hospitalizations and emergency department visits by 95%. This study investigated the effect in Jamaica. METHODS: The vaccine effect on rates of hospitalizations and emergency department visits in Jamaica was evaluated in both modified intention-to-treat and per-protocol analyses. Rates of serious adverse events, including intussusception, also were compared between groups. RESULTS: A total of 1804 Jamaican infants, 6 to 12 weeks of age at entry and primarily from low/middle-income families of African heritage, received ≥1 dose. During the first year after dose 1, there were 2 and 11 hospitalizations or emergency department visits attributable to rotavirus gastroenteritis involving any serotype among 831 evaluable vaccine recipients and 809 evaluable placebo recipients, respectively (rate reduction: 82.2% [95% confidence interval: 15.1%-98.0%]). In the per-protocol analysis, all 8 G1 to G4 rotavirus-attributable events that occurred ≥2 weeks after dose 3 were in the placebo group (rate reduction: 100% [95% confidence interval: 40.9%-100%]). Of the 1802 subjects included in the safety analyses, intussusception was confirmed for 1 vaccine recipient (115 days after the third dose) and 3 placebo recipients. One vaccine recipient and 3 placebo recipients died during the follow-up period, but none of the deaths was considered to be vaccine-related. CONCLUSIONS: In this posthoc subgroup analysis, the vaccine reduced health care resource utilization attributable to rotavirus gastroenteritis, without increased risk of intussusception or other serious adverse events, among infants in a resource-limited country.

The ER luminal binding protein (BiP) mediates an increase in drought tolerance in soybean and delays drought-induced leaf senescence in soybean and tobacco.

The ER-resident molecular chaperone BiP (binding protein) was overexpressed in soybean. When plants growing in soil were exposed to drought (by reducing or completely withholding watering) the wild-type lines showed a large decrease in leaf water potential and leaf wilting, but the leaves in the transgenic lines did not wilt and exhibited only a small decrease in water potential. During exposure to drought the stomata of the transgenic lines did not close as much as in the wild type, and the rates of photosynthesis and transpiration became less inhibited than in the wild type. These parameters of drought resistance in the BiP overexpressing lines were not associated with a higher level of the osmolytes proline, sucrose, and glucose. It was also not associated with the typical drought-induced increase in root dry weight. Rather, at the end of the drought period, the BiP overexpressing lines had a lower level of the osmolytes and root weight than the wild type. The mRNA abundance of several typical drought-induced genes [NAC2, a seed maturation protein (SMP), a glutathione-S-transferase (GST), antiquitin, and protein disulphide isomerase 3 (PDI-3)] increased in the drought-stressed wild-type plants. Compared with the wild type, the increase in mRNA abundance of these genes was less (in some genes much less) in the BiP overexpressing lines that were exposed to drought. The effect of drought on leaf senescence was investigated in soybean and tobacco. It had previously been reported that tobacco BiP overexpression or repression reduced or accentuated the effects of drought. BiP overexpressing tobacco and soybean showed delayed leaf senescence during drought. BiP antisense tobacco plants, conversely, showed advanced leaf senescence. It is concluded that BiP overexpression confers resistance to drought, through an as yet unknown mechanism that is related to ER functioning. The delay in leaf senescence by BiP overexpression might relate to the absence of the response to drought.

Pancreaticopleural fistula: a rare thoracic complication of pancreatic duct disruption.

Pancreaticopleural fistula resulting in a chronic pleural effusion is a rare complication of pancreatic duct disruption. We describe the presentation and management of 2 children with pancreaticopleural fistulas. Pleural fluid amylase concentration and contrast computed tomography were sufficient to establish the diagnosis in both cases. The initial management of these fistulas should be conservative, by tube thoracostomy and suppression of pancreatic secretion. Operative treatment is necessary for those who fail to resolve. Complete diversion of the pancreatic juice into the gastrointestinal tract by longitudinal pancreaticojejunostomy has been an effective surgical option leading to fistula closure.

