Interventions to prevent urinary catheter-associated infections in children and neonates: a systematic review.

INTRODUCTION: Few data are available to inform strategies for the prevention of catheter-associated urinary tract infection (CAUTI) in children and neonates. Many recommendations are derived from studies in adults and cannot be applied to the paediatric population. OBJECTIVE: This study was aimed to identify all studies that measured the efficacy of an intervention for the prevention of CAUTI in children and neonates. METHODS: A systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was conducted. Eligible studies published between January 1st, 1995 and December 31st, 2017, were identified in PubMed, the Cochrane Database of Systematic Reviews, LILACS, SciELO and DOAJ if applying an intervention with the aim of CAUTI prevention in inpatient children, infants or neonates. The following study designs were included: controlled and non-controlled before-and-after studies, (controlled) interrupted time series analyses and randomized controlled trials. Quantitative or qualitative studies on interventions in both adults and children were eligible if data on children could be extracted. Reviews, case series, letters, notes, conference abstracts and opinion articles were excluded. RESULTS: Of 99 articles identified, six were included in the final analysis, after consensus from three independent investigators. Four studies used a multimodal strategy (using at least four or more different components at the same time) as follows: aseptic rules during catheter insertion and removal; cleaning the urethral meatus with sterile water; use of a new silicone catheter per insertion with a closed sterile drainage system by a sterile technique; daily evaluation of catheter requirement; placement of indwelling urinary catheters only for approved indications; reducing of urinary catheter days and positioning of the patient and collection device to assist in urine drainage. One study tested periurethral cleaning intervention to reduce CAUTI. One study described the association of the presence of a physician safety champion with urinary catheter device utilization ratios. Catheter-associated UTI reduction rates were reported in four studies; three achieved statistically significant decreases in CAUTI rates. Positive results were achieved only when a multimodal strategy was used with at least four or more components. This strategy could be adopted for paediatric healthcare institutions to reduce CAUTI rates in children and neonates. CONCLUSION: Evidence exists to support the use of a multimodal strategy for CAUTI reduction in hospitalized children and neonates.

Role of antimicrobial stewardship programmes in children: a systematic review.

The United Nations and the World Health Organization have designated antimicrobial resistance (AMR) as a major health priority and developed action plans to reduce AMR in all healthcare settings. Establishment of institutional antimicrobial stewardship programmes (ASPs) is advocated as a key intervention to reduce antibiotic consumption in hospitals and address high rates of multi-drug-resistant (MDR) bacteria. PUBMED and the Cochrane Database of Systematic Reviews (January 2007-March 2017) were searched to identify studies reporting the effectiveness of ASPs in general paediatric wards and paediatric intensive care units (PICUs) for reducing antibiotic consumption, use of broad-spectrum/restricted antibiotics, and antibiotic resistance and healthcare-associated infections (HAIs). Neonatal units and antifungal agents were excluded. Of 2509 titles and abstracts, nine articles were eligible for inclusion in the final analysis. All studies reported a reduction in the use of broad-spectrum/restricted antibiotics or antibiotic consumption. One study reported a reduction in HAIs in a PICU, and another study evaluated bacterial resistance, showing no effect following ASP implementation. Prospective audit on antibiotic use was the most common ASP core component (eight of nine studies). Antibiotic pre-authorization was described in two studies. Other described interventions were the provision of guidelines or written information (five of nine studies), and training of healthcare professionals (one study). There is limited evidence for a reduction in antibiotic consumption and use of broad-spectrum/restricted agents following ASP implementation specifically in PICUs. Data evaluating the impact of ASPs on HAIs and AMR in PICUs are lacking. In addition, there is limited information on effective components of a successful ASP in PICUs.

Methotrexate associated to lipid core nanoparticles improves cardiac allograft vasculopathy and the inflammatory profile in a rabbit heart graft model.

