Estimating the savings of a national project to prevent healthcare-associated infections in intensive care units.

BACKGROUND: Healthcare-associated infections (HAIs) have a significant impact on patients' morbidity and mortality, and have a detrimental financial impact on the healthcare system. Various strategies exist to prevent HAIs, but economic evaluations are needed to determine which are most appropriate. AIM: To present the financial impact of a nationwide project on HAI prevention in intensive care units (ICUs) using a quality improvement (QI) approach. METHODS: A health economic evaluation assessed the financial results of the QI initiative 'Saúde em Nossas Mãos' (SNM), implemented in Brazil between January 2018 and December 2020. Among 116 participating institutions, 13 (11.2%) fully reported the aggregate cost and stratified patients (with vs without HAIs) in the pre-intervention and post-intervention periods. Average cost (AC) was calculated for each analysed HAI: central-line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTIs). The absorption model and time-driven activity-based costing were used for cost estimations. The numbers of infections that the project could have prevented during its implementation were estimated to demonstrate the financial impact of the SNM initiative. RESULTS: The aggregated ACs calculated for each HAI from these 13 ICUs - US$8480 for CLABSIs, US$10,039 for VAP, and US$7464 for CAUTIs - were extrapolated to the total number of HAIs prevented by the project (1727 CLABSIs, 3797 VAP and 2150 CAUTIs). The overall savings of the SNM as of December 2020 were estimated at US$68.8 million, with an estimated return on investment (ROI) of 765%. CONCLUSION: Reporting accurate financial data on HAI prevention strategies is still challenging in Brazil. These results suggest that a national QI initiative to prevent HAIs in critical care settings is a feasible and value-based approach, reducing financial waste and yielding a significant ROI for the healthcare system.

Native fungi from Amazon with potential for control of Aedes aegypti L. (Diptera: Culicidae).

Aedes aegypti L. (Diptera: Culicidae) is the main transmitter of pathogens that cause human diseases, including dengue, chikungunya, zika and yellow fever. Faced with this problem, this study aims to select fungi with entomopathogenic potential against Ae. aegypti and develop formulations that optimize the control action of entomopathogenic fungi in the semi-field condition. 23 fungal strains native from Amazon were inoculated in Potato-Dextrose-Agar (PDA) culture medium for 14 days and then transferred by scraping to tubes containing 0.9% NaCl solution. To obtain the larvae, eggs were collected using traps in peridomestic environments for 7 days. 20 larvae of Ae. aegypti in 125 mL erlenmeyers containing 20 mL of conidial suspension at a concentration of 1x106 conidia/mL for initial selection and 1×104, 1×105, 1×106 and 1×107 conidia/mL for determination of LC50. Mortality was checked every 24 h for 5 days. The three fungi with the best virulence rates were identified using molecular techniques. The compatibility between fungi at a concentration of 1×106 conidia/mL and oily adjuvants, mineral oil and vegetable oil (andiroba, chestnut and copaiba) at concentrations of 0.1, 0.5 and 1% was evaluated. The germination capacity of 100 conidia per treatment was evaluated after incubation at 28 ºC for 24 h. To evaluate the entomopathogenic potential of the fungal formulations, conidial suspensions (1×106 conidia/mL) were added with 0.1% mineral and vegetable oil. The treatments were submitted to laboratory and semi-field conditions and mortality was verified every 24 h for 5 days. Beauveria sp. (4,458) (LC50 = 8.66× 103), Metarhizium anisopliae (4,420) (LC50 = 5.48×104) and M. anisopliae (4,910) (LC50 = 1.13×105) were significantly more effective in the larval control of Ae. aegypti, in relation to the other fungal morphospecies evaluated. Mineral oil was better compatible in all treatments evaluated. Beauveria sp. (4,458) was considerably less virulent under semi-field conditions. M. anisopliae (4,910) formulated with mineral oil increased larval mortality to 100% on the 4th day in the laboratory and on the 5th day in the semi-field. Fungal formulations developed from native Amazonian isolates represent a promising tool for the development of strategies to control Ae. aegypti.

Rotavirus analyses by SYBR Green real-time PCR and microbiological contamination in bivalves cultivated in coastal water of Amazonian Brazil.

