Una experiencia docente universitaria en Pediatría, aceptación por alumnos y docentes / University teaching experience in Pediatrics, acceptance by students and teachers

La educación médica debe ser reflexiva, interactiva y debe promover la proactividad personal y profesional como elemento de aprendizaje. Describimos una experiencia docente en los estudios del Grado de Medicina, en la asignatura de Pediatría, con la participación activa de los estudiantes. Un estudiante propuso preparar y exponer un tema, eligiendo "tosferina y paperas". Este permite un abordaje de aspectos clínicos, epidemiológicos y comunitarios. En el modelo de clase invertida se promueve la lectura de documentos previos a la hora docente

Medical education training should be interactive and should promote personal and professional proactivity as a learning element. We describe a teaching experience in the studies of the Degree of Medicine (subject of Pediatrics) with the active participation of the students. A student proposed to prepare the theme "whooping cough and mumps, and that was the chosen one. This item allows an approach of clinical, epidemiological and community aspects. With the flipped classroom the reading of documents prior to teaching time is promoted

Streptococcus endophthalmitis outbreak after intravitreal injection of bevacizumab: one-year outcomes and investigative results.

PURPOSE: To report the 1-year clinical outcomes of an outbreak of Streptococcus endophthalmitis after intravitreal injection of bevacizumab, including visual acuity outcomes, microbiological testing, and compound pharmacy investigations by the Food and Drug Administration (FDA). DESIGN: Retrospective consecutive case series. PARTICIPANTS: Twelve eyes of 12 patients who developed endophthalmitis after receiving intravitreal bevacizumab prepared by a single compounding pharmacy. METHODS: Medical records of patients were reviewed; phenotypic and DNA analyses were performed on microbes cultured from patients and from unused syringes. An inspection report by the FDA based on site visits to the pharmacy that prepared the bevacizumab syringes was summarized. MAIN OUTCOME MEASURES: Visual acuity, interventions received, time to intervention, microbiological consistency, and FDA inspection findings. RESULTS: Between July 5 and 8, 2011, 12 patients developed endophthalmitis after intravitreal bevacizumab from syringes prepared by a single compounding pharmacy. All patients received initial vitreous tap and injection, and 8 patients (67%) subsequently underwent pars plana vitrectomy (PPV). After 12 months follow-up, outcomes have been poor. Seven patients (58%) required evisceration or enucleation, and only 1 patient regained pre-injection visual acuity. Molecular testing using real-time polymerase chain reaction, partial sequencing of the groEL gene, and multilocus sequencing of 7 housekeeping genes confirmed the presence of a common strain of Streptococcus mitis/oralis in vitreous specimens and 7 unused syringes prepared by the compounding pharmacy at the same time. An FDA investigation of the compounding pharmacy noted deviations from standard sterile technique, inconsistent documentation, and inadequate testing of equipment required for safe preparation of medications. CONCLUSIONS: In this outbreak of endophthalmitis, outcomes have been generally poor, and PPV did not improve visual results at 1-year follow-up. Molecular testing confirmed a common strain of S. mitis/oralis. Contamination seems to have occurred at the compounding pharmacy, where numerous problems in sterile technique were noted by public health investigators.

Importance of assessing CK19 immunostaining in core biopsies in patients subjected to sentinel node study by OSNA.