Coronary allograft vasculopathy is an inflammatory-proliferative process that compromises the long-term success of heart transplantation and has no effective treatment. A lipid nanoemulsion (LDE) can carry chemotherapeutic agents in the circulation and concentrates them in the heart graft. The aim of the study was to investigate the effects of methotrexate (MTX) associated to LDE. Rabbits fed a 0.5% cholesterol diet and submitted to heterotopic heart transplantation were treated with cyclosporine A (10 mg·kg-1·day-1 orally) and allocated to treatment with intravenous LDE-MTX (4 mg/kg, weekly, n=10) or with weekly intravenous saline solution (control group, n=10), beginning on the day of surgery. Animals were euthanized 6 weeks later. Compared to controls, grafts of LDE-MTX treated rabbits showed 20% reduction of coronary stenosis, with a four-fold increase in vessel lumen and 80% reduction of macrophage staining in grafts. Necrosis was attenuated by LDE-MTX. Native hearts of both LDE-MTX and Control groups were apparently normal. Gene expression of lipoprotein receptors was significantly greater in grafts compared to native hearts. In LDE-MTX group, gene expression of the pro-inflammatory factors tumor necrosis factor-α, monocyte chemoattractant protein-1, interleukin-18, vascular cell adhesion molecule-1, and matrix metalloproteinase-12 was strongly diminished whereas expression of anti-inflammatory interleukin-10 increased. LDE-MTX promoted improvement of the cardiac allograft vasculopathy and diminished inflammation in heart grafts.

Specific activation of CD4- CD8- double-negative T cells by Trypanosoma cruzi-derived glycolipids induces a proinflammatory profile associated with cardiomyopathy in Chagas patients.

Cardiomyopathy is the most severe outcome of Chagas disease, causing more than 12 000 deaths/year. Immune cells participate in cardiomyopathy development either by direct tissue destruction, or by driving inflammation. We have shown that CD4- CD8- [double-negative (DN)] T cells are major sources of inflammatory and anti-inflammatory cytokines, associated with the cardiac (CARD) and indeterminate (IND) forms of Chagas disease, respectively. Here, we sought to identify Trypanosoma cruzi-derived components that lead to activation of DN T cells in Chagas patients. Glycolipid (GCL), lipid (LIP) and protein-enriched (PRO) fractions derived from trypomastigote forms of T. cruzi were utilized to stimulate cells from IND and CARD patients to determine DN T cell activation by evaluating CD69 and cytokine expression. We observed that GCL, but not LIP or PRO fractions, induced higher activation of DN T cells, especially T cell receptor (TCR)-γδ DN T, from IND and CARD. GCL led to an increase in tumour necrosis factor (TNF) and interleukin (IL)-10 expression by TCR-γδ DN T cells from IND, while inducing IFN-γ expression by TCR-γδ DN T cells from CARD. This led to an increase in the ratio IFN-γ/IL-10 in TCR-γδ DN T cells from CARD, favouring an inflammatory profile. These results identify GCL as the major T. cruzi component responsible for activation of DN T cells in chronic Chagas disease, associated predominantly with an inflammatory profile in CARD, but not IND. These findings may have implications for designing new strategies of control or prevention of Chagas disease cardiomyopathy by modulating the response to GCL.

The monoclonal antibody against the major diagnostic antigen of Paracoccidioides brasiliensis mediates immune protection in infected BALB/c mice challenged intratracheally with the fungus.

The protective role of specific antibodies against Paracoccidioides brasiliensis is controversial. In the present study, we analyzed the effects of monoclonal antibodies on the major diagnostic antigen (gp43) using in vitro and in vivo P. brasiliensis infection models. The passive administration of some monoclonal antibodies (MAbs) before and after intratracheal or intravenous infections led to a reduced fungal burden and decreased pulmonary inflammation. The protection mediated by MAb 3E, the most efficient MAb in the reduction of fungal burden, was associated with the enhanced phagocytosis of P. brasiliensis yeast cells by J774.16, MH-S, or primary macrophages. The ingestion of opsonized yeast cells led to an increase in NO production by macrophages. Passive immunization with MAb 3E induced enhanced levels of gamma interferon in the lungs of infected mice. The reactivity of MAb 3E against a panel of gp43-derived peptides suggested that the sequence NHVRIPIGWAV contains the binding epitope. The present work shows that some but not all MAbs against gp43 can reduce the fungal burden and identifies a new peptide candidate for vaccine development.

