Comparison of epidemiological, clinical and microbiological characteristics of bloodstream infection in children with solid tumours and haematological malignancies.

Bloodstream infection (BSI) is a serious complication in immunocompromised hosts. This study compares epidemiological, clinical and microbiological characteristics of BSI among children with haematological malignancies (HM) and solid tumours (ST). The study was conducted from October 2012 through to November 2015 at a referral hospital for cancer care and included the first BSI episode detected in 210 patients aged 18 years or less. BSI cases were prospectively detected by daily laboratory-based surveillance. The Centers for Disease Control and Prevention definitions for primary or secondary BSI were used. A higher proportion of use of corticosteroids (P = 0.02), chemotherapy (P = 0.01) and antibiotics (P = 0.05) before the BSI diagnosis; as well as of neutropenia (P < 0.001) and mucositis (P < 0.001) at the time of BSI diagnosis was observed in patients with HM than with ST. Previous surgical procedures (P = 0.03), mechanical ventilation (P = 0.01) and bed confinement (P < 0.001) were more frequent among children with ST. The frequency of use of temporary (P = 0.01) and implanted vascular lines (P < 0.01) was significantly higher in children with ST than with HM while the tunnelled line (P = 0.01) use was more frequent in children with HM as compared to ST. Most (n = 181) BSI cases were primary BSI. BSI associated with a tunnelled catheter was more frequent in children with HM (P < 0.01), whereas BSI associated with an implanted (P < 0.01) or temporary central line (P < 0.02) was more common in patients with ST. BSI associated with mucosal barrier injury was more frequent (P = 0.01) in children with HM. Indication for intensive care was more frequent in children (P = 0.05) with ST. Mortality ratio was similar in children with ST and HM, and length of hospital stay after BSI was higher in patients with HM than with ST (median of 19 vs. 13 days; P = 0.02). Infection caused by Gram-negative bacteria (P = 0.04) and polymicrobial infections (P = 0.05) due to Gram-positive cocci plus fungus was more common in patients with HM. These findings suggest that the characteristics of BSI acquisition and mortality can be cancer-specific.

Elevated plasma levels of hepatocyte growth factor in rats experimentally envenomated with Bothrops jararaca venom: Role of snake venom metalloproteases.

The hepatocyte growth factor (HGF)/c-met pathway, which mainly consists of HGF activator (HGFA) and its substrate HGF, protects various types of cells via anti-apoptotic and anti-inflammatory signals. Thrombin is the main physiological activator of such plasmatic pathway, and increased plasma concentrations of HGF have been considered as a molecular marker for some pathological conditions, such as disseminated intravascular coagulation. Since thrombin generation is often linked to tissue injury, and these events are common during snake venom-induced consumption coagulopathies (VICC), our goals were to examine whether Bothrops jararaca venom (Bjv), which induces VICC in vivo: (i) activates the HGF/c-met pathway in vivo and (ii) cleaves zymogen forms of HGFA and HGF (proHGFA and proHGF, respectively) in vitro. Two experimental groups (n = 6, each) of male adult Wistar rats were subcutaneously injected with 500 µL of 0.9% NaCl solution (control) or sub-lethal doses (1.6 mg/kg) of Bjv. Three hours after envenomation, whole blood samples were collected from the carotid arteries to evaluate relevant coagulation parameters using rotational thromboelastometry and fibrinogen level (colorimetric assay). Additionally, the plasma concentration of HGF was assayed (ELISA). Thromboelastometric assays showed that blood clotting and fibrin polymerization were severely impaired 3 h after Bjv injection. Total plasma HGF concentrations were almost 6-fold higher in the Bjv-injected group (410.0 ±â€¯91) compared with control values (68 ±â€¯18 pg/mL, p < 0.05). Western blotting assay showed that Bjv processed proHGFA and proHGF, generating bands resembling those generated by thrombin and kallikrein, respectively. In contrast to the serine protease inhibitor 4-(2-aminoethyl)benzenesulfonyl fluoride hydrochloride (AEBSF), the metalloprotease inhibitor ethylenediaminetetraacetic acid disodium salt (Na2-EDTA) strongly reduced the ability of Bjv to process proHGFA and generated one active band similar to that of thrombin. Since Bjv contains prothrombin and factor X activators, increased intravascular thrombin formation might partly explain the increased HGF levels after bothropic envenomation. In conclusion, these findings suggest that snake venom metalloproteases may be determinant for elevation of plasma levels of HGF in rats experimentally envenomated with Bjv.