The contamination of mussels and oysters by viruses and bacteria is often associated with water contamination and gastroenteritis in humans. The present study evaluated viral and bacterial contamination in 380 samples, from nine mollusk-producing regions in coastal water north of the Brazilian Amazon. Rotavirus contamination was studied for groups A to H, using a two-step SYBR Green RT-qPCR (quantitative reverse transcription polymerase chain reaction), and bacterial families Enterobacteriaceae, Vibrionaceae, and Aeromonadaceae by classical and molecular methods. From the 19 pools analyzed, 26.3% (5/19) were positive for group A Rotavirus, I2 genotype for VP6 region, without amplifications for groups B-H. Bacteriological analysis identified Escherichia coli isolates in 89.5% (17/19) with identification of atypical enteropathogenic E. coli aEPEC in 10.5% (2/19), Salmonella (Groups C1 and G) (10.5%, 2/19), Vibrio alginolyticus (57.9%, 11/19) V. parahaemolyticus (63.2%, 12/19), V. fluvialis (42.1%, 8/19), V. vulnificus (10.5%, 2/19), V. cholerae non-O1, non O139(10.5%, 2/19) and Aeromonas salmonicida (52.6%, 10/19). All the samples investigated presented some level of contamination by enterobacteria, rotavirus, or both, and these results may reflect the level of contamination in the Northern Amazon Region, due to the natural maintenance of some of these agents or by the proximity with human populations and their sewer.

Population Development of Zabrotes subfasciatus (Coleoptera: Chrysomelidae) in Landrace Bean Varieties Occurring in Southwestern Amazonia.

The common bean, Phaseolus vulgaris (L.), is one of the most important sources of protein worldwide, and Latin America is one of the recognized centers of diversity of this species. However, storage of this product after harvest is not feasible because of bruchid attacks. This study determined the accumulated normalized rate of emergence and the daily emergence rate of Zabrotes subfasciatus (Boheman) (Coleoptera: Chrysomelidae:Bruchinae) in five landrace varieties of common bean (BRL 01, SNA 01, RDR 01, RBC 01, and RBC 13) that occurin southwestern Amazonia. These varieties were selected for this study because they are well-distributed throughout the Amazonian communities. Beans of each variety were infested with 50 unsexed adults, and the insects were removed 13 d after beginning the bioassays. The adult progeny obtained from the feeding substrate were counted and removed every other day after the first emergence, until the end of the emergence period. Differences were observed in the calculated rates of development; however, the time required for development and emergence of the insects was independent. Of the five varieties of bean investigated, we observed that the RDR 01, BRL 01, and SNA 01 cultivars are resistant to Z. subfasciatus; the results indicate that the use of these three varieties can reduce problems associated with bruchid attacks and enable storage of the product after harvesting.

Ozone toxicity and walking response of populations of Sitophilus zeamais (Coleoptera: Curculionidae).

Ozone is a recognized alternative to the fumigants methyl bromide and phosphine for the control of stored product insects. However, as with fumigants in general, the potential sublethal effects of ozone on targeted insect species may compromise its efficacy and has yet to be investigated. Here, we determined ozone toxicity of 30 field-collected populations of the maize weevil, Sitophilus zeamais (Coleoptera: Curculionidae), and assessed the walking response of adult insects from these populations to sublethal ozone exposure. Time-mortality toxicity to ozone at 50 ppm concentration in a continuous 2 liter/min flow indicated uniform susceptibility among the populations studied without any indication of ozone resistance (toxicity ratios [at LT50] > two-fold). In contrast, there was significant variation in walking activity among the maize weevil populations, which was not correlated with ozone susceptibility. This was not surprising because of the relatively uniform susceptibility to ozone among the maize weevil populations. Respiration rate affected ozone toxicity but not walking activity, whereas body mass was negatively correlated with walking activity but was not correlated with ozone toxicity. Based on our data, lower respiration rates may potentially lead to reduced ozone uptake whereas larger body mass limits walking activity. Ozone seems a promising alternative fumigant with low short-term risk of resistance development because of the high susceptibility and low variability of response to this compound. Furthermore, ozone reduces walking activity of S. zeamais that implies it likely reduces the chances of insects escaping exposure at the early stages of fumigation.

Low rectal cancer: impact of radiation and chemotherapy on surgical treatment.