Experimental paracoccidioidomycosis: alternative therapy with ajoene, compound from Allium sativum, associated with sulfamethoxazole/trimethoprim.

Ajoene has been described as an antithrombotic, anti-tumour, antifungal, antiparasitic and antibacterial agent. This study deals with the efficacy of ajoene to treat mice intratracheally infected with Paracoccidioides brasiliensis. The results indicate that ajoene therapy is effective in association with antifungal drugs (sulfametoxazol/trimethoprim), showing a positive additive effect. Ajoene-treated mice developed Th1-type cytokine responses producing higher levels of IFN-gamma and IL-12 when compared to the infected but untreated members of the control group. Antifungal activity of ajoene involves a direct effect on fungi and a protective pro-inflammatory immune response. Reduction of fungal load is additive to chemotherapy and therefore the combined treatment is mostly effective against experimental paracoccidioidomycosis.

Peptide immunization as an adjuvant to chemotherapy in mice challenged intratracheally with virulent yeast cells of Paracoccidioides brasiliensis.

Immunization with peptide P10, derived from gp43, and chemotherapy were used together in an attempt to improve treatment of paracoccidioidomycosis and prevent relapses. The combined treatment showed an additive protective effect when administered at 48 h or 30 days after intratracheal challenge. Its use is recommended to improve regular chemotherapy and reduce the duration of treatment.

Lead post-mortem intake in human bones of ancient populations by (109)Cd-based X-ray fluorescence and EDXRF.

In this work we measured the lead concentration in human bones of Middle Age by means of a portable X-ray fluorescence system based on (109)Cd radioactive source. The detection system consists on a Ge hyperpure detector. This system, conceived for in vivo Pb analysis in bone, is portable, non-destructive and is based on lead K lines detection. The analysed bones are part of two collections of bones both from the end of Middle Age and submitted for some years to a lead polluted burial environment. The bones of one collection were buried initially on the soil in a convent, in Lisbon (Portugal) and further on, kept in a lead coffin for around 100 years. The second collection contains bones buried permanently on the soil around an old church on the south of Portugal. This place became a parking car for around 20 years. In this work we studied the distribution of Pb in cortical bone, and trabecular regions from the outside surface to the inner part of the bone and the results are compared with the obtained ones by energy dispersive X-ray fluorescence (EDXRF). The obtained values present a strong contamination of Pb in spongy bones kept in the lead coffin with concentrations ranging from 250 to 350mugPb/g bone mineral, and 4 to 7mugPb/g bone mineral for bones buried in the soil. Good agreement was observed between the results obtained by the two techniques.

Metabolic fate of AMP, IMP, GMP and XMP in the cytosol of rat brain: an experimental and theoretical analysis.

A systematic study of the metabolic fate of AMP, IMP, GMP and XMP (NMP) in the presence of cytosol from rat brain is here presented; the kinetics of both disappearance of NMP, and appearance of their degradation products was followed by HPLC. In the absence of ATP, AMP was preferentially degraded to adenosine with concomitant appearance of inosine and hypoxanthine. In the presence of ATP, AMP was preferentially degraded via IMP. The nucleosides generated in the course of the reactions are further degraded, almost exclusively, via nucleoside phosphorylase using as cofactor the P(i) generated in the reaction mixture. In order to quantify the effect of each one of the enzymes involved in the degradation of NMP, two complementary approaches were followed: (i) the V:(max) and K:(m) values of the enzymes acting in the intermediate steps of the reactions were determined; (ii) these data were introduced into differential equations describing the concentration of the nucleotides and their degradation products as a function of the time of incubation. Factors affecting kinetic parameters of the equation velocity as a function of ATP concentration were introduced when required. The differential equations were solved with the help of Mathematica 3.0. The theoretical method can be used to simulate situations not feasible to be carried out, such as to measure the influence of nM-microM concentrations of ATP on the metabolism of AMP.