Colonic Lipomas at the University Hospital of the West Indies

Lipomas of the colon are uncommon but cause diagnostic difficulty when they are symptomatic. The clinical and pathological features of 17 cases of colonic lipomas diagnosed at the University Hospital of the West Indies between 1970 and 1999 are reported. Ten cases were symptomatic, two of these being diagnosed with adult intussusception. Six patients had incidental lipomas in bowel resected for other patholgoy while one lipomas was diagnosed an sigmoidoscopy. Increased awareness of these lesions will enhanced pre-operative diagnostic accuracy.(Au)

Cholecystectomy in Jamaican children with homozygous sicke-cell disease

Twenty-seven children aged 18 years and under with homozygous sickle-cell disease had open cholecystectomy for symptomatic gallstones over the 12 year period 1985-1997. Emergency procedures (done during period of acute exacerbation of symptoms) were performed on 16 patients. Four with haemoglobin levels greater than 1g/dl below their steady state received a simple blood transfusion preoperatively designed to raise haemoglobin levels to 10g/dl. All had acute or acute on chronic cholecystitis based on histological examination of gallbladder specimens. Twelve had common bile duct stones. In two patients calculi were missed intraoperatively but these subsequently passed into the duodenum after a period saline irrigation via an in-situ t-tube. Six developed the acute chest syndrome (aetiology not determined) and this progressed to multi system failure and death in one. This high level of postoperative mobility and mortality may in part be due to the high proportion of emergency procedures. (AU)

Chronic Relapsing Pancreatitis in a Child: Use of the Puestow Procedure to Achieve Ductal Drainage

A case of chronic relapsing pancreatitis presenting in an 8-year old African Jamaican girl is outlined. Aggressive supportive management failed to control pain and vomitting. The Puestow Procedure effectively aborted these symptoms. The use of the Puestow procedure should not be inordinately delayed in chronic relapsing pancreatitis if symptoms persist, since it may not only control pain but also halt declining pancreatic function.(Au)

Chronic relapsing pancreatitis in a child: use of the puestow procedure to achieve ductal drainage

A case of chronic relapsing pancreatitis presenting in an 8-year old African Jamaican girl is outlined. Aggressive supportive management failed to control pain and vomitting. The Puestow Procedure effectively aborted these symptoms. The use of the Puestow procedure should not be inordinately delayed in chronic relapsing pancreatitis if symptoms persist, since it may not only control pain but also halt declining pancreatic function.

Morbidity pattern of emergency room patients in Jamaica

OBJECTIVE: This study documents the morbidity pattern of diseases in patients presenting to the Accident and Emergency (A&E) Unit at the University Hospital of the West Indies in Jamaica. DESIGN and METHODS: Data were retrieved from a log book kept by the nursing staff in the A&E Unit at the UHWI. This SPSS software package was used to select 100 random days in 1997. All cases treated in the A&E Unit on those days were included in the study. Data collected included demographic data, discharge diagnosis and disposal. Diagnosis were coded and classified using the International Classification of Diseases - 9th edition coding system. RESULTS: In 1997, 16,798 patients were treated in the A&E Unit during the 100 random days selected, 4611 of these were seen. Twelve cases were excluded, as the diagnoses were unknown. Some patient had more than one diagnosis and therefore, 4762 diagnoses were made in 4599 patients. The mean age was 34ñ 24 (SD) years. The male to female ratio was 1.8:1. Injuries and poisoning accounted for 31 per cent of cases. Respiratory diseases were the next most prevalent (16.2 percent). Cardiovascular and digestive diseases accounted for 5.8 and 10.5 per cent of cases, respectively. Infectious diseases accounted for only 1.75 per cent of cases; 71.7 per cent of patients were discharged home, 23.5 per cent admitted and 4.2 per cent transferred to another institution. The mortality rate was 0.6 per cent. CONCLUSIONS: The pattern of diseases seen in this study demonstrates epidemiologic transition where injuries, cardiovascular and other chronic diseases are evolving as the most prevalent conditions seen. This is now seen frequently in the Caribbean and other developing countries. (Au)

Penetrating wounds to the torso: the University Hospital of the West Indies experience

OBJECTIVE: This study was done to determine the aetiology of penetrating torso injuries in patients presenting at the University Hospital of the West Indies (UHWI) as well as to document the organs frequently injured and to assess the outcome of these cases. DESIGN AND METHODS: Data were derived from the UHWI trauma registry. All patients presenting to the UHWI with penetrating torso injuries between January 1, 1998 and June 30, 1999 were studied. Biographic data, cause of injury, organs injured and procedures used in treatment were recorded. TRISS methodology was used to identify unexpected deaths. RESULTS: 1899 (42 percent) of the 4,496 admissions to the surgical services of the UHWI were due to trauma. Two hundred and twenty-nine (229) of these had torso injuries and 159 (8 percent) were due to penetrating injuries. Assaults accounted for 98 percent of cases. The male to female ratio was 7.4:1 and the mean age was 28 +or- 10 (SD) years. There were 92 (59 percent) stab wounds and 63 (41 percent) firearm injuries. Mean hospital stay was 8 +or- 15 (SD) days. Mortality rate was 10 percent. Small bowel (17), colon (15) and liver (15) were the abdominal organs most frequently injured. Pneumothorax or haemothorax was detected in 107 patients. All except 20 patients had a major surgical procedure done. There were seven non-therapeutic thoracotomies and 17 non-therapeutic laparotomies. Greater than 50 percent deaths were assessed as preventable. CONCLUSIONS: The wider use of imaging procedures in treatment protocols should reduce the number of non-therapeutic procedures. The preventable death rate may be decreased through training in ATLS protocols and improved equipment maintenance.(Au)