Analysis of sentinel lymph node (SLN) by means of One-Step Nucleic Acid Amplification (OSNA) is being used increasingly as a very sensitive and quick method for intraoperative axillary staging in patients with breast cancer. This molecular diagnostic assay detects the expression level of cytokeratin 19 (CK19), a luminal epithelial cell marker broadly expressed in most breast carcinomas and not normally found in lymph nodes. Almost all breast cancers express this cytoskeleton protein, but some breast tumors have been found to lose the expression of CK19. CK19 immunostaining in core biopsies has been recommended in selecting patients eligible for OSNA analysis because SLNs with metastatic involvement by CK19-negative breast cancers may result in a false negative result by OSNA. However, the real frequency of CK19-negative breast cancer has to be elucidated. In this study, we have assessed the frequency and molecular profile of CK19-negative breast carcinomas in three series of cases. The first is a prospective series of 197 breast carcinomas, 111 of which were subjected to SLN evaluation by OSNA. The second is a retrospective series of 41 triple-negative (TN) breast carcinomas, and the third is a retrospective series of 68 breast cancer patients (matched core biopsies and metastatic lymph nodes) that had been evaluated by conventional procedures before the OSNA methodology was adopted in our institution. Our results not only demonstrate that lack of expression of CK19 is infrequent in breast cancers but also that performing CK19 immunohistochemical staining is important on diagnostic core biopsies in taking the decision of using OSNA methodology in the evaluation of sentinel nodes in breast cancer patients.

An outbreak of streptococcus endophthalmitis after intravitreal injection of bevacizumab.

PURPOSE: To report a series of patients with Streptococcus endophthalmitis after injection with intravitreal bevacizumab prepared by the same compounding pharmacy. DESIGN: Noncomparative consecutive case series. METHODS: Medical records and microbiology results of patients who presented with endophthalmitis after injection with intravitreal bevacizumab between July 5 and July 8, 2011, were reviewed. RESULTS: Twelve patients were identified with endophthalmitis, presenting 1 to 6 days after receiving an intravitreal injection of bevacizumab. The injections occurred at 4 different locations in south Florida. All patients received bevacizumab prepared by the same compounding pharmacy. None of the infections originated at the Bascom Palmer Eye Institute, Miami, Florida, although 9 patients presented to its tertiary-care ophthalmic emergency room for treatment, and 3 additional patients were seen in consultation. All patients were treated initially with a vitreous tap and injection; 8 patients subsequently received a vitrectomy. Microbiology cultures for 10 patients were positive for Streptococcus mitis/oralis. Seven unused syringes of bevacizumab prepared by the compounding pharmacy at the same time as those prepared for the affected patients also were positive for S. mitis/oralis. After 4 months of follow-up, all but 1 patient had count fingers or worse visual acuity, and 3 required evisceration or enucleation. Local, state, and federal health department officials have been investigating the source of the contamination. CONCLUSIONS: In this outbreak of endophthalmitis after intravitreal bevacizumab injection, Streptococcus mitis/oralis was cultured from the majority of patients and from all unused syringes. Visual outcomes were generally poor. The most likely cause of this outbreak was contamination during syringe preparation by the compounding pharmacy.

Avastin doesn't blind people, people blind people.

PURPOSE: To review the appropriate preparation of bevacizumab for intravitreal injection by compounding pharmacies with specific recommendations designed to prevent microbial contamination. DESIGN: Perspective. METHODS: A review and discussion of compounding issues with supporting literature, clinical experience, illustrations, and expert opinion. RESULTS: Closer examination of the events surrounding the recent clusters of infectious endophthalmitis cases occurring after the intravitreal injection of bevacizumab suggest that the vision loss is not the result of the drug or the injection technique, but rather of the compounding procedures used to prepare the syringes containing the bevacizumab. Noncompliance with recognized standards and poor aseptic technique are the most likely causes of these outbreaks. The key to preventing these catastrophic occurrences depends on the implementation of and strict adherence to United States Pharmacopoeia Chapter 797 requirements. CONCLUSIONS: Recommendations arising from a root cause analysis of infectious endophthalmitis outbreaks should focus on the procedures used by pharmacies to compound bevacizumab. Microbial contamination of bevacizumab-containing syringes prepared from the same vial of drug can be avoided by using a single vial of bevacizumab for each eye or by following strict adherence to United States Pharmacopoeia Chapter 797 requirements when compounding a single vial of bevacizumab into multiple syringes.

Maintenance of sterility in 1-mL polypropylene syringes.