Risk factors for early onset prosthetic valve endocarditis: a case-control study.

BACKGROUND: Early onset prosthetic valve endocarditis (EO-PVE) is an infrequent complication of cardiac valve surgery. It is considered a healthcare-associated infection due to contamination of the prosthesis during the implant or in the early postoperative period. AIM: To evaluate which factors may be related to the acquisition of EO-PVE. METHODS: A nested case-control study was conducted from 2006 to 2016. Cases were patients who had definite prosthetic endocarditis by the modified Duke criteria up to 12 months of heart valve replacement. Cases and controls were matched by age, gender, date and type of surgery. FINDINGS: There were 26 cases and 78 controls, in 2496 valve surgeries. The median incidence of EO-PVE was 1.1%. Risk factors identified during surgery were: use of ≥2 cryoprecipitate units (odds ratio (OR): 5.95; 95% confidence interval (CI): 1.31-27.0) and ≥2 plasma units (OR: 2.73; 95% CI: 1.0-7.5). In the postoperative period, associated factors were bloodstream infection (OR: 14.00; CI: 1.49-131.77), pneumonia (4.38; 1.21-15.84), any infection (4.46; 1.63-12.21), central line for ≥2 weeks (5.33; 2.06-13.78), presence of dialysis catheter (3.22; 1.15-9.03), and new open chest surgery (3.89; 1.28-11.78). Mortality at 12 months was 34.6% in cases and 6.4% in controls (OR: 7.73; CI: 2.3-26.06). CONCLUSION: Cases had more infections, invasive procedures and surgical re-interventions in the early postoperative period, which favoured contamination of the newly implanted prosthesis. A preventive approach, with reinforcement of infection control practices, may curb the incidence of this condition.

Platelet participation in the pathogenesis of dermonecrosis induced by Loxosceles gaucho venom.

Loxosceles gaucho spider venom induces in vitro platelet activation and marked thrombocytopenia in rabbits. Herein, we investigated the involvement of platelets in the development of the dermonecrosis induced by L. gaucho venom, using thrombocytopenic rabbits as a model. L. gaucho venom evoked a drop in platelet and neutrophil counts 4 h after venom injection. Ecchymotic areas at the site of venom inoculation were noticed as soon as 4 h in thrombocytopenic animals but not in animals with initial normal platelet counts. After 5 days, areas of scars in thrombocytopenic animals were also larger, evidencing the marked development of lesions in the condition of thrombocytopenia. Histologically, local hemorrhage, collagen fiber disorganization, and edema were more severe in thrombocytopenic animals. Leukocyte infiltration, predominantly due to polymorphonuclears, was observed in the presence or not of thrombocytopenia. Thrombus formation was demonstrated by immunohistochemistry at the microvasculature, and it occurred even under marked thrombocytopenia. Taken together, platelets have an important role in minimizing not only the hemorrhagic phenomena but also the inflammatory and wound-healing processes, suggesting that cutaneous loxoscelism may be aggravated under thrombocytopenic conditions.

Longitudinal surveillance for meningitis by Acinetobacter in a large urban setting in Brazil.

The study aim was to describe the emergence of carbapenem resistance and clonal complexes (CC), defined by multilocus sequence typing (MLST), in Acinetobacter baumannii in a surveillance system for meningitis. Starting in 1996 in an urban setting of Brazil, surveillance detected meningitis by Acinetobacter sp for the first time in 2002. Up to 2008, 35 isolates were saved. Carbapenem resistance emerged in 2006, reaching 70% of A. baumannii isolates in 2008, including one that was colistin resistant. A. baumannii belonged to CC113/79 (University of Oxford/Institute Pasteur schemes), CC235/162 and CC103/15. Dissemination of infections resistant to all antimicrobial agents may occur in the future.

Severe infection in a lung transplant recipient caused by donor-transmitted carbapenem-resistant Acinetobacter baumannii.