IMP-GMP 5'-nucleotidase from rat brain: activation by polyphosphates.

IMP-GMP 5'-nucleotidase has been purified to homogeneity from total rat brain extracts. This preparation showed a unique band (Mr 54,000 +/- 1,509) in sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The enzyme presented the following properties: optimal pH value, 6.5-6.8; relative velocity measured in the presence of MgCl2, MnCL2, CoCl2, and NiCl2 (2 mM), 100, 60, 11, and <1, respectively; preferred substrates, IMP and GMP; and activation constant (Ka) found for Ap4A, Ap5A, and Ap6A, 83 +/- 38, 77 +/- 32, and 57 +/- 12 microM, respectively. Under assay conditions where activation by Ap4A was fivefold, the activation produced by dinucleotides was as follows: Ap4G (4.0), Ap4I (2.9), Ap4X (3.3), Ap4C (0.7), Ap4U (1.1), Ap4epsilonA (1.5), Ap4ddA (1.7), Gp4G (2.2), Ap3A (1.1), and Ap2A (1.2). Polyphosphates P18, P19, P20, and P35 were activators of the reaction with calculated Ka values of 3.5 +/- 0.5, 0.9 +/- 0.2, 0.6 +/- 0.2, and 1.3 +/- 0.5 microM, respectively. The following compounds, at 0.1 mM, were effectors of the phosphotransferase reaction producing the fold activation indicated: Ap4A (8.3), Ap5A (10.2), Ap6A (10.1), Ap4G (7.7), Ap4X (7.6), Ap4U (2.1), glycerate 2,3-bisphosphate (3.9), and unpurified P15 (7.6). Two enzyme forms of IMP-GMP 5'-nucleotidase were detected when the extracts from rat tissues or from the crustacean Artemia were subjected to chromatography on a Dyematrex Green A column. The ratio of the hydrolytic activities under both peaks (peak I/peak II) was as follows: brain (1.5), heart (1.9), liver (1.6), lung (2.0), testis (3.8), and Artemia cysts (2.0).

Immediate reconstruction of the central segment of the mandible using the masseter osteomuscular flap.

We describe a new technique for reconstruction of the central segment of the mandible using a masseter osteomuscular flap. The advantages of this method are that bone viability is preserved, both form and function of the mandible are maintained, it is a local flap with low donor-site morbidity, and the operative time is shortened.

Total reconstruction of the alar cartilage en bloc using the ear cartilage: a study in cadavers.

To determine whether the lamina tragi, isthmus, and cavum conchae are a donor area for reconstruction of the alar cartilage with all its elements (medial crus, junction of the medial and lateral crura, and lateral crus), with the same dimension and en bloc, 40 alar cartilages and 40 lower parts of ear cartilages of 20 cadavers were dissected. Several measurements were taken in the alar cartilages, such as distance, thickness, and angle. Then they were compared with the measurements performed in the ear cartilages and segments removed from the lamina tragi, isthmus, and cavum conchae. This study, done with cadavers, shows that from the lamina tragi, isthmus, and cavum conchae, en bloc resection is possible with characteristics of form and dimension similar to those of the homolateral alar cartilage. The segment removed en bloc from the intermediate part of the lamina tragi, isthmus, and cavum conchae replaces, respectively, the medial crus, junction of the medial and lateral crura, and lateral crus.

Total en bloc reconstruction of the alar cartilage using autogenous ear cartilage.

A new technique is described for increasing the nasal tip by using an en bloc autogenous ear cartilage graft in such a manner as to create, in essence, a replacement of the entire ipsilateral alar cartilage.