Alcohol, cannabis and cocaine usage in patients with trauma injuries

Sera from 111 patients with trauma injuries, who presented to the Accident and Emergency Unit (A&E), University Hospital of the West Indies, during a 3-month period, were screened for blood alcohol. Urine specimens were analysed for metabolites of cannabis and cocaine. Sixty-two percent (62 percent) of patients were positive for at least one substance and 20 percent for two or more. Positivity rates were as follows: cannabis (46 percent), alcohol (32 percent) with 71 percent of these having blood alcohol levels (BAC) greater than 80 mg per decilitre; cocaine (6 percent). Substance usage was most prevalent in the third decade of life. The patients who yielded a positive result were significantly younger than those who were negative. There was no significant difference in age or substance usage between the victims of interpersonal violence or road traffic accidents. In the group designated "other accidents", patients were significantly older and had a lower incidence of substance usage that the other two groups. Cannabis was the most prevalent substance in all groups. Fifty percent (50 percent) and fifty-five percent (55 percent) of victims of road accidents and interpersonal violence, respectively, were positive for cannabis compared with 43 percent and 27 percent for alcohol, respectively. There was no significant difference in Hospital Stay or Injury Severity Score between substance users and non-users.(AU)

Trauma aetiology and cost in the Accident and Emergency Unit of the University of the West Indies

Trauma accounted for 37 percent of 22,311 patients seen in the Accident and Emergency Unit (A&E) at the University Hospital of the West Indies (UHWI) during 1996. Thirty-nine percent of injuries were intentional and 18 percent were due to motor vehicle accidents. Knives, machetes and rocks accounted for 75 percent of the injuries compared with 5 percent for gunshot wounds. Passengers were injured in about 40 percent of motor vehicle accidents and pedestrians in 19 percent. The admission rate was 16 percent and the orthopaedic clinic received 75 percent of the patients referred to specialist clinics. Victims of motor vehicle accidents made up a greater proportion of admissions (24 percent) than those of unintentional violence (13 percent). The average cost of caring for each patient in the A&E Unit was US$70 resulting in an annual cost of US$578,000.(AU)

Necrotising enterocolitis: A management protocol for developing countries

28 cases of necrotising enterocolitis (NEC) comprising 11 term and 17 preterm patients were diagnosed between January 1990 and December 1995 at the University Hospital of the West Indies (UHWI). Treatment was in accordance with a management protocol which emphasised aggressive screening of potential cases, early laparotomy for bowel perforation and primary anastomosis after small bowel resection. There were three deaths among the 13 cases of bowel perforation. Centres in developing countries can achieve rates of survival comparable to those in the developed world in babies with NEC weighing over 1000 grams by adopting the UHWI management protocol.(AU)

Postsplenectomy course in homozygous sickle cell disease

OBJECTIVE: To determine whether children with homozygous sickle cell (SS) disease and splenectomy are at greater risk of death, overwhelming septicemia, or other complications. METHODS: A total of 130 patients with SS treated by splenectomy (46 recurrent acute splenic sequestration, 84 chronic hypersplenism) over a 22.5-year period at the Sickle Cell Clinic of the University Hospital of the West Indies, Kingston, Jamaica, were compared with a control group matched for sex, age, and duration of follow-up in a retrospective review. Deaths and bacteremias were examined over the whole study period. Painful crises, acute chest syndromes, and febrile episodes were compared in the 90 patients completing 5 years of postsplenectomy follow-up. FINDINGS: Mortality and bacteremic episodes did not differ between the splenectomy and control groups. Painful crises were more common in the splenectomy group than in the control group (P = .01) but did not differ between splenectomy indications. Acute chest syndrome was more common in the splenectomy group than in the control group (P < .01) and was more common in the acute splenic sequestration group than in the hypersplenism group (P = .01). Febrile events did not differ between the groups or between the indications for splenectomy. CONCLUSION: Splenectomy does not increase the risk of death or bacteremic illness in patients with SS disease and, if otherwise indicated, should not be deferred for these reasons (Au)