We describe a case of proven donor transmission of carbapenem-resistant Acinetobacter baumannii, which resulted in severe infectious complications after lung transplantation. A single bla(OXA-23) positive strain, belonging to a new multilocus sequence type (ST231), was isolated from donor and recipient, who died 65 days after transplantation. This report highlights the current challenges associated with the potential transmission of multidrug-resistant infections through organ transplantation.

Involvement of circulating platelets on the hyperalgesic response evoked by carrageenan and Bothrops jararaca snake venom.

BACKGROUND: The role of platelets in hemostasis is well known, but few papers have reported their role in pain and edema induced by inflammatory agents. OBJECTIVE: To evaluate the role of circulating platelets in the local injury induced by two diverse inflammatory agents, Bothrops jararaca venom (Bjv) and carrageenan. METHODS: Rats were (i) rendered thrombocytopenic by administration of polyclonal anti-rat platelet IgG (ARPI) or busulfan, or (ii) treated with platelet inhibitors (aspirin or clopidogrel). Edema formation, local hemorrhage and the pain threshold were assessed after intraplantar injection of Bjv or carrageenan in rat hind paws. Additionally, whole platelets or platelet releasate were tested whether they directly induced hyperalgesia. RESULTS: Platelet counts were markedly diminished in rats administered with either ARPI (± 88%) or busulfan (± 96%). Previous treatment with ARPI or busulfan slightly reduced edema induced by Bjv or carrageenan. Injection of Bjv, but not of carrageenan, induced a statistically significance increase in hemorrhage in the hind paws of thrombocytopenic rats. Remarkably, hyperalgesia evoked by Bjv or carrageenan was completely blocked in animals treated with ARPI or busulfan, or pre-treated with aspirin or clopidogrel. On the other hand, intraplantar administration of whole platelets or platelet releasate evoked hyperalgesia, which was inhibited by pre-incubation with alkaline phosphatase. CONCLUSIONS: Thrombocytopenia or inhibition of platelet function drastically reduced hyperalgesia induced by injection of carrageenan or Bjv; moreover, platelets per se secrete phosphorylated compounds involved in pain mediation. Thus, blood platelets are crucial cells involved in the pain genesis, and their role therein has been underestimated.

Involvement of circulating platelets on the hyperalgesic response evoked by carrageenan and Bothrops jararaca snake venom

Background:The role of platelets in hemostasis is well known, but few papers have reported their role in pain and edema induced by inflammatory agents. Objective:To evaluate the role of circulating platelets in the local injury induced by two diverse inflammatory agents, Bothrops jararaca venom (Bjv) and carrageenan. Methods:Rats were (i) rendered thrombocytopenic by administration of polyclonal anti-rat platelet IgG (ARPI) or busulfan, or (ii) treated with platelet inhibitors (aspirin or clopidogrel). Edema formation, local hemorrhage and the pain threshold were assessed after intraplantar injection of Bjv or carrageenan in rat hind paws. Additionally, whole platelets or platelet releasate were tested whether they directly induced hyperalgesia. Results:Platelet counts were markedly diminished in rats administered with either ARPI (±88%) or busulfan (±96%). Previous treatment with ARPI or busulfan slightly reduced edema induced by Bjv or carrageenan. Injection of Bjv, but not of carrageenan, induced a statistically significance increase in hemorrhage in the hind paws of thrombocytopenic rats. Remarkably, hyperalgesia evoked by Bjv or carrageenan was completely blocked in animals treated with ARPI or busulfan, or pre-treated with aspirin or clopidogrel. On the other hand, intraplantar administration of whole platelets or platelet releasate evoked hyperalgesia, which was inhibited by pre-incubation with alkaline phosphatase. Conclusions:Thrombocytopenia or inhibition of platelet function drastically reduced hyperalgesia induced by injection of carrageenan or Bjv; moreover, platelets per se secrete phosphorylated compounds involved in pain mediation. Thus, blood platelets are crucial cells involved in the pain genesis, and their role therein has been underestimated.

Preclinical assessment of the neutralizing capacity of antivenoms produced in six Latin American countries against medically-relevant Bothrops snake venoms.