INTRODUCTION: The aim of this study was to evaluate the impact of combined radiotherapy and chemotherapy (leucovorin and 5-fluorouracil) on the treatment of potentially resectable low rectal cancer using the following end points: 1) toxicity of this combined modality regimen; 2) clinical and pathologic response rate and local control; 3) down-staging of the tumor and its influence on the number of sphincter-saving operations; 4) disease-free interval, patterns of relapse, and overall survival. METHODS: From 1991 to 1996, 118 patients with potentially resectable cases of histologically proven adenocarcinoma and no distant metastases were enrolled into this protocol. All patients were evaluated by clinical and proctologic examination, abdominal computed tomography, transrectal ultrasound, and chest radiography. Therapy consisted of 5,040 cGy (6 weeks) and concurrent leucovorin (20/mg/m2/day) with bolus doses of 5-fluorouracil administered intravenously at 425 mg/m2/day for three consecutive days on the first and last three days of radiation therapy. After two months, all patients underwent repeat evaluation and biopsy of any suspected residual lesions or scar tissue. RESULTS: Median follow-up was 36 months. Toxicity of chemotherapy regimen was minimum. Thirty-six patients (30.5 percent) were classified as being complete responders. In six of these patients, complete response was confirmed by the absence of tumor in the surgical specimens (3 abdominoperineal resections and 3 proctosigmoidectomies with coloanal anastomosis). In the remaining 30 patients, confirmation of a complete response was made by the absence of symptoms, negative findings on physical examination, and biopsy, transrectal ultrasound, and pelvic computed tomographic test results during follow-up. Eighty-two patients (69.4 percent) were considered incomplete responders. Residual lesions had already been identified during the first examination in 74 patients. In the other eight patients, residual tumor was only identified after 3 to 14 months. All patients underwent surgical treatment, except one patient who refused surgery. Eighty-seven patients underwent 90 surgical procedures: local excision, 9; coloanal anastomosis, 36; abdominoperineal resection, 4; Hartmann's procedure, 1. Isolated local recurrences occurred in five patients (4.3 percent) and combined local and distant failure in eight patients (6.7 percent). Ninety patients are alive and disease-free at a median follow-up of 36 months. CONCLUSIONS: Combined up-front chemoradiotherapy was associated with tolerable and acceptable side effects. A significant number of patients had complete disappearance of their tumors (30.5 percent) within a median follow-up of 36 months. This regimen spared 26.2 percent of patients from surgical treatment and allowed sphincter-saving management in 38.1 percent of patients who may have required abdominoperineal resection. Preliminary results of this trial suggests a reduction in the number of local recurrences and reinforces the concept that infiltrative low rectal cancer may be initially treated by chemoradiotherapy.

Eight years experience using the inferior epigastric artery for myocardial revascularization.

We present the initial experience with the use of inferior epigastric artery as a free graft for myocardial revascularization in a series of 41 patients operated on between 1987 and 1989 to show the clinical and angiographic results. Of the 41 patients, 29 were male, 12 female, with ages ranging from 33 to 72 years, and weights from 50 to 86 kg. The inferior epigastric artery grafts were predominantly employed to the anterior interventricular branch and diagonal branch. The proximal anastomosis into the aorta was done directly or with a patch of vein or pericardium. The 32 patients who survived had mean follow-up of 82 months and 22 are in functional class I, 8 in class II and 2 in class III of angina. The early patency rate was: inferior epigastric artery-anterior interventricular branch, 85.7% and inferior epigastric artery-diagonal branch. 85.7%. Sixteen patients underwent angiographic study at a mean follow-up of 81.2 months and the patency rate to the anterior interventricular branch was 77.7% and to the diagonal branch was 100%. Three patients with early occluded inferior epigastric artery were reoperated on 3, 3 and 11 months after the operation. A filiform lumen of the graft and a small ostium in the aorta was found and explained the imperfection of the direct anastomosis due to unbalance thickness of the graft and the aortic wall. Therefore it is occluded that the inferior epigastric artery is an alternative arterial graft for myocardial revascularization and that the use of a vein or pericardium patch can help the proximal anastomosis and improve potency of the graft.

[Colectomy and anterior resection with a video-laparoscopic approach. Initial experience-results]. / Colectomia e ressecção anterior por acesso vídeo-laparoscópico. Experiência inicial-resultados.

Laparoscopic procedures are rapidly advancing. Laparoendoscopic colectomy appears to be an option the treatment of colonic disease and is increasingly being performed in selected patients. The purpose of this study is to review our initial experience with the method which initiated in 1992. Thirty-three patients underwent laparoscopic resection of colorectal segment. All the patient, charts were assessed and data were obtained about the diagnosis, operation performed, complications, conversion and postoperative course. Diverticular disease was the most frequent (54.5%) indication of laparoscopic colorectal procedure in our series followed by adenocarcinoma (27.3%). Left colectomy was performed in 19 (57.6%) patients. Anastomosis followed double-stapling technique in most of them. Conversion to open procedure occurred in six (18.2%) cases. There were 4 complications associated to the method resulting in an specifíc morbidity of 12.1% in this series. There were no complications related to the anastomosis and no death occurred. Postoperative course was favorable for the patients and all could take oral liquids in the day after the procedure. Colorectal surgery performed by video-laparoscopic access is feasible, safe and benefits all patients. Conversion and morbidity in our series are similar to those shown in literature. It must, however, be indicated in a selected basis and in centers of reference for treatment of colorectal disease.