PURPOSE: The sterility of syringes filled with a growth-promoting broth when stored under various temperature conditions was studied. METHODS: Samples of tryptic soy broth (TSB) were injected into 150 1-mL polypropylene syringes and incubated at 33-37 degrees C for 14 days, after which time they were visually inspected for microbial contamination. In addition to visual inspection, the sterility of all syringes was tested by inoculating samples into 10-mL tubes of thioglycollate broth, incubating at 35 degrees C, and observing for growth for 5 days. After the 14-day incubation period, 30 syringes were removed for sterility validation and microbial growth promotion. TSB from 15 syringes was transferred into sterile culture tubes and challenged with Staphylococcus aureus, Escherichia coli, Bacillus cereus, Candida albicans, and Aspergillus niger. The remaining 120 syringes were repackaged and stored at room temperature (22 degrees C), in a refrigerator (5 degrees C), or in a freezer (-20 degrees C). The sterility of the samples was evaluated at 30 days, 45 days, three months, and six months. RESULTS: No microbial growth was detected by visual inspection in any of the 15 syringes examined for turbidity during validation testing. All study syringes (n = 120) remained sterile throughout the respective evaluation periods, regardless of storage condition. CONCLUSION: Growth-promoting broth stored in 1-mL polypropylene syringes remained sterile when stored at room temperature, in a refrigerator, or in a freezer for six months.

Short-term safety and efficacy of intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration.

PURPOSE: To evaluate the safety and efficacy of intravitreal bevacizumab (Avastin, Genentech Inc.) for the treatment of neovascular age-related macular degeneration (ARMD). METHODS: A retrospective review was performed on consented patients with neovascular ARMD receiving intravitreal bevacizumab therapy. All patients received intravitreal bevacizumab at baseline with additional monthly injections given at the discretion of the treating physician. At each visit, a routine Snellen visual acuity assessment was performed followed by an ophthalmic examination and optical coherence tomography (OCT) imaging. RESULTS: Fifty-three eyes of 50 patients received an intravitreal bevacizumab injection between May and August 2005. Including the month 3 visit, the average number of injections was 2.3 out of a maximum of 4 injections. No serious drug-related ocular or systemic adverse events were identified. Improvements in visual acuity and central retinal thickness measurements were evident by week 1 and continued through month 3. At month 3, the mean visual acuity improved from 20/160 to 20/125 (P < 0.001) and the mean central retinal thickness decreased by 99.6 microm (P < 0.001). CONCLUSION: Off-label intravitreal bevacizumab therapy for neovascular ARMD was well tolerated over 3 months with improvements in visual acuity and OCT central retinal thickness measurements. While the long-term safety and efficacy of intravitreal bevacizumab remain unknown, these short-term results suggest that intravitreal bevacizumab may be the most cost effective therapy for the treatment of neovascular ARMD.

A cost analysis of the prostaglandin analogs.

BACKGROUND: The efficacy, ease of use, and favorable side effect profile has increased the popularity of the prostaglandin analogs for topical treatment of a variety of glaucoma types. We undertook a cost analysis study of all the prostaglandin analogs. METHODS: Mean number of drops per bottle, mean drop volume, total bottle volume, percent overfill per bottle, mean national bottle cost, daily cost of therapy, and yearly cost of therapy were calculated for all four of the prostaglandin analogs. RESULTS: Yearly cost of monocular therapy was $230.68 for latanoprost, $219.37 for travoprost, $211.34 for bimatoprost, and $178.85 for unoprostone. Unoprostone was by far the least expensive of the prostaglandin analogs tested. Bimatoprost, latanoprost, and travoprost were essentially the same price, varying in yearly cost to the patient by less than twenty dollars. Bimatoprost had the most expensive bottle price, unoprostone the least expensive. Bimatoprost also had the largest percentage of overfill from labeled volume. Unoprostone had the most monocular treatment days per bottle. CONCLUSION: Cost, in addition to efficacy and side affect profile, should be considered when determining which prostaglandin analog to prescribe to glaucoma patients.