Species of the genus Bothrops induce the vast majority of snakebite envenomings in Latin America. A preclinical study was performed in the context of a regional network of public laboratories involved in the production, quality control and development of antivenoms in Latin America. The ability of seven polyspecific antivenoms, produced in Argentina, Brazil, Peru, Bolivia, Colombia and Costa Rica, to neutralize lethal, hemorrhagic, coagulant, defibrinogenating and myotoxic activities of the venoms of Bothrops neuwiedi (diporus) (Argentina), Bothrops jararaca (Brazil), B. neuwiedi (mattogrossensis) (Bolivia), Bothrops atrox (Peru and Colombia) and Bothrops asper (Costa Rica) was assessed using standard laboratory tests. Despite differences in the venom mixtures used in the immunization of animals for the production of these antivenoms, a pattern of extensive cross-neutralization was observed between these antivenoms and all the venoms tested, with quantitative differences in the values of effective doses. This study reveals the capacity of these antivenoms to neutralize, in preclinical tests, homologous and heterologous Bothrops venoms in Central and South America, and also highlight quantitative differences in the values of Median Effective Doses (ED50s) between the various antivenoms.

Haematopoiesis in snakes (Ophidia) in early postnatal development.

The occurrence of haematopoiesis has been studied in various parts of the spine and in the ribs in four species of snakes (Boa constrictor L., Elaphe guttata L., Lamprophis fulaginosus Boie., Bothrops jararaca Wied.) from hatching until 150 days of postnatal development. Marrow spaces are formed by chondrolysis with various time frames depending on the studied species. Marrow cells egress to the general circulation in two ways: via migration through the endothelial cells lining the venous sinuses or by the rupture of protrusions. Erythroblasts are present in the lumen of marrow sinuses suggesting their final maturation there. Various relationships of the spleen to the pancreas have been found. No myelopoietic foci occur in the spleen, liver or kidney of any of the studied species. However, erythropoiesis (sparse islets) has been observed in Bothrops jararaca spleen.

Failure of chloramphenicol prophylaxis to reduce the frequency of abscess formation as a complication of envenoming by Bothrops snakes in Brazil: a double-blind randomized controlled trial.

Bites by many species of venomous snake may result in local necrosis at, or extending from, the site of the bite. The use of prophylactic antibiotics to prevent infection as a complication of local necrotic envenoming is controversial. A double-blind randomized controlled trial was carried out to assess whether antibiotic therapy is effective in this situation. Two hundred and fifty-one patients, with proven envenoming by snakes of the genus Bothrops, admitted to two hospitals in Brazil, between 1990 and 1996, were randomized to receive either oral chloramphenicol (500 mg every six hours for five days) or placebo. One hundred and twenty-two of these patients received chloramphenicol (group 1) and 129 were given placebo (group 2). There were no significant differences between the groups at the time of admission. Necrosis developed in seven (5.7%) patients in group 1 and in five (3.9%) patients in group 2 (P>0.05) while abscesses occurred in six patients (4.9%) in group 1 and in six (4.7%) patients in group 2 (P>0.05). In conclusion, the use of orally-administered chloramphenicol for victims of Bothrops snake bite with signs of local envenoming on admission, is not effective for the prevention of local infections.

Hematological, hemostatic and clinical chemistry disturbances induced by Crotalus durissus terrificus snake venom in dogs.

The aim of this study was to investigate the hematological, hemostatic and biochemical disturbances induced by the injection of Crotalus durissus terrificus venom in dogs under controlled conditions. For this purpose three groups of animals were used: an experimental group (E), which was injected i.m. with C. durissus terrificus venom (1 mg/kg); and two control groups--antivenom (AV) and control (C)--which were injected i.m. with 150 mM NaCl. Groups E and AV were treated i.v. with Crotalus antivenom 2 hours after the first injection. Serum levels of alkaline phosphatase and alanine aminotransferase were increased in groups E and AV at 24 and 48 hours after serumtherapy, respectively. The increased serum levels of myoglobin, creatine kinase and aspartate aminotransferase demonstrated that animals developed rhabdomyolysis. A persistent neutrophilic leukocytosis was already noticeable at 2 hours after envenomation and lasted even after serumtherapy. The animals of groups E and AV presented eosinopenia 24 hours after serumtherapy, and collagen-induced platelet hypoaggregation was observed without thrombocytopenia. Increased levels of fibrinogen/fibrin degradation products (FnDP/FgDP), hypofibrinogenemia, and alpha2-antiplasmin consumption were observed at 2 hours after envenomation, indicating secondary activation of fibrinolysis. Our data suggest that the biochemical and hemostatic disturbances induced by C. durissus terrificus venom in dogs are related to its myotoxic and thrombin-like activities.