Capsular hematoma as a late complication in breast reconstruction with silicone gel prostheses.

This paper presents a rare complication of breast reconstruction with silicone gel prostheses in which formation of intracapsular hematomas in the mammary region occurred 3 years after surgery. Treatment by bilateral capsular excision was successful. The rarity of this occurrence and the progress of the case are the major reasons for this publication.

Carcinoma of the vulva. Clinicopathologic factors involved in inguinal and pelvic lymph node metastasis.

Eighty-five women with vulvar squamous cell carcinoma were subjected to radical vulvectomy with bilateral inguinal and femoral node dissection or to radical vulvectomy with bilateral inguinofemoral and deep pelvic node dissection. The association between lymph node status (metastatic or not) and several parameters was analyzed: tumor location, size and clinical stage; tumor thickness, histologic grade and mitotic index; blood vessel, lymphatic and perineural infiltration; and lymphocytic and plasma cell infiltrates. There were no metastases to the pelvic lymph nodes without previous inguinal lymph node involvement. Unilateral vulvar carcinomas did not have contralateral metastatic nodes when there was no ipsilateral nodal involvement. Lymphatic vessel infiltration showed a statistically significant correlation with inguinal node metastases (P less than .05). No correlation was found between lymph node metastasis and tumor size, clitoral invasion, tumor thickness, histologic grade, blood vessel and perineural infiltration, lymphocytic and plasma cell infiltrates, and mitotic index.

Great omentum free flap in the repair of extensive loss of scalp / Uso de retalho livre do grande epíploo na reparaçäo de extensas perdas de couro cabeludo

Os autores apresentam um caso de grande exposiçäo de calota craniana. Como soluçäo terapêutica foi empregado o retalho livre do grande epíploo. A anastomose microcirúrgica foi feita apenas com vasos temporais superficiais direitos, devido à ausência congênita dos vasos gastrepiplóicos esquerdos. A cobertura do retalho foi obtida com enxerto de pele parcial. A paciente evoluiu para a cura, sem complicaçöes

Adenoid cystic carcinoma of Bartholin's gland: review of the literature and report of two cases.

Two patients with adenoid cystic carcinoma of Bartholin's gland and a review of the relevant literature are presented. With the inclusion of these two patients, there are now 24 cases reported. Both patients had large vulvar masses with a short clinical history, and several local tumor recurrences within the first 21/2 years after radical vulvectomy. The characteristic cribriform pattern and perineural involvement in addition to vascular invasion were present in the pathological material. No metastases were found in the inguino-femoral lymph nodes removed. Both patients are alive, without evidence of local recurrence but with lung metastases. A chemotherapeutic treatment scheme (adriamycin and cyclophosphamide) is underway but it is too early to evaluate its results.

Parada cardiaca anoxica hipotermica (20 graus) e alteracoes enzimaticas mitocondriais. / Anoxic hypothermic (20 degrees) heart arrest and mitochondrial enzymatic changes

Foram estudados 24 caes distribuidos nos seguintes grupos: Grupo I - Oito animais, cujos coracoes foram estudados imediatamente apos anestesia e toratocomia (controle).Grupo II Oito animais submetidos a 60 minutos de parada cardiaca anoxica normotermica. Grupo III Oito animais submetidos a 60 minutos de parada cardiaca anoxica hipotermica (20 graus).Os resultados obtidos possibilitaram as seguintes conclusoes: A) O esfriamento seletivo do miocardio impediu a diminuicao das concentracoes de ATP. B) As alteracoes nos sistemas enzimaticos estudados (alfa-ceco-glutario-desidrogenase: succino-desidrogenase; beta-hidroxi-butirico-desidrogenase; glutamico-desidrogenase e malico-desidrogenase), determinadas pela parada anoxica normotermica, excetuando-se o controle da beta-hidroxi-butiricodesidrogenase, nao foram prevenidas pelo esfriamento do miocardio a 20 graus C