Envenoming by Bothrops jararaca in Brazil: association between venom antigenaemia and severity at admission to hospital.

The association between the clinical severity of Bothrops jararaca envenoming at admission and serum venom and plasma fibrinogen concentrations before antivenom administration is reported in 137 patients admitted to Hospital Vital Brazil, Instituto Butantan, São Paulo, Brazil, between 1989 and 1990. Other variables such as age, gender, site of the bite, use of tourniquet and the time interval between the bite and start of antivenom therapy, spontaneous systemic bleeding, and the 20 minute whole blood clotting test (20WBCT) at admission showed no association with either severity or serum venom antigen concentration (SVAC). Mean SVAC in patients with mild envenoming was significantly lower than in the group with moderate envenoming (P = 0.0007). Patients with plasma fibrinogen concentrations > 1.5 g/L had a lower mean SVAC than patients with plasma fibrinogen concentrations < or = 1.5 g/L (P = 0.02). Those admitted with a tourniquet in place had significantly higher plasma fibrinogen concentrations than those without a tourniquet (P = 0.002). A multiple logistic regression model showed independent risk factors for severity: bites at sites other than legs or forearms, SVACs > or = 400 ng/mL, and the use of a tourniquet. Rapid quantification of SVAC before antivenom therapy might improve initial evaluation of severity in B. jararaca bites.

Hematopoiesis in snakes (Ophidia).

Locations of the hematopoietic tissue have been described in the following ophidian species: Bothrops jararaca, Bothrops jararacusu, Waglerophis merremii, Elaphe teniura teniura, Boa constrictor, and Python reticulatus. Studies were carried out on perfusion fixed vertebrae, ribs, spleen, liver, thymus, and kidney. Routine histological technique was applied using both light and electron microscopy. Hematopoietic tissue was found in the following locations of the vertebrae: neural spine, neural arch, postzygophysis processes, hypapophysis, vertebral centre. Moreover, intense hematopoiesis was found inside the ribs. In the spleen and thymus, only lymphopoiesis was found. Hematopoietic islets in the spleen were sporadically found only in young specimens. No hematopoiesis was observed in the liver and kidney. In the studied species, there were no differences in the location of hematopoietic tissue. A new model of mature and immature blood cell release to the lumen of marrow sinuses different from that known to operate in higher vertebrates is proposed.

Coagulopathy following lethal and non-lethal envenoming of humans by the South American rattlesnake (Crotalus durissus) in Brazil.

The South American tropical rattlesnake (Crotalus durissus subspp) is responsible for approximately 10% of bites from venomous snakes in Brazil. We studied 24 victims of bites by this species over 3 years, in south-eastern Brazil, particularly investigating haemostatic alterations. Thirteen patients were defined as moderately envenomed and 11 as severe. There were two deaths, which were not attributed to venom-induced haemostatic disturbances. However, envenoming by C. durissus is frequently associated with haemostatic disorders, which are probably attributable mainly to the action of the thrombin-like enzyme, with possible additional effects secondary to the powerful myotoxic activity of the venom.

Frequency of food consumption and lipoprotein serum levels in the population of an urban area, Brazil.

OBJECTIVE: To identify the association between food group consumption frequency and serum lipoprotein levels among adults. METHODS: The observations were made during a cross-sectional survey of a representative sample of men and women over 20 years old living in Cotia county, S. Paulo, Brazil. Data on food frequency consumption, serum lipids, and other covariates were available for 1, 045 adults. Multivariate analyses adjusted by age, gender, body mass index, waist-to-hip ratio, educational level, family income, physical activity, smoking, and alcohol consumption were performed. RESULTS: Consumption of processed meat, chicken, red meat, eggs and dairy foods were each positively and significantly correlated with LDL-C, whereas the intake of vegetables and fruits showed an inverse correlation. Daily consumption of processed meat, chicken, red meat, eggs, and dairy foods were associated with 16.6 mg/dl, 14.5 mg/dl, 11.1 mg/dl, 5.8 mg/dl, and 4.6 mg/dl increase in blood LDL-C, respectively. Increases of daily consumption of fruit and vegetables were associated with 5.2 mg/dl and 5.5 mg/dl decreases in LDL-C, respectively. Alcohol beverage consumption showed a significant positive correlation with HDL-C. CONCLUSIONS: Dietary habits in the study population seem to contribute substantially to the variation in blood LDL and HDL concentrations. Substantially CHD risk reduction could be achieved with dietary changes.

[Dietary fiber consumption in an adult population]. / Consumo de fibras alimentares em população adulta.

OBJECTIVE: The dietary fiber has emerged as a leading dietary factor in the prevention and treatment of chronic diseases. I was estimated the average consumption of total dietary fiber (DF), insoluble fiber (IF) and soluble fiber (SF) in the meals of both sex adults from the town of Cotia, a metropolitan area in S. Paulo State, Brazil. METHODS: A population sample of Cotia country, S. Paulo (Brazil), consisted of 559 adults older than 20 years old, was studied. Food consumption was assessed by the dietary history habits. The amount of dietary fiber in each meal (breakfast, lunch and dinner) was estimated by the serving size. The foods were classified according to their fiber content in Very High (7 g or more), High (4.5 to 6.9), Moderate (2.4 to 4.4) and Low (<2.4). RESULTS: The average population's consumption of dietary fiber was of 24 g/day, with an average consumption of insoluble fiber of 17 g/day and soluble of 7 g/day. Among women, the average consumption was 20 g/day and among men 29 g/day (p<0.01). Most of the foods in their diet were classified as having a low content of dietary fiber. Beans were the most important dietary fiber source in the population diet. Lunch and dinner were the meal with a higher content of dietary fiber. CONCLUSIONS: A low consumption of dietary fiber in the population sample could be detected. Their usual sources of dietary fiber were poor.

Efficacy of bothropic antivenom and its IgG(T) fraction in restoring fibrinogen levels of Bothrops jararaca envenomed mice.

Bothropic antivenom and its IgG(T) fraction, administered 4 h after experimental envenoming by Bothrops jararaca in Swiss mice, were compared for their abilities to restore fibrinogen 24 or 48 h after treatment. IgG(T) was able to normalise fibrinogen levels as efficiently as conventional antivenom. As IgG(T) also neutralises most anti-toxic activities of Bothrops venom, our results suggest that IgG(T) could be a better alternative treatment for envenoming due to the reduced amount of extraneous proteins, which may facilitate the induction of early adverse reactions.

Relationship between stature, overweight and central obesity in the adult population in São Paulo, Brazil.

OBJECTIVE: To test association between overweight, central obesity and stature. DESIGN: Cross-sectional study carried-out between 1990-1991. SUBJECTS: 951 adults (387 male and 564 female) aged 20-64 y, resident in the metropolitan area of São Paulo, Brazil. MEASUREMENTS: Anthropometry, blood lipid concentrations (total, high density lipoprotein (HDL) and low density lipoprotein (LDL)-cholesterol, triglycerides (TGs) and blood glucose. Body mass index (BMI), waist-to-hip ratio (WHR) and waist circumference were used to identify overweight (BMI > 25 kg/m2), abdominal obesity (WHR tertile 3 and waist circumference tertile 3), respectively. The subjects were categorised as those of short stature (women < 150 cm, men < 162cm) and those of normal stature (women > or = 150 cm, men > or = 162 cm). RESULTS: Prevalence of short stature was 19.6% and 15.4% in men and women, respectively. Short stature women had higher serum concentrations of total cholesterol, LDL-cholesterol, TGs and glucose than those of normal stature. Among men, this difference was not observed, except for glucose concentrations. Short stature women had high BMI and WHR means in some age categories, compared with those of normal stature. Both overweight and high WHR frequencies were greater in short stature women than in those of normal ones. In multivariate analysis, adjusted by age, income, marital status, education, physical activity and tobacco use, only women group with short stature compared with normal stature had significantly risk of overweight an high WHR. In the same group there was no association with waist circumference. Among the men there was significant opposite association with waist circumference. CONCLUSION: Short stature in women can potentially be an independent risk factor for overweight and high WHR.